Search

Abstract Background Integrated care is considered as a strategy to improve the delivery, efficiency, client outcomes and satisfaction rates of health care. To integrate the care from multiple providers into a coherent client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and patient transfers. The Development Model for Integrated care (DMIC) describes nine clusters containing in total 89 elements that contribute to the integration of care. We have empirically validated this model in practice by assessing the relevance, implementation and plans of the elements in three integrated care service settings in The Netherlands: stroke, acute myocardial infarct (AMI), and dementia. Methods Based on the DMIC, a survey was developed for integrated care coordinators. We invited all Dutch stroke and AMI-services, as well as the dementia care networks to participate, of which 84 did (response rate 83%). Data were collected on relevance, presence, and year of implementation of the 89 elements. The data analysis was done by means of descriptive statistics, Chi Square, ANOVA and Kruskal-Wallis H tests. Results The results indicate that the integrated care practice organizations in all three care settings rated the nine clusters and 89 elements of the DMIC as highly relevant. The average number of elements implemented was 50 ± 18, 42 ± 13, and 45 ± 22 for stroke, acute myocardial infarction, and dementia care services, respectively. Although the dementia networks were significantly younger, their numbers of implemented elements were comparable to those of the other services. The analyses of the implementation timelines showed that the older integrated care services had fewer plans for further implementation than the younger ones. Integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding their integrated care activities. Conclusions Although the patient composites and the characteristics of the 84 participating integrated care services differed considerably, the results confirm that the clusters and the vast majority of DMIC elements are relevant to all three groups. Therefore, the DMIC can serve as a general quality management tool for integrated care. Applying the model in practice can help in steering further implementations as well as the development of new integrated care practices.

Abstract Background Multidisciplinary and interorganizational arrangements for the delivery of coherent integrated care are being developed in a large number of countries. Although there are many integrated care programs worldwide, the process of developing these programs and interorganizational collaboration is described in the literature only to a limited extent. The purpose of this study is to explore how local integrated care services are developed in the Netherlands, and to conceptualize and operationalize a development model of integrated care. Methods The research is based on an expert panel study followed by a two-part questionnaire, designed to identify the development process of integrated care. Essential elements of integrated care, which were developed in a previous Delphi and Concept Mapping Study, were analyzed in relation to development process of integrated care. Results Integrated care development can be characterized by four developmental phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase; and the consolidation and transformation phase. Different elements of integrated care have been identified in the various developmental phases. Conclusion The findings provide a descriptive model of the development process that integrated care services can undergo in the Netherlands. The findings have important implications for integrated care services, which can use the model as an instrument to reflect on their current practices. The model can be used to help to identify improvement areas in practice. The model provides a framework for developing evaluation designs for integrated care arrangements. Further research is recommended to test the developed model in practice and to add international experiences.

Background: Despite the increasing use of patient-reported outcome measures (PROMs) for collecting self-reported data among hospital outpatients, clinicians' use of these data remains suboptimal. Insight into this issue and strategies to enhance the use of PROMs are critical but limited., Objective: This study aimed to examine clinicians' use of PROM data for value-based outpatient consultations and identify efforts to enhance their use of PROMs in a Dutch university hospital. First, we aimed to investigate clinicians' use of outpatients' PROM data in 2023, focusing on adoption, implementation, and maintenance. Second, we aimed to develop insights into the organizational-level strategies implemented to enhance clinicians' use of PROM data from 2020 to 2023. This included understanding the underlying rationales for these strategies and identifying strategies that appeared to be missing to address barriers or leverage facilitators. Third, we aimed to explore the key factors driving and constraining clinicians' use of PROMs in 2023., Methods: We integrated data from 4 sources: 1-year performance data on clinicians' use of PROMs (n=70 subdepartments), internal hospital documents from a central support team (n=56), a survey among clinicians (n=47), and interviews with individuals contributing to the organizational-level implementation of PROMs (n=20). The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used to analyze clinicians' adoption, implementation, and maintenance of PROMs. Strategies were analyzed using the Expert Recommendations for Implementing Change taxonomy, and results were structured around the constructs of capability, opportunity, and motivation., Results: On average, around 2023, clinicians accessed PROM data for approximately 3 of 20 (14%) patients during their outpatient consultation, despite numerous strategies to improve this practice. We identified issues in adoption, implementation, and maintenance. The hospital's strategies, shaped organically and pragmatically, were related to 27 (37%) out of 73 Expert Recommendations for Implementing Change strategies. These strategies focused on enhancing clinicians' capability, opportunity, and motivation. We found shortcomings in the quality of execution and completeness of strategies in relation to addressing all barriers and leveraging facilitators. We identified variations in the factors influencing the use of PROMs among frequent PROM users, occasional users, and nonusers. Challenges to effective facilitation were apparent, with certain desired strategies being unfeasible or impeded., Conclusions: Enhancing clinicians' use of PROMs has remained challenging despite various strategies aimed at improving their capability, opportunity, and motivation. The use of PROMs may require more substantial changes than initially expected, necessitating a shift in clinicians' professional attitudes and practices. Hospitals can facilitate rather than manage clinicians' genuine use of PROMs. They must prioritize efforts to engage clinicians with PROMs for value-based outpatient care. Specific attention to their professionalization may be warranted. Tailored strategies, designed to address within-group differences in clinicians' needs and motivation, hold promise for future efforts., (©Veerle van Engen, Igna Bonfrer, Kees Ahaus, Monique Den Hollander-Ardon, Ingrid Peters, Martina Buljac-Samardzic. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 18.10.2024.)

