Influence du financement sur la performance des systèmes de soins

La thèse a pour objectif d’étudier l’influence du financement des soins de santé sur la performance des systèmes de soins compte tenu des caractéristiques organisationnelles sanitaires des systèmes. Elle s’articule autour des trois objectifs suivants : 1) caractériser le financement des soins de santé à travers les différents modèles émergeant des pays à revenu élevé ; 2) apprécier la performance des systèmes de soins en établissant les divers profils apparaissant dans ces mêmes pays ; 3) examiner le lien entre le financement et la performance en tenant compte du pouvoir modérateur du contexte organisationnel des soins. Inspirée du processus de circulation de l’argent dans le système de soins, l’approche a d’abord consisté à classer les pays étudiés – par une analyse configurationnelle opérationnalisée par les analyses de correspondance multiples (ACM) et de classification hiérarchique ascendante (CHA) – dans des modèles types, chacun représentant une configuration particulière de processus de financement des soins de santé (article 1). Appliquée aux données recueillies auprès des 27 pays de l’OCDE à revenu élevé via les rapports Health Care in Transition des systèmes de santé des pays produits par le bureau Européen de l’OMS, la banque de données Eco-Santé OCDE 2007 et les statistiques de l’OMS 2008, les analyses ont révélé cinq modèles de financement. Ils se distinguent selon les fonctions de collecte de l’argent dans le système (prélèvement), de mise en commun de l’argent collecté (stockage), de la répartition de l’argent collecté et stocké (allocation) et du processus de paiement des professionnels et des établissements de santé (paiement). Les modèles ainsi développés, qui vont au-delà du processus unique de collecte de l’argent, donnent un portrait plus complet du processus de financement des soins de santé. Ils permettent ainsi une compréhension de la cohérence interne existant entre les fonctions du financement lors d’un éventuel changement de mode de financement dans un pays. Dans un deuxième temps, nous appuyant sur une conception multidimensionnelle de la performance des systèmes, nous avons classé les pays : premièrement, selon leur niveau en termes de ressources mobilisées, de services produits et de résultats de santé atteints (définissant la performance absolue) ; deuxièmement, selon les efforts qu’ils fournissent pour atteindre un niveau élevé de résultats de santé proportionnellement aux ressources mobilisées et aux services produits en termes d’efficience, d’efficacité et de productivité (définissant ainsi la performance relative) ; et troisièmement, selon les profils types de performance globale émergeant en tenant compte simultanément des niveaux de performance absolue et relative (article 2). Les analyses effectuées sur les données collectées auprès des mêmes 27 pays précédents ont dégagé quatre profils de performance qui se différencient selon leur niveau de performance multidimensionnelle et globale. Les résultats ainsi obtenus permettent d’effectuer une comparaison entre les niveaux globaux de performance des systèmes de soins. Pour terminer, afin de répondre à la question de savoir quel mode – ou quels modes – de financement générerait de meilleurs résultats de performance, et ce, dans quel contexte organisationnel de soins, une analyse plus fine des relations entre le financement et la performance (tous définis comme précédemment) compte tenu des caractéristiques organisationnelles sanitaires a été réalisée (article 3). Les résultats montrent qu’il n’existe presque aucune relation directe entre le financement et la performance. Toutefois, lorsque le financement interagit avec le contexte organisationnel sanitaire pour appréhender le niveau de performance des systèmes, des relations pertinentes et révélatrices apparaissent. Ainsi, certains modes de financement semblent plus attrayants que d’autres en termes de performance dans des contextes organisationnels sanitaires différents. Les résultats permettent ainsi à tous les acteurs du système de comprendre qu’il n’existe qu’une influence indirecte du financement de la santé sur la performance des systèmes de soins due à l’interaction du financement avec le contexte organisationnel sanitaire. L’une des originalités de cette thèse tient au fait que très peu de travaux ont tenté d’opérationnaliser de façon multidimensionnelle les concepts de financement et de performance avant d’analyser les associations susceptibles d’exister entre eux. En outre, alors que la pertinence de la prise en compte des caractéristiques du contexte organisationnel dans la mise en place des réformes des systèmes de soins est au coeur des