A delicate balance: how physicians manage change towards collaborative care within their institutions

Purpose: In response to the COVID-19 pandemic, in 2020–2022, the immutable and fragmented character of our healthcare system changed. Healthcare professionals and their institutional leads proved remarkably agile and managed to change toward collaborative care. The purpose of this paper is to examine experiences with collaborative practice in healthcare during the COVID-19 pandemic in two regions in the Netherlands, to explore and understand the relationship between policy and practice and the potential development of new collaborative care routines. Design/methodology/approach: Using a methodology informed by theories that have a focus on professional working practice (so called “activity theory”) or the institutional decision-makers (discursive institutionalism), respectively, the perspective of physicians on the relationship between policy and practice was explored. Transcripts of meetings with physicians from different institutions and medical specialities about their collaborative COVID-19 care were qualitatively analysed. Findings: The findings show how change during COVID-19 was primarily initiated from the bottom-up. Cultural-cognitive and normative forces in professional, collaborative working practice triggered the creation of new relationships and sharing of resources and capacity. The importance of top-down regulatory forces from institutional leads was less evident. Yet, both (bottom-up) professional legitimacy and (top-down) institutional support are mentioned as necessary by healthcare professionals to develop and sustain new collaborative routines. Practical implications: The COVID-19 crisis provided opportunity to build better healthcare infrastructure by learning from the responses to this pandemic. Now is the time to find ways to integrate new ways of working initiated from the bottom-up with those longstanding ones initiated from top-down. Originality: This paper presents a combination of theories for understanding collaboration in healthcare, which can inform future research into collaborative care initiatives

How Do Care Transitions Work?: Unraveling the Working Mechanisms of Care Transition Interventions

BACKGROUND: Failure of safe care transitions after hospital discharge results in unnecessary worsening of symptoms, extended period of illness or readmission to the hospital. OBJECTIVE: The objective of this study was to add to the understanding of the working of care transition interventions between hospital and home through unraveling the contextual elements and mechanisms that may have played a role in the success of these interventions, and by developing a conceptual model of how these components relate to each other. RESEARCH DESIGN: This was a qualitative study using in-person, semi-structured interviews, based on realist evaluation methods. SUBJECTS: A total of 26 researchers, designers, administrators, and/or practitioners of both current "leading" care transitions interventions and of less successful care transition intervention studies or practices. MEASURES: The contextual elements and working mechanisms of the different care transition intervention studies or practices. RESULTS: Three main contextual factors (internal environment, external environment, and patient population) and 7 working mechanisms (simplifiying, verifiying, connecting, translating, coaching, monitoring, and anticipating) were found to be relevant to the outcome of care transition interventions. Context, Intervention, Mechanism, and Outcome (CIMO) configurations revealed that, in response to these contextual factors, care transition interventions triggered one or several of the mechanisms, in turn generating outcomes, including a safer care transition. CONCLUSION: We developed a conceptual model which explains the working of care transition interventions within different contexts, and believe it can help support future successful implementation of care transition interventions

Factors determining development of researchers within a research network on cancer diagnosis in primary care (CanTest): an interview study.

OBJECTIVES: Developing connections with other researchers in a network, learning informally through these connections and using them to reach goals, is expected to increase research capacity and strengthen performance. So far, this has not been empirically demonstrated. We assessed what and how network collaboration adds to development of researchers. DESIGN: Exploratory qualitative study using semistructured online interviews, analysed by inductive and deductive methods. For the deductive analysis, an existing value creation framework to study informal learning in networks was used and adjusted to our context. SETTING: The CanTest Collaborative-an international team of primary care cancer researchers working on early detection and diagnosis of cancer. PARTICIPANTS: Sixteen primary care cancer researchers. RESULTS: Connections with other researchers in an international network created diverse value cycles, where most outcomes were in the potential value cycle, acquiring knowledge, skills, social capital, resources and ideas. Not all potential value will be applied but many interviewees described realised as well as transformational value. In our context, the transformational value from the framework appeared to be related to other perspectives on the research process. Advancement of the network depends on opportunities, timing, role models and connections between different perspectives. CONCLUSIONS: Focus on the factors that are relevant for network advancement will support researchers in early detection and diagnosis of cancer research patients who participate in an international network and bring sustainable change in this domain. When, subsequently, researchers in the CanTest network bring about more realised and transformational learning outcomes, this will contribute to capacity development

