We need to work differently in a crisis: peer-professional leadership to redesign physicians' work.

BACKGROUND: Understanding physician leadership is critical during pandemics and other health crises when formal organisational leaders may be unable to respond expeditiously. This study examined how physician leaders managed to quickly design a new model for acute-care physicians' work, adopted across four large hospitals in a public health authority in Canada during the COVID-19 pandemic. METHODS: The research employed a qualitative case study methodology, with inductive analysis of interview transcripts and documents. Shortly after a physician work model redesign, we interviewed key informants: the physician leaders and others who participated in or supported the model's development. Participants were chosen based on their leadership role and through snowballing. All those who were approached agreed to participate. RESULTS: A process model describes leadership actions during four phases of work model development (priming, early planning, readying for operations and transition). These actions were: (1) recognising the threat, (2) committing to action, (3) forming and organising, (4) building and relying on relationships, (5) developing supporting processes and (6) designing functions and structure. We offer three additional contributions to knowledge about leadership in a time of crisis: (1) leveraging peer-professional leadership to initiate, formalise and organise change processes, (2) designing a new work model on existing and emerging evidence and (3) building and relying on relationships to unify various actors. CONCLUSIONS: The model of peer-professional leadership can deepen understanding of how to lead professionals. Our findings could assist peer-professional and organisational leaders to encourage quick redesign of professionals' work in response to new phases of the COVID-19 pandemic or other crises.

Perspectives on primary care management of obstructive sleep apnea: a qualitative study of patients and health care providers.

STUDY OBJECTIVES: Difficulties in providing timely access to care have prompted interest in primary care delivery models for obstructive sleep apnea (OSA). Sustainable implementation of such models requires codesign with input from key stakeholders. The purpose of this study was to identify patient and provider perspectives on barriers and facilitators to optimal, patient-centered management of OSA in a primary care setting. METHODS: This study was conducted in Alberta, Canada. Data from key stakeholders were collected through an online survey of primary care providers (n = 119), focus groups and interviews with patients living with OSA (n = 28), and workshops with primary care and sleep providers (n = 36). Quantitative survey data were reported using descriptive statistics, and qualitative data were analyzed using an inductive thematic approach. RESULTS: Several barriers were identified, including poor specialist access, variable primary care providers knowledge of OSA, and lack of clarity about provider roles for OSA management. Barriers contributed to patients being poorly informed about OSA, leading them to separate OSA from their overall health and eroding trust in the system. Suggestions for improvement included integration of care providers in a comprehensive model of care, facilitated by improved system navigation and more effective use of technology. Themes were consistent across data collection methods and between stakeholder groups. CONCLUSIONS: Although primary care delivery models may improve access to OSA management, stakeholders identified important challenges in the current system. Innovative models of care, developed with input from patients and providers, may mitigate barriers and support optimal primary care management of OSA.

Disrupting activities in quality improvement initiatives: a qualitative case study of the QuICR Door-To-Needle initiative.

BACKGROUND: Healthcare quality improvement (QI) efforts are ongoing but often create modest improvement. While knowledge about factors, tools and processes that encourage QI is growing, research has not attended to the need to disrupt established ways of working to facilitate QI efforts. OBJECTIVE: To examine how a QI initiative can disrupt professionals' established way of working through a study of the Alberta Stroke Quality Improvement and Clinical Research (QuICR) Door-to-Needle Initiative. DESIGN: A multisite, qualitative case study, with data collected through semistructured interviews and focus groups. Inductive data analysis allowed findings to emerge from the data and supported the generation of new insights. FINDINGS: In stroke centres where improvements were realised, professionals' established understanding of the clinical problem and their belief in the adequacy of existing treatment approaches shifted-they no longer believed that their established understanding and treating the clinical problem were appropriate. This shift occurred as participants engaged in specific activities to improve quality. We identify these activities as ones that create urgency, draw professionals away from regular work and encourage questioning about established processes. These activities constituted disrupting action in which both clinical and non-clinical persons were engaged. CONCLUSIONS: Disrupting action is an important yet understudied element of QI. Disrupting action can be used to create gaps in established ways of working and may help encourage professionals' involvement and support of QI efforts. While non-clinical professionals can be involved in disrupting action, it needs to engage clinical professionals on their own terms.

Integrated versus fragmented implementation of complex innovations in acute health care.

BACKGROUND: Increased demand and escalating costs necessitate innovation in health care. The challenge is to implement complex innovations-those that require coordinated use across the adopting organization to have the intended benefits. PURPOSE: We wanted to understand why and how two of five similar hospitals associated with the same health care authority made more progress with implementing a complex inpatient discharge innovation whereas the other three experienced more difficulties in doing so. METHODOLOGY: We conducted a qualitative comparative case study of the implementation process at five comparable urban hospitals adopting the same inpatient discharge innovation mandated by their health care authority. We analyzed documents and conducted 39 interviews of the health care authority and hospital executives and frontline managers across the five sites over a 1-year period while the implementation was ongoing. FINDINGS: In two and a half years, two of the participating hospitals had made significant progress with implementing the innovation and had begun to realize benefits; they exemplified an integrated implementation mode. Three sites had made minimal progress, following a fragmented implementation mode. In the former mode, a semiautonomous health care organization developed a clear overall purpose and chose one umbrella initiative to implement it. The integrative initiative subsumed the rest and guided resource allocation and the practices of hospital executives, frontline managers, and staff who had bought into it. In contrast, in the fragmented implementation mode, the health care authority had several overlapping, competing innovations that overwhelmed the sites and impeded their implementation. PRACTICE IMPLICATIONS: Implementing a complex innovation across hospital sites required (a) early prioritization of one initiative as integrative, (b) the commitment of additional (traded off or new) human resources,