Objectives: During the COVID-19 pandemic, healthcare professionals were faced with prioritisation dilemmas due to limited surgical capacity. While the views of healthcare professionals on fair allocation have been given considerable attention, the views of patients have been overlooked. To address this imbalance, our study aimed to identify which ethical principles are most supported by patients regarding the fair allocation of surgical resources., Design: A Q-methodology study was conducted. Participants ranked ordered 20 statements covering different viewpoints on fair allocation according to their point of view, followed by an interview. Principal component analysis followed by varimax rotation was used to identify subgroups who broadly agreed in terms of their rankings., Setting: The setting of this study was in the Netherlands., Participants: 16 patient representatives were purposively sampled., Results: Two perspectives were identified, both of which supported utilitarianism. In perspective 1, labelled as 'clinical needs and outcomes', resource allocation should aim to maximise the health gains based on individual patient characteristics. In perspective 2, labelled as 'population outcomes and contribution to society', allocation should maximise health gains as with perspective 1, but this should also consider societal gains., Conclusions: There was a broad agreement among patient representatives that utilitarianism should be the guiding ethical principle for fair allocation of scarce surgical resources. The insights gained from this study should be integrated into policymaking and prioritisation strategies in future healthcare crises., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: While healthcare organizations in several countries are embracing Value-Based Health Care (VBHC), there are limited insights into how to achieve this paradigm shift. This study examines the decade-long (2012-2023) change towards VBHC in a pioneering Dutch university hospital., Method: Through retrospective, complexity-informed process research, we study how a Dutch university hospital's strategy to implement VBHC evolved, how implementation outcomes unfolded, and the underlying logic behind these developments. Data include the hospital's internal documents (n = 10,536), implementation outcome indicators (n = 4), a survey among clinicians (n = 47), and interviews with individuals contributing to VBHC at the hospital level (n = 20)., Results: The change towards VBHC is characterized by three sequential strategies. Initially, the focus was on deep change through local, tailored implementation of multiple VBHC elements. The strategy then transitioned to a hospital-wide program aimed at evolutionary change on a large scale, emphasizing the integration of VBHC into mainstream IT and policies. Recognizing the advantages and limitations of both strategies, the hospital currently adopts a "hybrid" strategy. This strategy delicately combines deep and broad change efforts. The strategy evolved based on accumulated insights, contextual developments and shifts in decision-makers. The complexity of change was downplayed in plans and stakeholder communication. By the end of 2023, 68 (sub)departments engaged in VBHC, enabled to discuss patients' responses to Patient Reported Outcomes Measures (PROMs) during outpatient care. However, clinicians' use of PROMs data showed limitations. While pioneers delved deeper into VBHC, laggards have yet to initiate it., Conclusions: VBHC does not lend itself to linear planning and is not easily scalable. While there appears to be no golden standard for implementation, blending local and larger-scale actions appears advantageous. Local, deep yet harmonized and system-integrated changes culminate in large scale transformation. Embracing complexity and focusing on the ultimate aims of (re)institutionalization and (re)professionalization are crucial., (© 2024. The Author(s).)

Introduction: Global interest is growing in new value-based models of financing, delivering, and paying for health care services that could produce higher-quality and lower cost outcomes for patients and for society. However, research indicates evidence gaps in knowledge related to alternative payment models (APMs) in early experimentation phases or those contracted between private insurers and their health care provider-partners. The aim of this research was to understand and update the literature related to learning how industry experts design and implement APMs, including specific elements of their models and their choice of stakeholders to be involved in the design and contractual details., Methods: A literature review was conducted to guide the research focus and to select themes. The sample was selected using snowball sampling to identify subject matter experts (SMEs). Researchers conducted 16 semi-structured interviews with SMEs in the US, the Netherlands, and Germany in September and October 2021. Interviews were transcribed and using Braun and Clarke's six-phase approach to thematic analysis, researchers independently read, reviewed, and coded participants' responses related to APM design and implementation and subsequently reviewed each other's codes and themes for consistency., Results: Participants represented diverse perspectives of the payer, provider, consulting, and government areas of the health care sector. We found design considerations had five overarching themes: (1) population and scope of care and services, (2) benchmarking, metrics, data, and technology; (3) finance, APM type, risk adjustment, incentives, and influencing provider behavior, (4) provider partnerships and the role of physicians, and (5) leadership and regulatory issues., Discussion: This study confirmed several of the core components of APM model designs and implementations found in the literature and brought insights on additional aspects not previously emphasized, particularly the role of physicians (especially in leadership) and practice transformation/care processes necessary for providers to thrive under APM models. Importantly, researchers found significant concerns relevant for policymakers about regulations relating to health data sharing, rigid price-setting, and inter-organizational data communication that greatly inhibit the ability to experiment with APMs and those models' abilities to succeed long-term., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Howard, Bradford, Belue, Henning, Qian, Ahaus and Reindersma.)

Objectives: This study investigated changes in the length of stay (LoS) at a level III/IV neonatal intensive care unit (NICU) and level II neonatology departments until discharge home for very preterm infants and identified factors influencing these trends., Design: Retrospective cohort study based on data recorded in the Netherlands Perinatal Registry between 2008 and 2021., Setting: A single level III/IV NICU and multiple level II neonatology departments in the Netherlands., Participants: NICU-admitted infants (n=2646) with a gestational age (GA) <32 weeks., Main Outcome Measures: LoS at the NICU and overall LoS until discharge home., Results: The results showed an increase of 5.1 days (95% CI 2.2 to 8, p<0.001) in overall LoS in period 3 after accounting for confounding variables. This increase was primarily driven by extended LoS at level II hospitals, while LoS at the NICU remained stable. The study also indicated a strong association between severe complications of preterm birth and LoS. Treatment of infants with a lower GA and more (severe) complications (such as severe retinopathy of prematurity) during the more recent periods may have increased LoS., Conclusion: The findings of this study highlight the increasing overall LoS for very preterm infants. LoS of very preterm infants is presumably influenced by the occurrence of complications of preterm birth, which are more frequent in infants at a lower gestational age., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department., Methods: This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals (N = 8) and patients (N = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach., Results: Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: 'structure', 'culture', 'education', 'emotional', and 'physical and technology'. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients., Conclusions: Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, 'politics'. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations' structure, culture and practices., (© 2024. The Author(s).)

Objective: The study objective was to determine the effect of a rapid cycle deliberate practice (RCDP) program on simulated and actual airway skills by pediatric emergency medicine (PEM) fellows., Methods: We designed and implemented a 12-month RCDP airway skills curriculum for PEM fellows at an academic pediatric institution. The curriculum was designed using airway training literature, RCDP principals, and internal quality assurance airway video review program. Simulation training scenarios increased in complexity throughout the curriculum. PEM fellows participated in monthly sessions. Two PEM faculty facilitated the sessions, utilizing a step-by-step objective structured clinical evaluation (OSCE)-style tool for each scenario. Data were collected for all four levels of the Kirkpatrick Model of Training Evaluation-participant response (reaction, pre-post session survey), skills performance in the simulation setting (learning, pre-post OSCE), skills performance for actual patients (behavior, video review), and patient outcomes (results, video review)., Results: During the study period (August 2021 to June 2022), 13 PEM fellows participated in 112 sessions (mean nine sessions per fellow). PEM fellows reported improved comfort in all domains of airway management, including intubation performance. Participant OSCE scores improved posttraining (pretraining median score for trainees 57 [IQR 57-59], posttraining median 61 [IQR 61-62], p  = 0.0005). Over the 12 months, PEM fellows performed 45 intubation attempts in the pediatric emergency department (median patient age 4 years [IQR 1-9 years]). Compared to a 5-year historical cohort, participants had higher first-pass success (87% vs. 71%, p  = 0.028) and shorter attempt duration (22 s vs. 29 s, p  = 0.018). There was no significant difference in the frequency of oxyhemoglobin desaturation in the training period versus the historical period (7% vs. 15%, p  = 0.231)., Conclusions: At multiple levels of educational outcomes, including participant behavior and patient outcomes, an RCDP program was associated with improved airway skills and performance of PEM fellows., Competing Interests: The authors declare no conflicts of interest., (© 2024 Society for Academic Emergency Medicine.)

