Exploring quality improvement for diabetes care in First Nations communities in Canada: a multiple case study.

BACKGROUND: Indigenous peoples in Canada experience higher rates of diabetes and worse outcomes than non-Indigenous populations in Canada. Strategies are needed to address underlying health inequities and improve access to quality diabetes care. As part of the national FORGE AHEAD Research Program, this study explores two primary healthcare teams' quality improvement (QI) process of developing and implementing strategies to improve the quality of diabetes care in First Nations communities in Canada. METHODS: This study utilized a community-based participatory and qualitative case study methodology. Multiple qualitative data sources were analyzed to understand: (1) how knowledge and information was used to inform the teams' QI process; (2) how the process was influenced by the context of primary care services within communities; and (3) the factors that supported or hindered their QI process. RESULTS: The findings of this study demonstrate how teams drew upon multiple sources of knowledge and information to inform their QI work, the importance of strengthening relationships and building relationships with the community, the influence of organizational support and capacity, and the key factors that facilitated QI efforts. CONCLUSIONS: This study contributes to the ongoing calls for research in understanding the process and factors affecting the implementation of QI strategies, particularly within Indigenous communities. The knowledge generated may help inform community action and the future development, implementation and scale-up of QI programs in Indigenous communities in Canada and globally.

Understanding the nursing practices and perspectives of transfusion reaction reporting.

AIMS AND OBJECTIVES: The aim of this study was to investigate nurse perspectives on transfusion-related adverse reaction reporting practices. BACKGROUND: Transfusion-related adverse reaction reporting is an essential component of hemovigilance in Canada, but reporting rates vary and under-reporting of minor transfusion-related adverse reactions exists. To our knowledge, this is the first report of nursing transfusion-related adverse reaction reporting attitudes. DESIGN: This qualitative descriptive study explored the nursing practices and perspectives of transfusion-related adverse reaction reporting by conducting one-on-one interviews with nurses (n = 25) working in adult oncology inpatient and outpatient units. METHODS: Data were thematically analysed; data collection ended when saturation was reached. The COREQ checklist was used to guide this study. RESULTS: The study revealed that the nursing practices of transfusion-related adverse reaction reporting are not standardised to meet the institutional reporting guidelines. Under-reporting of febrile reactions exists at this institution. Major concepts uncovered included the factors impacting nurses' transfusion-related reporting practices, as well as barriers and facilitators to transfusion reporting. CONCLUSION: A practice change in transfusion-related adverse reaction reporting is needed to achieve optimal hemovigilance at this institution. Using the barriers and facilitators identified in this study, institutions can better inform future interventions by employing strategies like TR reporting education in order to improve reporting of transfusion-related adverse reactions in this hospital and other similar institutions. RELEVANCE TO CLINICAL PRACTICE: This study informs clinical practice and decision-making for nurses and nursing educators who manage blood transfusion administration procedures.

Designing systems for the care we need: A transformation journey in Southwestern Ontario.

Primary care is considered the foundation of any health system. In Ontario, Canada Bills 41 and 74 introduced in 2016 and 2019, respectively, aimed to move towards a primary care-focused and sustainable integrated care approach designed around the needs of local populations. These bills collectively set the stage for integrated care and population health management in Ontario, with Ontario Health Teams (OHTs) introduced as a model of integrated care delivery systems. OHTs aim to streamline patient connectivity through the healthcare system and improve outcomes aligned with the Quadruple Aim. When Ontario released a call for health system partners to apply to become an OHT, providers, administrators, and patient/caregiver partners from the Middlesex-London area were quick to respond. We highlight the critical elements and journey of the Middlesex-London Ontario Health Team since its start.

The roles of family physicians during a pandemic.

Family physicians play important roles throughout all stages of a pandemic response; however, actionable descriptions outlining these roles are absent from current pandemic plans. Using a multiple case study design, we conducted a document analysis and interviewed 68 family physicians in four Canadian regions. We identified roles performed by family physicians in five distinct stages of pandemic response: pre-pandemic, phased closure and re-opening, acute care crisis, vaccination, and pandemic recovery. In addition to adopting public health guidance to ensure continued access to primary care services, family physicians were often expected to operationalize public health roles (eg, staffing assessment centres), modulate access to secondary/tertiary services, help provide surge capacity in acute care facilities, and enhance supports and outreach to vulnerable populations. Future pandemic plans should include family physicians in planning, explicitly incorporate family physician roles, and ensure needed resources are available to allow for an effective primary care response.

