Enhanced Multi-Service Markets: An Evolution in Military Health System Governance.

Background: The evolution of governance models for the Military Health System's (MHS) large hospitals, called medical treatment facilities (MTFs), has culminated with the effort to implement Enhanced Multi-Service Markets (eMSM). The term eMSM refers to two separate concepts. First, MSM refers to those geographic areas, that is, markets, which have the following characteristics: they have MTFs that are operated by two or more Department of Defense (DoD) Services, that is, Army, Navy, or Air Force; there is a large beneficiary population; there is a substantial amount of direct care (i.e., beneficiaries are treated at MTFs instead of TRICARE's purchased care from civilian providers); and there is a substantial readiness and training platform. Second, the term "enhanced" refers to an increase in management authority over clinical and business operations, readiness, and MTF workload. Methods: A retrospective review was conducted to study the evolution of military and civilian health care delivery models for the purpose of understanding how governance models have changed since the 1980s to design and manage MTFs with overlapping catchments areas. Primary and secondary data sources were analyzed through a comprehensive literature review. Findings: Since the 1980s, the MHS governance models have evolved from testing various managed care models to a regionally focused TRICARE model and culminating with an overlapping catchment area model entitled eMSMs. The eMSM model partially fulfills the original vision because the eMSM leaders have limited budgetary and resource allocation authority. Discussion: The various models sought to improve governance of overlapping catchment areas with the intent to enhance medical readiness, community health, and individual health care while reducing costs. However, the success of the current model, that is, eMSMs, cannot be fully assessed because the eMSM model was not fully implemented as originally envisioned. Instead, the current eMSM model partially implements the eMSM model. As a result, the current eMSMs operate solely through cooperation and collaboration, without directive authority. Nevertheless, there have been some market-specific initiatives. Further analysis is necessary in the event that eMSM market managers are granted governance authority. This authority would include the ability to allocate the overall market's budget, determine common clinical and business functions, optimize the readiness of both the medical and the operational forces assigned to the market, and reallocate resources to optimize MTF workload. The results of this analysis may determine whether the fully implemented eMSMs optimize patient-centric initiatives as well as improve the market's efficiency and effectiveness.

Tobacco Control and Health Advocacy in the European Union: Understanding Effective Coalition-Building.

INTRODUCTION: Coalitions of supporters of comprehensive tobacco control policy have been crucial in achieving policy success nationally and internationally, but the dynamics of such alliances are not well understood. METHODS: Qualitative semi-structured, narrative interviews with 35 stakeholders involved in developing the European Council Recommendation on smoke-free environments. These were thematically analyzed to examine the dynamics of coalition-building, collaboration and leadership in the alliance of organizations which successfully called for the development of comprehensive European Union (EU) smoke-free policy. RESULTS: An alliance of tobacco control and public health advocacy organizations, scientific institutions, professional bodies, pharmaceutical companies, and other actors shared the goal of fighting the harms caused by second-hand smoke. Alliance members jointly called for comprehensive EU smoke-free policy and the protection of the political debates from tobacco industry interference. The alliance's success was enabled by a core group of national and European actors with long-standing experience in tobacco control, who facilitated consensus-building, mobilized allies and synchronized the actions of policy supporters. Representatives of Brussels-based organizations emerged as crucial strategic leaders. CONCLUSIONS: The insights gained and identification of key enablers of successful tobacco control advocacy highlight the strategic importance of investing into tobacco control at European level. Those interested in effective health policy can apply lessons learned from EU smoke-free policy to build effective alliances in tobacco control and other areas of public health.

The Kuwait-Scotland eHealth Innovation Network (KSeHIN): a sustainable approach to quality improvement in healthcare.

