Be careful what you ask for: Things policy-makers should know before mandating networks.

Agents of government have increasingly used networks as policy tools to connect organizations within and/or across public sector jurisdictions. This has been particularly striking in health systems across Canada. Cynics argue they are pseudo-fixes; we take a more optimistic view. We explore the unique features of mandated networks, sharing their limitations and possibilities and providing targeted messages for policy-makers considering using them, ultimately suggesting that they should "be careful what they ask for."

Legitimizing new practices in primary health care.

BACKGROUND: Finding ways to reinvent primary health care is imperative. One way is to change practices from a physician-focused model to an interdisciplinary team approach where other health professionals (nurses, nurse practitioners, dieticians, rehabilitation therapists, and other qualified primary care providers) collectively take on much stronger roles-often providing services instead of the physician. Health care policy makers and professionals agree that these new practices are a good idea, and yet they have not been widely adopted. PURPOSE: Our goal was to understand how new interdisciplinary practices became legitimized as the new accepted working standards. METHODOLOGY: We conducted a qualitative, longitudinal comparative case study of 8 primary health care innovation sites established to provide services through interdisciplinary teams. We followed changes in practices over a 3-year period by conducting 150 interviews with professionals and managers across the 8 sites. FINDINGS: At the end of 3 years, new practices were adopted in 5 of the sites, but in 3 sites, they were not. We explain the differences by identifying a series of strategies used by managers in the successful sites and compare them with those used in the other 3 sites. Strategies used in the successful sites were (a) gaining full engagement, (b) enticing people to try new practices, (c) encouraging structured disagreement, and (d) staying focused on overall goals. PRACTICE IMPLICATIONS: Managers of health care change initiatives must gain buy-in from professionals, but that is not enough. They must also facilitate trying the new practices as soon as possible. Open disagreement should be carefully encouraged, but any concerns must also be successfully addressed. Finally, managers must keep professionals focused on the overall goals of change rather than allowing paralysis in response to external events.

Dimensions of patient safety culture in family practice.

Safety culture has been shown to affect patient safety in healthcare. While the United States and United Kingdom have studied the dimensions that reflect patient safety culture in family practice settings, to date, this has not been done in Canada. Differences in the healthcare systems between these countries and Canada may affect the dimensions found to be relevant here. Thus, it is important to identify and compare the dimensions from the United States and the United Kingdom in a Canadian context. The objectives of this study were to explore the dimensions of patient safety culture that relate to family practice in Canada and to determine if differences and similarities exist between dimensions found in Canada and those found in previous studies undertaken in the United States and the United Kingdom. A qualitative study was undertaken applying thematic analysis using focus groups with family practice offices and supplementary key stakeholders. Analysis of the data indicated that most of the dimensions from the United States and United Kingdom are appropriate in our Canadian context. Exceptions included owner/managing partner/leadership support for patient safety, job satisfaction and overall perceptions of patient safety and quality. Two unique dimensions were identified in the Canadian context: disclosure and accepting responsibility for errors. Based on this early work, it is important to consider differences in care settings when understanding dimensions of patient safety culture. We suggest that additional research in family practice settings is critical to further understand the influence of context on patient safety culture.

Positively deviant networks: what are they and why do we need them?

PURPOSE: This paper aims to report "positively deviant" experiences of three public sector networks seeking to enhance organizational and system level capacities. It is the authors' thesis that the knowledge base concerning the true benefits and pitfalls of networks can be captured and interpreted only through intense, ongoing learning effort embedded in practice on the ground, combined with sustained in-depth observation and collaborative research. DESIGN/METHODOLOGY/APPROACH: The paper describes through case examples why and how different kinds of networks within different jurisdictional contexts and different organizational cultures are being used to enhance the climate for change towards better health care and improved health. The authors describe the contexts, structures, processes and impacts of three "positively deviant" networks. FINDINGS: The network form can provide opportunity for nurturing changes and innovations within large organizational and complex system environments. This opportunity to create additional and different pathways for improved decision making and service provision comes with challenges that should be recognized. PRACTICAL IMPLICATIONS: The authors' experiences indicate that, for networks, a key component of success relates to pulling and pushing at the edges of multiple connections and boundaries in "positively deviant" ways. This pushing and pulling is intrinsically evidence of organizational and intraorganizational learning--in the examples presented--for the improvement of health care and health. ORIGINALITY/VALUE: Other networks can learn from the reported experiences and add their own cases to the empirical understanding of how networks can make a difference; this in turn can help the conceptual and theoretical understanding of them.

Revisiting interaction in knowledge translation.