préoccupations, ce travail est l’un des premiers à analyser l’influence de l’interaction entre le financement et le contexte organisationnel sanitaire sur la performance des systèmes de soins.The aim of this thesis is to investigate the influence of health care financing on the performance of health care systems when organizational characteristics of health care system contexts are taken into consideration. It focuses on the following three objectives: 1) to characterize health care financing across the various models emerging in high-income countries; 2) to assess the performance of these health care systems by identifying the different profiles seen in these countries; and 3) to examine the relationship between health care financing and system performance, taking into account the moderating influence of the organizational context of health care. Inspired by the revenue flow process in health care systems, the approach adopted consisted in first classifying the countries studied – using configurational analysis operationalized through multiple components analysis (MCA) and ascending hierarchical classification (AHC) – into typical models, each representing a particular configuration of health care financing processes (article 1). Analysis of data collected on 27 high-income OECD countries from the Health Care in Transition reports produced by the WHO Regional Office for Europe, the 2007 Éco-Santé OCDE database and the 2008 WHO statistics revealed five financing models. These models differ among themselves in terms of the functions of collecting money (collection), pooling the collected funds (pooling), distributing the collected and pooled funds (allocation) and paying the professionals and health care establishments (payment). The models thus developed, which extend beyond the simple process of collecting money, provide a more complete picture of the health care financing process. As such, they enable a better understanding of the internal coherence that exists among the four health care financing functions that will impact any change in a country’s health care financing system. Next, based on a multidimensional conception of health care system performance, we classified the same 27 countries according to three parameters: (1) their levels of resources mobilized, health care services provided and health outcomes achieved (absolute performance); (2) the efforts they invested to achieve higher levels of health outcomes in proportion to resources mobilized and health care services provided, in terms of efficiency, efficacy and productivity (relative performance); and (3) the overall performance profiles that emerged when absolute performance and relative performance were combined (article 2). The analyses we carried out on the data collected for these 27 countries produced four profiles that were differentiated in their multidimensional and overall performance. The results thus obtained allow us to compare overall health care system performance among high-income countries. Finally, to answer the question of what financing modalities would generate the best performance, and in what types of health care organizational contexts, we carried out an in-depth analysis of the relations between health care financing and health care system performance (as defined above), taking into account the organizational characteristics of the health care contexts (article 3). The analysis revealed almost no direct relations between health care financing and health care performance. However, when we looked at interactions between financing and health care organizational contexts to capture the level of system performance, some relevant relations emerged. Thus, in terms of performance, some health care financing modalities would appear to be more appealing than others, depending on the organizational characteristics of the health care context. These results can help health care system stakeholders to understand that there is only an indirect relationship between financing and system performance, due to the interaction between health care financing and the organizational characteristics of health care contexts. One original aspect of this thesis lies in the fact that very few studies have attempted to operationalize the concepts of health care system financing and performance using multidimensional approaches before analyzing any relationships that might exist between them. Furthermore, despite the relevance of taking into account the organizational characteristics of health care contexts in health system reforms, this thesis is the one of the first to analyze the impact of the interaction between health care financing and organizational contexts on health care system performance

