The Impact of COVID-19 on the Organization of Personal Support Work in Ontario, Canada

The COVID-19 pandemic has exposed fault-lines in the organization of personal support work, including low wages, part-time employment, and risky working condition, despite its essential nature in long-term care (LTC). This is, in part, because personal support work has long-existed on the fringes of what is considered health work, thereby precluding its status as a health profession. In this perspective paper, we explore how the pandemic may contribute to the semi-professionalization of personal support work based on the provision of LTC by personal support workers (PSWs) working in LTC facilities in Ontario, Canada. We first characterize personal support work to illustrate its current organization based on the logics of work control. We then speculate how the pandemic may shift control and map speculated changes onto existing checklists of professionalism and semi-professionalism in health work. We propose the pandemic will shift control away from existing market and hierarchical controls. At most, personal support work may undergo changes that are more characteristic of semi-professional control (semi-professionalism), characterized by the formation of a PSW registry that may improve role clarity, provide market shelter, and standardize wages. We do not believe this shift in control will solve all organizational problems that the pandemic has exposed, and continued market and hierarchical controls may be necessary. This perspective may provide insights for other high-income settings, where the pandemic has exposed similar fault-lines in the organization of personal support work in LTC

Standardising Costs or Standardising Care? Qualitative Evaluation of the Implementation and Impact of a Hospital Funding Reform in Ontario, Canada

Background  Since 2011, the Government of Ontario, Canada, has phased in hospital funding reforms hoping to encourage standardised, evidence-based clinical care processes to both improve patient outcomes and reduce system costs. One aspect of the reform – quality-based procedures (QBPs) – replaced some of each hospital’s global budget with a pre-set price per episode of care for patients with specific diagnoses or procedures. The QBP initiative included publication and dissemination of a handbook for each of these diagnoses or procedures, developed by an expert technical group. Each handbook was intended to guide hospitals in reducing inappropriate variation in patient care and cost by specifying an evidence-based episode of care pathway. We explored whether, how and why hospitals implemented these episode of care pathways in response to this initiative. Methods  We interviewed key informants at three levels in the healthcare system, namely individuals who conceived and designed the QBP policy, individuals and organisations supporting QBP adoption, and leaders in five case-study hospitals responsible for QBP implementation. Analysis involved an inductive approach, incorporating framework analysis to generate descriptive and explanatory themes from data. Results  The 46 key informants described variable implementation of best practice episode of care pathways across QBPs and across hospitals. Handbooks outlining evidence-based clinical pathways did not address specific barriers to change for different QBPs nor differences in hospitals’ capacity to manage change. Hospitals sometimes found it easier to focus on containing and standardising costs of care than on implementing standardised care processes that adhered to best clinical practices. Conclusion  Implementation of QBPs in Ontario’s hospitals depended on the interplay between three factors, namely complexity of changes required, internal capacity for organisational change, and availability and appropriateness of targeted external facilitators and supports to manage change. Variation in these factors across QBPs and hospitals suggests the need for more tailored and flexible implementation supports designed to fit all elements of the policy, rather than one-size-fits-all handbooks alone. Without such supports, hospitals may enact quick fixes aimed mainly at preserving budgets, rather than pursue evidence- and value-based changes in care management. Overestimating hospitals’ change management capacity increases the risk of implementation failure

Qualitative Analysis of the Dynamics of Policy Design and Implementation in Hospital Funding Reform

