The ELIAS framework: A prescription for innovation and change.

Healthcare is a complex adaptive system with multiple stakeholders and dynamic environments. Therefore, healthcare organizations must continuously learn, innovate, adapt, and co-evolve to be successful. This article describes a systematic, comprehensive, and holistic performance management framework that healthcare managers can use to achieve these goals. The framework involves the ongoing assessment, modification, or replacement of current programs or services aimed at adapting successfully to achieve the organization's strategic objectives. This is engendered by the presence of a culture that is premised on continuous learning and innovation. The foundation of the framework is based on accountability, the organization's strategy, and its culture. This then acts as the basis for an ongoing process of measurement, disconfirmation, contextualization, implementation, and routinization that enhances learning, innovation, adaptation, and sustainability within the healthcare organization.

Physician engagement: a concept analysis.

The term "physician engagement" is used quite frequently, yet it remains poorly defined and measured. The aim of this study is to clarify the term "physician engagement." This study used an eight step-method for conducting concept analyses created by Walker and Avant. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched on February 14, 2019. No limitations were put on the searches with regard to year or language. Results identify that the term "physician engagement" is regular participation of physicians in (1) deciding how their work is done, (2) making suggestions for improvement, (3) goal setting, (4) planning, and (5) monitoring of their performance in activities targeted at the micro (patient), meso (organization), and/or macro (health system) levels. The antecedents of "physician engagement" include accountability, communication, incentives, interpersonal relations, and opportunity. The results include improved outcomes such as data quality, efficiency, innovation, job satisfaction, patient satisfaction, and performance. Defining physician engagement enables physicians and health care administrators to better appreciate and more accurately measure engagement and understand how to better engage physicians.

Designing a Performance Measurement System for Accountability, Quality Improvement, and Innovation.

The purpose of this article is to detail a system for the design of performance measures that will be used to assess the achievement of a health care organization's strategic goals and its need for change. The article begins by emphasizing the importance of accountability and the need for the presence of a dynamic learning culture that is premised on a foundation of accountability, continuous improvement, learning, and innovation. This is followed by describing the importance of utilizing an interdisciplinary team with physician and patient involvement to guide the design and implementation of the performance measurement system. The goals of the system are then outlined and followed by a description of the process for the determination of the framework, scope, domains, measures, and reporting mechanisms for displaying the performance measures. Lastly, guidelines for the design of valid, reliable, and cost-effective performance measures are discussed with the aim of maximizing their utility by health care professionals, managers, and administrators.

Diversity of hepatitis C virus infection among HIV-infected people who inject drugs in India.

The availability of generic direct acting antivirals (DAAs) for hepatitis C virus (HCV) treatment has prompted many low-and-middle-income countries to launch HCV elimination programs. Because the efficacy of some of these generic DAAs varies by HCV viral subtype, information on subtype distribution can contribute important information to these elimination programs. We conducted a cross-sectional serosurvey to characterize HCV subtype diversity among HIV positive people who inject drugs (PWID) across 14 cities in India. Of 801 HIV positive PWID sampled, 639 tested HCV antibody positive (78.9%). Among 105 samples sequenced, genotype 3 (58.1%) was the most commonly observed followed by genotype 1 (36.2%) and genotype 6 (5.7%). Of the genotype 3 infections, 65% were subtype 3a and 35% were subtype 3b. Of the genotype 1 infections, 94% were subtype 1a and 6% were subtype 1b. All genotype 6 samples were subtype 6n. There was some variability in genotype diversity depending on geographic region and PWID epidemic stage with greater diversity observed in older PWID epidemics. One sequence, HY018, did not cluster with any known reference sequences in phylogenetic analysis. Nearly 80% of HIV infected PWID across India are co-infected with HCV, and subtype prevalence and genetic diversity varied by region and PWID epidemic stage. HCV elimination programs in India will need to consider HCV subtype.

Introduction of spirometry into clinical practice in Georgetown, Guyana: quality and diagnostic outcomes.