BACKGROUND: Although the study of research utilization is not new, there has been increased emphasis on the topic over the recent past. Science push models that are researcher driven and controlled and demand pull models emphasizing users/decision-maker interests have largely been abandoned in favour of more interactive models that emphasize linkages between researchers and decisionmakers. However, despite these and other theoretical and empirical advances in the area of research utilization, there remains a fundamental gap between the generation of research findings and the application of those findings in practice. METHODS: Using a case approach, the current study looks at the impact of one particular interaction approach to research translation used by a Canadian funding agency. RESULTS: Results suggest there may be certain conditions under which different levels of decisionmaker involvement in research will be more or less effective. Four attributes are illuminated by the current case study: stakeholder diversity, addressability/actionability of results, finality of study design and methodology, and politicization of results. Future research could test whether these or other variables can be used to specify some of the conditions under which different approaches to interaction in knowledge translation are likely to facilitate research utilization. CONCLUSION: This work suggests that the efficacy of interaction approaches to research translation may be more limited than current theory proposes and underscores the need for more completely specified models of research utilization that can help address the slow pace of change in this area.

e-Health readiness assessment tools for healthcare institutions in developing countries.

e-Health Readiness refers to the preparedness of healthcare institutions or communities for the anticipated change brought by programs related to Information and Communications Technology (ICT). This paper presents e-Health Readiness assessment tools developed for healthcare institutions in developing countries. The objectives of the overall study were to develop e-health readiness assessment tools for public and private healthcare institutions in developing countries, and to test these tools in Pakistan. Tools were developed using participatory action research to capture partners' opinions, reviewing existing tools, and developing a conceptual framework based on available literature on the determinants of access to e-health. Separate tools were developed for managers and for healthcare providers to assess e-health readiness within their institutions. The tools for managers and healthcare providers contained 54 and 50 items, respectively. Each tool contained four categories of readiness. The items in each category were distributed into sections, which either represented a determinant of access to e-health, or an important aspect of planning. The conceptual framework, and the validity and reliability testing of these tools are presented in separate papers. e-Health readiness assessment tools for healthcare providers and managers have been developed for healthcare institutions in developing countries.

Examining the role of context in the implementation of a deliberative public participation experiment: results from a Canadian comparative study.

To resolve tensions among competing sources of evidence and public expectations, health-care managers and policy makers are turning more than ever to involve the public in a wide range of decisions. Yet efforts to use research evidence to inform public involvement decisions are hampered by an absence of rigorous public participation evaluation research. In particular, greater rigour in exploring the roles played by different contextual variables--such as characteristics of the issue of interest, the culture of the sponsoring organization and attributes of the decision being made--is needed. Using a comparative quasi-experimental design, we assessed the performance of a generic public participation method implemented in 5 Canadian regionalized health settings between 2001 and 2004. Participant and decision-maker perspectives were assessed and, through direct observation, the roles exerted by contextual variables over the public involvement processes were documented and analysed. Our findings demonstrate that a generic public participation method can be implemented in a variety of contexts and with considerable success. Context exerts fostering and inhibiting influences that contribute to more (or less) successful implementation. Public participation practitioners are encouraged to pay careful attention to the types of issues and decisions for which they are seeking public input. Sufficient organizational resources and commitment to the goals of the public participation process are also required. Attention to these contextual attributes and their influence on the design and outcomes of public participation processes is as important as choosing the "right" public participation mechanism.

Addressing the non-medical determinants of health: a survey of Canada's health regions.

BACKGROUND: The Canadian health system is undergoing reform. Over the past decade a prominent trend has been creation of health regions. This structural shift is concurrent with a greater emphasis on population health and the broad determinants of health. In parallel, there is a movement toward more intersectoral collaboration (i.e., collaboration between diverse segments of the health system, and between the health system and other sectors of society). The purpose of this exploratory study is to determine the self-reported level of internal action (within regional health authorities) and intersectoral collaboration around 10 determinants of health by regional health authorities across Canada. METHODS: From September 2003 to February 2004, we undertook a survey of regional health authorities in Canadian provinces (N = 69). Using SPSS 12.0, we generated frequencies for the self-reported level of internal and intersectoral action for each determinant. Other analyses were done to compare rural/suburban and urban regions, and to compare Western, Central and Eastern Canada. RESULTS: Of the 10 determinants of health surveyed, child development and personal health practices were self-reported by the majority of health regions to receive greatest attention, both internally and through intersectoral activities. Culture, gender and employment/working conditions received least attention in most regions. CONCLUSION: The exploratory survey results give us the first Canadian snapshot of health regions' activities in relation to the broad range of non-medical determinants of health. They provide a starting data set for baselining future progress, and for beginning deeper analyses of specific areas of action and intersectoral collaboration.

Using networks to enhance health services delivery: perspectives, paradoxes and propositions.

