Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia.

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

Orchestrating performance of healthcare networks subjected to the compound events of natural disasters and pandemic.

The current COVID-19 pandemic has demonstrated the vulnerability of healthcare systems worldwide. When combined with natural disasters, pandemics can further strain an already exhausted healthcare system. To date, frameworks for quantifying the collective effect of the two events on hospitals are nonexistent. Moreover, analytical methods for capturing the dynamic spatiotemporal variability in capacity and demand of the healthcare system posed by different stressors are lacking. Here, we investigate the combined impact of wildfire and pandemic on a network of hospitals. We combine wildfire data with varying courses of the spread of COVID-19 to evaluate the effectiveness of different strategies for managing patient demand. We show that losing access to medical care is a function of the relative occurrence time between the two events and is substantial in some cases. By applying viable mitigation strategies and optimizing resource allocation, patient outcomes could be substantially improved under the combined hazards.

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria.

BACKGROUND: Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities. METHODS: This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high). RESULTS: Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high. CONCLUSION: Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

Manual de organización y funciones: Departamento de Regulación, Acreditación y Control de Establecimientos de salud / Organization and functions manual: Department of Regulation, Accreditation and Control of Health Establishments

Un poco apagado, que dificulta un poco la lectura. Entre los diversos objetivos del reglamento, está la de servir de inducción al nuevo personal de la unidad, puesto que da sentido al trabajo, desde los aspectos: técnicos, administrativos y legales. Específicamente el objetivo general es: tener un documento técnico de gestión institucional que describa y establezca la organización, funciones generales y específicas de cada unidad y puesto de trabajo. Contiene la base legal del departamento en cuestión, así como los antecedentes del mismo; se describen además, su visión y misión, objetivos generales y específicos, así como las funciones del mismo. Incluye la estructura organizacional, organigrama, así como una detallada descripción de los puestos de mando, técnicos y administrativos. Otro tanto se hace con cada unidad del departamento.

Guidance for the Prevention of the COVID-19 Epidemic in Long-Term Care Facilities: A Short-Term Prospective Study.

BACKGROUND: Guidance aiming at limiting the entry and spread of the COVID-19 have been widely communicated to Long-term Care Facilities (LTCFs). However, no clinical research has investigated their relevance. OBJECTIVE: Our objective was to compare the guidance applied for the prevention of the COVID-19 epidemic between the LTCFs having been contaminated by COVID-19 and LTCFs having not been contaminated. METHODS: A questionnaire was sent and systematically accompanied by phone call to the 132 LTCFs of Haute-Garonne (Occitania region, South-West of France). The questionnaire focused on the preventive measures implemented before March 23, 2020 (first LTCFs contaminated in this area). The questionnaire focused on physician support, implementation of usual guidance (eg, masks, hydro-alcoholic solute used), training on hygiene, containment in residents' rooms and other distancing measures, use of temporary workers, compartmentalization within zones of residents and staff and a self-assessment analogic scale on the quality of the application of the preventive measures. We compared implementation of the guidance between the LTCFs with at least one case of COVID-19 among residents and/or health care professionals and LTCFs without COVID-19 case (between March 23rd and May 6th). RESULTS: 124 LTCFs participated (93.9%). 30 LTCFs (24.19%) were contaminated with COVID-19. Large heterogeneity of the application of the guidance was observed. Public LTCFs (OR= 0.39 (0.20-0.73), LTCFs which organized staff compartmentalization within zones (OR= 0.19 (0.07-0.48)), and LTCF with a staff who self-assessed a higher quality implementation of the preventive measures (OR= 0.65 (0.43-0.98)) were significantly more likely to avoid contamination by the COVID-19 outbreak. CONCLUSION: Our study supports the relevance of guidance to prevent the entry of COVID-19, in particular the staff compartmentalization within zones, as well as the perception of the staff regarding the quality of implementation of those measures in LTCFs.

Addressing Sexual Harassment in the #MeToo Era: An Institutional Approach.

Sexual harassment is a particularly pernicious form of harassment that can result in long-lasting psychological damage to victims. In health care, it has deleterious effects on teamwork and communication and may affect patient care. Although concerns regarding sexual harassment in the workplace, including within health care, are not new, increased attention has been focused on this topic since late 2017 as a result of the #MeToo movement. As in other sectors, health care centers have experienced instances of sexual harassment. Evidence indicates that harassment in health care centers is not uncommon and has not decreased with time. Beyond reporting and addressing, health care institutions must establish policies that clearly outline the unacceptability of harassing behaviors. Moreover, institutions must have a systematic method to thoroughly investigate allegations of sexual harassment and to impose fair and consistent corrective actions when allegations are substantiated. This article describes Mayo Clinic's approach to this complex problem, including targeted efforts toward developing a culture intolerant of sexually harassing behavior.

