Easing the Nursing Shortage: Tools for Retaining Nurses through Mentorship.

To increase retention of nurses and ease the nursing shortage, innovative mentorship strategies must be implemented. Our rapid review shows that mentorship programs in hospitals for early-, mid- and late-career nurses is an effective way to improve nurse retention. The unique needs of internationally educated nurses must also be considered in these programs to bolster the Canadian nursing workforce supply. We highlight five tools that are critical to the successful implementation of nurse mentorship programs in hospitals: (1) establish reciprocal relationships between mentors, mentees, hospital administrators and leaders ; (2) facilitate administrative structures, resources and support for mentors and mentees ; (3) enable effective features of mentorship programs ; (4) ensure that mentorship promotes professional and personal development ; and (5) support internationally educated nurses through mentorship.

For health or for profit? Understanding how private financing and for-profit delivery operate within Canadian healthcare (4H|4P): protocol for a multimethod knowledge mobilisation research project.

INTRODUCTION: Privatisation through the expansion of private payment and investor-owned corporate healthcare delivery in Canada raises potential conflicts with equity principles on which Medicare (Canadian public health insurance) is founded. Some cases of privatisation are widely recognised, while others are evolving and more hidden, and their extent differs across provinces and territories likely due in part to variability in policies governing private payment (out-of-pocket payments and private insurance) and delivery. METHODS AND ANALYSIS: This pan-Canadian knowledge mobilisation project will collect, classify, analyse and interpret data about investor-owned privatisation of healthcare financing and delivery systems in Canada. Learnings from the project will be used to develop, test and refine a new conceptual framework that will describe public-private interfaces operating within Canada's healthcare system. In Phase I, we will conduct an environmental scan to: (1) document core policies that underpin public-private interfaces; and (2) describe new or emerging forms of investor-owned privatisation ('cases'). We will analyse data from the scan and use inductive content analysis with a pragmatic approach. In Phase II, we will convene a virtual policy workshop with subject matter experts to refine the findings from the environmental scan and, using an adapted James Lind Alliance Delphi process, prioritise health system sectors and/or services in need of in-depth research on the impacts of private financing and investor-owned delivery. ETHICS AND DISSEMINATION: We have obtained approval from the research ethics boards at Simon Fraser University, University of British Columbia and University of Victoria through Research Ethics British Columbia (H23-00612). Participants will provide written informed consent. In addition to traditional academic publications, study results will be summarised in a policy report and a series of targeted policy briefs distributed to workshop participants and decision/policymaking organisations across Canada. The prioritised list of cases will form the basis for future research projects that will investigate the impacts of investor-owned privatisation.

Understanding How Post-COVID-19 Condition Affects Adults and Health Care Systems.

Importance: Post-COVID-19 condition (PCC), also known as long COVID, encompasses the range of symptoms and sequelae that affect many people with prior SARS-CoV-2 infection. Understanding the functional, health, and economic effects of PCC is important in determining how health care systems may optimally deliver care to individuals with PCC. Observations: A rapid review of the literature showed that PCC and the effects of hospitalization for severe and critical illness may limit a person's ability to perform day-to-day activities and employment, increase their risk of incident health conditions and use of primary and short-term health care services, and have a negative association with household financial stability. Care pathways that integrate primary care, rehabilitation services, and specialized assessment clinics are being developed to support the health care needs of people with PCC. However, comparative studies to determine optimal care models based on their effectiveness and costs remain limited. The effects of PCC are likely to have large-scale associations with health systems and economies and will require substantial investment in research, clinical care, and health policy to mitigate these effects. Conclusions and Relevance: An accurate understanding of additional health care and economic needs at the individual and health system levels is critical to informing health care resource and policy planning, including identification of optimal care pathways to support people affected by PCC.

Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis.

BACKGROUND: Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery. METHODS: This was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends. RESULTS: The difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was - 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours - 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy. CONCLUSIONS: We found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

Divergent notions of "quality" in healthcare policy implementation: a framing perspective.

PURPOSE: This paper examines how "quality" was framed in the design and implementation of a policy to reform hospital funding and associated care delivery. The aims of the study were: (1) To describe how government policy-makers who designed the policy and managers and clinicians who implemented the policy framed the concept of "quality" and (2) To explore how frames of quality and the framing process may have influenced policy implementation. DESIGN/METHODOLOGY/APPROACH: The authors conducted a secondary analysis of data from a qualitative case study involving semi-structured interviews with 45 purposefully selected key informants involved in the design and implementation of the quality-based procedures policy in Ontario, Canada. The authors used framing theory to inform coding and analysis. FINDINGS: The authors found that policy designers perpetuated a broader frame of quality than implementers who held more narrow frames of quality. Frame divergence was further characterized by how informants framed the relationship between clinical and financial domains of quality. Several environmental and organizational factors influenced how quality was framed by implementers. ORIGINALITY/VALUE: As health systems around the world increasingly implement new models of governance and financing to strengthen quality of care, there is a need to consider how "quality" is framed in the context of these policies and with what effect. This is the first framing analysis of "quality" in health policy.