BACKGROUND: The rising prevalence of obesity and diabetes in Kuwait represents a significant challenge for the country's healthcare system. Diabetes care in Scotland has improved by adopting a system of managed clinical networks supported by a national informatics platform. In 2010, a Kuwait-Dundee collaboration was established with a view to transforming diabetes care in Kuwait. This paper describes the significant progress that has been made to date. METHODS: The Kuwait-Scotland eHealth Innovation Network (KSeHIN) is a partnership among health, education, industry and government. KSeHIN aims to deliver a package of clinical service development, education (including a formal postgraduate programme and continuing professional development) and research underpinned by a comprehensive informatics system. RESULTS: The informatics system includes a disease registry for children and adults with diabetes. At the patient level, the system provides an overview of clinical and operational data. At the population level, users view key performance indicators based on national standards of diabetes care established by KSeHIN. The national childhood registry (CODeR) accumulates approximately 300 children a year. The adult registry (KHN), implemented in four primary healthcare centres in 2013, has approximately 4000 registered patients, most of whom are not yet meeting national clinical targets. A credit-bearing postgraduate educational programme provides module-based teaching and workplace-based projects. In addition, a new clinical skills centre provides simulator-based training. Over 150 masters students from throughout Kuwait are enrolled and over 400 work-based projects have been completed to date. CONCLUSION: KSeHIN represents a successful collaboration between multiple stakeholders working across traditional boundaries. It is targeting patient outcomes, system performance and professional development to provide a sustainable transformation in the quality of diabetes healthcare for the growing population of Kuwaitis with diabetes in Kuwait.

The Aligning Forces for Quality experience: lessons on getting consumers involved in health care improvements.

Aligning Forces for Quality is the Robert Wood Johnson Foundation's signature effort to improve the overall quality of health care in targeted communities, reduce racial and ethnic disparities in care, and provide models for national reform. Activities in each of the sixteen Aligning Forces for Quality alliance communities are guided by a multistakeholder alliance of consumers, providers, and payers. To achieve goals established at the national and local levels, the alliances integrate local consumers into governance and decision making, program design and implementation, and information dissemination efforts. This article describes how the Aligning Forces for Quality investments have evolved since the initiative's launch in 2006 and offers some early lessons learned. Individual alliances have engaged consumers in numerous capacities, from serving on dedicated consumer advisory boards to representing the consumer's perspective in the design of public reports of providers' quality. The alliances' ongoing and mindful inclusion of consumers provides insights into eliciting and applying their perspectives in the pursuit of improved health care quality, value, and transparency.

A role for communities in primary prevention of chronic illness? Case studies in regional Australia.

In regional Australia "communities of place," defined as bounded geographic locations with a local society, undertake community-wide primary prevention programs. In helping to prevent chronic illness, communities provide valuable resources to the health system. To understand the role of community-health sector partnerships for primary prevention and the community contextual factors that affect them, we studied eight partnerships. We used an embedded multiple case study design and collected data through interviews, nonparticipant observation, and document analysis. These data were analyzed using a typology of community-health sector partnerships and community interaction theory to frame the key community contextual factors that affected partnerships. The dominant factor affecting all partnerships was the presence of a collective commitment that communities brought to making the community a better place through developing health. We call this a communitarian approach. Additional research to investigate factors influencing a communitarian approach and the role it plays in partnerships is required.

Developing a proactive research agenda to advance nail salon worker health, safety, and rights.

THE PROBLEM: Nail salons represent a burgeoning industry with Vietnamese immigrant workers making up the majority. Workers routinely handle cosmetic products containing hazardous compounds, with implications for their health. PURPOSE OF ARTICLE: This paper describes how a collaborative of multiple organizations and community members collectively developed a proactive research agenda for salon worker health, safety, and rights during a pivotal multistakeholder convening, and advanced on such recommendations, including creating groundbreaking policy changes. KEY POINTS: Key recommendations included (1) creating a multidisciplinary research advisory committee, (2) conducting research on workplace exposures and long-term health impacts, (3) advocating for better governmental oversight of product manufacturers, and (4) identifying safer product alternatives via green chemistry, albeit with cost considerations to salon businesses. CONCLUSION: The participation of diverse stakeholders in the discussions allowed for cross-dialogue on a complex issue, helped to align different stakeholders as allies, and identified critical resources to addressing research gaps.

Vocational rehabilitation, interagency collaboration and social representations.

OBJECTIVE: The aim of this study is to describe and analyse two important dimensions of vocational rehabilitation for disadvantaged groups and persons with disabilities: interagency collaboration and social representations. PARTICIPANTS: Four focus group discussions were conducted. The participants were 20 officials of various agencies who had taken part in collaboration projects in vocational rehabilitation. METHODS: Qualitative content analysis was used for the analysis. The material was categorised and central themes identified. RESULTS: Three themes emerged: 'Collaboration Process', 'Other Agencies' and 'Object for Collaboration'. The results indicate that interagency collaboration is very important in vocational rehabilitation, but that there are a number of obstacles to smooth collaboration. The professionals of the different agencies shared social representations to a great extent. Working with people with psychiatric disorders is especially challenging, and conflicts tended to arise between the projects and the home organisations. CONCLUSIONS: Recognition of others' knowledge and respectfulness toward other professions facilitated vocational rehabilitation and the interagency collaboration process. The agencies' lack of flexibility increased the risk of conflicts as attempts were made to integrate the new working methods developed within the projects into the ordinary activities of the agencies.