SETTING: Georgetown Public Hospital Corporation (GPHC), a 600-bed publicly funded referral hospital in Georgetown, Guyana. OBJECTIVE: To assess spirometry quality and diagnostic outcomes 2 years after the introduction of spirometry into routine clinical practice at GPHC. DESIGN: We performed a retrospective review of 476 consecutive spirometry assessments performed from November 2013 to November 2015. We assessed the proportion and trend of spirometry tests meeting acceptability criteria, along with diagnostic interpretations and spirometry laboratory referral patterns. RESULTS: Overall, 80.4% of the 454 initial spirometry measurements on unique patients met the acceptability criteria, with no significant change in the proportion of acceptable spirometry over the study period (P = 0.450). Of the 369 (81.3%) first tests considered interpretable, 139 (30.6%) were normal, 151 (33.3%) were obstructive, 54 (11.9%) were suggestive of a restrictive pattern, 25 (5.5%) were suggestive of a mixed disorder and 119 (26.2%) tests met the definition of reversibility. CONCLUSION: Over a 2-year period, high-quality spirometry was performed in GPHC, a publicly funded hospital in a middle-income country with no pre-existing specialised respiratory service.

Enhancing learning, innovation, adaptation, and sustainability in health care organizations: the ELIAS performance management framework.

The development of sustainable health care organizations that provide high-quality accessible care is a topic of intense interest. This article provides a practical performance management framework that can be utilized to develop sustainable health care organizations. It is a cyclical 5-step process that is premised on accountability, performance management, and learning practices that are the foundation for a continuous process of measurement, disconfirmation, contextualization, implementation, and routinization This results in the enhancement of learning, innovation, adaptation, and sustainability (ELIAS). Important considerations such as recognizing that health care organizations are complex adaptive systems and the presence of a dynamic learning culture are necessary contextual factors that maximize the effectiveness of the proposed framework. Importantly, the ELIAS framework utilizes data that are already being collected by health care organizations for accountability, improvement, evaluation, and strategic purposes. Therefore, the benefit of the framework, when used as outlined, would be to enhance the chances of health care organizations achieving the goals of ongoing adaptation and sustainability, by design, rather than by chance.

Diagnosing and improving functioning in interdisciplinary health care teams.

Interdisciplinary teams play a key role in the delivery of health care. Team functioning can positively or negatively impact the effective and efficient delivery of health care services as well as the personal well-being of group members. Additionally, teams must be able and willing to work together to achieve team goals within a climate that reflects commitment to team goals, accountability, respect, and trust. Not surprisingly, dysfunctional team functioning can limit the success of interdisciplinary health care teams. The first step in improving dysfunctional team function is to conduct an analysis based on criteria necessary for team success, and this article provides meaningful criteria for doing such an analysis. These are the following: a common team goal, the ability and willingness to work together to achieve team goals, decision making, communication, and team member relationships. High-functioning interdisciplinary teams must exhibit features of good team function in all key domains. If a team functions well in some domains and needs to improve in others, targeted strategies are described that can be used to improve team functioning.

Cytotoxicity of Ni from Surface-Treated Porous Nitinol (PNT) on Osteoblast Cells.

The leaching of nickel from the surface of porous Nitinol (PNT) is mainly dependent on its surface characteristics, which can be controlled by appropriate surface treatments. In this investigation, PNT was subjected to two surface treatments, namely, water-boiling and dry-heating passivations. Phosphate buffer saline (PBS) solutions obtained from cyclic potentiodynamic polarization tests on PNT were employed to assess the cytotoxicity of Ni contained therein on osteoblast cells by Sulforhodamine B (SRB) assay. In addition, similar concentrations of Ni were added exogenously to cell culture media to determine cytotoxic effects on osteoblast cells. The morphologies of the untreated and the surface-treated PNTs were examined using SEM and AFM. Furthermore, growth of human osteoblast cells was observed on the PNT surfaces.

The development of community health indicators: a district-wide approach.

INTRODUCTION: In response to high rates of chronic disease, the Capital District Health Authority in Nova Scotia recognized a need to move from a focus on acute care in decision making to one that also values a population health approach guided by community health indicators. METHODS: Stakeholders were surveyed on the choice, knowledge and utility of selected indicators. RESULTS: Respondents reported high scores for changes in their knowledge and attitude regarding community health indicators, and identified priority indicators for action.Decision makers' use of community health indicators was increased by stakeholder involvement, supporting evidence in plain language, and wide dissemination.

Analysis of the optimal cut-point for HIV-p24 antigen testing to diagnose HIV infection in HIV-exposed children from resource-constrained settings.