La pertinence des stages de formation pratique pour le développement de l’identité professionnelle d’étudiantes infirmières au Québec

Afin d’explorer le processus peu documenté du développement de l’identitéprofessionnelle (IP) d’étudiantes infirmières inscrites à un continuum de formation DECBAC, huit entretiens collectifs (N = 46) ont été analysés à l’aide de concepts issus du modèle psychosociologique de l’IP (Gohier, Anadón, Bouchard, Charbonneau, & Chevrier, 2001). L’analyse de contenu a été effectuée selon l’approche qualitative de Miles et Huberman (2003). Les situations qui conduisent à une remise en question ou minent le désir de devenir infirmière de même que les contextes favorables au développement de l’IP sont précisés. Il s’avère que les stages permettent la mise en pratique de l’IP anticipée dans un contexte sécuritaire. Les attitudes d’accueil en stage favorisent l’émergence d’une IP affirmée. Le site web devenirinfirmiere.org donne accès aux outils éducatifs, aux détails sur le projet et à des données de recherche

Development and Validation of a Tool for Measuring the Professional Identity of Nursing Students: the Q-IPEI / Le développement et la validation d’un instrument de mesure de l’identité professionnelle chez les étudiantes infirmières : le Q-IPEI

Background: The various pressures on nurses in their practice environment, given the complexity of care, have exposed the confusion around the role definition and level of professional identity (PI) of future nurses. To support them in their practice, it is important throughout their education to know their commitment, representations, and sense of identity with respect to their future profession. To our knowledge, there is no measurement tool in the literature that can be used to measure the PI of nursing students throughout their education, given its complex multidimensional nature. Objective: Based on a framework that takes into account the diversity of meanings of PI, the aim of this study was to construct and validate a questionnaire, the Q-IPEI that describes the PI of future nursing students at the personal, relational, and professional practice levels. Methods: A development research approach was used. It was based on a literature review, expert consultation, and validation of the psychometric properties of the Q-IPEI. Data were collected from 488 nursing students in 2013 and 504 in 2014 at five levels of nursing education in the province of Quebec, Canada. Results: The validated Q-IPEI is a questionnaire divided into three components, 11 dimensions, and 68 items. Its factor structure was explored through principal component analyses using 2013 data. It was then confirmed with 2014 data, with an RMSEA of 0.072 and CFI of 0.861. Internal consistency was considered acceptable with a Cronbach’s alpha of 0.823 in 2013 and 0.832 in 2014. Discussion: Using the Q-IPEI, key decision-makers in the health system would serve to consolidate and develop proactive strategies with nursing students throughout their education to strengthen their confidence as future nurses and especially help them cope with the current challenges facing the nursing profession. Résumé Contexte : Les diverses pressions imposées aux infirmières dans l’exercice de leur profession, compte tenu de la complexité des soins, ont révélé une confusion quant à la définition du rôle et le niveau d’identité professionnelle (IP) de futures infirmières. Afin de les appuyer dans leur pratique, il est important de connaître leur engagement, leur représentation et leur perception identitaire quant à leur future profession, et ce, tout au long de leur formation. À notre connaissance, en raison de sa nature multidimensionnelle complexe, il n’existe aucun outil dans la littérature permettant de mesurer l’IP des étudiantes durant leur formation en sciences infirmières. Objectif : Fondé sur un cadre qui tient compte de la diversité des significations de l’IP, l’objectif de cette étude était d’élaborer et de valider un questionnaire, le Q-IPEI, qui décrit l’IP des futures étudiantes en sciences infirmières au niveau personnel, relationnel et au niveau de la pratique professionnelle. Méthodologie : Une approche de recherche et développement basée sur une recension des écrits, une consultation d’experts et la validation des propriétés psychométriques du Q-IPEI a été utilisée. Des données ont été recueillies auprès de 488 étudiantes infirmières en 2013 et de 504 étudiantes en 2014 à cinq niveaux de formation infirmière dans la province de Québec, au Canada. Résultats : Le Q-IPEI validé est un questionnaire divisé en 3 éléments, 11 dimensions et 68 énoncés. La structure factorielle a été explorée à l’aide d’analyses de la composante principale en utilisant les données de 2013. Cette structure a ensuite été confirmée avec les données de 2014 (RMSEA de 0,072 et CFI de 0,861). La cohérence interne a été considérée comme acceptable avec un coefficient alpha de Cronbach de 0,823 en 2013 et de 0,832 en 2014. Discussion : À l’aide du Q-IPEI, les décideurs clés du système de santé pourront consolider et développer des stratégies proactives auprès des étudiantes en sciences infirmières durant leur formation, qui renforceraient davantage leur confiance en tant que futures infirmières et surtout les aideraient à mieux faire face aux difficultés actuelles de la profession

Promising Best Practices Implemented in Long- Term Care Facilities During the COVID-19 Pandemic to Address Social Isolation and Loneliness: A Scoping Review