Developing a regional transmural care database: A roadmap

INTRODUCTION: In primary care health care systems, primary care physicians (PCPs) provide most basic care services, and if necessary, refer to secondary care for specialized work-up and treatment. If hospital care is required, agreement between PCPs and secondary care physicians (SCPs) on the conditions for patient referral and back-referral are considered crucial to providing high quality patient care. The regional healthcare network of Utrecht, a region in the Netherlands, developed a set of collaborative patient care agreements (CPCAs) for specific chronic conditions. Even though these CPCA are endorsed by all relevant regional health care organisations, the adoption of these agreements in practice remains substandard. In this project, through linkage of routine care data, as registered in daily practice by PCPs and SCPs, a regional transmural care database (RTD) was developed for monitoring the use of the CPCAs. Its data was transformed into' mirror data' used to support PCPs and SCPs in discussing and improving current practice and to support a learning healthcare system within the region. METHODS: The development of the RTD is part of a larger action research project on joint care, called ZOUT (an acronym which is translated as "The right care at the right place in the Utrecht region"). The RTD includes data from three regional hospitals, and about 70 affiliated primary care practices which are united in the Julius General Practitioners Network (JGPN). These data were extracted, linked and presented in the form of mirror data, following simple methods to allow replication of our approach. CPCAs addressing transmural care for three chronic conditions were selected. Data from the primary care practices and the hospitals were linked by an independent trusted third party. This enabled relevant hospital data to be added to the primary care dataset, thereby providing transmural routine care data for individual patients. RESULTS: During the development of the RTD, a roadmap was created including a detailed step-by-step checklist of the organizational, administrative, technical and legal arrangements which needed to be made. Legal and administrative challenges proved most challenging. Also, incompleteness of data and the impossibility to translate several agreements into extractable data limited the potential for providing a comprehensive overview of the extent to which agreements in the CPCA were adhered to in daily care. DISCUSSION: We present a systematic, comprehensive (technical as well as practical) and reproducible roadmap to developing a regional transmural care database suitable for generating mirror data on joint transmural care between PCPs and SCPs. This approach includes all technical steps in data selection and linkage, as well as the substantive steps that need to be taken in the analysis and application of the results. The mirror data, which reflects the follow-up of agreements formulated in the CPCAs, enabled shared reflection and discussion between PCPs and SCPs. This supports the search for bottlenecks and potentialities for improving daily collaborative care, thereby showing great potential to serve a learning regional healthcare system

Towards learning healthcare systems: Collaboration and boundary crossing in research and practice

The complex balance between scientific evidence, clinical expertise and the patient’s experience makes healthcare systems prone to inefficiency and fragmentation. This sparks the interest into a care system that aligns the input from researchers providing scientific evidence, healthcare professionals building their clinical expertise on that, and patients experiencing outcomes: a Learning Healthcare System (LHS). Yet, to build such a system requires insight into the role of, and interplay between, researchers, healthcare professionals and patients. In the first part of this thesis, we zoom in on the role of researchers. Using a Social Network Analysis (SNA) perspective, we explore with whom they collaborate, how, and why. The second part of this thesis focuses on the role of healthcare professionals and patients. We assess how the process of collaboration between them unfolds from a Cultural Historical Activity Theory (CHAT) perspective. We conclude that combining different units of analysis (researchers, healthcare professionals and patients) and theoretical frameworks (e.g. SNA and CHAT) is necessary to understand and develop a complex system as the LHS. We should increasingly think in, design and invest in healthcare networks and research communities – and, essentially, include herein the patient perspective as one on which developments and changes are based

Towards learning healthcare systems: Collaboration and boundary crossing in research and practice

The complex balance between scientific evidence, clinical expertise and the patient’s experience makes healthcare systems prone to inefficiency and fragmentation. This sparks the interest into a care system that aligns the input from researchers providing scientific evidence, healthcare professionals building their clinical expertise on that, and patients experiencing outcomes: a Learning Healthcare System (LHS). Yet, to build such a system requires insight into the role of, and interplay between, researchers, healthcare professionals and patients. In the first part of this thesis, we zoom in on the role of researchers. Using a Social Network Analysis (SNA) perspective, we explore with whom they collaborate, how, and why. The second part of this thesis focuses on the role of healthcare professionals and patients. We assess how the process of collaboration between them unfolds from a Cultural Historical Activity Theory (CHAT) perspective. We conclude that combining different units of analysis (researchers, healthcare professionals and patients) and theoretical frameworks (e.g. SNA and CHAT) is necessary to understand and develop a complex system as the LHS. We should increasingly think in, design and invest in healthcare networks and research communities – and, essentially, include herein the patient perspective as one on which developments and changes are based