BACKGROUND: Nucleic-acid-testing (NAT) to diagnose HIV infection in children under age 18 months provides a barrier to HIV-testing in exposed children from resource-constrained settings. The ultrasensitive HIV-p24-antigen (Up24) assay is cheaper and easier to perform and is sensitive (84-98%) and specific (98-100%). The cut-point optical density (OD) selected for discriminating between positive and negative samples may need assessment due to regional differences in mother-to-child HIV-transmission rates. OBJECTIVES: We used receiver operator characteristics (ROC) curves and logistic regression analyses to assess the effect of various cut-points on the diagnostic performance of Up24 for HIV-infection status among HIV-exposed children. Positive and negative predictive values at different rates of disease prevalence were also estimated. STUDY DESIGN: A study of Up24 testing on dried blood spot (DBS) samples collected from 278 HIV-exposed Haitian children, 3-24-months of age, in whom HIV-infection status was determined by NAT on the same DBS card. RESULTS: The sensitivity and specificity of Up24 varied by the cut-point-OD value selected. At a cut-point-OD of 8-fold the standard deviation of the negative control (NCSD), sensitivity and specificity of Up24 were maximized [87.8% (95% CI, 83.9-91.6) and 92% (95% CI, 88.8-95.2), respectively]. In lower prevalence settings (5%), positive and negative predictive values of Up24 were maximal (75.9% and 98.8%, respectively) at a cut-point-OD that was 15-fold the NCSD. CONCLUSIONS: In low prevalence settings, a high degree of specificity can be achieved with Up24 testing of HIV-exposed children when a higher cut-point OD is used; a feature that may facilitate more frequent use of Up24 antigen testing for HIV-exposed children.

Global health and local poverty: rich countries' responses to vulnerable populations.

Poverty is an important determinant of ill health, mortality and suffering across the globe. This commentary asks what we can learn about poverty by looking at the way rich countries respond to the needs of vulnerable populations both within their own societies and those of low-income countries. Taking advantage of recent efforts to redefine child poverty in a way that is consistent with the World Health Organization's Commission on Social Determinants of Health, three sets of data are reviewed: levels of child well-being within 23 Organization of Economic Community Development countries; the amount of official development assistance these countries disburse to poor countries; and, government social transfers targeted at families as a percentage of GDP. Analysis shows that countries in Northern Europe tend to have lower levels of child poverty, and are the most generous with social transfers and providing development assistance to poor countries; in contrast, the non-European countries like Australia, Canada, Japan, and the United States, and generally, the G7 countries, are the least generous towards the vulnerable at home and abroad and tend to have the highest levels of child poverty. The findings suggest that nations' responses tend to be ideologically based rather than evidence or needs based and that poverty is neither inevitable nor intractable.

The utilization of systematic outcome mapping to improve performance management in health care.

Performance management is an important mechanism for ensuring accountability and improving the quality of health-care services. The last decade has witnessed a proliferation in the development of performance measurement systems for assessing health-care processes and outcomes at the program, hospital, district, system and national level. This has allowed for comparison and benchmarking between similar aspects of care at each of these levels. Unfortunately, most performance systems are devoid of clear mechanisms for translating feedback from measures into strategies for action, thus leaving largely unfulfilled the quality and management aspect necessary to improve health-care services. Therefore, the thinking that goes into designing these systems must change. This article outlines a management framework called systematic outcome mapping that provides for performance management rather than just performance measurement by allowing for quality improvement to be built into performance indicator development. It utilizes evidence-based medicine and expert consensus opinion to establish linkages between processes of care and their outcomes with the clear intent that feedback from information provided by performance indicators can be used to modify health-care activities so as to improve health outcomes. This fulfils the quality improvement aspect of performance measurement and makes it an integral part of a performance management framework that reinforces organizational learning through feedback from outcomes and the assessment of organizational routines.

Investigation of penetration abilities of various oils into human hair fibers.

In this work we have explored capillary adhesion between hair fibers treated with different types of oils. With coconut, olive, and sunflower oils the capillary adhesion was found to decrease with time, but not with mineral oil. Application of heat reduced the capillary adhesion further for coconut and sunflower oils. Again, this was not observed with mineral oil. Based on an earlier study, where coconut oil was found to penetrate hair while mineral oil was unable to do so, it was hypothesized that the reduction in capillary adhesion resulted from the penetration of oil into the fiber, leaving a thinner oil film on the surface. Such a reduction in capillary adhesion can be explained by changes in Laplace pressure and in the areas of liquid bridges formed between the fibers. The thinning of oil films on the surface of hair has been confirmed independently by goniophotometric measurements on single hair fibers treated with coconut, sunflower, and mineral oils. Thick films of oil (thicker than approximately 0.5 microm) are known to mask the scale structure. As the oil is absorbed into the hair, the film thins with time and application of heat, and the scale structure reappears. This change can be conveniently determined by measuring the scale angle, using the well established goniophotometric protocol. The agreement between the two methods supports the concept that the reduction in capillary adhesion between hair fibers is most likely due to thinning of oil films by absorption of oil into the hair.