A qualitative study of stakeholder views of the conditions for and outcomes of successful clinical networks.

BACKGROUND: Clinical networks have been established to improve health outcomes and processes of care by implementing a range of innovations and undertaking projects based on perceived local need. Limited research exists on the necessary conditions required to bring about successful network outcomes and what characterises network success from the perspective of those involved in network initiatives. This qualitative study identified stakeholder views on i) the conditions for effective clinical networks; and ii) desirable outcomes of successful clinical networks. METHODS: Twenty-seven participants were interviewed using face-to-face audio-recorded semi-structured interviews. Transcribed data were coded and analysed to generate themes relating to the study aims. RESULTS: Five key factors represented as sub-themes were identified as important conditions for the establishment of successful clinical networks under the main theme of effective network structure, organisation and governance. These were: building relationships; effective leadership; strategic evidence-based workplans; adequate resources; and ability to implement and evaluate network initiatives. Two major themes encapsulated views on desirable outcomes of successful clinical networks: connecting and engaging which represented the outcomes of interdisciplinary and consumer collaboration and, partnerships with state health and local health services, and changing the landscape of care, which represented the importance of outcomes associated with improving services, care and patient health outcomes and implementing evidence-based practice. CONCLUSIONS: This study provides new knowledge on the conditions needed to establish successful clinical networks and on desirable outcomes arising from network projects and initiatives that are considered to be valuable by those working in or associated with clinical networks. This provides health services with information on what needs to be in place for successful networks and on the types of outcomes that can be considered for assessing network effectiveness.

Building the scaffold to improve health care quality in Western New York.

Many health policy leaders are promoting the community as a place to try out new ideas for improving the quality of health care. Alliances with multiple stakeholders are moving forward with communitywide efforts to improve the quality of care without the benefit of an established evidence base or guiding framework. This article presents a profile of one community's attempt to facilitate and coordinate quality improvement in its geographic area. The P(2) Collaborative of Western New York is one of sixteen sites supported by the Robert Wood Johnson Foundation's national Aligning Forces for Quality initiative. The strategy and vision of the collaborative has evolved as it has tried to capitalize on opportunities and overcome barriers in its work. The article concludes with a discussion of eight tasks that community alliances may consider undertaking when establishing an infrastructure for improving the quality of health care, such as convening area stakeholders to develop a strategy and finding ways to monitor health outcomes at the local level on an ongoing basis.

A quality improvement framework for equity in cardiovascular care: results of a national collaborative.

Disparities in the quality of cardiovascular care provided to minorities have been well documented, but less is known about the use of quality improvement methods to eliminate these disparities. Measurement is also often impeded by a lack of reliable patient demographic data. The objective of this study was to assess the ability of hospitals with large minority populations to measure and improve the care rendered to Black and Hispanic patients. The Expecting Success: Excellence in Cardiac Care project utilized the standardized collection of self-reported patient race, ethnicity, and language data to generate stratified performance measures for cardiac care coupled with evidence-based practice tools in a national competitively selected sample of 10 hospitals with high cardiac volumes and largely minority patient populations. Main outcomes included changes in nationally recognized measures of acute myocardial infarction and heart failure quality of care and 2 composite measures, stratified by patient demographic characteristics. Quality improved significantly at 7 of the 10 hospitals as gauged by composite measures (p < .05), and improvements exceeded those observed nationally for all hospitals. Three of 10 hospitals found racial or ethnic disparities which were eliminated in the course of the project. Clinicians and institutions were able to join the standardized collection of self-reported patient demographic data to evidence-based measures and quality improvement tools to improve the care of minorities and eliminate disparities in care. This framework may be replicable to ensure equity in other clinical areas.

Case management intervention in cervical cancer prevention: the Boston REACH coalition women's health demonstration project.

