Tackling the wicked problem of health networks: the design of an evaluation framework.

Networks are everywhere. Health systems and public health settings are experimenting with multifarious forms. Governments and providers are heavily investing in networks with an expectation that they will facilitate the delivery of better services and improve health outcomes. Yet, we lack a suitable conceptual framework to evaluate the effectiveness and sustainability of clinical and health networks. This paper aims to present such a framework to assist with rigorous research and policy analysis. The framework was designed as part of a project to evaluate the effectiveness and sustainability of health networks. We drew on systematic reviews of the literature on networks and communities of practice in health care, and on theoretical and evidence-based studies of the evaluation of health and non-health networks. Using brainstorming and mind-mapping techniques in expert advisory group sessions, we assessed existing network evaluation frameworks and considered their application to extant health networks. Feedback from stakeholders in network studies that we conducted was incorporated. The framework encompasses network goals, characteristics and relationships at member, network and community levels, and then looks at network outcomes, taking into account intervening variables. Finally, the short-term, medium-term and long-term effectiveness of the network needs to be assessed. The framework provides an overarching contribution to network evaluation. It is sufficiently comprehensive to account for many theoretical and evidence-based contributions to the literature on how networks operate and is sufficiently flexible to assess different kinds of health networks across their life-cycle at community, network and member levels. We outline the merits and limitations of the framework and discuss how it might be further tested.

Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A Social Network Analysis and Examination of Prescribing Error Rates.

OBJECTIVES: To measure the weekly medication advice-seeking networks of hospital staff, to compare patterns across professional groups, and to examine these in the context of prescribing error rates. METHOD: A social network analysis was conducted. All 101 staff in 2 wards in a large, academic teaching hospital in Sydney, Australia, were surveyed (response rate, 90%) using a detailed social network questionnaire. The extent of weekly medication advice seeking was measured by density of connections, proportion of reciprocal relationships by reciprocity, number of colleagues to whom each person provided advice by in-degree, and perceptions of amount and impact of advice seeking between physicians and nurses. Data on prescribing error rates from the 2 wards were compared. RESULTS: Weekly medication advice-seeking networks were sparse (density: 7% ward A and 12% ward B). Information sharing across professional groups was modest, and rates of reciprocation of advice were low (9% ward A, 14% ward B). Pharmacists provided advice to most people, and junior physicians also played central roles. Senior physicians provided medication advice to few people. Many staff perceived that physicians rarely sought advice from nurses when prescribing, but almost all believed that an increase in communication between physicians and nurses about medications would improve patient safety. The medication networks in ward B had higher measures for density, reciprocation, and fewer senior physicians who were isolates. Ward B had a significantly lower rate of both procedural and clinical prescribing errors than ward A (0.63 clinical prescribing errors per admission [95%CI, 0.47-0.79] versus 1.81/ admission [95%CI, 1.49-2.13]). CONCLUSIONS: Medication advice-seeking networks among staff on hospital wards are limited. Hubs of advice provision include pharmacists, junior physicians, and senior nurses. Senior physicians are poorly integrated into medication advice networks. Strategies to improve the advice-giving networks between senior and junior physicians may be a fruitful area for intervention to improve medication safety. We found that one ward with stronger networks also had a significantly lower prescribing error rate, suggesting a promising area for further investigation.

Gaps, disconnections, and discontinuities--the role of information exchange in the delivery of quality long-term care.

PURPOSE OF THE STUDY: The smart use of information and communication technologies (ICT) is widely seen as a means of enhancing the quality of aged care services. One of the barriers to ICT diffusion in aged care is the failure to cater for the complex and interdisciplinary requirements of the aged care environment. The aim of this qualitative study was to identify the layers of information exchange and communication and produce a conceptual model that can help to inform decisions related to the design, implementation, and sustainability of ICT. DESIGN AND METHODS: A qualitative study conducted in 2010 within seven Australian residential aged care facilities. It included 11 focus groups involving 47 staff and 54 individual interviews and observation sessions. RESULTS: The analysis of work processes identified key information exchange components related to the type of information (residential, clinical, and administrative) that is collected, stored, and communicated. This information relies on a diverse number of internal and external communication channels that are important for the organization of care. IMPLICATIONS: The findings highlight potential areas of communication dysfunction as a consequence of structural holes, fragmentation, or disconnections that can adversely affect the continuity and coordination of care, its safety, and quality.