A framework to support the progressive implementation of integrated team-based care for the management of COPD: a collective case study.

BACKGROUND: In Canada, there is widespread agreement about the need for integrated models of team-based care. However, there is less agreement on how to support the scale-up and spread of successful models, and there is limited empirical evidence to support this process in chronic disease management. We studied the supporting and mitigating factors required to successfully implement and scale-up an integrated model of team-based care in primary care. METHODS: We conducted a collective case study using multiple methods of data collection including interviews, document analysis, living documents, and a focus group. Our study explored a team-based model of care for chronic obstructive pulmonary disease (COPD) known as Best Care COPD (BCC) that has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants included healthcare providers involved in the delivery of the BCC program. RESULTS: We identified several mechanisms influencing the scale-up and spread of BCC and categorized them as Foundational (e.g., evidence-based program, readiness to implement, peer-led implementation team), Transformative (adaptive process, empowerment and collaboration, embedded evaluation), and Enabling Mechanisms (provider training, administrative support, role clarity, patient outcomes). Based on these results, we developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management. Our framework builds off our empirical work and is framed by local contextual factors. CONCLUSIONS: This study explores the implementation and spread of integrated team-based care in a primary care setting. Despite the study's focus on COPD, we believe the findings can be applied in other chronic disease contexts. We provide a framework to support the progressive implementation of integrated team-based care for chronic disease management.

Building a virtual community of practice: experience from the Canadian foundation for healthcare improvement's policy circle.

BACKGROUND: Communities of Practice are formed by people who interact regularly to engage in collective learning in a shared domain of human endeavor. Virtual Communities of Practice (VCoP) are online communities that use the internet to connect people who share a common concern or passion. VCoPs provide a platform to share and enhance knowledge. The Policy Circle is a VCoP that connects mid-career professionals from across Canada who are committed to improving healthcare policy and practice. We wanted to understand the perceived value of the VCoP. METHODS: We used qualitative and quantitative survey research to explore past and current Policy Circle members' thoughts, feelings, and behaviours related to the program. Our research was guided by the Value Creation Framework proposed by Wenger and colleagues. Three surveys were created in collaboration with stakeholders. Data were analyzed within cohort and in aggregate across cohorts. Qualitative data was analyzed thematically, and quantitative data was analyzed using descriptive statistics (means of ranked and scaled responses). RESULTS: Survey participation was high among members (Cohort 1: 67%, Cohort 2: 64%). Participants came from a variety of disciplines including medicine, health policy, allied health, and nursing, with most members having a direct role in health services research or practice. The program was successful in helping participants make connections (mean = 2.43 on a scale from 1 to 5: 1 = yes, significantly, 5 = not at all); variances in both qualitative and quantitative data indicated that levels of enthusiasm within the program varied among individuals. Members appreciated the access to resources; quarterly meetings (n = 11/11), and a curated reading list (n = 8/11) were the most valued resources. Participants reported the development of a sense of belonging (mean = 2.29) and facilitated knowledge exchange (mean = 2.43). At the time of this study, participants felt the program had minor impact on their work (mean = 3.5), however a majority of participants (50%) from Cohort 2 planned to acknowledge the program in their professional or academic endeavours. Through reflective responses, participants expressed a desire for continued and deeper professional network development. CONCLUSIONS: The Policy Circle was successful in facilitating knowledge exchange by creating a community that promoted trust, a sense of belonging and a supportive environment. Members were satisfied with the program; to promote further value, the Policy Circle should implement strategies that will continue member participation and networking after the program is finished.

Patient and paramedic experiences with a direct electronic referral programme for focused hypoglycaemia education following paramedic service assist-requiring hypoglycaemia in London and Middlesex County, Ontario, Canada.