Protocol for a systematic review of the effects of interventions for vaccine stock management.

BACKGROUND: Inadequate vaccine stock management in health facilities leads to vaccine stock-outs. The latter threatens the success of immunisation programmes. Countries have used various approaches to reduce stock-outs and improve vaccine availability, but we are not aware of a systematic review of these interventions. This protocol describes the methods we will use to assess the effects of existing approaches for improving vaccine stock management. METHODS: We include randomised and non-randomised studies identified through a compehensive search of peer-reviewed and grey literature databases. We will search PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science, PDQ-Evidence and Scopus. We will also search websites of the World Health Organisation (WHO), Global Alliance for Vaccine and Immunisation, PATH Vaccine Resources Library and United Nations Children's Fund. In addition, we will search the WHO International Clinical Trials Registry Platform and reference lists of included studies and relevant reviews. Finally, we plan to do a citation search for included studies. We will use Cochrane recommended methods to screen search outputs, assess study eligibility and risk of bias, extract and analyse study results. We will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool to assess the certainty of the evidence on the effects of the interventions. DISCUSSION: We believe that the findings of this review will serve as valuable information for policy makers on ways to improve vaccine stock management and vaccine availability. When vaccine availability is improved, those who need them, especially children, will be adequately protected from vaccine-preventable diseases. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018092215.

Assessing Unwanted Variations in Rheumatology Clinic Previsit Rooming.

BACKGROUND: Rheumatologists face time pressures similar to primary care but have not generally benefitted from optimized team-based rooming during the time from the waiting room until the rheumatologist enters the room. OBJECTIVE: The aim of this study was to assess current capacity for population management in rheumatology clinics; we aimed to measure the tasks performed by rheumatology clinic staff (medical assistants or nurses) during rooming. METHODS: We performed a cross-sectional time-study and work-system analysis to measure rooming workflows at 3 rheumatology clinics in an academic multispecialty practice during 2014-2015. We calculated descriptive statistics and compared frequencies and durations using Fisher exact test and analysis of variance. RESULTS: Observing 190 rheumatology clinic previsit rooming sequences (1419 minutes), we found many significant variations. Total rooming duration varied by clinic (median, 6.75-8.25 minutes; p < 0.001). Vital sign measurement and medication reconciliation accounted for more than half of rooming duration. Among 3 clinics, two of 15 tasks varied significantly in duration, and 9 varied in frequency. Findings led clinic leaders to modify policies and procedures regarding 6 high-variation tasks streamlining assessment of weight, height, pain scores, tobacco use, disease activity, and refill needs. CONCLUSIONS: Assessing rheumatology rooming tasks identified key opportunities to improve quality and efficiency without burdening providers. This project demonstrated user-friendly methods to identify opportunities to standardize rooming and support data-driven decisions regarding rheumatology clinic practice changes to improve population management in rheumatology.

How to improve healthcare? Identify, nurture and embed individuals and teams with "deep smarts".

Purpose Unlocking and transferring skills and capabilities in individuals to the teams they work within, and across, is the key to positive organisational development and improved patient care. Using the "deep smarts" model, the purpose of this paper is to examine these issues. Design/methodology/approach The "deep smarts" model is described, reviewed and proposed as a way of transferring knowledge and capabilities within healthcare organisations. Findings Effective healthcare delivery is achieved through, and continues to require, integrative care involving numerous, dispersed service providers. In the space of overlapping organisational boundaries, there is a need for "deep smarts" people who act as "boundary spanners". These are critical integrative, networking roles employing clinical, organisational and people skills across multiple settings. Research limitations/implications Studies evaluating the barriers and enablers to the application of the deep smarts model and 13 knowledge development strategies proposed are required. Such future research will empirically and contemporary ground our understanding of organisational development in modern complex healthcare settings. Practical implications An organisation with "deep smarts" people - in managerial, auxiliary and clinical positions - has a greater capacity for integration and achieving improved patient-centred care. Originality/value In total, 13 developmental strategies, to transfer individual capabilities into organisational capability, are proposed. These strategies are applicable to different contexts and challenges faced by individuals and teams in complex healthcare organisations.

[The experience of a health centre undergoing an ecological transition]. / Établissement en transition écologique, retour d'expérience.

A health centre and its staff have undertaken a sustainable health approach which aims to reduce the impact of the environment on health. One of the initiatives focused on the improvement of indoor air quality. A change to practices was possible thanks to a participative approach, the support of the staff and constant communication.

Pathways to high and low performance: factors differentiating primary care facilities under performance-based financing in Nigeria.

