A pre-pandemic COVID-19 assessment of the costs of prevention and control interventions for healthcare associated infections in medical and surgical wards in Québec.

BACKGROUND: Healthcare-associated infections (HCAIs) present a major public health problem that significantly affects patients, health care providers and the entire healthcare system. Infection prevention and control programs limit HCAIs and are an indispensable component of patient and healthcare worker safety. The clinical best practices (CBPs) of handwashing, screening, hygiene and sanitation of surfaces and equipment, and basic and additional precautions (e.g., isolation, and donning and removing personal protective equipment) are keystones of infection prevention and control (IPC). There is a lack of rigorous IPC economic evaluations demonstrating the cost-benefit of IPC programs in general, and a lack of assessment of the value of investing in CBPs more specifically. OBJECTIVE: This study aims to assess overall costs associated with each of the four CBPs. METHODS: Across two Quebec hospitals, 48 healthcare workers were observed for two hours each shift, for two consecutive weeks. A modified time-driven activity-based costing framework method was used to capture all human resources (time) and materials (e.g. masks, cloths, disinfectants) required for each clinical best practice. Using a hospital perspective with a time horizon of one year, median costs per CBP per hour, as well as the cost per action, were calculated and reported in 2018 Canadian dollars ($). Sensitivity analyses were performed. RESULTS: A total of 1831 actions were recorded. The median cost of hand hygiene (N = 867) was 20 cents per action. For cleaning and disinfection of surfaces (N = 102), the cost was 21 cents per action, while cleaning of small equipment (N = 85) was 25 cents per action. Additional precautions median cost was $4.1 per action. The donning or removing or personal protective equipment (N = 720) cost was 76 cents per action. Finally, the total median costs for the five categories of clinical best practiced assessed were 27 cents per action. CONCLUSIONS: The costs of clinical best practices were low, from 20 cents to $4.1 per action. This study provides evidence based arguments with which to support the allocation of resources to infection prevention and control practices that directly affect the safety of patients, healthcare workers and the public. Further research of costing clinical best care practices is warranted.

Economic Analysis of the Prevention and Control of Nosocomial Infections: Research Protocol.

Background: Nosocomial infections (NIs) are among the main preventable healthcare adverse events. Like all countries, Canada and its provinces are affected by NIs. In 2004, Ministry of Health and Social Services (MSSS) of Quebec instituted a mandatory surveillance NI program for the prevention and control (NIPC) in the hospitals of the province. One target of the MSSS 2015-2020 action plan is to assess the implementation, costs, effects, and return on investment of NIPC measures. This project goes in the same way and is one of the first major studies in Canada to evaluate the efficiency of the NIPC measures. Three objectives will be pursued: evaluate the cost of implementing clinical best practices (CBPs) for infection control; evaluate the economic burden attributable to NIs; and examine the cost-effectiveness of the NIPC by comparing the costs of CBPs against those of NIs. Methods: This project is based on an infection control intervention framework that includes four CBPs: hand hygiene; hygiene and sanitation; screening; and additional precautions. Four medical and surgical units in two hospitals (nonUniversity, University) in the province of Quebec will be studied. The project has four components. Component 1 will construct and content validate an observation grid for measuring the costs of CBPs. Component 2 will estimate CBP costs via 2-week prospective observations of health workers, conducted every 2 months over a 1-year period. Component 3 will evaluate, through a matched case-control study, the economic burden of the four most monitored NIs in Quebec (C-difficile, MRSA, VRE, and CPGNB). Archival patient data will be collected retrospectively. Component 4 will determine the optimal breakeven point for CBPs associated with NIPC. Discussion: This project will produce evidence of the economic analysis of NIPC and give health stakeholders an overview of NIPC cost-effectiveness. It will meet the objectives of the Canadian Patient Safety Institute and the MSSS action plan to analyze the efficiency of NIPC preventive measures. To our knowledge, this is the first such exercise in Quebec and Canada. It will provide governments with a decision support tool through a major empirical study that could be replicated nationally to capture the financial benefits of NIPC.

Development and validation of a time and motion guide to assess the costs of prevention and control interventions for nosocomial infections: A Delphi method among experts.