AIMS: Hypoglycaemia is a common treatment consequence in diabetes mellitus. Prior studies have shown that a large proportion of people with paramedic assist-requiring hypoglycaemia prefer not to be transported to hospital. Thus, these episodes are "invisible" to their usual diabetes care providers. A direct electronic referral programme where paramedics sent referrals focused hypoglycaemia education at the time of paramedic assessment was implemented in our region for 18 months; however, referral programme uptake was low. In this study, we examined patient and paramedic experiences with a direct electronic referral programme for hypoglycaemia education postparamedic assist-requiring hypoglycaemia, including barriers to programme referral and education attendance. METHODS: We surveyed paramedics and conducted semistructured telephone interviews of patients with paramedic-assisted hypoglycaemia who consented to the referral programme and were scheduled for an education session in London and Middlesex County, Canada. RESULTS: Paramedics and patient participants felt that the direct referral programme was beneficial. A third of paramedics who responded to our survey used the referral programme for each encounter where they treated patients for hypoglycaemia. Patients felt very positive about the referral programme and their paramedic encounter; however, they described embarrassment, guilt and prior negative experience as key barriers to attending education. CONCLUSIONS: Paramedics and patients felt that direct referral for focused hypoglycaemia education postparamedic assist-requiring hypoglycaemia was an excellent strategy. Despite this, referral programme participation was low and thus there remain ongoing barriers to implementation and attendance. Future iterations should consider how best to meet patient needs through innovative delivery methods.

Evaluating the implementation of a chronic obstructive pulmonary disease management program using the Consolidated Framework for Implementation Research: a case study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a prevalent chronic disease that requires comprehensive approaches to manage; it accounts for a significant portion of Canada's annual healthcare spending. Interprofessional teams are effective at providing chronic disease management that meets the needs of patients. As part of an ongoing initiative, a COPD management program, the Best Care COPD program was implemented in a primary care setting. The objectives of this research were to determine site-specific factors facilitating or impeding the implementation of a COPD program in a new setting, while evaluating the implementation strategy used. METHODS: A qualitative case study was conducted using interviews, focus groups, document analysis, and site visits. Data were deductively analyzed using the Consolidated Framework for Implementation Research (CFIR) to assess the impact of each of its constructs on Best Care COPD program implementation at this site. RESULTS: Eleven CFIR constructs were determined to meaningfully affect implementation. Five were identified as the most influential in the implementation process. Cosmopolitanism (partnerships with other organizations), networks and communication (amongst program providers), engaging (key individuals to participate in program implementation), design quality and packaging (of the program), and reflecting and evaluating (throughout the implementation process). A peer-to-peer implementation strategy included training of registered respiratory therapists (RRT) as certified respiratory educators and the establishment of a communication network among RRTs to discuss experiences, collectively solve problems, and connect with the program lead. CONCLUSIONS: This study provides a practical example of the various factors that facilitated the implementation of the Best Care COPD program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the Best Care COPD program and future implementation of other chronic care programs.

Lessons learned from inadequate implementation planning of team-based chronic disease management: implementation evaluation.

BACKGROUND: This study was a retrospective evaluation of an unsuccessfully implemented team-based, chronic disease management program, with an aim to understand more about implementation barriers. The program, the Chronic Disease Management Initiative (CDMI) was a new collaborative model of care for patients with COPD. It utilized customized health information and interactive tools, mainly smartphones, for ongoing disease management. The program's goal was to demonstrate that integrated team-based models of care could improve patient care, as well as reduce readmission rates and emergency department visits. The program planning for CDMI began in 2017, followed by the implementation and evaluation period in 2018. After a 10-month implementation period, the program was unable to enroll a sufficient number of patients to examine if there was an improvement in patient outcomes. METHODS: A retrospective case-study design using multiple data sources was used to gather feedback from participants involved in CDMI. Data collection occurred throughout planning and implementation and continued into early 2019. Semi-structured interviews were conducted, and transcripts were analyzed using NVivo 10 software. This was followed by content analysis. RESULTS: Analysis revealed four key themes as barriers to CDMI's implementation: 1) lack of a needs assessment with key stakeholders; 2) lack of buy-in from medical staff; 3) inadequate patient engagement and; 4) contextual barriers. Planners did not conduct a proper needs assessment, nor include patients in the study design. In addition, there was insufficient consideration for how CDMI should be integrated into the usual COPD care plan, leading to confusion in roles and responsibilities. Poor communication between the implementation team and healthcare providers implementing the program, led to a lack of buy-in and engagement. CONCLUSION: The key themes resonate with what is already known in the literature. This study supports the importance of using a theoretically grounded plan for implementation. Using a model only in the planning stages is insufficient even when an intervention is based on evidence to support higher quality care. It is imperative to consider practical and contextual factors of program implementation and their interactions. By detailing the 'failed implementation' of this intervention, we hope to share important lessons about the need to plan implementation processes early in program planning.