The determinants of primary health facility performance in developing countries have not been well studied. One of the most under-researched areas is health facility management. This study investigated health facilities under the pilot performance-based financing (PBF) scheme in Nigeria, and aimed to understand which factors differentiated primary health care centres (PHCCs) which had performed well, vs those which had not, with a focus on health facility management practices. We used a multiple case study where we compared two high-performing PHCCs and two low-performing PHCCs for each of the two PBF target states. Two teams of two trained local researchers spent 1 week at each PHCC and collected semi-structured interview, observation and documentary data. Data from interviews were transcribed, translated and coded using a framework approach. The data for each PHCC were synthesized to understand dynamic interactions of different elements in each case. We then compared the characteristics of high and low performers. The areas in which critical differences between high and low-performers emerged were: community engagement and support; and performance and staff management. We also found that (i) contextual and health system factors particularly staffing, access and competition with other providers; (ii) health centre management including community engagement, performance management and staff management; and (iii) community leader support interacted and drove performance improvement among the PHCCs. Among them, we found that good health centre management can overcome some contextual and health system barriers and enhance community leader support. This study findings suggest a strong need to select capable and motivated health centre managers, provide long-term coaching in managerial skills, and motivate them to improve their practices. The study also highlights the need to position engagement with community leaders as a key management practice and a central element of interventions to improve PHCC performance.

Quality Improvement in Nursing Homes: Alignment Among Leaders Across the Organizational Chart.

Background and Objectives: This article describes nursing home (NH) leaders' involvement in quality improvement (QI) decisions, with an emphasis on the concept of alignment in QI decisions across leaders. Research Design and Methods: We used a qualitative approach and semistructured interviews to collect data from a convenience sample of 39 NH leaders, including corporate/executive-level leaders and facility-level leaders. Thematic analysis was used to inductively capture key patterns in data. Results: Variations in alignment emerged as a major theme to describe the interface and interaction among facility- and corporate/executive-level leaders around QI decision making and implementation of QI decisions. For this study, alignment refers to the extent of shared understanding, beliefs, motivations, and implied or explicit agreement among leaders in regards to: (a) goals, values, priorities, and expectations for quality or QI (and/or applicable resources); and (b) expectations for leaders to carry out QI decisions made by other leaders. Discussion and Implications: This study offers new insights into the complexities associated with leadership alignment toward improving NH quality. The findings provide a glimpse into leaders' involvement in QI based on their position on the facility's organizational chart and extend our understanding of the centrality of the concept of alignment in promoting QI. These findings may inform future research on facility- and corporate/executive-level leader interactions and how these interactions impact quality outcomes.

Gestión: prácticas, mitos e ideologías / Administration: practices, myths and ideologies

RESUMEN Se aborda la gestión en el campo social a partir de analizar sus prácticas, el mito racionalista y sus dimensiones ideológicas. Para ello, se discuten los conceptos más utilizados (administración, gerencia, managment, gestión) y sus etimologías; las fuertes limitaciones para su enseñanza; la complejidad de la práctica atravesada por dimensiones de la ciencia, el arte y el juego; y la cuestión ideológica provista por la gran usina de pensamiento que, desde inicios del siglo XIX, conforma la teoría general de la administración. Se reflexiona, además, sobre la necesidad de construir una teoría de esa práctica contextualizada desde el sur y por fuera de sus encuadres clásicos y, sobre todo, de transformar la gestión en un problema a ser discutido por fuera de los conocimientos que la reconocen como una práctica técnica.

ABSTRACT Administration in the social field is examined based on an analysis of its practices, the rationalist myth and its ideological dimensions. In this way, the article discusses the most frequently utilized concepts (administration, management, gerencia, gestión) and their etymologies; the limitations of teaching administration; the complexity of a practice marked by the dimensions of science, art and the social game; and the ideological question underlying the great thought factory that the general theory of administration has been since the start of the 19th century. The article reflects upon the need to construct a theory based in practice contextualized in the global south that goes beyond the classic frames of reference and, above all, to transform administration into a problem to be discussed outside of the knowledge that recognizes it as a technical practice.

Understanding the implementation of maternity waiting homes in low- and middle-income countries: a qualitative thematic synthesis.