Factors critical to implementation success of cleaner cooking interventions in low-income and middle-income countries: protocol for an umbrella review

Introduction Over a third of the world’s population relies on solid fuels as their primary energy source. These fuels have damaging effects on health, air quality and forest resources. Interventions to promote access to cleaner solid fuel cookstoves and clean fuels have existed for decades. However, the adoption by local communities has largely failed, which led to a waste of resources and suboptimal outcomes. Therefore, the objective of this umbrella review is to identify factors that determine implementation success for cleaner cooking interventions in low-resource settings and weigh their level of confidence in the evidence.Methods and analysis We identified systematic and narrative reviews examining factors that influence the acquisition, initial adoption or sustained use of cleaner solid fuel cookstoves and clean fuels at any scale by a literature search in PubMed, Embase, Global Health Database, Cochrane, PsycINFO, Emcare, Web of Science and CINAHL, without date or language restrictions. The search was conducted on 23 October 2017 and updated on 10 July 2019. Reviews based on qualitative, quantitative or mixed-methods studies were included and will be appraised using the Meta Quality Appraisal Tool combined with the Assessment of Multiple Systematic Reviews. Data will be extracted and factors affecting implementation will be coded using the Consolidated Framework for Implementation Research. The Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative Research tool will be used to determine the level of confidence in the coded factors. Two researchers will independently conduct these steps.Ethics and dissemination This umbrella review does not require the approval of an ethical review board. Study results will be published in an international peer-reviewed journal. The outcomes will be converted into two practical tools: one for cleaner solid fuel cookstoves and one for clean fuels. These tools can guide the development of evidence-based implementation strategies for cleaner cooking interventions in low-income and middle-income countries to improve implementation success. These tools should be pilot-tested and promoted among regional and global initiatives.PROSPERO registration number CRD42018088687

Dealing with Discontinuity in Cancer Care Trajectories: Patients’ Solutions

Introduction: Patients with cancer require specialized care from different care providers, challenging continuity of care in terms of information, relationships, and/or management. The recognition of discontinuity of care has led to different initiatives by the healthcare system over the years. Yet, making use of the theory on boundary objects and brokers, this research explores the active role of patients themselves in resolving discontinuity along their care trajectories. Methods: Semi-structured interviews were conducted with 33 patients to unravel the discontinuities that they experience and their attempts to resolve these. Interview data were analyzed using directed-content analysis informed by concepts from boundary crossing literature (i.e., data were searched for potential boundary objects and brokers). Results: To re-establish continuity of care, patients actively use the objects and people provided by the healthcare system when these meet their needs. Patients also introduce own objects and people into the care trajectory. As such, information and management discontinuity can typically be resolved. Relational continuity appears to be more difficult to resolve, in some cases leaving patients to take drastic measures, such as changing care providers. Discussion: The use of boundary crossing theory in improving care from a patient perspective is relatively novel. When patients and providers together address the objects and people that support establishing continuity of care, a continuous care process may be encouraged. We advocate an integrated approach, rather than provider or healthcare system initiatives exclusively, to patient care and continuity

The evolution and co-evolution of a primary care cancer research network: From academic social connection to research collaboration.

Academic networks are expected to enhance scientific collaboration and thereby increase research outputs. However, little is known about whether and how the initial steps of getting to know other researchers translates into effective collaborations. In this paper, we investigate the evolution and co-evolution of an academic social network and a collaborative research network (using co-authorship as a proxy measure of the latter), and simultaneously examine the effect of individual researcher characteristics (e.g. gender, seniority or workplace) on their evolving relationships. We used longitudinal data from an international network in primary care cancer research: the CanTest Collaborative (CanTest). Surveys were distributed amongst CanTest researchers to map who knows who (the 'academic social network'). Co-authorship relations were derived from Scopus (the 'collaborative network'). Stochastic actor-oriented models were employed to investigate the evolution and co-evolution of both networks. Visualizing the development of the CanTest network revealed that researchers within CanTest get to know each other quickly and also start collaborating over time (evolution of the academic social network and collaborative network respectively). Results point to a stable and solid academic social network that is particularly encouraging towards more junior researchers; yet differing for male and female researchers (the effect of individual researcher characteristics). Moreover, although the academic social network and the research collaborations do not grow at the same pace, the benefit of creating academic social relationships to stimulate effective research collaboration is clearly demonstrated (co-evolution of both networks)