Background  As in many health care systems, some Canadian jurisdictions have begun shifting away from global hospital budgets. Payment for episodes of care has begun to be implemented. Starting in 2012, the Province of Ontario implemented hospital funding reforms comprising three elements: Global Budgets; Health Based Allocation Method (HBAM); and Quality-Based Procedures (QBP). This evaluation focuses on implementation of QBPs, a procedure/diagnosis-specific funding approach involving a pre-set price per episode of care coupled with best practice clinical pathways. We examined whether or not there was consensus in understanding of the program theory underpinning QBPs and how this may have influenced full and effective implementation of this innovative funding model. Methods  We undertook a formative evaluation of QBP implementation. We used an embedded case study method and in-depth, one-on-one, semi-structured, telephone interviews with key informants at three levels of the health care system: Designers (those who designed the QBP policy); Adoption Supporters (organizations and individuals supporting adoption of QBPs); and Hospital Implementers (those responsible for QBP implementation in hospitals). Thematic analysis involved an inductive approach, incorporating Framework analysis to generate descriptive and explanatory themes that emerged from the data. Results  Five main findings emerged from our research: (1) Unbeknownst to most key informants, there was neither consistency nor clarity over time among QBP designers in their understanding of the original goal(s) for hospital funding reform; (2) Prior to implementation, the intended hospital funding mechanism transitioned from ABF to QBPs, but most key informants were either unaware of the transition or believe it was intentional; (3) Perception of the primary goal(s) of the policy reform continues to vary within and across all levels of key informants; (4) Four years into implementation, the QBP funding mechanism remains misunderstood; and (5) Ongoing differences in understanding of QBP goals and funding mechanism have created challenges with implementation and difficulties in measuring success. Conclusions  Policy drift and policy layering affected both the goal and the mechanism of action of hospital funding reform. Lack of early specification in both policy goals and hospital funding mechanism exposed the reform to reactive changes that did not reflect initial intentions. Several challenges further exacerbated implementation of complex hospital funding reforms, including a prolonged implementation schedule, turnover of key staff, and inconsistent messaging over time. These factors altered the trajectory of the hospital funding reforms and created confusion amongst those responsible for implementation. Enacting changes to hospital funding policy through a process that is transparent, collaborative, and intentional may increase the likelihood of achieving intended effects

Limitations in representative sampling of unpaid caregivers from minority ethnocultural backgrounds in a population-based survey

Abstract Objective Historically, persons from minority ethnic, religious and linguistic backgrounds have been un- or under-represented in population-based research studies. Emerging scholarship suggests challenges in representative sampling, particularly of minority ethnocultural groups, has been exacerbated by the COVID-19 pandemic. This research note offers additional insights concerning these challenges in the context of a population-based survey of unpaid caregivers conducted in Ontario, Canada, between August and December, 2020, the analysis of which is currently underway. Results Beyond limitations intrinsic to study design, including time and budget constraints, the study sample underrepresents unpaid caregivers from minority ethnocultural backgrounds due to differences in conceptions of caregiving across minority cultures, the time-consuming nature of caregiving that disproportionately affects minority groups, and a propensity to avoid research which is rooted in tokenism. These hypotheses are non-exhaustive, speculative and warrant further empirical investigation

Supplemental Material - Challenges navigating publicly funded home care in Ontario, Canada: Perspectives from unpaid caregivers of persons living with dementia

Supplemental Material for Challenges navigating publicly funded home care in Ontario, Canada: Perspectives from unpaid caregivers of persons living with dementia by Husayn Marani, James Shaw, and Gregory P Marchildon in Dementia</p

Out of sync: a Shared Mental Models perspective on policy implementation in healthcare

Abstract The impact of policy ambiguity on implementation is a perennial concern in policy circles. The degree of ambiguity of policy goals and the means to achieve them influences the likelihood that a policy will be uniformly understood and implemented across implementation sites. We argue that the application of institutional and organisational theories to policy implementation must be supplemented by a socio-cognitive lens in which stakeholders’ interpretations of policy are investigated and compared. We borrow the concept of ‘Shared Mental Models’ from the literature on industrial psychology to examine the microprocesses of policy implementation. Drawing from interviews with 45 key informants involved in the implementation of a hospital funding reform, known as Quality-Based Procedures in Ontario, Canada, we identify divergent mental models and explain how these divergences may have affected implementation and change management. We close with considerations for future research and practice

Additional file 1: of Standardising costs or standardising care? Qualitative evaluation of the implementation and impact of a hospital funding reform in Ontario, Canada

Handbooks for Quality-Based Procedures implemented between 2012 and 2017 [5]. (DOCX 16 kb

Simplified schematic of principle findings.

<p>The evolution of QBP implementation—some purposeful, some unintentional—started with (A) incomplete policy design, which (B) influenced the goals of the policy and (C) changed the funding reform mechanism, ultimately (D) altering the trajectory of the entire hospital funding reform policy.</p