BACKGROUND: Nosocomial infections place a heavy burden on patients and healthcare providers and impact health care institutions financially. Reducing nosocomial infections requires an integrated program of prevention and control using key clinical best care practices. No instrument currently exists that measures these practices in terms of personnel time and material costs. OBJECTIVE: To develop and validate an instrument that would measure nosocomial infection control and prevention best care practice costs, including estimates of human and material resources. METHODS: An evaluation of the literature identified four practices essential for the control of pathogens: hand hygiene, hygiene and sanitation, screening and additional precaution. To reflect time, materials and products used in these practices, our team developed a time and motion guide. Iterations of the guide were assessed in a Delphi technique; content validity was established using the content validity index and reliability was assessed using Kruskall Wallis one-way ANOVA of rank test. RESULTS: Two rounds of Delphi review were required; 88% of invited experts completed the assessment. The final version of the guide contains eight dimensions: Identification [83 items]; Personnel [5 items]; Additional Precautions [1 item]; Hand Hygiene [2 items]; Personal Protective Equipment [14 items]; Screening [4 items]; Cleaning and Disinfection of Patient Care Equipment [33 items]; and Hygiene and Sanitation [24 items]. The content validity index obtained for all dimensions was acceptable (> 80%). Experts statistically agreed on six of the eight dimensions. DISCUSSION/CONCLUSION: This study developed and validated a new instrument based on expert opinion, the time and motion guide, for the systematic assessment of costs relating to the human and material resources used in nosocomial infection prevention and control. This guide will prove useful to measure the intensity of the application of prevention and control measures taken before, during and after outbreak periods or during pandemics such as COVID-19.

Physician perceptions of recruitment and retention factors in an area with a regional medical campus.

BACKGROUND: The factors that influence physicians to establish and maintain their practice in a region are variable. The presence of a regional medical campus (RMC) could influence physicians' choice. The objective of this study was to explore the factors influencing physician recruitment and retention, and in particular the role of a RMC, in a region of Quebec. METHODS: A literature review of factors influencing physicians to stay in a rural area was conducted in order to create an interview guide. Questions were divided into sections: general information, family situation, medical training, career choice, current practice, intent to stay in the region, and impact of the RMC. Thirteen semi-structured individual interviews were conducted with practicing physicians. Data were analyzed using QDAMiner. RESULTS: Recruitment factors were divided into six major themes: type of practice, spousal interest, opportunity for teaching, training in a region, workforce planning, and quality of life. Participants identified positive and negative factors associated with retention. In both cases, family and quality of work environment were mentioned. The RMC was perceived as having important impacts on the quality of professional life, research, medical practice, and regional development. CONCLUSION: This study highlights the role of RMCs in physician recruitment and retention via multiple impacts on the quality of practice of physicians working in the same area.

CONTEXTE: Les facteurs influençant les médecins à s'établir et à rester dans une région sont variables. La présence d'un campus médical régional (CMR) pourrait influencer ce choix. L'objectif de cette étude était d'explorer les facteurs de recrutement et de rétention influençant les médecins ayant choisi de pratiquer dans la région du Saguenay-Lac-Saint-Jean au Québec, en particulier le rôle du CMR. MÉTHODES: Une synthèse de la littérature a permis d'identifier différents facteurs influençant les médecins dans leur choix de lieu de pratique. Un guide d'entrevue a été élaboré à partir de ces facteurs. Les questions étaient séparées selon les sections suivantes: informations générales, situation familiale, études médicales, choix de carrière, pratique actuelle, intention de rester dans la région, impact du CMR. Treize entrevues semi-dirigées individuelles ont été réalisées avec des médecins en pratique. Les données ont été analysées avec QDA Miner. RÉSULTATS: Les facteurs influençant le recrutement étaient séparés en six thèmes majeurs : type de pratique, intérêt du conjoint, opportunité d'enseigner, formation en région, planification gouvernementale des effectifs médicaux et qualité de vie. Les participants ont identifié des facteurs de rétention négatifs et positifs. Ceux-ci concernaient la famille et la qualité de l'environnement de travail. D'après les participants, le CMR avait un impact direct sur la qualité de la vie professionnelle, la recherche, la pratique médicale et le développement régional. CONCLUSION: Cette étude a permis de mettre en évidence le rôle des CMRs dans le recrutement et la rétention via de multiples impacts sur la qualité de pratique des médecins exerçant dans la même région.

Healthcare reforms, inertia polarization and group influence.

Healthcare systems performance is the focus of intense policy and media attention in most countries. Quebec (Canada) is no exception, where successive governments have struggled for decades with apparently intractable problems in care accessibility overall, poor performance, and rising costs. This article explores the underlying causes of the disconnection between the high salience of healthcare system dysfunctions in both media and policy debates and the lack of policy change likely to remedy those dysfunctions. Academically, public policies' evolution is usually conceptualized as the product of complex, long-term interactions among diverse groups with specific power sources and preferences. In this context, we wanted to examine empirically whether divergences in stakeholders' views concerning various healthcare reform options could explain why certain policy changes are not implemented despite consensus on their programmatic coherence. The research design was an exploratory sequential design. Data were analyzed narratively as well as graphically using a method derived from social network analysis and graph theory. Results showed striking intergroup convergence around a programmatically sound policy package centred on the general objective of strengthening primary care delivery capacities. Those results, interpreted in light of political science elitist perspectives on the policy process, suggest that the incapacity to reform the system might be explained by one or two groups' having a de facto veto in policy-making.

