The Journey toward the Patient-Centered Medical Home: A Grounded, Dynamic Theory of Primary Care Transformation

Introduction: This dissertation develops a grounded and dynamic theory of primary care transformation (PCT) in a health service delivery organization (HSDO) implementing the Patient-Centered Medical Home model, in the United States of America. The focus of this theory is on the structural facilitators and challenges to achieving and sustaining high quality primary care. Methodology: Fieldwork performed included semi-structured interviews conducted across the HSDO (n=82), direct observations (n=10 clinics) and archival review. This dissertation utilizes newly-developed methods for theory development and validation, in concert with existing system dynamics methods; with an improved potential to integrate findings across quantitative and qualitative research directions. Results: My theory illuminates how the actions of various stakeholders (medical assistants, managers, clinicians and patients) interact with each other and with the fundamental characteristics of primary care service delivery to create diverse transformation trajectories. Two types of leverage points are identified: policies and preferences. The latter are more difficult to modify as they require changing stakeholders’ mental models. It is the combination of policies and preferences interacting within the system structure that produces hoped-for and feared transformation trajectories. There is no policy that induces success regardless of stakeholder preferences. There are some preferences that induce success or failure regardless of the policies being implemented. Conclusion: Sustaining success requires understanding the system structure within which policies and preferences operate – how decisions are made, their consequences, and the delays involved. Otherwise, transformation risks being overwhelmed by unintended consequences, misunderstood system behavior or impatience. This work presents an improved understanding of what PCT involves, and of how operational and cognitive aspects intersect. Overall, this work is more than a study of transformation. It presents theory, methods and a case for the development of an integrative methodology and paradigm

Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon.

From Europe PMC via Jisc Publications RouterHistory: ppub 2023-11-01Publication status: PublishedFunder: Wellcome Trust; Grant(s): 215654/Z/19/ZIntroductionDespite rapidly growing academic and policy interest in health system resilience, the empirical literature on this topic remains small and focused on macrolevel effects arising from single shocks. To better understand health system responses to multiple shocks, we conducted an in-depth case study using qualitative system dynamics. We focused on routine childhood vaccination delivery in Lebanon in the context of at least three shocks overlapping to varying degrees in space and time: large-scale refugee arrivals from neighbouring Syria; COVID-19; and an economic crisis.MethodsSemistructured interviews were performed with 38 stakeholders working at different levels in the system. Interview transcripts were analysed using purposive text analysis to generate individual stakeholder causal loop diagrams (CLDs) mapping out relationships between system variables contributing to changes in coverage for routine antigens over time. These were then combined using a stepwise process to produce an aggregated CLD. The aggregated CLD was validated using a reserve set of interview transcripts.ResultsVarious system responses to shocks were identified, including demand promotion measures such as scaling-up community engagement activities and policy changes to reduce the cost of vaccination to service users, and supply side responses including donor funding mobilisation, diversification of service delivery models and cold chain strengthening. Some systemic changes were introduced-particularly in response to refugee arrivals-including task-shifting to nurse-led vaccine administration. Potentially transformative change was seen in the integration of private sector clinics to support vaccination delivery and depended on both demand side and supply side changes. Some resilience-promoting measures introduced following earlier shocks paradoxically increased vulnerability to later ones.ConclusionFlexibility in financing and human resource allocation appear key for system resilience regardless of the shock. System dynamics offers a promising method for ex ante modelling of ostensibly resilience-strengthening interventions under different shock scenarios, to identify-and safeguard against-unintended consequences.pubpu

In Vitro Sensitivity Research Concerning Some Microorganisms at Hydroxyquinoline and Cupric Derivatives Deposited onto Hydroxyapatite