Context: Throughout the current COVID-19 pandemic, tremendous effort has been made to implement innovative practices to address social isolation and loneliness (SIL) in long-term care facilities (LTCFs), disproportionally affected by COVID-19. These interventions have not yet been synthesized. This review intended to gather the current promising best practices (PBPs) implemented in LTCFs to alleviate SIL in older persons during the COVID-19 pandemic as well as during the SARS and H1N1 pandemics, using an intersectional lens. Methods: An extensive search was done in nine electronic databases. Arksey and O’Malley’s framework was used to format the scoping review. Two independent reviewers screened citations for inclusion, blindly. The selection of articles was conducted blindly by two coauthors. Finally, 16 studies were analyzed out of 9,077 records. Results: Two main themes of findings arose from this review. They comprised proximal PBPs directly addressing SIL in LTCF residents such as pseudo-contact interventions (e.g., chat from balcony or behind transparent barriers/glasses), remote communication tools (e.g., phone or video chat, voice mail/text messaging), and humanoid robots. Distal PBPs included measures implemented to prevent or mitigate the development of COVID-19, including COVID-19 screening approaches, outbreak preparedness, quarantining approaches for both residents and staff. Conclusion: This scoping review found varied PBP implemented during the multiple waves of the COVID-19 pandemic as well as evidence supporting their effectiveness. The contribution of this study is significant as most of the PBP investigated should be prioritized by public policymakers or institutions to provide more satisfactory services to the elderly and their families

An Analysis of the Social Impacts of a Health System Strengthening Program Based on Purchasing Health Services

Abstract Access to universal health coverage is a fundamental right that ensures that even the most disadvantaged receive health services without financial hardship. The Democratic Republic of Congo is among the poorest countries in the world, yet healthcare is primarily made by direct payment which renders care inaccessible for most Congolese. Between 2017 and 2021 a purchasing of health services initiative (Le Programme de Renforcement de l’Offre et Développement de l’accès aux Soins de Santé or PRO DS), was implemented in Kongo Central and Ituri with the assistance of the non-governmental organization Memisa Belgium. The program provided funding for health system strengthening that included health service delivery, workforce development, improved infrastructure, access to medicines and support for leadership and governance. This study assessed the social and health impacts of the PRO DS Memisa program using a health impact assessment focus. A documentary review was performed to ascertain relevant indicators of program effect. Supervision and management of health zones and health centers, use of health and nutritional services, the population’s nutritional health, immunization levels, reproductive and maternal health, and newborn and child health were measured using a controlled longitudinal model. Positive results were found in almost all indicators across both provinces, with a mean proportion of positive effect of 60.8% for Kongo Central, and 70.8% in Ituri. Barriers to the program’s success included the arrival of COVID-19, internal displacement of the population and resistance to change from the community. The measurable positive impacts from the PRO DS Memisa program reveal that an adequately funded multi-faceted health system strengthening program can improve access to healthcare in a low-income country such as the Democratic Republic of Congo

A taxonomy of nursing care organization models in hospitals

Abstract Background Over the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features. Methods This study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units’ profile data. Results The study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses’ professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses’ perceptions that the practice environment is less supportive of their professional work. Conclusions This study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an “ideal” nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.</p

Strengthening Social Capital to Address Isolation and Loneliness in Long-term Care Facilities During the COVID-19 Pandemic: Protocol for a Systematic Review of Research on Information and Communication Technologies