Visualising differences in professionals' perspectives on quality and safety.

BACKGROUND: The safety-and-quality movement is now two decades old. Errors persist despite best efforts, indicating that there are entrenched overt and perhaps less explicit barriers limiting the success of improvement efforts. OBJECTIVES AND HYPOTHESES: To examine the perspectives of five groups of healthcare workers (administrative staff, nurses, medical practitioners, allied health and managers) and to compare and contrast their descriptions of quality-and-safety activities within their organisation. Differences in perspectives can be an indicator of divergence in the conceptualisation of, and impetus for, quality-improvement strategies which are intended to engage healthcare professions and staff. DESIGN, SETTING AND PARTICIPANTS: Study data were collected in a defined geographical healthcare jurisdiction in Australia, via individual and group interviews held across four service streams (aged care and rehabilitation; mental health; community health; and cancer services). Data were collected in 2008 and analysed, using data-mining software, in 2009. RESULTS: Clear differences in the perspectives of professional groups were evident, suggesting variations in the perceptions of, and priorities for, quality and safety. CONCLUSIONS: The visual representation of quality and safety perspectives provides insights into the conceptual maps currently utilised by healthcare workers. Understanding the similarity and differences in these maps may enable more effective targeting of interprofessional improvement strategies.

Evaluation of current Australian health service accreditation processes (ACCREDIT-CAP): protocol for a mixed-method research project.

INTRODUCTION: Accreditation programmes aim to improve the quality and safety of health services, and have been widely implemented. However, there is conflicting evidence regarding the outcomes of existing programmes. The Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork-Current Accreditation Processes (ACCREDIT-CAP) project is designed to address key gaps in the literature by evaluating the current processes of three accreditation programmes used across Australian acute, primary and aged care services. METHODS AND DESIGN: The project comprises three mixed-method studies involving documentary analyses, surveys, focus groups and individual interviews. Study samples will comprise stakeholders from across the Australian healthcare system: accreditation agencies; federal and state government departments; consumer advocates; professional colleges and associations; and staff of acute, primary and aged care services. Sample sizes have been determined to ensure results allow robust conclusions. Qualitative information will be thematically analysed, supported by the use of textual grouping software. Quantitative data will be subjected to a variety of analytical procedures, including descriptive and comparative statistics. The results are designed to inform health system policy and planning decisions in Australia and internationally. ETHICS AND DISSEMINATION: The project has been approved by the University of New South Wales Human Research Ethics Committee (approval number HREC 10274). Results will be reported to partner organisations, healthcare consumers and other stakeholders via peer-reviewed publications, conference and seminar presentations, and a publicly accessible website.

Narrative synthesis of health service accreditation literature.

AIMS: To systematically identify and synthesise health service accreditation literature. METHODS: A systematic identification and narrative synthesis of health service accreditation literature published prior to 2012 were conducted. The search identified 122 empirical studies that examined either the processes or impacts of accreditation programmes. Study components were recorded, including: dates of publication; research settings; levels of study evidence and quality using established rating frameworks; and key results. A content analysis was conducted to determine the frequency of key themes and subthemes examined in the literature and identify knowledge-gaps requiring research attention. RESULTS: The majority of studies (n=67) were published since 2006, occurred in the USA (n=60) and focused on acute care (n=79). Two thematic categories, that is, 'organisational impacts' and 'relationship to quality measures', were addressed 60 or more times in the literature. 'Financial impacts', 'consumer or patient satisfaction' and 'survey and surveyor issues' were each examined fewer than 15 times. The literature is limited in terms of the level of evidence and quality of studies, but highlights potential relationships among accreditation programmes, high quality organisational processes and safe clinical care. CONCLUSIONS: Due to the limitations of the literature, it is not prudent to make strong claims about the effectiveness of health service accreditation. Nonetheless, several critical issues and knowledge-gaps were identified that may help stimulate and inform discussion among healthcare stakeholders. Ongoing effort is required to build upon the accreditation evidence-base by using high quality experimental study designs to examine the processes, effectiveness and financial value of accreditation programmes and their critical components in different healthcare domains.