ABSTRACT Introduction: The preparations based on hydroxyquinoline, in various combinations, are used in medicine, being shown to have an inhibitory effect against bacteria, molds, fungi, parasites, and viruses, but also having other beneficial effects mentioned in other medical conditions (anti-cancer, anti-degenerative, anti-inflammatory). Aims: In vitro susceptibility testing of microorganisms: bacteria (Gram positive and Gram negative), yeast (Candida spp.,) and unicellular algae (Prototheca spp.) at the preparations based on hydroxyquinoline (HQ) and its cupric derivatives deposited on hydroxyapatite (HAP). Materials and methods: There were tested microbial strains of the following genera: Escherichia, Staphylococcus, Micrococcus, Bacillus, Candida, and Prototheca. The tested products (developed in the Laboratory for Nanobiomaterials Synthesis, Center of Physical Chemistry, Faculty of Chemistry and Chemical Engineering, UBB Cluj-Napoca) were developed in three versions: 1) HQ-Cu2+-HAP1; 2) HQ-Cu2+-HAP2; and 3) NHQ-Cu2+-HAP2, where NHQ stands for nitro hydroxyquinoline. Determination of the inhibitory effect was conducted by diffusion technique in nutrient agar, according to CLSI 2013 standards, with necessary adaptations for testing of products made in the form of suspensions. Results: Following interpretation, it was found that the inhibition zones, arising from the antimicrobial effect of the tested products showed variability in size, depending on the test product and the microbial strain: Escherichia coli (8-10 mm), Staphylococcus sp. (17.6 - 23.2 mm), Micrococcus spp. (24.4 - 27.6 mm), Bacillus spp. (14.0 - 16.0 mm), Candida spp. (20.4 - 25.2 mm), Prototheca spp. (20.8 - 30.0 mm). From the three tested products, the best efficacy was found at the product no. 3 (NHQ - Cu2+ - HAP2), followed by no. 1 (HQ- Cu2+-HAP1) and no. 2 (HQ-Cu2+-HAP2). Conclusions: The inhibitory effect was bactericidal, manifested more intensively against Gram-positive bacteria, yeasts, and prototheca. Such products, prepared in the form of suspensions, may have practical application in the prevention and treatment of skin or hooves disorders. No resistance phenomena are recorded. Keywords: copper, hydroxyapatite, hydroxyquinoline, microorganisms, sensitivity

Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS)

BACKGROUND: To create a theory-informed survey that quality improvement (QI) teams can use to understand stakeholder perceptions of an intervention. METHOD: We created the survey then performed a cross-sectional survey of QI stakeholders of three QI projects. The projects sought to: (1) reduce unplanned extubations in a neonatal intensive care unit; (2) maintain normothermia during colorectal surgery and (3) reduce specimen processing errors for ambulatory gastroenterology procedures. We report frequencies of responses to survey items, results of exploratory factor analysis, and how QI team leaders used the results. RESULTS: Overall we received surveys from 319 out of 386 eligible stakeholders (83% response rate, range for the three QI projects 57%-86%). The QI teams found that the survey results confirmed existing concerns (eg, the intervention would not make work easier) and revealed unforeseen concerns such as lack of consensus about the overall purpose of the intervention and its importance. The results of our factor analysis indicate that one 7-item scale (Cronbach\u27s alpha 0.9) can efficiently measure important aspects of stakeholder perceptions, and that two additional Likert-type items could add valuable information for leaders. Two QI team leaders made changes to their project based on survey responses that indicated the intervention made stakeholders\u27 jobs harder, and that there was no consensus about the purpose of the intervention. CONCLUSIONS: The Stakeholder Quality Improvement Perspectives Survey was feasible for QI teams to use, and identified stakeholder perspectives about QI interventions that leaders used to alter their QI interventions to potentially increase the likelihood of stakeholder acceptance of the intervention

Patient care experiences and perceptions of the patient-provider relationship: A mixed method study

Improving interpersonal continuity of care—the personal relationship forged between a patient and their primary care provider (PCP) over time—is often considered a goal of primary care. Continuity of care is frequently assessed in terms of longitudinal continuity, or the proportion of encounters with one practitioner, overlooking aspects of the patient-provider relationship that are key to interpersonal continuity of care. Further, few studies explore patients’ perspectives regarding which care experiences enhance or detract from the patient-provider relationship. This study, using focus group interviews, a patient experience CAHPS-PCMH survey, and electronic medical records, explored how patients’ experiences at 10 primary care clinics influenced their perceptions of their relationship with their PCPs. Focus group interviews with 63 participants indicated that patients’ experiences in the clinics, such as wait-times, influenced their perceptions of the patient-provider relationship. The relationship between patient experience and interpersonal continuity was empirically assessed using survey responses and medical records (n=645). We used patients’ perceptions that their provider knows them as a person as a measure of interpersonal continuity. Logistic regression results indicated that being seen within 15 minutes, receiving visit reminders, effective provider communication, and satisfaction, positively influenced patient perceptions of the patient-provider relationship. Furthermore, patients’ care experiences shaped their perceptions of the patient-provider relationship independent of their satisfaction with care. The mixed methods design adds depth to our understanding of patients’ care experiences, and illustrates that these experiences are critical for understanding the patient-provider relationship. Future research on interpersonal continuity should take patient experiences into account

Conceptualising and assessing health system resilience to shocks: a cross-disciplinary view

