Governance tensions in the healthcare sector: a contrasting case study in France

Background Political and managerial reforms affect the health sector by translating into governance tensions. As identified in the public management literature, these tensions come from the diffusion of management principles and practices from the business world. These tensions manifest at four levels: institutional, organisational, managerial and instrumental. The aim of this research is to understand how these tensions are expressed in healthcare organisations of different status. Methods We conduct a contrasting case study exploring the cases of two French healthcare organisations, one private for-profit (clinic) and one public not-for-profit (cancer treatment centre). Our analyses are mainly based on the content analysis of 32 semi-structured interviews conducted with staff (nurses, doctors, management and administrative staff) of these two organisations. Results Our results show that these tensions can be distinguished into three categories (tensions on professional values, standards and practices) which are expressed differently depending on the type of healthcare organisation and its main management characteristics. Conclusions Unexpectedly, in the for-profit organisation, the most intense tensions concern professional standards, whereas they concern professional practices in the not-for-profit organisation. These analyses can help guide policy makers and healthcare managers to better integrate these tensions into their political and managerial decisions.

Managers do it their way: How managers act in a decentralised healthcare services provider organisation – a mixed methods study

Purpose: Decentralisation is considered a way to get managers more committed and more prone to respond to local needs. This study analyses how managers perceive a decentralised management model within a large public healthcare delivery organisation in Sweden. Design/methodology/approach: A programme theory evaluation was performed applying direct content analysis to in-depth interviews with healthcare managers. Balance score card data were used in a blinded comparative content analysis to explore relations between performance and how the delegated authority was perceived and used by the managers. Findings: Managers’ perceptions of the decentralised management model supported its intentions to enable the front-line to make decisions to better meet customer needs and flexibly adapt to local conditions. The managers appreciated and used their delegated authority. Central policies and control on human resources and investments were accepted as those are to the benefit of the whole organisation. Leadership development and organisation-wide improvement programmes were of support. Units showing high organisational performance had proactive managers, although differences in manager perceptions across units were small. Originality: This, one of the first of its kind, study of a decentralisation in service delivery organisation shows a congruence between the rationale of a management model, the managers’ perceptions of the authority and accountability as well as management practises. These observations stemming from a large public primary and community healthcare organisation has not, to our knowledge, been reported and provide research-informed guidance on decentralisation as one strategy for resolving challenges in healthcare service delivery organisations.

Innovations in clinical documentation integrity practice: Continual adaptation in a data-intensive healthcare organisation

Background Numbers of clinical documentation integrity specialists (CDIS) and CDI programs have increased rapidly. CDIS review patient records concurrently with patient admissions and visits to ensure that information is accurate, complete and non-ambiguous, and query clinicians when they see opportunities for improving data. The occupation was initially focused on improving data for reimbursement, but rapid changes to clinical coding requirements, technologies and payment systems led to a quickly evolving role for CDI programs and changes in CDIS practice. Objective This case study seeks to uncover the ongoing innovation and adaptation occurring in a CDI program by tracing the evolution of a single CDI program over time. Method We present a case study of the CDI program at the HonorHealth hospital system in Arizona. Results The HonorHealth CDI program holds a unique hybrid expertise and role within the healthcare organisation that allows it to rapidly adapt to support emergent demands both internal and external to the organisation, such as supporting accurate data collection for the COVID-19 pandemic. Conclusion CDIS are a vital component in present data-intensive resourcing efforts. The hybrid expertise of CDIS and capacity for adaption and relationship building has enabled the HonorHealth CDI program to adapt rapidly to meet a growing array of clinical documentation integrity needs, including emergent needs during the COVID-19 pandemic. Implications The HonorHealth case study can guide other CDI programs in adaptation of the CDI role and practices in response to changing organisational needs.