Background: Informal caregivers of people with dementia (PwD) living at home are often the primary source of care, and, in their role, they often experience loss of quality of life. Implementation science knowledge is needed to optimize the real-world outcomes of evidence-based interventions (EBIs) for informal caregivers. This scoping review aims to systematically synthesize the literature that reports implementation strategies employed to deliver home- and community-based EBIs for informal caregivers of PwD, implementation outcomes, and the barriers and facilitators to implementation of these EBIs., Methods: Embase, MEDLINE, Web of Science, and Cochrane Library were searched from inception to March 2021; included studies focused on "implementation science," "home- and community-based interventions," and "informal caregivers of people with dementia." Titles and abstracts were screened using ASReview (an innovative AI-based tool for evidence reviews), and data extraction was guided by the ERIC taxonomy, the Implementation Outcome Framework, and the Consolidated Framework for Implementation Science Research; each framework was used to examine a unique element of implementation., Results: Sixty-seven studies were included in the review. Multicomponent (26.9%) and eHealth (22.3%) interventions were most commonly reported, and 31.3% of included studies were guided by an implementation science framework. Training and education-related strategies and provision of interactive assistance were the implementation strategy clusters of the ERIC taxonomy where most implementation strategies were reported across the reviewed studies. Acceptability (82.1%), penetration (77.6%), and appropriateness (73.1%) were the most frequently reported implementation outcomes. Design quality and packaging (intervention component suitability) and cosmopolitanism (partnerships) constructs, and patient's needs and resources and available resources (infrastructure) constructs as per the CFIR framework, reflected the most frequently reported barriers and facilitators to implementation., Conclusion: Included studies focused largely on intervention outcomes rather than implementation outcomes and lacked detailed insights on inner and outer setting determinants of implementation success or failure. Recent publications suggest implementation science in dementia research is developing but remains in nascent stages, requiring future studies to apply implementation science knowledge to obtain more contextually relevant findings and to structurally examine the mechanisms through which implementation partners can strategically leverage existing resources and regional networks to streamline local implementation. Mapping local evidence ecosystems will facilitate structured implementation planning and support implementation-focused theory building., Trial Registration: Not applicable., (© 2023. The Author(s).)

Background: This study assesses whether out-of-hospital coaching of re-hospitalized, severe COPD patients by specialized respiratory nurses is feasible in terms of cost-effectiveness, implementation, and recipient acceptability. The coaching was aimed at improving patients' health management abilities, motivation for healthy behavior, strengthening the professional and informal care network, stimulating physiotherapy treatment and exercise training, improving knowledge on symptom recognition and medication use, and providing safety and support., Methods: Cost-effectiveness of 6 months of out-of-hospital coaching was assessed based on a before-after intervention design, with real-life data and one-year follow-up. A total of 170 patients were included. Primary (questionnaires, meeting reports) and secondary data (insurance reimbursement data) were collected in one province in the Netherlands. The implementing and recipient acceptability was assessed based on the number of successfully delivered coaching sessions, questionnaire response rate, Patient Reported Experience Measure, and interviews with coaches., Results: Post-intervention, the COPD-related hospitalization rate was reduced by 24%, and patients improved in terms of health status, anxiety, and nutritional status. Patients with a high mental burden and a poor score for health impairment and wellbeing at the start of the intervention showed the greatest reduction in hospitalizations. The coaching service was successfully implemented and considered acceptable by recipients, based on patient and coach satisfaction and clinical use of patient-reported measures., Conclusion: The study demonstrates the value of coaching patients out-of-hospital, with a strong link to primary care, but with support of hospital expertise, thereby adding to previous studies on disease- or self-management support in either primary or secondary care settings. Patients benefit from personal attention, practical advice, exercise training, and motivational meetings, thereby improving health status and reducing the likelihood of re-hospitalization and its associated costs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Noort, van der Vaart, van der Maten, Metting and Ahaus.)