Why Canada Is in Court to Protect Healthcare for All: Global Implications for Universal Health Coverage.

Countries worldwide are currently endeavoring to safeguard the long-term health of their populations through implementing Universal Health Coverage (UHC), in line with the United Nation's 2015-30 Sustainable Development Goals (SDGs). Canada has some of the world's strongest legislation supporting equitable access to care for medically necessary hospital and physician services based on need, not ability to pay. A constitutional challenge to this legislation is underway in British Columbia (BC), led by a corporate plaintiff, Cambie Surgeries Corporation (CSC). This constitutional challenge threatens to undermine the high bar for UHC protection that Canada has set for the world, with potential adverse implications for equitable international development. CSC claims that BC's healthcare law-the Medicare Protection Act (MPA)-infringes patients' rights under Canada's constitution, by essentially preventing physicians who are enrolled in BC's publicly-funded Medicare plan from providing expedited care to patients for a private fee. In September 2020, after a trial that ran for 3.5 years and included testimony by more than 100 witnesses from around the world, the court dismissed the plaintiffs' claim. Having lost their case in the Supreme Court of BC, the plaintiffs' appealed in June 2021. The appellate court's ruling and reasons for judgment are expected sometime in 2021. We consider the evidence before the court from the perspective of social epidemiology and health inequalities, demonstrating that structural features of a modern society that exacerbate inequalities, including inequitable access to healthcare, can be expected to lead to worse overall societal outcomes.

Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study.

BACKGROUND: The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction. METHODS: Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010-2017. Outcomes included return to hospital or death within 30 days, acute length of stay (LOS), volume of admissions, and patient characteristics. RESULTS: At 2 years post-QBPs, the percentage of hip fracture patients who returned to hospital or died was 3.13% higher in absolute terms (95% CI: 0.37% to 5.89%) than if QBPs had not been introduced. There were no other statistically significant changes for return to hospital or death. For LOS, the only statistically significant change was an increase for prostate cancer surgery of 0.33 days (95% CI: 0.07 to 0.59). Volume increased for congestive heart failure admissions by 80 patients (95% CI: 2 to 159) and decreased for hip fracture surgery by 138 patients (95% CI: -183 to -93) but did not change for pneumonia or prostate cancer surgery. The percentage of patients who lived in the lowest neighborhood income quintile increased slightly for those diagnosed with congestive heart failure (1.89%; 95% CI: 0.51% to 3.27%) and decreased for those who underwent prostate cancer surgery (-2.08%; 95% CI: -3.74% to -0.43%). INTERPRETATION: This policy initiative involving a change to hospital funding for certain conditions was not associated with substantial, jurisdictional-level changes in access or quality.

Out of sync: a Shared Mental Models perspective on policy implementation in healthcare.

The impact of policy ambiguity on implementation is a perennial concern in policy circles. The degree of ambiguity of policy goals and the means to achieve them influences the likelihood that a policy will be uniformly understood and implemented across implementation sites. We argue that the application of institutional and organisational theories to policy implementation must be supplemented by a socio-cognitive lens in which stakeholders' interpretations of policy are investigated and compared. We borrow the concept of 'Shared Mental Models' from the literature on industrial psychology to examine the microprocesses of policy implementation. Drawing from interviews with 45 key informants involved in the implementation of a hospital funding reform, known as Quality-Based Procedures in Ontario, Canada, we identify divergent mental models and explain how these divergences may have affected implementation and change management. We close with considerations for future research and practice.

Management Strategies and Patient Selection After a Hospital Funding Reform for Prostate Cancer Surgery in Canada.