There is a growing need to better understand and address the consequences of an increasing reliance on networks used to enhance health services delivery. Networks seem to have emerged as the definitive solution for tackling complex healthcare problems together that we have not been able to adequately address separately. Emphasizing the collective and the collaborative, networks are assumed to address healthcare issues in ways that are superior to previous service-delivery models. While this assumption would appear to be sound theoretically, we have little empirical information available to actually understand what networks are, what they do and whether they achieve their stated goals--truly making a difference in the delivery of care and the maintenance of health. With a diversity of networks within Canada focused on health services delivery, this paper offers a multi-dimensional framework for conceptualizing how these complex inter-organizational relationships generate both challenges and opportunities. We identify six paradoxes that the networks create when used to enhance the delivery of health services and posit several propositions concerning the evaluative work that needs to be done to enhance our understanding of and confidence in this inter-organizational form. Unless these paradoxes are adequately recognized and addressed, the value and costs associated with developing and using networks in healthcare contexts will remain unclear at best. Given the broad interest in and use of networks proliferating in health-related arenas, it is time to amass the evidence and than align the perspectives. Are networks here to stay in healthcare because they make a difference or because we got tired of talking about the need for greater collaboration and so gave it a new name and frame? At the very least, it will be important to build on what we have already learned through research into collaboration in healthcare and related fields, and even more critical to be mindful of the pitfalls and possibilities of using networks as the solution of choice as we move forward.

Experiences of regionalization: assessing multiple stakeholder perspectives across time.

This paper constructs a beginning frame for analyzing experiences of regionalizing in healthcare systems. Using Alberta as a case example, it traces the perspectives of multiple stakeholders (government, RHAs, frontline staff and public) on key organizational dimensions to describe the various experiences of organizing healthcare through regionalization. As a team of organizational and health researchers, we have been studying this case together and separately for 10 years. We present the framing and our case example to encourage future discussions, debates and consideration of this structural arrangement for healthcare that has swept across most of Canada. We believe that it is critical to learn more about both the pitfalls and potentials that regionalization produces across time and through change for the delivery of care and the protection and improvement of health. And we believe that perspective matters when assessing the full impacts of regionalizing and re-regionalizing and the multiple change processes embedded within these large structural reconfigurations.

Performance measurement in healthcare: part I--concepts and trends from a State of the Science Review.

OBJECTIVE: Performance measurement is touted as an important mechanism for organizational accountability in industrialized countries. This paper describes a systematic review of business and health performance measurement literature to inform a research agenda on healthcare performance measurement. METHODS: A search of the peer-reviewed business and healthcare literature for articles about organizational performance measurement yielded 1,307 abstracts. Multi-rater relevancy ratings, citation checks, expert nominations and quality ratings resulted in 664 articles for review. Key themes were extracted from the papers, followed by multi-reader validation. Information was supplemented with grey literature. RESULTS: The performance literature was diverse and fragmented, and relevant evidence was difficult to locate. Most literature is non-empirical and originates from the United States and the United Kingdom. No agreement on definitions or concepts is evident within or across disciplines. Study quality is not high in either field. Performance measurement arose in public services and business at about the same time. The evolution of thought on performance measurement ranges from unfettered enthusiasm to sober reassessment. CONCLUSIONS: The research base on performance measurement is in its infancy, and evidence to guide practice is sparse. A coherent multidisciplinary research agenda on the topic is needed.

Performance measurement in healthcare: part II--state of the science findings by stage of the performance measurement process.

OBJECTIVE: This paper summarizes findings of a comprehensive, systematic review of the peer-reviewed and grey literature on performance measurement according to each stage of the performance measurement process--conceptualization, selection and development, data collection, and reporting and use. It also outlines implications for practice. METHODS: Six hundred sixty-four articles about organizational performance measurement from the health and business literature were reviewed after systematic searches of the literature, multi-rater relevancy ratings, citation checks and expert author nominations. Key themes were extracted and summarized from the most highly rated papers for each performance measurement stage. RESULTS: Despite a virtually universal consensus on the potential benefits of performance measurement, little evidence currently exists to guide practice in healthcare. Issues in conceptualizing systems include strategic alignment and scope. There are debates on the criteria for selecting measures and on the types and quality of measures. Implementation of data collection and analysis systems is complex and costly, and challenges persist in reporting results, preventing unintended effects and putting findings for improvement into action. CONCLUSION: There is a need for further development and refinement of performance measures and measurement systems, with a particular focus on strategies to ensure that performance measurement leads to healthcare improvement.

Assessment of mental health and illness by telephone survey: experience with an Alberta mental health survey.