Introduction: Value-based healthcare suggests that care outcomes should be evaluated in relation to the costs of delivering that care from the perspective of the provider. However, few providers achieve this because measuring cost is considered complex and elaborate and, further, studies routinely omit cost estimates from 'value' assessments due to lacking data. Consequently, providers are currently unable to steer towards increased value despite financial and performance pressures. This protocol describes the design, methodology and data collection process of a value measurement and process improvement study in fertility care featuring complex care paths with both long and non-linear patient journeys., Methods and Analysis: We employ a sequential study design to calculate total costs of care for patients undergoing non-surgical fertility care treatments. In doing so, we identify process improvement opportunities and cost predictors and will reflect on the benefits of the information generated for medical leaders. Time-to-pregnancy will be viewed in relation to total costs to determine value. By combining time-driven, activity-based costing with observations and process mining, we trial a method for measuring care costs for large cohorts using electronic health record data. To support this method, we create activity and process maps for all relevant treatments: ovulation induction, intrauterine insemination, in vitro fertilisation (IVF), IVF with intracytoplasmic sperm injection and frozen embryo transfer after IVF. Our study design, by showing how different sources of data can be combined to enable cost and outcome measurements, can be of value to researchers and practitioners looking to measure costs for care paths or entire patient journeys in complex care settings., Ethics and Dissemination: This study was approved by the ESHPM Research Ethics Review Committee (ETH122-0355) and the Reinier de Graaf Hospital (2022-032). Results will be disseminated through seminars, conferences and peer-reviewed publications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The disclosure of online test results (i.e., laboratory, radiology and pathology results) on patient portals can vary from immediate disclosure (in real-time) via a delay of up to 28 days to non-disclosure. Although a few studies explored patient opinions regarding test results release, we have no insight into actual patients' preferences. To address this, we allowed patients to register their choices on a hospital patient portal. Our research question was: When do patients want their test results to be disclosed on the patient portal and what are the reasons for these choices? We used a mixed methods sequential explanatory design that included 1) patient choices on preferred time delay to test result disclosure on the patient portal for different medical specialties (N = 4592) and 2) semi-structured interviews with patients who changed their mind on their initial choice (N = 7). For laboratory (blood and urine) results, 3530 (76.9%) patients chose a delay of 1 day and 912 (19.9%) patients chose a delay of 7 days. For radiology and pathology results 4352 (94.8%) patients chose a delay of 7 days. 43 patients changed their mind about when they wanted to receive their results. By interviewing seven patients (16%) from this group we learned that some participants did not remember why they made changes. Four participants wanted a shorter delay to achieve transparency in health-related information and communication; to have time to process bad results; for reassurance; to prepare for a medical consultation; monitoring and acting on deviating results to prevent worsening of their disease; and to share results with their general practitioner. Three participants extended their chosen delay to avoid the disappointment about the content and anxiety of receiving incomprehensible information. Our study indicates that most patients prefer transparency in health-related information and want their test results to be disclosed as soon as possible., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Hulter et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Although previous studies largely emphasize the positive effects of patient participation in patient safety, negative effects have also been observed. This study focuses on bringing together the separate negative effects that have been previously reported in the literature. This study set out to uncover how these negative effects manifest themselves in practice within an obstetrics department., Design: An exploratory qualitative interview study with 16 in-depth semistructured interviews. The information contained in the interviews was deductively analysed., Setting: The study was conducted in one tertiary academic healthcare centre in the Netherlands., Participants: Patients (N=8) and professionals (N=8) from an obstetrics department., Results: The results of this study indicate that patient participation in patient safety comes in five different forms. Linked to these different forms, four negative effects of patient participation in patient safety were identified. These can be summarised as follows: patients' confidence decreases, the patient-professional relationship can be negatively affected, more responsibility can be demanded of the patient than they wish to accept and the professional has to spend additional time on a patient., Conclusion: This study identifies and brings together four negative effects of patient participation in patient safety that have previously been individually identified elsewhere. In our interviews, there was a consensus among patients and professionals on five different forms of participation that would allow patients to positively participate in patient safety. Further studies should investigate ways to prevent and to mitigate the potential negative effects of patient participation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Although value-based healthcare (VBHC) views accurate cost information to be crucial in the pursuit of value, little is known about how the costs of care should be measured. The aim of this review is to identify how costs are currently measured in VBHC, and which cost measurement methods can facilitate VBHC or value-based decision making., Design: Two reviewers systematically search the PubMed/MEDLINE, Embase, EBSCOhost and Web of Science databases for publications up to 1 January 2022 and follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify relevant studies for further analysis., Eligibility Criteria: Studies should measure the costs of an intervention, treatment or care path and label the study as 'value based'. An inductive qualitative approach was used to identify studies that adopted management accounting techniques to identify if or how cost information facilitated VBHC by aiding decision-making., Results: We identified 1930 studies, of which 215 measured costs in a VBHC setting. Half of these studies measured hospital costs (110, 51.2%) and the rest relied on reimbursement amounts. Sophisticated costing methods that allocate both direct and indirect costs to care paths were seen as able to provide valuable managerial information by facilitating care path adjustments (39), benchmarking (38), the identification of cost drivers (47) and the measurement of total costs or cost savings (26). We found three best practices that were key to success in cost measurement: process mapping (33), expert input (17) and observations (24)., Conclusions: Cost information can facilitate VBHC. Time-driven activity-based costing (TDABC) is viewed as the best method although its ability to inform decision-making depends on how it is implemented. While costing short, or partial, care paths and surgical episodes produces accurate cost information, it provides only limited decision-making information. Practitioners are advised to focus on costing full care cycles and to consider both direct and indirect costs through TDABC., Competing Interests: Competing interests: The third author, KA, was a speaker at the 2022 TDABC conference and was reimbursed for his stay in Lisbon by the TDABC consortium., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Healthcare professionals have to give substance to the role of a champion in order to successfully lead quality improvement (QI) initiatives. This study aims to unravel how hospitalists in training shape their role as a champion within the context of QI projects in hospital care and why some are more effective in leading a QI project than others. We focus on the role of credibility, as it is a prerequisite for fulfilling the role of champion. This multiple-case study builds upon 23 semi-structured interviews with hospitalists in training: quality officers and medical specialists. We first coded data for each case and then described the different contexts of each case in detail to enable comparison across settings. We then compared the cases and contrasted the attributes of credibility. Four attributes of credibility emerged and were identified as essential for the hospitalist in training to succeed as a champion: (1) being convincing about the need for change by providing supportive clinical evidence, (2) displaying competence in their clinical work and commitment to their tasks, (3) generating shared ownership of the QI project with other healthcare professionals, and (4) acting as a team player to foster collaboration during the QI project. We also identified two contextual factors that supported the credibility of the hospitalist in training: (1) choosing a subject for the QI project that was perceived as urgently required by the group of stakeholders involved, and (2) being supported by the board of directors and other formal and informal leaders as the leader of a QI project. Further research is needed to gain a deeper understanding of the relationship between credibility and sustainability of change.

The current models used for paying for health and social care are considered a major barrier to integrated care. Despite the implementation of integrated payment schemes proving difficult, such initiatives are still widely pursued. In the Netherlands, this development has led to a payment architecture combining traditional and integrated payment models. To gain insight into the justification for and future viability of integrated payment, this paper's purpose is to explain the current duality by identifying discourses on integrated payment models, determining which discourses predominate, and how they have changed over time and differ among key stakeholders in healthcare. The discourse analysis revealed four discourses, each with its own underlying assumptions and values regarding integrated payment. First, the Quality-of-Care discourse sees integrated payment as instrumental in improving care. Second, the Affordability discourse emphasizes how integrated payment can contribute to the financial sustainability of the healthcare system. Third, the Bureaucratization discourse highlights the administrative burden associated with integrated payment models. Fourth, the Strategic discourse stresses micropolitical and professional issues that come into play when implementing such models. The future viability of integrated payment depends on how issues reflected in the Bureaucratization and Strategic discourses are addressed without losing sight of quality-of-care and affordability, two aspects attracting significant public interest in The Netherlands.