Importance: Hospital funding reforms for prostate cancer surgery may have altered management of localized prostate cancer in the province of Ontario, Canada. Objective: To determine whether changes in hospital funding policy aimed at improving health care quality and value were associated with changes in the management of localized prostate cancer or the characteristics of patients receiving radical prostatectomy (RP) for localized prostate cancer. Design, Setting, and Participants: This population-based, interrupted time series study used linked population-based administrative data regarding adults in Ontario with incidental localized prostate cancer and those who underwent RP for localized prostate cancer. Patients who underwent RP were compared with patients who underwent surgical procedures for localized renal cell carcinoma, which was not included in the policy change but was subjected to similar secular trends and potential confounders. Monthly outcomes were analyzed using interventional autoregressive integrated moving average models. Data were collected from January 2011 to November 2017 and analyzed in January 2019. Exposures: Funding policy change in April 2015 from flexible block funding for all hospital-based care to prespecified payment amounts per procedure for treatment of localized prostate cancer, coupled with the dissemination of a diagnosis-specific handbook outlining best practices. Main Outcomes and Measures: Initial management (RP vs radiation therapy vs active surveillance) and tumor risk profiles per management strategy among incident cases of localized prostate cancer. Additional outcomes were case volume, mean length of stay, proportion of patients returning to hospital or emergency department within 30 days, proportion of patients older than 65 years, mean Charlson Comorbidity Index, and proportion of minimally invasive surgical procedures among patients undergoing RP for localized prostate cancer. Results: A total of 33 128 patients with incident localized prostate cancer (median [interquartile range (IQR)] age, 67 [61-73] years; median [IQR] cases per monthly observation interval, 466 [420-516]), 17 159 patients who received radical prostatectomy (median [IQR] age, 63 [58-68] years; median [IQR] cases per monthly observation interval, 209 [183-225]), and 5762 individuals who underwent surgery for renal cell carcinoma (median [IQR] age, 62 [53-70] years; median [IQR] cases per monthly observation interval, 71 [61-77]) were identified. By the end of the observation period, radical prostatectomy and radiation therapy were used in comparable proportions (30.3% and 28.9%, respectively) and included only a small fraction of low-risk patients (6.4% and 2.9%, respectively). No statistically significant association of the funding policy change with most outcomes was found. Conclusions and Relevance: The implementation of funding reform for hospitals offering RP was not associated with changes in the management of localized prostate cancer, although it may have encouraged more appropriate selection of patients for RP. Mostly preexisting trends toward guideline-conforming practice were observed. Co-occurring policy changes and/or guideline revisions may have weakened signals from the policy change.

Standardising costs or standardising care? Qualitative evaluation of the implementation and impact of a hospital funding reform in Ontario, Canada.

BACKGROUND: Since 2011, the Government of Ontario, Canada, has phased in hospital funding reforms hoping to encourage standardised, evidence-based clinical care processes to both improve patient outcomes and reduce system costs. One aspect of the reform - quality-based procedures (QBPs) - replaced some of each hospital's global budget with a pre-set price per episode of care for patients with specific diagnoses or procedures. The QBP initiative included publication and dissemination of a handbook for each of these diagnoses or procedures, developed by an expert technical group. Each handbook was intended to guide hospitals in reducing inappropriate variation in patient care and cost by specifying an evidence-based episode of care pathway. We explored whether, how and why hospitals implemented these episode of care pathways in response to this initiative. METHODS: We interviewed key informants at three levels in the healthcare system, namely individuals who conceived and designed the QBP policy, individuals and organisations supporting QBP adoption, and leaders in five case-study hospitals responsible for QBP implementation. Analysis involved an inductive approach, incorporating framework analysis to generate descriptive and explanatory themes from data. RESULTS: The 46 key informants described variable implementation of best practice episode of care pathways across QBPs and across hospitals. Handbooks outlining evidence-based clinical pathways did not address specific barriers to change for different QBPs nor differences in hospitals' capacity to manage change. Hospitals sometimes found it easier to focus on containing and standardising costs of care than on implementing standardised care processes that adhered to best clinical practices. CONCLUSION: Implementation of QBPs in Ontario's hospitals depended on the interplay between three factors, namely complexity of changes required, internal capacity for organisational change, and availability and appropriateness of targeted external facilitators and supports to manage change. Variation in these factors across QBPs and hospitals suggests the need for more tailored and flexible implementation supports designed to fit all elements of the policy, rather than one-size-fits-all handbooks alone. Without such supports, hospitals may enact quick fixes aimed mainly at preserving budgets, rather than pursue evidence- and value-based changes in care management. Overestimating hospitals' change management capacity increases the risk of implementation failure.

Correction: Qualitative analysis of the dynamics of policy design and implementation in hospital funding reform.

[This corrects the article DOI: 10.1371/journal.pone.0191996.].

Qualitative analysis of the dynamics of policy design and implementation in hospital funding reform.