Complex wound care by a nurse practitioner in primary care: a quality improvement evaluation on healing rates, costs and patient satisfaction

Complex wounds are a major burden for healthcare professionals. Patients with complex wounds are often referred to hospitals or wound expertise centres. Complex wound care could be organised in primary care, but very little published evidence for this is available. In this study, members of a primary healthcare organisation were interviewed to ascertain how the wound care was organised. Patient characteristics and data regarding wound care, healing rates and costs were collected from medical records. Patients filled in a questionnaire concerning accessibility, communication, medical counselling and the overall experience of their treatment. This study followed 25 patients with a total of 42 wounds. Some 82% of the wounds were healed within a mean treatment duration of 9.7 weeks. Mean treatment costs were calculated at €155 (£130) for healed patients. Patients were generally very satisfied with their treatment, illustrated by an overall 8.7 out of 10 scoring on an amended survey based on the Consumer Quality Index. Treating complex wounds in primary care seemed adequate, with high patient satisfaction and tolerable costs.

A systematic review of ePCR systems on reducing the response time of prehospital medical care

Background Poor communication at the time of patient handover is recognized as a root cause of a considerable proportion of preventable deaths. Despite several advantages, the Patient Care Report (PCR) implementation may include insufficient details for demonstrating the functional status of the patients during the actual response which can further prolong the response time. Healthcare entities have been emphasizing the need to implement e-PCR systems. This systematic review aimed to examine the impact of e-PCR systems on reducing response time of prehospital care. Methods Literature search was carried out using the relevant search terms and keywords with inclusion and exclusion criteria. N=6 researchers that focused on the impact of e-PCR systems on reducing response time of prehospital medical care were included within this review. Results The findings indicated that ePCR implementation led to prominent improvements in the quality of the care services provided by the healthcare organisation. Additionally, ePCR reduces the response rate by data standardization. Conclusion The implementation of e-PCR systems ensures the availability of records and automates reporting on given quality metrics. Moreover, the implementation of e-PCR systems also improved response time and increased the out of hospital rates of survival. However, fear of increasing the ambulance run time, compromise on the availability of ambulance, and challenges in integration with the existing information systems implemented within the hospitals, were some of the most common challenging situations associated with implementing e-PCR systems.

Elapsed time since BNT162b2 vaccine and risk of SARS-CoV-2 infection: test negative design study

Objectives To determine whether time elapsed since the second injection of the Pfizer-BioNTech BNT162b2 mRNA vaccine was significantly associated with the risk of covid-19 infection after vaccination in people who received two vaccine injections. Design Test negative design study. Setting Electronic health records of a large state mandated healthcare organisation, Israel. Participants Adults aged ≥18 years who had received a reverse transcription polymerase chain reaction (RT-PCR) test between 15 May 2021 and 17 September 2021, at least three weeks after their second vaccine injection, had not received a third vaccine injection, and had no history of covid-19 infection. Main outcome measures Positive result for the RT-PCR test. Individuals who tested positive for SARS-CoV-2 and controls were matched for week of testing, age category, and demographic group (ultra-orthodox Jews, individuals of Arab ancestry, and the general population). Conditional logistic regression was adjusted for age, sex, socioeconomic status, and comorbid conditions. Results 83 057 adults received an RT-PCR test for SARS-CoV-2 during the study period and 9.6% had a positive result. Time elapsed since the vaccine injection was significantly longer in individuals who tested positive (P<0.001). Adjusted odds ratio for infection at time intervals >90 days since vaccination were significantly increased compared with the reference of <90 days: 2.37 (95% confidence interval 1.67 to 3.36) for 90-119 days, 2.66 (1.94 to 3.66) for 120-149 days, 2.82 (2.07 to 3.84) for 150-179 days, and 2.82 (2.07 to 3.85) for ≥180 days (P<0.001 for each 30 day interval). Conclusions In this large population of adults tested for SARS-CoV-2 by RT-PCR after two doses of mRNA BNT162b2 vaccine, a gradual increase in the risk of infection was seen for individuals who received their second vaccine dose after at least 90 days.