Introduction: Traditional payment models reward volume rather than value. Moving away from reimbursing separate providers to network-level reimbursement is assumed to support structural changes in health care organizations that are necessary to improve patient care. This scoping review evaluates the performance of care networks that have adopted network-level payment models., Methods: A scoping review of the empirical literature was conducted according to the five-step York framework. We identified indicators of performance, categorized them in four categories (quality, utilization, spending and other consequences) and scored whether performance increased, decreased, or remained stable due to the payment model., Results: The 76 included studies investigated network-level capitation, disease-based bundled payments, pay-for-performance and blended global payments. The majority of studies stem from the USA. Studies generally concluded that performance in terms of quality and utilization increased or remained stable. Most payment models were associated with improved spending performance. Overall, our review shows that network-level payment models are moderately successful in improving network performance., Discussion/conclusion: As health care networks are increasingly common, it seems fruitful to continue experimenting with reimbursement models for health care networks. It is also important to broaden the scope to not only scrutinize outcomes, but also the contexts and mechanisms that lead to certain outcomes., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Introduction: Ageing in place, supported by formal home and community services and informal caregivers, is the most used long-term care option for people with dementia (PwD). Informal caregivers are inundated by their caregiving responsibilities and resultantly suffer consequences. Despite the multitude of clinical effectiveness studies on interventions that support informal caregivers, there is a paucity of information regarding their implementation process. This scoping review aims to identify the implementation strategies, implementation outcomes, and barriers and facilitators that impede or support the dissemination and uptake of interventions that support informal caregivers of PwD at home., Methods and Analysis: This protocol is guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols, and the scoping review will follow the systematic steps of the PRISMA-Extension for Scoping Reviews guideline. The search strategy will include publications produced from inception to 8 March 2021 and will be conducted in the search engines Embase, Medline (Ovid), Web of Science and Cochrane Central Register of Controlled Trials (Wiley), followed by a three-stage approach. First, title and abstracts will be screened by two independent reviewers. Second, full-text articles will also be screened by both reviewers and, in case of disagreement, by a third reviewer. The first two stages are based on a set of inclusion and exclusion criteria. Reference lists of the final included studies will also be checked for relevant articles. Data from the final included studies will be extracted and synthesised using the Expert Recommendations for Implementing Change compilation and Proctor's implementation outcomes to ensure homogenous and standardised reporting of implementation information., Ethics and Dissemination: The review findings will be published in a peer-reviewed journal and disseminated at geriatric and implementation conferences to inform researchers, health service planners and practice professionals with an overview of the existing literature to guide them in the effective implementation of caregiver-focused interventions in dementia support., Competing Interests: Competing interests: NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no conflicts of interest to declare., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Various forms of videoconferenced collaborations exist in oncology care. In regional oncology networks, multidisciplinary teams (MDTs) are essential in coordinating care in their region. There is no recent overview of the benefits and drawbacks of videoconferenced collaborations in oncology care networks. This scoping review presents an overview of videoconferencing (VC) in oncology care and summarises its benefits and drawbacks regarding decision-making and care coordination., Design: We searched MEDLINE, Embase, CINAHL (nursing and allied health) and the Cochrane Library from inception to October 2020 for studies that included VC use in discussing treatment plans and coordinating care in oncology networks between teams at different sites. Two reviewers performed data extraction and thematic analyses., Results: Fifty studies were included. Six types of collaboration between teams using VC in oncology care were distinguished, ranging from MDTs collaborating with similar teams or with national or international experts to interactions between palliative care nurses and experts in that field. Patient benefits were less travel for diagnosis, better coordination of care, better access to scarce facilities and treatment in their own community. Benefits for healthcare professionals were optimised treatment plans through multidisciplinary discussion of complex cases, an ability to inform all healthcare professionals simultaneously, enhanced care coordination, less travel and continued medical education. VC added to the regular workload in preparing for discussions and increased administrative preparation., Discussion: Benefits and drawbacks for collaborating teams were tied to general VC use. VC enabled better use of staff time and reduced the time spent travelling. VC equipment costs and lack of reimbursement were implementation barriers., Conclusion: VC is highly useful for various types of collaboration in oncology networks and improves decision-making over treatment plans and care coordination, with substantial benefits for patients and specialists. Drawbacks are additional time related to administrative preparation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Client-centred care serves as the foundation for healthcare policy. Indeed, various instruments for assessing clients' experiences of care and support are increasingly used to provide insights into the quality, and client-centred nature, of the care and support provided, which, in turn, aids the development of subsequent improvements. The unique characteristics of care and support for people with intellectual disabilities (ID), such as the need for both lifelong and life-wide care and support across all aspects of clients' lives, led to an initiative within Dutch ID care to jointly develop a range of instruments to assess the experiences of clients receiving ID care and support. Individual clients' experiences and suggestions for improvement, which are embedded in clients' care plan cycles, constitute the foundation of this Range of Instruments. This paper provides a unique, bottom-up, exhaustive account of the process of developing the Range of instruments used to assess the experiences of clients in the field of Dutch ID care., Methods: Relevant documents at three levels (i.e. 1) national documents, such as policy papers and governmental reports, 2) documents and reports from the Dutch Association of Healthcare Providers for People with Disabilities (VGN) along with minutes from the meetings of the expert Committee who assessed the instruments, and 3) correspondence between the Committee and developers as well as the forms used in the assessment process for each instrument) were qualitatively analysed by two researchers who had no affiliation with the development of the Range of instruments used to assess clients' experiences in ID care and support. All of the documents were inductively coded using a thematic analytical approach. Informants who were either currently or previously involved in the development of these instruments were asked to provide clarification over the documents themselves and to explain the context in which they were produced., Results: The development of the range of instruments can be classified into four phases, namely: 1) supporting the bottom-up development of initiatives to assess clients' experiences, 2) focusing on learning and further development, 3) stimulating exchange between the developers and users of the instruments and the Committee responsible for assessing them, and 4) further development in response to the changing times and new landscape., Conclusions: The range of instruments were found to be appropriate for a variety of clients in ID care and support, specifically in terms of assessing their individual experiences and gaining insight into their suggestions for improvement, and effective in terms of collaboratively improving the quality of ID care and support. In so doing, these instruments potentially provide an avenue through which clients' experiences can be embedded in the process of ID care and support. Other specific features in the development of these instruments, namely their incremental adoption, ongoing evaluation and strong practice orientation, were also found to be suitable for other care contexts' attempts to respond to the top-down policy objectives of client-centeredness and translating outcomes into direct care practice., (© 2021. The Author(s).)

Background: Healthcare purchasers such as health insurers and governmental bodies are expected to strategically manage chronic care chains. In doing so, purchasers can contribute to the goal of improving task division and collaboration between chronic care providers as has been recommended by numerous studies. However, healthcare purchasing research indicates that, in most countries, purchasers still struggle to fulfil a proactive, strategic approach. Consequently, a typical pattern occurs in which care improvement initiatives are instigated, but not transformed into regular care. By acknowledging that healthcare purchasers are embedded in a care chain of stakeholders who have different, sometimes conflicting, interests and, by taking an institutional logics lens, we seek to explain why achieving strategic purchasing and sustainable improvement is so elusive., Method and Findings: We present a longitudinal case study in which we follow a health insurer and care providers aiming to improve the care of patients with Chronic Obstructive Pulmonary Disease (COPD) in a region of the Netherlands. Taking a theoretical lens of institutional logics, our aim was to answer 'how stakeholder pressures influence a purchaser's use of institutional logics when pursuing the right care at the right place'. The insurer by default predominantly expressed a bookkeeper's logic, reflecting a focus on controlling short-term care costs by managing individual providers. Over time, a contrasting orchestrator's logic emerged in an attempt to achieve chain-wide improvement, striving for better health outcomes and lower long-term costs. We established five types of stakeholder pressure to explain the shift in logic adoption: relationship pressures, cost pressures, medical demands, public health demands and uncertainty. Linking the changes in logic over time with stakeholder pressures showed that, firstly, the different pressures interact in influencing the purchaser. Secondly, we saw that the lack of intra-organisational alignment affects how the purchaser deals with the different stakeholder pressures., Conclusions: By highlighting the purchaser's difficult position in the care chain and the consequences of their own internal responses, we now better understand why the intended orchestrator's logic and thereby a strategic approach to purchasing chronic care proves unsustainable within the Dutch healthcare system of managed competition., Competing Interests: The authors have declared that no competing interests exist.

