Making Health Data Work for Maori: attitudes and current challenges

This article explores the experience of health services decision makers using Mäori health data to inform decision making. It draws on selected findings from the second phase of a three-year Health Research Council-funded study and discusses how Mäori health data identification, data analysis and data interpretation processes are being used by decision makers to help to identify the most promising strategies to improve Mäori health. Data is critical to monitoring inequity and has the potential to drive health service change. However, improvement is needed at all steps in the decisionmaking process to better facilitate utilising data to leverage change in Mäori health outcomes

Gaming New Zealand’s Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?

Background: Gaming is a potentially dysfunctional consequence of performance measurement and management systems in the health sector and more generally. In 2009, the New Zealand government initiated a Shorter Stays in Emergency Department (SSED) target in which 95% of patients would be admitted, discharged or transferred from an emergency department (ED) within 6 hours. The implementation of similar targets in England led to well-documented practices of gaming. Our research into ED target implementation sought to answer how and why gaming varies over time and between organisations. Methods: We developed a mixed-methods approach. Four organisation case study sites were selected. ED lengths of stay (ED LOS) were collected over a 6-year period (2007-2012) from all sites and indicators of target gaming were developed. Two rounds of surveys with managers and clinicians were conducted. Interviews (n = 68) were conducted with clinicians and managers in EDs and the wider hospital in two phases across all sites. The interview data was used to develop explanations of the patterns of variation across time and across sites detected in the ED LOS data.Results: Our research established that gaming behaviour – in the form of ‘clock-stopping’ and decanting patients to short-stay units (SSUs) or observation beds to avoid target breaches – was common across all 4 case study sites. The opportunity to game was due to the absence of independent verification of ED LOS data. Gaming increased significantly over time (2009-2012) as the means to game became more available, usually through the addition or expansion of short-stay facilities attached to EDs. Gaming varied between sites, but those with the highest levels of gaming differed substantially in terms of organisational dynamics and motives. In each case, however, high levels of gaming could be attributed to the strategies of senior management more than to the individual motivations of frontline staff.Conclusion: Gaming of New Zealand’s ED target increased after the real benefits (in terms of process improvement) of the target were achieved. Gaming of ED targets could be minimised by eliminating opportunities to game through independent verification, or by monitoring and limiting the means and motivations to game

Public administration reform for Aboriginal affairs: an institutionalist analysis

Persistent underperformance of public policy and program implementation in Aboriginal affairs is widely recognised. We analysed the results of two case studies of attempted reforms in public administration of Aboriginal primary health care in the Northern Territory, using a framework based on the institutionalist and systemic racism literatures, with the aim of better understanding the sources of implementation failure. Implementation of the agreed reforms was unsuccessful. Contributing factors were as follows: strong recognition of the need for change was not sustained; the seeds of change, present in the form of alternative practices, were not built on; there was a notable absence of sustained political/bureaucratic authorisation; and, interacting with all of these, systemic racism had important consequences and implications. Our framework was useful for making sense of the results. It is clear that reforms in Aboriginal affairs will require government authorities to engage with organisations and communities. We conclude that there are four requirements for improved implementation success: clear recognition of the need for change in 'business as usual'; sustainable commitment and authorisation; the building of alternative structures and methods to enable effective power sharing (consistent with the requirements of parliamentary democracy); and addressing the impact of systemic racism on decision-making, relationships, and risk management

Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol

<p>Abstract</p> <p>Background</p> <p>In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?</p> <p>Methods/design</p> <p>The study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.</p> <p>Discussion</p> <p>At the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.</p

Indigenous Peoples’ Health Care: New approaches to contracting and accountability at the public administration frontier

© 2013 The Author(s). Published by Taylor & Francis. This is an Open Access article. Non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly attributed, cited, and is not altered, transformed, or built upon in any way, is permitted. The moral rights of the named author(s) have been asserted.This article analyses reforms to contracting and accountability for indigenous primary health care organizations in Canada, New Zealand, and Australia. The reforms are presented as comparative case studies, the common reform features identified and their implications analysed. The reforms share important characteristics. Each proceeds from implicit recognition that indigenous organizations are ‘co-principals’ rather than simply agents in their relationship with government funders and regulators. There is a common tendency towards more relational forms of contracting; and tentative attempts to reconceptualize accountability. These ‘frontier’ cases have broad implications for social service contracting

Power to the people? An international review of the democratizing effects of direct elections to healthcare organizations

Ensuring that publicly funded health systems are democratically accountable is an enduring challenge in policy and practice. One strategy for enhancing public officials' accountability is to elect members of the public to oversee their performance. Several countries have experimented with direct elections to healthcare organizations. The most directly comparable examples involve some Canadian regional health authorities, New Zealand district health boards, foundation trusts in England and health boards in Scotland. We propose three aspects of the process by which the democratizing effects of elections should be judged: authorization, accountability and influence. Evidence from these countries suggests that the democratization of health systems is a complex task, which cannot be completed simply by introducing elections

Dominant stakeholders, activity and accountability discharge in the CSO Sector

Civil Society Organisations (CSOs) comprise a diverse range of associations, including NGOs, community groups, political parties and social networks. Nevertheless, despite heterogeneity, regulators, funders and donors often treat CSOs as homogeneous when demanding accountability. This paper highlights differences in to whom CSOs across different categories (or types) perceive themselves to be accountable, what for, and the different practices they undertake to discharge accountability. It calls for stakeholders to acknowledge diversity in accountability across different CSO types. This survey-based research finds CSOs weight upwards and downwards stakeholders equally, and undertake voluminous reporting. They would benefit from negotiating multiple-use mechanisms, especially with dominant stakeholders. In combining stakeholder and accountability theory, the research highlights specific CSO types needing further study

Public involvement in the priority setting activities of a wait time management initiative: a qualitative case study

<p>Abstract</p> <p>Background</p> <p>As no health system can afford to provide all possible services and treatments for the people it serves, each system must set priorities. Priority setting decision makers are increasingly involving the public in policy making. This study focuses on public engagement in a key priority setting context that plagues every health system around the world: wait list management. The purpose of this study is to describe and evaluate priority setting for the Ontario Wait Time Strategy, with special attention to public engagement.</p> <p>Methods</p> <p>This study was conducted at the Ontario Wait Time Strategy in Ontario, Canada which is part of a Federal-Territorial-Provincial initiative to improve access and reduce wait times in five areas: cancer, cardiac, sight restoration, joint replacements, and diagnostic imaging. There were two sources of data: (1) over 25 documents (e.g. strategic planning reports, public updates), and (2) 28 one-on-one interviews with informants (e.g. OWTS participants, MOHLTC representatives, clinicians, patient advocates). Analysis used a modified thematic technique in three phases: open coding, axial coding, and evaluation.</p> <p>Results</p> <p>The Ontario Wait Time Strategy partially meets the four conditions of 'accountability for reasonableness'. The public was not directly involved in the priority setting activities of the Ontario Wait Time Strategy. Study participants identified both benefits (supporting the initiative, experts of the lived experience, a publicly funded system and sustainability of the healthcare system) and concerns (personal biases, lack of interest to be involved, time constraints, and level of technicality) for public involvement in the Ontario Wait Time Strategy. Additionally, the participants identified concern for the consequences (sustainability, cannibalism, and a class system) resulting from the Ontario Wait Times Strategy.</p> <p>Conclusion</p> <p>We described and evaluated a wait time management initiative (the Ontario Wait Time Strategy) with special attention to public engagement, and provided a concrete plan to operationalize a strategy for improving public involvement in this, and other, wait time initiatives.</p