BACKGROUND: Maternity waiting homes (MWHs) are accommodations located near a health facility where women can stay towards the end of pregnancy and/or after birth to enable timely access to essential childbirth care or care for complications. Although MWHs have been implemented for over four decades, different operational models exist. This secondary thematic +analysis explores factors related to their implementation. METHODS: A qualitative thematic analysis was conducted using 29 studies across 17 countries. The papers were identified through an existing Cochrane review and a mapping of the maternal health literature. The Supporting the Use of Research Evidence framework (SURE) guided the thematic analysis to explore the perceptions of various stakeholders and barriers and facilitators for implementation. The influence of contextual factors, the design of the MWHs, and the conditions under which they operated were examined. RESULTS: Key problems of MWH implementation included challenges in MWH maintenance and utilization by pregnant women. Poor utilization was due to lack of knowledge and acceptance of the MWH among women and communities, long distances to reach the MWH, and culturally inappropriate care. Poor MWH structures were identified by almost all studies as a major barrier, and included poor toilets and kitchens, and a lack of space for family and companions. Facilitators included reduced or removal of costs associated with using a MWH, community involvement in the design and upkeep of the MWHs, activities to raise awareness and acceptance among family and community members, and integrating culturally-appropriate practices into the provision of maternal and newborn care at the MWHs and the health facilities to which they are linked. CONCLUSION: MWHs should not be designed as an isolated intervention but using a health systems perspective, taking account of women and community perspectives, the quality of the MWH structure and the care provided at the health facility. Careful tailoring of the MWH to women's accommodation, social and dietary needs; low direct and indirect costs; and a functioning health system are key considerations when implementing MWH. Improved and harmonized documentation of implementation experiences would provide a better understanding of the factors that impact on successful implementation.

Leaders go first: Creating and sustaining a culture of high performance.

The culture of a healthcare organization plays a critically important role in determining whether strategic plans will be executed effectively and organizational goals will be achieved. A culture of high performance serves as a foundation that supports the implementation of healthcare strategies and enables health leaders to evaluate, select, optimize, and sustain a full portfolio of improvement initiatives linked directly to top priorities and mandates. This article argues that a culture of high performance should become an integral part of all strategic planning and, further, that a strong and explicit leadership commitment, beginning with the board and CEO and extending throughout all leadership levels, is required to implement a successful culture transformation. Proven methods for developing a culture of high performance in practice are described, addressing key areas such as alignment, accountability, standard behaviours and practices, leader development, discipline, and consistency.

Retos de la planificación estratégica en instituciones de salud / Challenges of strategic planning in health institutions

La planificación estratégica constituye una de las actividades clave de todas las organizaciones, urgidas de extender su actuación más allá del corto plazo, en un entorno marcado por la incertidumbre, el riesgo y los cambios multicausales. Particularmente para las instituciones de salud este es un tema trascendental, si se considera su alta responsabilidad social que implica a diversos grupos internos y externos, cuyos objetivos deberán ser manejados con coherencia a través de un adecuado proceso de planificación estratégica. El objetivo de la presente comunicación es analizar los principales retos que tiene esta actividad en instituciones de salud, satisfaciendo las necesidades de todos los involucrados y garantizando el rigor técnico requerido(AU)

Strategic planning is one of the key activities of all organizations, urged to extend their actions beyond the short term, in an environment marked by uncertainty, risk and multicausal changes. Particularly for health institutions, this is a transcendental issue, considering their high social responsibility, which involves various internal and external groups, whose objectives must be managed consistently through an adequate process of strategic planning. The objective of this communication is to analyze the main challenges that this activity has in health institutions, meeting the needs of all involved and guaranteeing the required technical rigor(AU)

La gestión de los intangibles en la percepción de los servicios sanitarios públicos / The management of intangibles on the perception of public health services

Conscientes de la importancia de la orientación de la gestión sanitaria hacia la satisfacción de sus usuarios, en este artículo pretendemos identificar cuáles son los aspectos que más influyen en la satisfacción de los españoles con la sanidad pública, y de qué manera lo hacen. De este modo, es posible orientar las políticas públicas sanitarias hacia la maximización de los objetivos de eficiencia y eficacia que, entendemos, no residen únicamente en mejorar el estado de salud de los ciudadanos, sino también en generarles confianza en el sistema, contribuyendo a legitimar las instituciones sanitarias, y con ellas el Estado del Bienestar que las sustenta. Para ello, construimos un modelo de explicación de la satisfacción ciudadana con el sistema sanitario público que testamos a través de modelos de ecuaciones estructurales

Aware of the importance of the orientation of health management towards the satisfaction of its users, this article aims to identify what are the aspects that most influence the satisfaction of the Spaniards with the public health system, and how they do so. With the identification of these elements, it is possible to guide the public policies in health towards the maximization of the objectives of efficiency and effectiveness which we understand, lie not only in improving the state of health of the citizens, but also on building confidence in the system, contributing to legitimize public health institutions and the Welfare State that sustains them. To do this, we build a model of explanation of the citizen satisfaction with the public healthcare system that we test through Structural Equation Models