Background: Patients in a range of health care sectors can access their medical health records using a patient portal. In mental health care, the use of patient portals among mental health care professionals remains low. Mental health care professionals are concerned that patient access to electronic health records (EHRs) will negatively affect the patient's well-being and privacy as well as the professional's own workload., Objective: This study aims to provide insights into the appraisal work of mental health care professionals to assess and understand patient access to their EHRs through a patient portal., Methods: We conducted a qualitative study that included 10 semistructured interviews (n=11) and a focus group (n=10). Participants in both the interviews and the focus group were mental health care professionals from different professional backgrounds and staff employees (eg, team leaders and communication advisors). We collected data on their opinions and experiences with the recently implemented patient portal and their attempts to modify work practices., Results: Our study provides insights into mental health care professionals' appraisal work to assess and understand patient access to the EHR through a patient portal. A total of four topics emerged from our data analysis: appraising the effect on the patient-professional relationship, appraising the challenge of sharing and registering delicate information, appraising patient vulnerability, and redefining consultation routines and registration practices., Conclusions: Mental health care professionals struggle with the effects of web-based patient access and are searching for the best ways to modify their registration and consultation practices. Our participants seem to appraise the effects of web-based patient access individually. Our study signals the lack of systematization and communal appraisal. It also suggests various solutions to the challenges faced by mental health care professionals. To optimize the effects of web-based patient access to EHRs, mental health care professionals need to be involved in the process of developing, implementing, and embedding patient portals., (©Antonius Mattheus van Rijt, Pauline Hulter, Anne Marie Weggelaar-Jansen, Kees Ahaus, Bettine Pluut. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 27.08.2021.)

Objectives: While the uptake of value-based health care (VBHC) is remarkable, uncertainty prevails regarding the most important actions and practices in establishing a value-based healthcare system. In this paper, we generate expert consensus on the most important aspects of VBHC., Design: The Delphi technique was used to reach consensus on the most important practices in moving towards a value-based healthcare system., Setting and Participants: A Dutch expert panel consisting of nine members participated in a two-round survey., Primary and Secondary Outcome Measures: We developed 39 initial items based on the pioneering literature on VBHC and recent health policies in the Netherlands. Experts rated the importance of each item on a 4-point Likert scale. Experts could change items or add new ones as they saw fit. We retained items that were rated (very) important by ≥80% of the panel., Results: After two survey rounds, 32 items (72%) were included through expert consensus. Experts unanimously agree on the importance of shared decision-making, with this item uniquely obtaining the maximum score. Experts also reached consensus on the importance of outcome measurements, a focus on medical conditions, and full cycles of care. No consensus was reached on the importance of benchmarking., Conclusion: This paper provides new insight into the most important actions and practices for establishing a value-based healthcare system in the Netherlands. Interestingly, several of our findings contrast with the pioneering literature on VBHC. This raises the question whether VBHC's widespread international uptake indicates its actual implementation, or rather that the original concept primarily serves as an inspiring idea., Competing Interests: Competing interests: The fourth author, DD, is professor at the Erasmus University Rotterdam while also employed at Zorginstituut Nederland (National Health Care Institute), which partially funds this research., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Several types of audits have been used to promote quality improvement (QI) in hospital care. However, in-depth studies into the mechanisms responsible for the effectiveness of audits in a given context is scarce. We sought to understand the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality of hospital care., Methods: A realist review was conducted to systematically search and synthesise the literature on audits. Data from individual papers were synthesised by coding, iteratively testing and supplementing initial programme theories, and refining these theories into a set of context-mechanism-outcome configurations (CMOcs)., Results: From our synthesis of 85 papers, seven CMOcs were identified that explain how audits work: (1) externally initiated audits create QI awareness although their impact on improvement diminishes over time; (2) a sense of urgency felt by healthcare professionals triggers engagement with an audit; (3) champions are vital for an audit to be perceived by healthcare professionals as worth the effort; (4) bottom-up initiated audits are more likely to bring about sustained change; (5) knowledge-sharing within externally mandated audits triggers participation by healthcare professionals; (6) audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions; and (7) audits legitimise the provision of feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration., Conclusions: This realist review has identified seven CMOcs that should be taken into account when seeking to optimise the design and usage of audits. These CMOcs can provide policy makers and practice leaders with an adequate conceptual grounding to design contextually sensitive audits in diverse settings and advance the audit research agenda for various contexts., Prospero Registration: CRD42016039882., Competing Interests: The authors have declared that no competing interests exist.

Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative., Methods: There were 3 study periods: baseline (April 2009-March 2010), improvement (July 2012-December 2013), and operational (January 2014-December 2018). All patients undergoing RSI were eligible. We collected data using a structured video review. We compared key processes and outcomes with statistical process control charts., Results: We collected data for 615 of 643 (96%) patient encounters with RSI performed: 114 baseline (12 months), 105 improvement (18 months), and 396 operational (60 months). Key characteristics were similar, including patient age. Statistical process control charts indicated sustained improvement of all 6 key processes and the primary outcome measure (oxyhemoglobin desaturation) throughout the 5-year operational period., Conclusions: Improvements in RSI safety were sustained 5 years after a successful improvement initiative, with further improvement seen in several key processes. Further research is needed to elucidate the factors contributing to sustainability., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Theoretical models help to explain or predict the adoption of electronic health (eHealth) technology and illustrate the complexity of the adoption process. These models provide insights into general factors that influence the use of eHealth technology. However, they do not give hospitals much actionable knowledge on how to facilitate the adoption process., Objective: Our study aims to provide insights into patient portal adoption processes among patients and hospital staff, including health care professionals (HCPs), managers, and administrative clerks. Studying the experiences and views of stakeholders answers the following question: How can hospitals encourage patients and HCPs to adopt a patient portal?, Methods: We conducted 22 semistructured individual and group interviews (n=69) in 12 hospitals and four focus groups with members of national and seminational organizations and patient portal suppliers (n=53)., Results: The effort hospitals put into adopting patient portals can be split into three themes. First, inform patients and HCPs about the portal. This communication strategy has four objectives: users should (1) know about the portal, (2) know how the portal works, (3) know that action on the portal is required, and (4) know where to find help with the portal. Second, embed the patient portal in the daily routine of HCPs and management. This involves three forms of support: (1) hospital policy, (2) management by monitoring the numbers, and (3) a structured implementation strategy that includes all staff of one department. Third, try to adjust the portal to meet patients' needs to optimize user-friendliness in two ways: (1) use patients' feedback and (2) focus on optimizing for patients with special needs (eg, low literacy and low digital skills)., Conclusions: Asking stakeholders what they have learned from their efforts to stimulate patient portal use in hospitals elicited rich insights into the adoption process. These insights are missing in the theoretical models. Therefore, our findings help to translate the relatively abstract factors one finds in theoretical models to the everyday pragmatics of eHealth projects in hospitals., (©Pauline Hulter, Bettine Pluut, Christine Leenen-Brinkhuis, Marleen de Mul, Kees Ahaus, Anne Marie Weggelaar-Jansen. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 19.05.2020.)