BackgroundThe COVID-19 pandemic has had the greatest impact in long-term care facilities (LTCFs) by disproportionately harming older adults and heightening social isolation and loneliness (SIL). Living in close quarters with others and in need of around-the-clock assistance, interactions with older adults, which were previously in person, have been replaced by virtual chatting using information and communication technologies (ICTs). ICT applications such as FaceTime, Zoom, and Microsoft Teams video chatting have been overwhelmingly used by families to maintain residents’ social capital and subsequently reduce their SIL. ObjectiveBecause of the lack of substantive knowledge on this ever-increasing form of social communication, this systematic review intends to synthesize the effects of ICT interventions to address SIL among residents in LTCFs during the COVID-19 period. MethodsWe will include studies published in Chinese, English, and French from December 2019 onwards. Beyond the traditional search strategy approach, 4 of the 12 electronic databases to be queried will be in Chinese. We will include quantitative and intervention studies as well as qualitative and mixed methods designs. Using a 2-person approach, the principal investigator and one author will blindly screen eligible articles, extract data, and assess risk of bias. In order to improve the first round of screening, a pilot-tested algorithm will be used. Disagreements will be resolved through discussion with a third author. Results will be presented as structured summaries of the included studies. We plan to conduct a meta-analysis if sufficient data are available. ResultsA total of 1803 articles have been retrieved to date. Queries of the Chinese databases are ongoing. The systematic review and subsequent manuscript will be completed by the fall of 2022. ConclusionsICT applications have become a promising avenue to reduce SIL by providing a way to maintain communication between LTCF residents and their families and will certainly remain in the post–COVID-19 period. This review will investigate and describe context-pertinent and high-quality programs and initiatives to inform, at the macro level, policy makers and researchers, frontline managers, and families. These methods will remain relevant in the post–COVID-19 era. International Registered Report Identifier (IRRID)DERR1-10.2196/3626

L’étendue du rôle de l’infirmière praticienne spécialisée en soins de première ligne dans différents milieux de pratique au Québec : une étude de temps et mouvements

Introduction : Le rôle de l’infirmière praticienne spécialisée en soins de première ligne (IPSPL) est relativement récent au Québec. Il y a peu de données sur le déploiement de ce rôle. Objectif : Cette étude vise à décrire le temps passé dans les activités de soins selon les différentes dimensions cliniques et non-cliniques du rôle des IPSPL. Méthodes : Une étude de temps et mouvements (399 heures et 34 minutes (min)) a été réalisée dans 6 milieux de première ligne incluant les soins ambulatoires, l’hébergement et les soins de longue durée, et le soutien à domicile auprès de 12 IPSPL. Résultats : La dimension clinique occupe 72 % à 83 % du temps de travail. Le temps moyen de consultation est influencé par le milieu et varie de 13 min et 32 secondes (sec) à 26 min et 25 sec. En soutien à domicile, le temps (déplacement et coordination des soins) de consultation est plus long. La documentation, 9 % à 20 %, est l’activité qui prend le plus de temps. La durée des appels téléphoniques varie en moyenne entre 4 min à 8 min et 39 sec selon les milieux. Discussion et conclusion : La dimension clinique occupe la plus grande partie du temps de travail des IPSPL. Les consultations téléphoniques permettent de répondre aux interrogations des patients. Puisqu’elles sont fréquentes, ces dernières devraient être comptabilisées dans l’évaluation de la charge de travail des IPSPL. Une meilleure compréhension du rôle des IPSPL pourrait soutenir la planification de la main d’œuvre IPSPL pour mieux répondre aux besoins des patients.Introduction: The primary healthcare nurse practitioner (PHCNP) role is relatively new in Quebec. Few studies have examined the implementation of this role. Objective: To describe the time spent in care activities according to the clinical and non-clinical dimensions of the PHCNP role. Methods: A time and motion study (399 hours and 34 minutes (min)) was carried out in 6 settings including ambulatory care, long-term care and home care with 12 PHCNPs. Results: The clinical dimension is the most important dimension making up 72 % to 83 % of work time. The average consultation time is influenced by the setting and varies from 13 min and 32 seconds (sec) to 26 minutes and 25 sec. In home care, consultation times (travel time and care coordination activities) are the longest. Documentation is the most time-consuming activity taking up 9% to 20%. The duration of telephone calls varies on average from 4 min to 8 min and 39 sec depending on the setting. Discussion and conclusion: The clinical dimension occupies the largest portion of the PHCNPs’ work time. Telephone consultations allow PHCNPs to answer patients’ questions. They should be included in the assessment of the PHCNP’s workload since they occur frequently. A better understanding of the PHCNPs’ role could support PHCNP workforce planning to better meet patient care needs