The importance of learning and knowledge sharing to support implementation of total quality management in healthcare

Background/Aims Implementation of total quality management in healthcare services has often been unsuccessful. This is a result of a variety of factors, including the inadequacy of learning and knowledge sharing methods to support implementation. This study aimed to explore how learning and knowledge sharing policies influence total quality management initiatives in the healthcare sector. Methods An extended total quality management model, named the ethical, adaptive, learning, and improvement model, was developed and implemented in a private healthcare organisation in the UK. Using action research, data were collected from 91 participants over a 21-month period from qualitative interviews, focus groups and participant observations. Results Practice-based training was found to increase employee competence, reflecting the importance of tacit knowledge sharing. The model led to the prevalent blame culture changing to a learning culture through an appreciative management style that focused on recognising what is done right. In addition, patients' satisfaction and quality of care improved through community groups that were set up to address quality problems and patients' needs. Conclusions Adequate knowledge sharing methods play an important role in improving quality in healthcare. Greater consideration should be given to this widely ignored aspect when implementing total quality management in NHS trusts.

Impacts of clinical academic activity: qualitative interviews with healthcare managers and research-active nurses, midwives, allied health professionals and pharmacists

ObjectivesTo explore the perceived impacts of clinical academic activity among the professions outside medicine.DesignQualitative semistructured interviews.Setting and participantsThere were two groups of interviewees: Research-active nurses, midwives, allied health professionals, healthcare scientists, psychologists and pharmacists (NMAHPPs) and managers of these professions. All participants were employed in a single, multisite healthcare organisation in the UK.AnalysisInterview transcripts were analysed using the framework method to identify key themes, subthemes and areas of divergence.ResultsFour themes were identified. The first, cultural shifts, described the perceived improvements in the approach to patient care and research culture that were associated with clinical academic activity. The second theme explored visibility and included the positive reputation that clinical academics were identified as bringing to the organisation in contrast with perceived levels of invisibility and inaccessibility of these roles. The third theme identified the impacts of the clinical academic pathways, including the precarity of these roles. The final theme explored making impact tangible, and described interviewees’ suggestions of possible methods to record and demonstrate impact.ConclusionsPerceived positive impacts of NMAHPP clinical academic activity focused on interlinked positive changes for patients and clinical teams. This included delivery of evidence-based healthcare, patient involvement in clinical decision making and improved staff recruitment and retention. However, the positive impacts of clinical academic activity often centred around individual clinicians and did not necessarily translate throughout the organisation. The current clinical academic pathway was identified as causing tension between the perceived value of clinical academic activity and the need to find sufficient staffing to cover clinical services.

Awareness, attitude and practice towards personal health information privacy among health information management professionals in South Korea

Background: While information and communication technology has continued to advance, privacy of personal health information (PHI) has remained a challenge for health information management (HIM) professionals. Objective: This study aims to examine the awareness, attitude and practice relating to PHI privacy among HIM professionals in South Korea. Method: A survey questionnaire was developed for the study based on critical appraisal of relevant literature and expert consensus. It was completed by a sample of 312 respondents who were members of the Korean Health Information Management Association, over the age of 21, and worked in a healthcare organisation. Demographic data and questionnaire items (assessed on a 5-point Likert-type scale) were analysed using descriptive statistics, t-tests and ANOVA. Results: Mean scores and SDs for awareness, attitude and practice related to PHI privacy were calculated: 4.21 (0.60) for awareness, 4.17 (0.60) for attitude and 4.31 (0.63) for practice. Significant positive correlations were found between awareness and attitude scores (r = 0.765, p < 0.01); awareness and practice scores (r = 0.585; p < 0.01); and attitude and action scores (r = 0.672; p < 0.01). HIM professionals’ awareness, attitude, and practice towards PHI privacy differed significantly according to age, level of education, years of HIM experience, type of employment, main task, number of completed privacy education activities within the previous 3 years and whether or not they had signed a pledge of confidentiality on PHI. Better-educated, full-time employed respondents, those who had completed a greater number of privacy education activities and had more experience as HIM professionals, achieved higher scores on awareness, attitude and practice than did other respondents. These differences were all statistically significant ( p < 0.01). Conclusion: Although causality cannot be inferred from results of this study, findings suggest that there is a relationship between PHI being a core responsibility of HIM professionals and their subsequent awareness, attitude and practice to ensure its privacy and confidentiality. To improve privacy practice, educational efforts should be prioritised and supported at all levels, including national, organisational, individual, and by professional HIM associations.