BACKGROUND: The Boston REACH Coalition developed a case management intervention for Black women in primary care settings to identify and reduce medical and social obstacles to cervical cancer screening and following up abnormal results. METHODS: The 5-year intervention was evaluated among 732 Black women aged 18 to 75 who were at high risk for inadequate Pap smear screening and follow-up. Case managers provided social services referrals to address patient-identified social concerns (e.g., transportation, housing), as well as navigation to prompt screening and follow-up of abnormal tests. The three study aims were to (1) identify the social factors associated with Pap smear screening at baseline before intervention, (2) evaluate the correlation between exposure to case management intervention and achieving recommended Pap screening intervals, and (3) evaluate the correlation between exposure to case management intervention and having timely follow-up of abnormal Pap smear tests. RESULTS: We found that a lack of a regular clinical provider, concerns communicating with providers, poor self-rated health, and having less than a high school education were important correlates of recent Pap smear screening before the case management intervention. During the case management intervention, we found a significant increase in achieving recommended Pap smear screening intervals among women with a recent Pap smear at study entry (increasing from 52% in the first year to 80% after 4 or more years; p < .01), but not among women who entered the study without a recent Pap smear (increasing from 31% in the first year to 44% after 4 or more years; p = .39). During case management intervention, having social support for childcare was associated with regular screening among women without a recent Pap smear (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.28-9.69). Insurance status was the key factor in timely clinically indicated follow-up of abnormal results (uninsured OR, 0.27; 95% CI, 0.08-0.86), rather than case management intervention. CONCLUSIONS: Exposure to case management was associated with regular Pap smear screening among women who recently engaged in screening. Future research should focus on systems changes to address social determinants of health, including strategies to facilitate screening for Black women without social support for childcare. To improve follow-up of abnormal results, financial access to care should be addressed.

The Asian American hepatitis B program: building a coalition to address hepatitis B health disparities.

BACKGROUND: Community coalitions are increasingly recognized as important strategies for addressing health disparities. By providing the opportunity to pool resources, they provide a means to develop and sustain innovative approaches to affect community health. OBJECTIVES: This article describes the challenges and lessons learned in building the Asian American Hepatitis B Program (AAHBP) coalition to conduct a community-based participatory research (CBPR) initiative to address hepatitis B (HBV) among New York City Asian-American communities. METHODS: Using the stages of coalition development as a framework, a comprehensive assessment of the process of developing and implementing the AAHBP coalition is presented. LESSONS LEARNED: Findings highlight the importance of developing a sound infrastructure and set of processes to foster a greater sense of ownership, shared vision, and investment in the program. CONCLUSION: Grassroots community organizing and campus-community partnerships can be successfully leveraged to address and prevent a significant health disparity in an underserved and diverse community.

A community-engaged approach to select geographic areas for interventions to reduce health disparities.

BACKGROUND: While neighborhood-based approaches to eliminate health disparities are on the rise, there is little guidance on how researchers may engage with community partners to select geographic areas for interventions to reduce health disparities. We aimed to identify a small geographic area to target interventions to improve diabetes-related outcomes. OBJECTIVES: We describe lessons learned from a community-engaged approach to specify the geographic area of focus. METHODS: A community-academic partnership of more than 20 organizations collaborated to develop and employ a 5-stage process to specify a target area for diabetes preventions and control activities. LESSONS LEARNED: A coalition with local knowledge and ties to the community can develop criteria and direct a process leading to selection of a geographic area, increased research capacity, and strengthened relationships among partners. CONCLUSION: A participatory approach can be effective in defining a geographic area for targeting interventions to reduce health disparities.

Health-care organizations as "patients": transforming the fundamental od paradigm.

Hidden behind such frequently used phrases as "The system/policy requires...," "The organization has decided..." is one simple fact. Systems/policies don't drop from the sky etched in stone tablets and organizations don't decide anything. People make decisions and design systems and write policies. Embracing this fact increases the likelihood that the provision of health-care emanates from a "care dealership" in contrast to a "car dealership." Ignoring this fact leads to less humane, less effective, and more costly health-care. This chapter will challenge all of us concerned with caring for all of us--from Organizational Development (OD). Practitioners to CEOs to ... to ... all of us at some point in our lives--to step up to the need to transform our most basic paradigms. To remind ourselves that human beings give birth to, nurture, sustain, and care for that which we call an organization. In so doing, we will be able to begin to act from the premise that a health-care organization is itself a living breathing human organism, a "Patient" in need of care. The quality of care we afford this "Patient" directly and inevitably impacts the quality of care we are afforded as patients. Acting from this premise will transform all of health-care, all "care dealerships" ... and potentially "car dealerships" as well. OD professionals, therefore, can propel us all to a fourth dimension of caring for all of us.