BACKGROUND: As in many health care systems, some Canadian jurisdictions have begun shifting away from global hospital budgets. Payment for episodes of care has begun to be implemented. Starting in 2012, the Province of Ontario implemented hospital funding reforms comprising three elements: Global Budgets; Health Based Allocation Method (HBAM); and Quality-Based Procedures (QBP). This evaluation focuses on implementation of QBPs, a procedure/diagnosis-specific funding approach involving a pre-set price per episode of care coupled with best practice clinical pathways. We examined whether or not there was consensus in understanding of the program theory underpinning QBPs and how this may have influenced full and effective implementation of this innovative funding model. METHODS: We undertook a formative evaluation of QBP implementation. We used an embedded case study method and in-depth, one-on-one, semi-structured, telephone interviews with key informants at three levels of the health care system: Designers (those who designed the QBP policy); Adoption Supporters (organizations and individuals supporting adoption of QBPs); and Hospital Implementers (those responsible for QBP implementation in hospitals). Thematic analysis involved an inductive approach, incorporating Framework analysis to generate descriptive and explanatory themes that emerged from the data. RESULTS: Five main findings emerged from our research: (1) Unbeknownst to most key informants, there was neither consistency nor clarity over time among QBP designers in their understanding of the original goal(s) for hospital funding reform; (2) Prior to implementation, the intended hospital funding mechanism transitioned from ABF to QBPs, but most key informants were either unaware of the transition or believe it was intentional; (3) Perception of the primary goal(s) of the policy reform continues to vary within and across all levels of key informants; (4) Four years into implementation, the QBP funding mechanism remains misunderstood; and (5) Ongoing differences in understanding of QBP goals and funding mechanism have created challenges with implementation and difficulties in measuring success. CONCLUSIONS: Policy drift and policy layering affected both the goal and the mechanism of action of hospital funding reform. Lack of early specification in both policy goals and hospital funding mechanism exposed the reform to reactive changes that did not reflect initial intentions. Several challenges further exacerbated implementation of complex hospital funding reforms, including a prolonged implementation schedule, turnover of key staff, and inconsistent messaging over time. These factors altered the trajectory of the hospital funding reforms and created confusion amongst those responsible for implementation. Enacting changes to hospital funding policy through a process that is transparent, collaborative, and intentional may increase the likelihood of achieving intended effects.

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis.

BACKGROUND: Activity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care. METHODS: We undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication. RESULTS: Of 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk  = 1.24, 95% CI 1.18-1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences. CONCLUSIONS: Transitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

Physicians' perceptions of quality of care, professional autonomy, and job satisfaction in Canada, Norway, and the United States.

BACKGROUND: We lack national and cross-national studies of physicians' perceptions of quality of patient care, professional autonomy, and job satisfaction to inform clinicians and policymakers. This study aims to compare such perceptions in Canada, the United States (U.S.), and Norway. METHODS: We analyzed data from large, nationwide, representative samples of physicians in Canada (n = 3,213), the U.S. (n = 6,628), and Norway (n = 657), examining demographics, job satisfaction, and professional autonomy. RESULTS: Among U.S. physicians, 79% strongly agreed/agreed they could provide high quality patient care vs. only 46% of Canadian and 59% of Norwegian physicians. U.S. physicians also perceived more clinical autonomy and time with their patients, with differences remaining significant even after controlling for age, gender, and clinical hours. Women reported less adequate time, clinical freedom, and ability to provide high-quality care. Country differences were the strongest predictors for the professional autonomy variables. In all three countries, physicians' perceptions of quality of care, clinical freedom, and time with patients influenced their overall job satisfaction. Fewer U.S. physicians reported their overall job satisfaction to be at-least-somewhat satisfied than did Norwegian and Canadian physicians. CONCLUSIONS: U.S. physicians perceived higher quality of patient care and greater professional autonomy, but somewhat lower job satisfaction than their colleagues in Norway and Canada. Differences in health care system financing and delivery might help explain this difference; Canada and Norway have more publicly-financed, not-for-profit health care delivery systems, vs. a more-privately-financed and profit-driven system in the U.S. None of these three highly-resourced countries, however, seem to have achieved an ideal health care system from the perspective of their physicians.

Prenatal care in the Commonwealth of the Northern Mariana Islands.

Adequacy of prenatal care is assessed in this retrospective analysis of the births occurring in the Commonwealth of the Northern Mariana Islands (CNMI) from 1986 - 1996. Overall, adequacy of prenatal care has not changed significantly, despite a large increase in population and births. Adequacy was measured by assessing trimester of prenatal care onset as well as total number of visits. 'Adequate' prenatal care, defined as onset of care in 1st or 2nd trimester and at least 7 prenatal clinic visits, was received by less than half of the mothers delivering in the CNMI. Early (1 trimester) prenatal care was received by less than 2 of all mothers. Most indicators of 'adequate' prenatal care are significantly worse in the CNMI than in the U.S. or Guam.