Confronting complexity and supporting transformation through health systems mapping: a case study.

INTRODUCTION: Health systems are a complex web of interacting and interconnected parts; introducing an intervention, or the allocation of resources, in one sector can have effects across other sectors and impact the entire system. A prerequisite for effective health system reorganisation or transformation is a broad and common understanding of the current system amongst stakeholders and innovators. Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are common chronic diseases with high health care costs that require an integrated health system to effectively treat. STUDY DESCRIPTION: This case study documents the first phase of system transformation at a regional level in Ontario, Canada. In this first phase, visual representations of the health system in its current state were developed using a collaborative co-creation approach, and a focus on COPD and HF. Multiple methods were used including focus groups, open-ended questionnaires, and document review, to develop a series of graphical and visual representations; a health care ecosystem map. RESULTS: The ecosystem map identified key sectoral components, inter-component interactions, and care requirements for patients with COPD and HF and inventoried current programs and services available to deliver this care. Main findings identified that independent system-wide navigation for this vulnerable patient group is limited, primary care is central to the accessibility of nearly half of the identified care elements, and resources are not equitably distributed. The health care ecosystem mapping helped to identify care gaps and illustrates the need to resource the primary care provider and the patient with system navigation resources and interdisciplinary team care. CONCLUSION: The co-created health care ecosystem map brought a collective understanding of the health care system as it applies to COPD and HF. The map provides a blueprint that can be adapted to other disease states and health systems. Future transformation will build on this foundational work, continuing the robust interdisciplinary co-creation strategies, exploring predictive health system modelling and identifying areas for integration.

Implementation of interprofessional team-based care: A cross-case analysis.

Two out of five Canadians have at least one chronic disease and four out of five are at risk of developing a chronic disease. Successful disease management relies on interprofessional team-based approaches, yet lack of purposeful cultivation and patient engagement has led to systematic inefficiencies. Two primary care teams in Southwestern Ontario implementing interprofessional chronic care programs for patients with chronic obstructive pulmonary disease were compared. A mixed-methods cross-case analysis was conducted including interviews, focus groups, observations and document analysis. Cases (n = 2) were chosen based on intrinsic and unique value. Participants (n = 46) were sampled using a combination of purposive and multi-level sampling. Data was analyzed using an iterative process; inductive coding was used to gain a sense of context followed by a deductive cross-case analysis to compare and contrast themes across sites. Kompier's five-step framework was used to assess factors contributing to successful implementation and to provide insight into interactions between teams, providers and patients. Both cases satisfied all five factors (systemic and gradual approach, identification of risk factors, theory-driven, participatory approach and sustained committed support). However, one case was more successful at fully implementing their model, attributed to a flexible implementation, plans to mitigate risks, theory use, a supportive team and continued buy-in from leadership. By better understanding key facilitators and barriers, we can support the implementation of chronic disease management programs, foster sustainability of high-performing interprofessional teams, and engage patients in the development and maintenance of team-based chronic disease management.

Continuing to enhance the quality of case study methodology in health services research.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Foundations, Functions and Current State of Collaborative Leadership: A Case of Newly Developing Integrated Care in Ontario.