Mental health is an emerging priority for health surveillance. It has not been determined that the existing data sources can adequately meet surveillance needs. The objective of this project was to explore the use of telephone surveys as a means of collecting supplementary surveillance information. A computer-assisted telephone interview was administered to 5,400 subjects in Alberta. The interview included a set of brief, validated measures for evaluating mental disorder prevalence and related variables. The individual subject response rate was 78 percent, but a substantial number of refusals occurred at the initial household contact. The age and sex distribution of the study sample differed from that of the provincial population prior to weighting. Prevalence proportions did not vary substantially across administrative health regions. There is a potential role for telephone data collection in mental health surveillance, but these results highlight some associated methodological challenges. They also draw into question the importance of regional variation in mental disorder prevalence--which might otherwise have been a key advantage of telephone survey methodologies.

Creating frameworks for providing services closer to home in the context of a network.

Networks can be used to develop shared frameworks that extend limited specialized healthcare services beyond tertiary level settings to provide services closer to home. This article provides an overview of networks, describes the context and purpose of the Southern Alberta Child & Youth Health Network, reports on early experiences with implementation of an Outreach Services Framework, and discusses implications from a network perspective.

Public participation in regional health policy: a theoretical framework.

How best to involve the public in local health policy development and decision-making is an ongoing challenge for health systems. In the current literature on this topic, there is discussion of the lack of rigorous evaluations upon which to draw generalizable conclusions about what public participation methods work best and for what kinds of outcomes. We believe that for evaluation research on public participation to build generalizable claims, some consistency in theoretical framework is needed. A major objective of the research reported on here was to develop such a theoretical framework for understanding public participation in the context of regionalized health governance. The overall research design followed the grounded theory tradition, and included five case studies of public participation initiatives in an urban regional health authority in Canada, as well as a postal survey of community organizations. This particular article describes the theoretical framework developed, with an emphasis on explaining the following major components of the framework: public participation initiatives as a process; policy making processes with a health region; social context as symbolic and political institutions; policy communities; and health of the population as the ultimate outcome of public participation. We believe that this framework is a good beginning to making more explicit the factors that may be considered when evaluating both the processes and outcomes of public participation in health policy development.

An educational intervention to enhance nurse leaders' perceptions of patient safety culture.

OBJECTIVE: To design a training intervention and then test its effect on nurse leaders' perceptions of patient safety culture. STUDY SETTING: Three hundred and fifty-six nurses in clinical leadership roles (nurse managers and educators/CNSs) in two Canadian multi-site teaching hospitals (study and control). STUDY DESIGN: A prospective evaluation of a patient safety training intervention using a quasi-experimental untreated control group design with pretest and posttest. Nurses in clinical leadership roles in the study group were invited to participate in two patient safety workshops over a 6-month period. Individuals in the study and control groups completed surveys measuring patient safety culture and leadership for improvement prior to training and 4 months following the second workshop. EXTRACTION METHODS: Individual nurse clinical leaders were the unit of analysis. Exploratory factor analysis of the safety culture items was conducted; repeated-measures analysis of variance and paired t-tests were used to evaluate the effect of the training intervention on perceived safety culture (three factors). Hierarchical regression analyses looked at the influence of demographics, leadership for improvement, and the training intervention on nurse leaders' perceptions of safety culture. PRINCIPAL FINDINGS: A statistically significant improvement in one of three safety culture measures was shown for the study group (p<.001) and a significant decline was seen on one of the safety culture measures for the control group (p<.05). Leadership support for improvement was found to explain significant amounts of variance in all three patient safety culture measures; workshop attendance explained significant amounts of variance in one of the three safety culture measures. The total R(2) for the three full hierarchical regression models ranged from 0.338 and 0.554. CONCLUSIONS: Sensitively delivered training initiatives for nurse leaders can help to foster a safety culture. Organizational leadership support for improvement is, however, also critical for fostering a culture of safety. Together, training interventions and leadership support may have the most significant impact on patient safety culture.

Role of telehealth in seating clinics: a case study of learners' perspectives.

We conducted a qualitative case study of the introduction of telehealth in a seating clinic, which was an existing outreach service between two hospitals in Alberta, approximately 300 km apart. Interviews were conducted with the staff who were involved in planning and implementing the telehealth initiative. The study showed that, from the perspective of the staff (who were learners), implementation of telehealth in seating clinics differs from other less tactile telehealth applications in certain ways: (1) the importance of multidisciplinary teams in the procedures, (2) the importance of proper visualization and communication among the staff to convey the pressure changes and measurements to the technicians at the major centre to help them build or adjust the seating devices and (3) the reluctance of staff to trust others' judgements. Planning of service provision and telelearning for seating clinics requires the involvement of staff at all stages. Thus, the implementation of telehealth should be a stepwise process, allowing a highly interactive approach, without affecting the multidisciplinary nature of seating clinics.