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Rationale, aims and objectives: Strong health systems are said to be paramount to achieving effective and equitable health care. The World Health Organization has been advocating for using system-wide approaches such as 'systems thinking' to guide intervention design and evaluation. In this paper we report the system-wide effects of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality. Methods: We conducted a qualitative study in three target districts. We used a systems thinking conceptual framework to guide the analysis focusing on intended and unintended consequences of the intervention. NVivo version 10 was used for data analysis. Results: The addressed community responded positively to the BHOMA intervention. The indications were that in the short term there was increased demand for services but the health worker capacity was not severely affected. This means that the prediction that service demand would increase with implementation of BHOMA was correct and the workload also increased, but the help of clinic lay supporters meant that some of the work of clinicians was transferred to these lay workers. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA. Conclusions: We applied an innovative approach to evaluate a complex intervention in low-income settings, exploring empirically how systems thinking can be applied in the context of health system strengthening. Although the intervention had some positive outcomes by employing system-wide approaches, we also noted unintended consequences. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The shortage of kidney donors and benefits of kidney transplantation make graft success imperative. Medication adherence is critical to prevent the risk of graft rejection. This paper examines how adults are prepared and supported by renal transplant co-ordinators and pharmacists to take their medications as prescribed in kidney transplantation. Methods Renal transplant co-ordinators and pharmacists of all five hospitals offering adult kidney transplantation in Victoria, Australia, were interviewed between November 2013 and February 2014. All data underwent qualitative descriptive analysis. Results Nine renal transplant co-ordinators and six pharmacists were interviewed. Although there was no standardized approach to education or other evidence-based strategies to facilitate medication adherence, there were similarities between sites. These similarities included printed information, pre-transplant education sessions, the use of medication lists and medication administration aids, intensive education in hospital and ensuring an adequate supply of medications post-discharge. Conclusions Renal transplant co-ordinators and pharmacists recognized the importance of early patient education concerning immunosuppressant medication. However, each site had developed their own way of preparing a patient for kidney transplantation and follow-up in the acute hospital setting based on experience and practice. Other non-educational strategies involving behavioural and emotional aspects were less common. Differences in usual care reinforce the necessity for evidence-based health care for best patient outcomes. [ABSTRACT FROM AUTHOR]

Rationale: Patients with complex care needs who frequently use health services often face challenges in managing their health and with integrated care, leading to frequent decision making. These complex care needs require a good understanding of health issues and their impact on daily life. As the decisional needs of this particular clientele have yet to be described in scientific literature, they warrant further study. Objectives: To assess the decision‐making needs of patients with complex care needs (PCCN) who frequently use health care services. Methods: We performed a multicenter cross‐sectional qualitative descriptive study in four institutions of the health and social services network of Quebec (Canada). We enrolled a convenience sample of PCCNs who frequently use health care services, health care providers, case managers, and decision‐makers. We conducted interviews and focus groups and investigated decisional needs according to the Ottawa decision support framework: roles played and desired in the decision‐making process, facilitators, and barriers. We conducted qualitative data collection and qualitative deductive/inductive thematic analysis within and across participating groups. Results: In total, 16 patients, 38 clinicians, six case managers, and 14 decision‐makers participated in the study. The decisional needs of this clientele are numerous, varied and different from those of the general population. We identified 26 decisional needs grouped under five themes. The most frequent decisions related to visiting the emergency department, moving to a nursing home, and adhering to a plan or treatment. In addition, we identified new themes such as patients' fear and mistrust of health professionals, differences of opinion between health professionals and health professionals' preconceived opinions of patients. Conclusion: We observed a wide range of types of decisions that patients face and differences in decision‐making needs across participating groups. Our results should inform future research on the development of a patient decision aid tool. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Guidelines are intended as a means of getting research evidence into practice and ensuring provided care is of sufficient quality. However, the effect of guidelines is hindered by limited guideline adherence. The aim of this study is to identify and classify barriers to adherence by nurses to a guideline on delirium care. Methods Open-ended interviews were conducted with a purposive sample of 63 research participants. The sample included 28 nurses, 18 doctors and 17 policy advisors working in 19 hospitals in the Netherlands. The interviews were conducted between June and September 2011. The data were analysed using thematic analysis. Results Barriers to guideline adherence that were identified could be grouped into four themes: motivation and goals, knowledge and skills, professional role and identity, and context and resources. While the interviews with nurses, doctors and policy advisors produced similar views of the current situation, doctors and policy advisors placed a higher importance on education as a means of stimulating adherence. Conclusions This study illustrates that individual, social and organizational factors play a role in nurse's adherence to a delirium guideline. The potential benefits of following a guideline, both for patients and for nursing staff, need to be highlighted in order to motivate nurses. When formulating new guidelines, nurses' perceptions of their professional role and patient care need to be taken into account to ensure that policy makers and managers are realistic about guideline adherence and engage with nurses from a position of mutual respect and trust. [ABSTRACT FROM AUTHOR]

To investigate perceived factors relating to the reliable application of four clinical care practices targeting ventilator-associated pneumonias, in the context of a patient safety improvement initiative called the Safer Patients Initiative (SPI). Qualitative case study. Seventeen semi-structured individual interviews with clinical operational leads, programme coordinators and executive managers who were involved in the implementation of the programme's critical care work stream during its pilot phase. The interviews had a focus on perceived aspects pertaining to the reliable implementation of the four clinical practices, promoted by the Institute for Healthcare Improvement as the 'ventilator care bundle'. Thematic analysis of the verbatim transcripts revealed three overarching themes experienced by the participants during the implementation of the clinical practices included in the SPI ventilator care bundle: the power of measurement, feedback to peers and experts and improvement tools specific to SPI. Consistent measurement of compliance with the four elements of the bundle and outcomes made the staff realize that their engagement in previous improvement work for ventilated patients was inadequate and motivated them to apply the introduced clinical practices more reliably. Feedback to experts and peers of staff compliance with the four clinical practices and outcome improvement was perceived as a very influential aspect of SPI. Small tests of change (Plan-Do-Study-Act cycles), teaching sessions and daily goal sheets were quoted as particularly useful tools throughout the implementation of the four clinical care practices. Future initiatives that aim to improve the adherence of clinical staff with clinical practice guidelines in intensive care units could benefit from integrating in their methodology consistent measurement and feedback practices of both process compliance and outcome data. [ABSTRACT FROM AUTHOR]

A recent trend in health care system is to provide more choices to the patients. This study surveyed the general public's choices for primary care in Hong Kong which has the setting of free choices for private or public service and also direct access to specialists. We used a combined qualitative and quantitative approach. We held five focus group interviews with participants of different socio-economic categories. Information from the focus groups helped to design a questionnaire for random telephone interviews with members of the public aged 18 or above. There were 37 participants in the focus groups and 1647 respondents in the telephone survey. The most important factor for choosing a doctor was proximity to home or workplace, followed by quick relief from the illness. Once continuity of care had been established, distance was of less importance but comprehensive care was valued. Nearly 70% of the public had regular doctors. About 93% of the public would consult specialists directly when they thought they needed a specialist's opinion. Nearly 30% chose specialists for any medical care and 38% preferred specialists to also look after their primary care problems. Convenient accessibility was the most important factor for the initial choice of primary care doctors by the general public. The perceived clinical proficiency of the doctor determined future continuity of care. Patients liked to have direct access to specialists. Though some chose to see the specialists even for primary care problems, most people had regular doctors who were likely to have the attributes of family doctors. [ABSTRACT FROM AUTHOR]