Objectives: Given the difficulties in diagnosing and treating head-and-neck cancer, care is centralised in the Netherlands in eight head-and-neck cancer centres and six satellite regional hospitals as preferred partners. A requirement is that all patients of the partner should be discussed in a multidisciplinary team meeting (MDT) with the head-and-neck centre as part of a Dutch health policy rule. In this mixed-method study, we evaluate the value that the video-conferenced MDT adds to the MDTs in the care pathway, quantitative regarding recommendations given and qualitative in terms of benefits for the teams and the patient., Design: A sequential mixed-method study., Setting: One oncology centre and its partner in the Northern part of the Netherlands., Participants: Head-and-neck cancer specialists presenting patient cases during video-conferenced MDT over a period of 6 months. Semistructured interviews held with six medical specialists, three from the centre and three from the partner., Primary and Secondary Outcome Measures: Percentage of cases in which recommendations were given on diagnostic and/or therapeutic plans during video-conferenced MDT., Results: In eight of the 336 patient cases presented (2%), specialists offered recommendations to the collaborating team (three given from centre to partner and five from partner to centre). Recommendations mainly consisted of alternative diagnostic modalities or treatment plans for a specific patient. Interviews revealed that specialists perceive added value in discussing complex cases because the other team offered a fresh perspective by hearing the case 'as new'. The teams recognise the importance of keeping their medical viewpoints aligned, but the requirement (that the partner should discuss all patients) was seen as outdated., Conclusions: The added value of the video-conferenced MDT is small considering patient care, but the specialists recognised that it is important to keep their medical viewpoints aligned and that their patients benefit from the discussions on complex cases., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To investigate the consequences of increasing capacity to reduce access times, and to explore how patient waiting times and use of physical capacity were influenced by variability., Design: A retrospective case study that combines both primary and secondary data. Secondary data were retrieved from a hospital database to establish inflow and outflow of patients, utilisation of resources and available capacity, realised access times and the weekly number of new patients seen over 1 year. Primary data consisted of field notes, onsite visits and observations, and semistructured interviews., Setting: A secondary care facility, that is, a rheumatology department, in a large Dutch hospital., Participants: Analyses are based on secondary patient data from the hospital database, and the responses of the interviews with physicians, nurses and Lean Six Sigma project leaders., Results: The study shows that artificial variability was increased by managerial decisions to add capacity and to allow an increased inflow of new patients. This, in turn, resulted in undesirable and significant fluctuations in access times. We argue that we witnessed a new multiplier effect that typifies the fluctuations., Conclusions: Adding capacity resources to reduce access times might appear an obvious and effective solution. However, the outcomes were less straightforward than expected, and even led to new artificial variability. The study reveals a phenomenon that is specific to service environments, and especially healthcare, and has detrimental consequences for access times., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objectives: This study investigated whether the attitudes of physicians towards justified and unjustified litigation, and their perception of patient pressure in demanding care, influence their use of defensive medical behaviours., Design: Cross-sectional survey using exploratory factor analysis was conducted to determine litigation attitude and perceived patient pressure factors. Regression analyses were used to regress these factors on to the ordering of extra tests or procedures (defensive assurance behaviour) or the avoidance of high-risk patients or procedures (defensive avoidance behaviour)., Setting: Data were collected from eight Dutch hospitals., Participants: Respondents were 160 physicians and 54 residents (response rate 25%) of the hospital departments of (1) anaesthesiology, (2) colon, stomach and liver diseases, (3) gynaecology, (4) internal medicine, (5) neurology and (6) surgery., Primary Outcome Measures: Respondents' application of defensive assurance and avoidance behaviours., Results: 'Disapproval of justified litigation' and 'Concerns about unjustified litigation' were positively related to both assurance (β=0.21, p<0.01, and β=0.28, p<0.001, respectively) and avoidance (β=0.16, p<0.05, and β=0.18, p<0.05, respectively) behaviours. 'Self-blame for justified litigation' was not significantly related to both defensive behaviours. Perceived patient pressures to refer (β=0.18, p<0.05) and to prescribe medicine (β=0.23, p<0.01) had direct positive relationships with assurance behaviour, whereas perceived patient pressure to prescribe medicine was also positively related to avoidance behaviour (β=0.14, p<0.05). No difference was found between physicians and residents in their defensive medical behaviour., Conclusions: Physicians adopted more defensive medical behaviours if they had stronger thoughts and emotions towards (un)justified litigation. Further, physicians should be aware that perceived patient pressure for care can lead to them adopting defensive behaviours that negatively affects the quality and safety of patient care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To investigate the relationship between lean adoption and problem-solving behaviour in nursing teams, and to explore the practices of lean leaders on nursing wards to reveal how they can stimulate second-order problem-solving within their teams., Design: A mixed-methods retrospective multiple case study using semistructured interviews. Interview data were used to assess the level of lean maturity (based on a customised validated instrument) and the level of second-order problem-solving (based on scenarios). Within-case and cross-case analyses were employed to identify lean leadership practices., Setting: 14 nursing teams, with different levels of lean maturity, in a Dutch hospital., Participants: Three members of each nursing team were interviewed: the team leader, one nurse from the ward's core team for the lean-based quality improvement programme and one nurse outside the core team., Interventions: The nursing teams were in various phases of a lean-based quality improvement programme: 'The Productive Ward - Releasing Time to Care'., Results: A strongly significant positive relationship between lean maturity and second-order problem-solving was found: β=0.68, R 2 =0.46, p<0.001. Further, the results indicated a potential strengthening effect of lean leadership on this relationship. Seven lean leadership practices emerged from the data collected in a nursing ward setting: (1) convincing and setting an example; (2) unlocking individual and team potential; (3) solving problems systematically; (4) enthusing, actively participating and visualising; (5) developing self-managing teams; (6) sensing, as orchestrator, what is needed for change; and (7) listening, sharing information and appreciating. These practices have a strong link with transformational leadership., Conclusions: As lean matures, nursing teams reach a higher level of second-order problem-solving. In later stages, lean leaders increasingly relinquish responsibility by developing self-managing teams., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Many types of audits are commonly used in hospital care to promote quality improvements. However, the evidence on the effectiveness of audits is mixed. The objectives of this proposed realist review are (1) to understand how and why audits might, or might not, work in terms of delivering the intended outcome of improved quality of hospital care and (2) to examine under what circumstances audits could potentially be effective. This protocol will provide the rationale for using a realist review approach and outline the method., Methods and Analysis: This review will be conducted using an iterative four-stage approach. The first and second steps have already been executed. The first step was to develop an initial programme theory based on the literature that explains how audits are supposed to work. Second, a systematic literature search was conducted using relevant databases. Third, data will be extracted and coded for concepts relating to context, outcomes and their interrelatedness. Finally, the data will be synthesised in a five-step process: (1) organising the extracted data into evidence tables, (2) theming, (3) formulating chains of inference from the identified themes, (4) linking the chains of inference and formulating CMO configurations and (5) refining the initial programme theory. The reporting of the review will follow the 'Realist and Meta-Review Evidence Synthesis: Evolving Standards' (RAMESES) publication standards., Ethics and Dissemination: This review does not require formal ethical approval. A better understanding of how and why these audits work, and how context impacts their effectiveness, will inform stakeholders in deciding how to tailor and implement audits within their local context. We will use a range of dissemination strategies to ensure that findings from this realist review are broadly disseminated to academic and non-academic audiences., Prospero Registration Number: CRD42016039882., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Although the guiding principle of clinical governance states that healthcare professionals are the leading contributors to quality and safety in healthcare, little is known about what healthcare professionals perceive as important for clinical governance. The aim of this study is to clarify this by exploring healthcare professionals' views on clinical governance., Design: Based on a literature search, a list of 99 elements related to clinical governance was constructed. This list was refined, extended and restricted during a three-round Delphi study., Setting and Participants: The panel of experts was formed of 24 healthcare professionals from an academic hospital that is seen as a leader in terms of its clinical governance expertise in the Netherlands., Main Outcome Measures: Rated importance of each element on a four-point scale., Results: The 50 elements that the panel perceived as most important related to adopting a bottom-up approach to clinical governance, ownership, teamwork, learning from mistakes and feedback. The panel did not reach a consensus concerning elements that referred to patient involvement. Elements that referred to a managerial approach to clinical governance and standardisation of work were rejected by the panel., Conclusions: In the views of the panel of experts, clinical governance is a practice-based, value-driven approach that has the goal of delivering the highest possible quality care and ensuring the safety of patients. Bottom-up approaches and effective teamwork are seen as crucial for high quality and safe healthcare. Striving for high quality and safe healthcare is underpinned by continuous learning, shared responsibility and good relationships and collaboration between healthcare professionals, managers and patients., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Based on practices in commercial organizations and public services, healthcare organizations are using service charters to inform patients about the quality of service they can expect and to increase patient-centeredness. In the Netherlands, an integrated regional stroke service involving five organizations has developed and implemented a single service charter. The purpose of this study is to determine the organizational enablers for the effective development and implementation of this service charter., Methods: We have conducted an exploratory qualitative study using Grounded Theory to determine the organizational enablers of charter development and implementation. Individual semi-structured interviews were held with all members of the steering committee and the taskforce responsible for the service charter. In these twelve interviews, participants were retrospectively asked for their opinions of the enablers. Interview transcripts have been analysed using Glaser's approach of substantive coding consisting of open and selective coding in order to develop a framework of these enablers. A tabula rasa approach was used without any preconceived frameworks used in the coding process., Results: We have determined seven categories of enablers formed of a total of 27 properties. The categories address a broad spectrum of enablers dealing with the basic foundations for cooperation, the way to manage the project's organization and the way to implement the service charter. In addition to the enablers within each individual organization, enablers that reflect the whole chain seem to be important for the effective development and implementation of this service charter. Strategic alignment of goals within the chain, trust between organizations, willingness to cooperate and the extent of process integration are all important properties., Conclusions: This first exploratory study into the enablers of the effective development and implementation was based on a single case study in the Netherlands. This is the only integrated care chain using a single service charter that we could find. Nevertheless, the results of our explorative study provide an initial framework for the development and implementation of service charters in integrated care settings. This research contributes to the literature on service charters, on patient-centeredness in integrated care and on the implementation of innovations.

