Implementation of a health care policy: An analysis of barriers and facilitators to practice change

BACKGROUND: Governments often create policies that rely on implementation by arms length organizations and require practice changes on the part of different segments of the health care system without understanding the differences in and complexities of these agencies. In 2000, in response to publicity about the shortening length of postpartum hospital stay, the Ontario government created a universal program offering up to a 60-hour postpartum stay and a public health follow-up to mothers and newborn infants. The purpose of this paper is to examine how a health policy initiative was implemented in two different parts of a health care system and to analyze the barriers and facilitators to achieving practice change. METHODS: The data reported came from two studies of postpartum health and service use in Ontario Canada. Data were collected from newly delivered mothers who had uncomplicated vaginal deliveries. The study samples were drawn from the same five purposefully selected hospitals for both studies. Questionnaires prior to discharge and structured telephone interviews at 4-weeks post discharge were used to collect data before and after policy implementation. Qualitative data were collected using focus groups with hospital and community-based health care practitioners and administrators at each site. RESULTS: In both studies, the respondents reflected a population of women who experienced an "average" or non-eventful hospital-based, singleton vaginal delivery. The findings of the second study demonstrated wide variance in implementation of the offer of a 60-hour stay among the sites and focus groups revealed that none of the hospitals acknowledged the 60-hour stay as an official policy. The uptake of the offer of a 60-hour stay was unrelated to the rate of offer. The percentage of women with a hospital stay of less than 25 hours and the number with the guideline that the call be within 48 hours of hospital discharge. Public health telephone contact was high although variable in relation to compliance the guideline that the call be within 48 hours of hospital discharge. Home visits were offered at consistently high rates. CONCLUSION: Policy enactment is sometimes inadequate to stimulate practice changes in health care. Policy as a tool for practice change must thoughtfully address the organizational, professional, and social contexts within which the policy is to be implemented. These contexts can either facilitate or block implementation. Our examination of Ontario's universal postpartum program provides an example of differential implementation of a common policy intended to change post-natal care practices that reflects the differential influence of context on implementation

Rationality versus reality: the challenges of evidence-based decision making for health policy makers

<p>Abstract</p> <p>Background</p> <p>Current healthcare systems have extended the evidence-based medicine (EBM) approach to health policy and delivery decisions, such as access-to-care, healthcare funding and health program continuance, through attempts to integrate valid and reliable evidence into the decision making process. These policy decisions have major impacts on society and have high personal and financial costs associated with those decisions. Decision models such as these function under a shared assumption of rational choice and utility maximization in the decision-making process.</p> <p>Discussion</p> <p>We contend that health policy decision makers are generally unable to attain the basic goals of evidence-based decision making (EBDM) and evidence-based policy making (EBPM) because humans make decisions with their naturally limited, faulty, and biased decision-making processes. A cognitive information processing framework is presented to support this argument, and subtle cognitive processing mechanisms are introduced to support the focal thesis: health policy makers' decisions are influenced by the subjective manner in which they individually process decision-relevant information rather than on the objective merits of the evidence alone. As such, subsequent health policy decisions do not necessarily achieve the goals of evidence-based policy making, such as maximizing health outcomes for society based on valid and reliable research evidence.</p> <p>Summary</p> <p>In this era of increasing adoption of evidence-based healthcare models, the rational choice, utility maximizing assumptions in EBDM and EBPM, must be critically evaluated to ensure effective and high-quality health policy decisions. The cognitive information processing framework presented here will aid health policy decision makers by identifying how their decisions might be subtly influenced by non-rational factors. In this paper, we identify some of the biases and potential intervention points and provide some initial suggestions about how the EBDM/EBPM process can be improved.</p

'Feminism rules! Now, where’s my swimsuit?' Re-evaluating Feminist Discourse in Print Media 1968-2008

More than forty years after the Second Wave feminist movement emerged in the Western world, it is frequently claimed that feminism is “dead” or redundant, and that we now live in a “postfeminist” society. Although such claims are regularly refuted by a range of academics and activists (Baumgardner and Richards, 2001; Lumby, 2011; McRobbie, 2007; National Organisation for Women, 2011; Smith, 2003; Redfern and Aune, 2010; Tasker and Negra, 2007; Thornham and Weissmann, forthcoming; Valenti, 2007; Walby, 2011; Walter, 2010), it is worthwhile interrogating the extent to which feminism is discussed in popular and political contexts. In light of the persistent and longstanding “backlash” against feminism in Britain and the United States (see Faludi, 1992; Author Removed, 2011a), is it reasonable to assume that discussions of feminism and discourses utilizing feminist concepts, language and critiques are absent? Furthermore, what does the presence – or erasure – of discourses of feminism tell us about its standing today, and how might such discourses have shifted over time? In answering these questions, this paper traces the emergence of, and changes in the ways feminism has been discursively constructed in British and American newspapers during two periods – 1968-82 which I define as the “height” of the Second Wave in both countries, and 2008, a period marking 40 years after the movement began gaining momentum. Through analysing four British (The Times, Daily Mirror, Daily Mail, The Guardian) and American (The New York Times, Washington Post, Chicago Tribune, Washington Times) newspapers, I argue that not only has there been an erasure of feminist activism from our newspapers over time, but that discourses of feminism have become both de-politicised and de-radicalised since the 1960s, and can now largely be considered neoliberal in nature – a problematic construction for those seeking collective social change