In 2019, the Government of Ontario announced a health system transformation to end hallway healthcare by implementing integrated care systems known as Ontario Health Teams (OHTs). Establishing an integrated care system is a monumental task requiring collaborative and participatory leadership structures. Based on a survey of 480 OHT signatory members and 125 in-depth interviews with leaders from 12 OHTs, we describe how developing OHTs conceptualized and executed leadership. While collaborative leadership is common, the approaches are varied and the leadership structure is informed by contextual differences. We provide suggestions on how to support the success of collaborative leadership for decision and policy makers, leaders and anyone working toward integrated care.

Collaborative health research partnerships: a survey of researcher and knowledge-user attitudes and perceptions.

BACKGROUND: Integrated knowledge translation describes the process of partnered research between different stakeholders with the goal of producing research that ultimately achieves a greater impact when put into practice. A better understanding of research partnerships and integrated knowledge translation has implications for future partnerships and collaborative initiatives in practice. Our research describes and expands upon previous work done to identify barriers and attitudes toward collaboration in the context of research funding opportunities that required researcher-knowledge-user partnerships. METHODS: A survey was sent out to researchers funded by the Canadian Institutes of Health Research and knowledge-users who worked collaboratively on their research projects. There were two mirror versions of the survey, one for researchers and one for knowledge-users. Descriptive statistics, χ2 analysis and Mann-Whitney U analysis were used to understand the processes, barriers, perceived impact and sustainability of the partnerships. RESULTS: The results revealed that, although there were differences in the roles of researchers and knowledge-users, both groups felt very positive towards their partnerships. Some of the barriers identified as inhibiting effective partnerships were resource constraints (funding/time) and differences in contribution and involvement amongst team members. Despite these barriers, both researchers and knowledge-users felt that the partnership was not only sustainable, but also helped create an impact. CONCLUSIONS: Our results provide useful information for funding agencies launching opportunities requiring or encouraging collaborative research projects between researchers and knowledge-users.

An Opportunity for Quality: The Need for Better Evaluation of Family Health Teams in Ontario.

In the past decade, primary care has undergone significant changes toward system improvement, which has improved patient outcomes and reduced costs. Family health teams (FHTs) were introduced in Ontario as part of primary care renewal. FHTs address a lack of capacity and integration among providers and service inaccessibility experienced by the population. We explore, the potential for positive impact of FHTs and the lack of built-in evaluation strategies to assess performance. We provide four suggestions to better support rigorous evaluation of FHTs. This commentary considers Ontario's efforts to improve capacity, quality and evaluation in primary care through FHTs.

Exploring role clarity in interorganizational spread and scale-up initiatives: the 'INSPIRED' COPD collaborative.

BACKGROUND: Role clarification is consistently documented as a challenging process for inter professional healthcare teams, despite being a core tenet of interprofessional collaboration. This paper explores the role clarification process in two previously unexplored contexts: i) in the dissemination phase of a quality improvement (QI) program, and ii) as part of interorganizational partnerships for the care of chronic disease patients. METHODS: A secondary analysis using asynchronous purposive coding was conducted on an innovative pan-Canadian Chronic Obstructive Pulmonary Disease QI program. RESULTS: Our study reveals that the iterative structure of QI initiatives in the spread phase can offer numerous unique benefits to role clarification, with the potential challenge of time commitment. In addition, the role clarification process within interorganizational partnerships proved to be relatively well-structured, characterized by three phases: relationship conceptualization or early contact, familiarization, and finally, role division. Common strategies in the last stage included the establishment of working groups and new information-sharing networks. CONCLUSION: This article characterizes some ways in which providers and organizational partners negotiate their roles in a changing professional environment. As the movement towards integrated care continues, issues of role clarity are assuming increasing importance in healthcare contexts, and understanding role dynamics can provide valuable insight into the optimization of QI initiatives.

"I Just Roll Over, Pick Myself Up, and Carry On!" Exploring the Fall-Risk Experience of Canadian Masters Athletes.