Background: Practicing safe behavior regarding patients is an intrinsic part of a physician's ethical and professional standards. Despite this, physicians practice behaviors that run counter to patient safety, including practicing defensive medicine, failing to report incidents, and hesitating to disclose incidents to patients. Physicians' risk of malpractice litigation seems to be a relevant factor affecting these behaviors. The objective of this study was to identify conditions that influence the relationship between malpractice litigation risk and physicians' behaviors., Methods: We carried out an exploratory field study, consisting of 22 in-depth interviews with stakeholders in the malpractice litigation process: five physicians, two hospital board members, five patient safety staff members from hospitals, three representatives from governmental healthcare bodies, three healthcare law specialists, two managing directors from insurance companies, one representative from a patient organization, and one representative from a physician organization. We analyzed the comments of the participants to find conditions that influence the relationship by developing codes and themes using a grounded approach., Results: We identified four factors that could affect the relationship between malpractice litigation risk and physicians' behaviors that run counter to patient safety: complexity of care, discussing incidents with colleagues, personalized responsibility, and hospitals' response to physicians following incidents., Conclusion: In complex care settings procedures should be put in place for how incidents will be discussed, reported and disclosed. The lack of such procedures can lead to the shift and off-loading of responsibilities, and the failure to report and disclose incidents. Hospital managers and healthcare professionals should take these implications of complexity into account, to create a supportive and blame-free environment. Physicians need to know that they can rely on the hospital management after reporting an incident. To create realistic care expectations, patients and the general public also need to be better informed about the complexity and risks of providing health care.

Purpose: Health care organizations have to improve their performance for multiple stakeholders and organize integrated care. To facilitate this, various integrated quality management models can be used. This article reviews the literature on the Malcolm Baldrige Quality Award (MBQA) criteria, the European Foundation Quality Management (EFQM) Excellence model (Excellence award models) and the Chronic Care Model. The focus is on the empirical evidence for improved performance by the implementation of interventions based on these models., Data Sources: A systematic literature review from 1995 to May 2006 in the Pubmed, Cochrane, and ABI- databases was conducted., Study Selection: After selection, 37 studies were included, 16 in the Excellence award model search and 21 in the Chronic Care Model search. DATA EXTRACTION AND RESULTS OF ANALYSIS: Data were retrieved about the main intervention elements, study design, evidence level, setting and context factors, data collection and analysis, principal results and performance dimensions. No Excellence Award model studies with controlled designs were found. For the Chronic Care Model, one systematic review, one meta analysis and six controlled studies were included. Seventeen studies (2 in Excellence award model, 15 in Chronic Care Model) reported one or more significant results., Conclusion: There is some evidence that implementing interventions based on the 'evidence-based developed' Chronic Care Model may improve process or outcome performances. The evidence for performance improvement by interventions based on the 'expert-based developed' MBQA criteria and the EFQM Excellence model is more limited. Only a few studies include balanced measures on multiple performance dimensions. Considering the need for integrated care and chronic care improvement, the further development of these models for guiding improvements in integrated care settings and their specific context factors is suggested.