An incremental cost analysis of telehealth in Nova Scotia from a societal perspective.

We examined the costs of telehealth in Nova Scotia from a societal perspective. The clinical outcomes of telepsychiatry and teledermatology services were assumed to be similar to those for conventional face-to-face consultations. Cost information was obtained from the Nova Scotia Department of Health, the Canadian Institute for Health Information, and questionnaires to patients, physicians and telehealth coordinators. There were 215 questionnaires completed by patients, 135 by specialist physicians and eight by telehealth coordinators. Patient costs for a face-to-face consultation ranged from $240 to $1048 (all costs in Canadian dollars), whereas patient costs for telehealth were lower, from $17 to $70. However, from a societal perspective, the overall cost of providing face-to-face services was lower than for telehealth: the total costs for face-to-face services ranged from $325 to $1133, while the total costs for telehealth services ranged from $1736 to $28,084. A threshold analysis showed that, above a certain patient workload, telehealth services would be more cost-effective than face-to-face services from a societal perspective. This workload is attainable in Nova Scotia.

Enhancing vision care integration: 1. Development of practice algorithms.

BACKGROUND: Appropriate access to the best quality of vision care is enhanced when patients receive eye care services from the right professional, at the right time, and in the right place. This paper, the first in a two-part series, describes the development of an integrated framework for vision care delivery. Specifically, two patient-centred vision care algorithms for the multidisciplinary management of diabetic retinopathy and the red eye are outlined, and the process that resulted in their development is described. METHODS: The method used relies on a description of a multidisciplinary collaboration that occurred among ophthalmologists, optometrists, general practitioners and representatives of the Nova Scotia Department of Health with the aim of developing an integrated patient-focused multidisciplinary framework for vision care delivery. RESULTS: The process of collaborative negotiation among the four groups resulted in the development of multidisciplinary algorithms for the screening of patients with diabetes mellitus and the treatment of those presenting with a red eye. INTERPRETATION: Professional scope of practice has always been a contentious issue among health care professions. However, where parties agree to work within an atmosphere of respect and to accept guidance in areas of disagreement from a third party respected by all, compromise is possible. The result was the development of two vision care algorithms and ongoing efforts on the development of other algorithms.

Enhancing vision care integration: 2. Implementation of practice algorithms.

BACKGROUND: Appropriate access to the best quality of vision care is enhanced when patients receive eye care services from the right professional, at the right time, and in the right place. In the preceding article the authors describe the development of two patient-centred vision care algorithms for the multidisciplinary management of diabetic retinopathy and red eye. Subsequently, a questionnaire survey was done to determine ophthalmologist, optometrist and general practitioner (GP) familiarity with and acceptance of the vision care algorithms. METHODS: The survey was conducted in the summer of 2001 among all ophthalmologists, optometrists and GPs registered with their respective professional body in Nova Scotia to assess their knowledge and acceptance of the diabetes mellitus and red eye algorithms. They were also asked to indicate their preferred method(s) of education and dissemination regarding these and future algorithms. RESULTS: Of the 740 practising GPs in Nova Scotia, 188 completed the questionnaire, for a response rate of 25.4%. The corresponding figures for optometrists and ophthalmologists were 73.6% (53/72) and 43.5% (20/46) respectively. Most of all three types of clinicians practise in Halifax County. More than 80% of the optometrists and ophthalmologists were aware of the algorithms, but less than 50% of the GPs were aware of them. A large majority of respondents in all three groups (77% to 98%) indicated that they were comfortable using the diabetes and red eye algorithms as presented. INTERPRETATION: Ophthalmologists, optometrists and GPs indicated an understanding of and willingness to use the diabetes and red eye algorithms. However, they were not unanimous regarding the choice of implementation method. Therefore, six different strategies for implementing the vision care algorithms are currently being used and are described in the paper.