Activity-based funding model provides foundation for province-wide best practices in renal care.

British Columbia has a unique funding model for renal care in Canada. Patient care is delivered through six health authorities, while funding is administered by the Provincial Renal Agency using an activity-based funding model. The model allocates funding based on a schedule of costs for every element of renal care, excluding physician fees. Accountability, transparency of allocation and tracking of outcomes are key features that ensure successful implementation. The model supports province-wide best practices and equitable care and fosters innovation. Since its introduction, the outpatient renal services budget has grown less than the population, while maintaining or improving clinical outcomes.

Using systems thinking to support clinical system transformation.

Purpose - The British Columbia Ministry of Health's Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC's health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings. Design/methodology/approach - Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey. Findings - The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system. Research limitations/implications - The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels - policy, management and practice - about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue. Practical implications - Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues. Originality/value - Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

Time to shift from systems thinking-talking to systems thinking-action: Comment on "Constraints to applying systems thinking concepts in health systems: A regional perspective from surveying stakeholders in Eastern Mediterranean countries".

A recent International Journal of Health Policy and Management (IJHPM) article by Fadi El-Jardali and colleagues makes an important contribution to the literature on health system strengthening by reporting on a survey of healthcare stakeholders in Low- and Middle-Income Countries (LMICs) about Systems Thinking (ST). The study's main contributions are its confirmation that healthcare stakeholders understand the importance of ST but do not know how to act on that understanding, and the call for collective action by the global community of systems thinkers committed to healthcare improvement. We offer three basic considerations for next steps by this community, derived from our recent work in ST and the related field of Knowledge Translation (KT): resist the temptation to adopt a reductionist approach; recognize not everyone needs to understand ST; and do not wait for everything to be in place before getting started.

Comparative sequence and x-inactivation analyses of a domain of escape in human xp11.2 and the conserved segment in mouse.

We have performed X-inactivation and sequence analyses on 350 kb of sequence from human Xp11.2, a region shown previously to contain a cluster of genes that escape X inactivation, and we compared this region with the region of conserved synteny in mouse. We identified several new transcripts from this region in human and in mouse, which defined the full extent of the domain escaping X inactivation in both species. In human, escape from X inactivation involves an uninterrupted 235-kb domain of multiple genes. Despite highly conserved gene content and order between the two species, Smcx is the only mouse gene from the conserved segment that escapes inactivation. As repetitive sequences are believed to facilitate spreading of X inactivation along the chromosome, we compared the repetitive sequence composition of this region between the two species. We found that long terminal repeats (LTRs) were decreased in the human domain of escape, but not in the majority of the conserved mouse region adjacent to Smcx in which genes were subject to X inactivation, suggesting that these repeats might be excluded from escape domains to prevent spreading of silencing. Our findings indicate that genomic context, as well as gene-specific regulatory elements, interact to determine expression of a gene from the inactive X-chromosome.