Structural analysis of health-relevant policy-making information exchange networks in Canada.

BACKGROUND: Health systems worldwide struggle to identify, adopt, and implement in a timely and system-wide manner the best-evidence-informed-policy-level practices. Yet, there is still only limited evidence about individual and institutional best practices for fostering the use of scientific evidence in policy-making processes The present project is the first national-level attempt to (1) map and structurally analyze-quantitatively-health-relevant policy-making networks that connect evidence production, synthesis, interpretation, and use; (2) qualitatively investigate the interaction patterns of a subsample of actors with high centrality metrics within these networks to develop an in-depth understanding of evidence circulation processes; and (3) combine these findings in order to assess a policy network's "absorptive capacity" regarding scientific evidence and integrate them into a conceptually sound and empirically grounded framework. METHODS: The project is divided into two research components. The first component is based on quantitative analysis of ties (relationships) that link nodes (participants) in a network. Network data will be collected through a multi-step snowball sampling strategy. Data will be analyzed structurally using social network mapping and analysis methods. The second component is based on qualitative interviews with a subsample of the Web survey participants having central, bridging, or atypical positions in the network. Interviews will focus on the process through which evidence circulates and enters practice. Results from both components will then be integrated through an assessment of the network's and subnetwork's effectiveness in identifying, capturing, interpreting, sharing, reframing, and recodifying scientific evidence in policy-making processes. DISCUSSION: Knowledge developed from this project has the potential both to strengthen the scientific understanding of how policy-level knowledge transfer and exchange functions and to provide significantly improved advice on how to ensure evidence plays a more prominent role in public policies.

Supporting nurse practitioners' practice in primary healthcare settings: a three-level qualitative model.

BACKGROUND: While greater reliance on nurse practitioners in primary healthcare settings can improve service efficiency and accessibility, their integration is not straightforward, challenging existing role definitions of both registered nurses and physicians. Developing adequate support practices is therefore essential in primary healthcare nurse practitioners' integration. This study's main objective is to examine different structures and mechanisms put in place to support the development of primary healthcare nurse practitioner's practice in different healthcare settings, and develop a practical model for identifying and planning adequate support practices. METHODS: This study is part of a larger multicentre study on primary healthcare nurse practitioners in the province of Quebec, Canada. It focuses on three healthcare settings into which one or more primary healthcare nurse practitioners have been integrated. Case studies have been selected to cover a maximum of variations in terms of location, organizational setting, and stages of primary healthcare nurse practitioner integration. Findings are based on the analysis of available documentation in each primary healthcare setting and on semi-structured interviews with key actors in each clinical team. Data were analyzed following thematic and cross-sectional analysis approaches. RESULTS: This article identifies three types of support practices: clinical, team, and systemic. This three-level analysis demonstrates that, on the ground, primary healthcare nurse practitioner integration is essentially a team-based, multilevel endeavour. Despite the existence of a provincial implementation plan, the three settings adopted very different implementation structures and practices, and different actors were involved at each of the three levels. The results also indicated that nursing departments played a decisive role at all three levels. CONCLUSIONS: Based on these findings, we suggest that support practices should be adapted to each organization's environment and experience and be modified as needed throughout the integration process. We also stress the importance of combining this approach with a strong coordination mechanism involving managers who have in-depth understanding of nursing professional roles and scopes of practice. Making primary healthcare nurse practitioner integration frameworks more flexible and clarifying and strengthening the role of senior nursing managers could be the key to successful integration.

The Impact of a Researcher's Structural Position on Scientific Performance: An Empirical Analysis.

This article discusses the nature and structure of scientific collaboration as well as the association between academic collaboration networks and scientific productivity. Based on empirical data gathered from the CVs of 73 researchers affiliated with an academic research network in Canada, this study used social network analysis (SNA) to examine the association between researchers' structural position in the network and their scientific performance. With reference to Granovetter's and Burt's theories on weak ties and structural holes, we argue it is the bridging position a researcher holds in a scientific network that matters most to improve scientific performance. The results of correlation scores between network centrality and two different indicators of scientific performance indicate there is a robust association between researchers' structural position in collaboration networks and their scientific performance. We believe this finding, and the method we have developed, could have implications for the way research networks are managed and researchers are supported.