Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability.

BACKGROUND: This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change. METHODS: We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. RESULTS: CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. CONCLUSIONS: A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Why healthcare renewal matters: lessons from diabetes.

In this commentary, we offer evidence about the burden of chronic conditions and use diabetes as a case study to reveal the gap between recommended and actual care in Canada. What we found through our research is cause for concern - namely, that the care that Canadians with diabetes receive is simply not good enough (an inconvenient truth) and that the country has tremendous untapped potential to prevent chronic illness and improve the quality of care (a convenient truth). Our work and the work of others help Canadians understand the benefits that will accrue to them from investments to close the gap between what we know and what we do. Given the extent of recent initiatives highlighted in this commentary - initiatives that align with evidence regarding optimal prevention and chronic illness care - we should expect governments to simultaneously invest in assessing the degree to which progress is being attained. Without better data, more transparency and comprehensive reporting, Canadians will not be kept fully informed about the results of critical healthcare investments and governments will find it increasingly difficult to demonstrate that they are meeting their commitments.

Intergenerational differences in workloads among primary care physicians: a ten-year, population-based study.

Analyses of population-based services and surveys in Canada from the early 1990s and early 2000s indicate that younger and middle-aged family physicians carried smaller workloads in 2003 than their same-age peers did ten years earlier and that older family physicians carried larger workloads in 2003 than their same-age peers did ten years earlier. Yet family physicians in all age groups worked similar numbers of hours in 2003. Intergenerational effects are similar for male and female physicians, although feminization of the workforce will affect supply, as a result of the falling service volumes delivered by women.

Family physician workloads and access to care in Winnipeg: 1991 to 2001.

BACKGROUND: Current perceptions of family physician (FP) shortages in Canada have prompted policies to expand medical schools. Our objective was to assess how FP supply, workloads and access to care have changed over the past decade. METHODS: We used an anonymized physician and population registry and administrative health service data from Winnipeg for the period 1991/92 to 2000/01. We calculated the following measures of supply and workload: ratios of FPs to population, of population to FPs and of FP full-time equivalents (FTEs) to population, as well as FP activity ratios (sum of FTEs/number of FPs), annual number of visits per FP and visits per FP per full-time day of work. Trends in FP remuneration were analyzed by age and sex. We also measured standardized visit rates and stratified the analysis by populations deemed at risk of needing FP services. RESULTS: In 2000/01 FPs between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-age peers did 10 years previously. Conversely, FPs 60 to 69 years of age (11% of the workforce) provided 33% more visits per year than the corresponding group a decade earlier. On a per capita basis, the number of FPs declined by 5%, from 97 per 100 000 population in 1991/92 to 92 per 100 000 population in 2000/01, which paralleled changes in national estimates of FP supply. Per capita visit rates among Winnipeg citizens (3.5 per year in 2000/01) and average workloads among FPs (4193 visits per year in 2000/01) were stable over the decade. INTERPRETATION: Despite relative homeostasis in aggregate FP supply and use, there have been substantial temporal shifts in the volume of services provided by FPs of different age groups. Younger FPs are providing many fewer visits and older FPs are providing many more visits than their same-age predecessors did 10 years ago, a finding that was independent of physician sex. Given these data, the perpetual focus of policy-makers and care providers on increasing numbers of FPs will not help in diagnosing or treating issues of supply, workloads and access to care.