OBJECTIVES: The risk of falling increases in adults aged 65 years and older. A common barrier to take up physical activity in sedentary older adults is the fear of falls and injury. Experiences of master athletes can provide insights into management of the risk of falling. The purpose of this phenomenological study was to explore the fall-risk experience of masters athletes actively competing in sport. METHODS: Masters athletes aged 55 years and older (N = 22) described their experiences in semistructured interviews. Data were analyzed through an interpretive-constructivist paradigm using inductive content analysis. RESULTS: Five dominant themes emerged: acceptance, learning, awareness, resilience, and self-fulfillment. Participants of this study reported an acceptance of the risk they take in sport for falls and injuries in their pursuits for self-fulfillment. DISCUSSION: Findings indicate that master athletes accept the risk for falls and injuries in sport, find ways to adapt, and continue to compete because it is self-fulfilling. Sharing their experiences might inspire other older adults to get active as a rewarding means of remaining independent.

Without Compromising Integrity: Research and Planning Around the Primary Healthcare Landscape in Southwestern Ontario.

Primary care is the foundation of any high-performing healthcare system. We report a subset of findings that characterize the existing primary care system in southwestern Ontario, Canada, and describe the experiences of primary healthcare providers (PHCPs). Between December 2015 and January 2016, in collaboration with the South West Local Health Integration Network (LHIN), we conducted a mixed-methods research study to gain a better understanding of experiences in providing primary care to support systems planning for primary care. We believe our approach allowed for integrity across both the research and planning process.

Optimization of the Hockey Fans in Training (Hockey FIT) weight loss and healthy lifestyle program for male hockey fans.

BACKGROUND: The health outcomes of men continue to be poorer than women globally. Challenges in addressing this problem include difficulties engaging men in weight loss programs as they tend to view these programs as contrary to the masculine narrative of independence and self-reliance. Researchers have been turning towards sports fans to engage men in health promotion programs as sports fans are typically male, and tend to have poor health habits. METHODS: Developed from the highly successful gender-sensitized Football Fans in Training program, Hockey Fans in Training (Hockey FIT) recruited 80 male hockey fans of the London Knights and Sarnia Sting who were overweight or obese into a weekly, 90-minute classroom education and group exercise program held over 12 weeks; a 40-week minimally-supported phase followed. A process evaluation of the Hockey FIT program was completed alongside a pragmatic randomized controlled trial and outcome evaluation in order to fully explore the acceptability of the Hockey FIT program from the perspectives of coaches delivering and participants engaged in the program. Data sources included attendance records, participant focus groups, coach interviews, assessment of fidelity (program observations and post-session coach reflections), and 12-month participant interviews. RESULTS: Coaches enjoyed delivering the program and found it simple to deliver. Men valued being among others of similar body shape and similar weight loss goals, and found the knowledge they gained through the program helped them to make and maintain health behaviour changes. Suggested improvements include having more hockey-related information and activities, greater flexibility with timing of program delivery, and greater promotion of technology support tools. CONCLUSIONS: We confirmed Hockey FIT was an acceptable "gender-sensitized" health promotion program for male hockey fans who were overweight or obese. Minor changes were required for optimization, which will be evaluated in a future definitive trial. TRIAL REGISTRATION: NCT02396524 (Clinicaltrials.gov). Date of registration: Feb 26, 2015.

A Qualitative Study of Challenges and Opportunities in Mobilizing Research Knowledge on Violence Against Women.

Background Effective delivery of interventions by health and social services requires research-based knowledge which identifies the causes and consequences of violence against women. Methods to effectively share new knowledge with violence against women decision-makers remain under studied. Purpose This paper examines how new research-based knowledge-namely, the lack of efficacy of health-care screening for exposure to intimate partner violence against women-is received by stakeholders in the violence against women field. Methods Data from 10 stakeholder group discussions ( N = 86) conducted during a knowledge-sharing forum were analyzed to assess how stakeholders responded to the new knowledge. Results Participant reactions ranged from full acceptance to significant resistance to the research findings. We suggest themes that help explain these reactions, including the context and content of our findings and their epistemological match to participants' experiences and beliefs, and the perceived value of research evidence, compared to other forms of knowledge. Conclusions Violence against women is a complex psycho-social phenomenon, and people with an interest in this field bring diverse and even conflicting perspectives regarding its causes, consequences, and potential solutions.