Health systems worldwide face major challenges in anticipating, planning for and responding to shocks from infectious disease epidemics, armed conflict, climatic and other crises. Although the literature on health system resilience has grown substantially in recent years, major uncertainties remain concerning approaches to resilience conceptualisation and measurement. This narrative review revisits literatures from a range of fields outside health to identify lessons relevant to health systems. Four key insights emerge. Firstly, shocks can only be understood by clarifying how, where and over what timescale they interact with a system of interest, and the dynamic effects they produce within it. Shock effects are contingent on historical path-dependencies, and on the presence of factors or system pathways (e.g. financing models, health workforce capabilities or supply chain designs) that may amplify or dampen impact in unexpected ways. Secondly, shocks often produce cascading effects across multiple scales, whereas the focus of much of the health resilience literature has been on macro-level, national systems. In reality, health systems bring together interconnected sub-systems across sectors and geographies, with different components, behaviours and sometimes even objectives – all influencing how a system responds to a shock. Thirdly, transformability is an integral feature of resilient social systems: cross-scale interactions help explain how systems can show both resilience and transformational capability at the same time. We illustrate these first three findings by extending the socioecological concept of adaptive cycles in social systems to health, using the example of maternal and child health service delivery. Finally, we argue that dynamic modelling approaches, under-utilised in research on health system resilience to date, have significant promise for identification of shock-moderating or shock-amplifying pathways, for understanding effects at multiple levels and ultimately for building resilience.</ns3:p

Understanding the maternal and child health system response to payment for performance in Tanzania using a causal loop diagram approach.

Payment for performance (P4P) has been employed in low and middle-income (LMIC) countries to improve quality and coverage of maternal and child health (MCH) services. However, there is a lack of consensus on how P4P affects health systems. There is a need to evaluate P4P effects on health systems using methods suitable for evaluating complex systems. We developed a causal loop diagram (CLD) to further understand the pathways to impact of P4P on delivery and uptake of MCH services in Tanzania. The CLD was developed and validated using qualitative data from a process evaluation of a P4P scheme in Tanzania, with additional stakeholder dialogue sought to strengthen confidence in the diagram. The CLD maps the interacting mechanisms involved in provider achievement of targets, reporting of health information, and population care seeking, and identifies those mechanisms affected by P4P. For example, the availability of drugs and medical commodities impacts not only provider achievement of P4P targets but also demand of services and is impacted by P4P through the availability of additional facility resources and the incentivisation of district managers to reduce drug stock outs. The CLD also identifies mechanisms key to facility achievement of targets but are not within the scope of the programme; the activities of health facility governing committees and community health workers, for example, are key to demand stimulation and effective resource use at the facility level but both groups were omitted from the incentive system. P4P design considerations generated from this work include appropriately incentivising the availability of drugs and staffing in facilities and those responsible for demand creation in communities. Further research using CLDs to study heath systems in LMIC is urgently needed to further our understanding of how systems respond to interventions and how to strengthen systems to deliver better coverage and quality of care

Facilitators and “deal breakers”: a mixed methods study investigating implementation of the goal setting and action planning (G-AP) framework in community rehabilitation teams

Background: High quality goal setting in stroke rehabilitation is vital, but challenging to deliver. The G-AP framework (including staff training and a stroke survivor held G-AP record) guides patient centred goal setting with stroke survivors in community rehabilitation teams. We found G-AP was acceptable, feasible to deliver and clinically useful in one team. The aim of this study was to conduct a mixed methods investigation of G-AP implementation in diverse community teams prior to a large-scale evaluation. Methods: We approached Scottish community rehabilitation teams to take part. Following training, G-AP was delivered to stroke survivors within participating teams for 6 months. We investigated staff experiences of G-AP training and its implementation using focus groups and a training questionnaire. We investigated fidelity of G-AP delivery through case note review. Focus group data were analysed using a Framework approach; identified themes were mapped into Normalisation Process Theory constructs. Questionnaire and case note data were analysed descriptively. Results: We recruited three teams comprising 55 rehabilitation staff. Almost all staff (93%, 51/55) participated in G-AP training; of those, 80% (n = 41/51) completed the training questionnaire. Training was rated as ‘good’ or ‘very good’ by almost all staff (92%, n = 37/41). G-AP was broadly implemented as intended in two teams. Implementation facilitators included - G-AP ‘made sense’; repetitive use of G-AP in practice; flexible G-AP delivery and positive staff appraisals of G-AP impact. G-AP failed to gain traction in the third team. Implementation barriers included - delays between G-AP training and implementation; limited leadership engagement; a poor ‘fit’ between G-AP and the team organisational structure and simultaneous delivery of other goal setting methods. Staff recommended (i) development of training to include implementation planning; (ii) ongoing local implementation review and tailoring, and (iii) development of electronic and aphasia friendly G-AP records. Conclusions: The interaction between G-AP and the practice setting is critical to implementation success or failure. Whilst facilitators support implementation success, barriers can collectively act as implementation “deal breakers”. Local G-AP implementation efforts should be planned, monitored and tailored. These insights can inform implementation of other complex interventions in community rehabilitation settings