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This Chapter provides a case narrative of the role of medical doctors in healthcare reforms in the England, starting with the creation of the NHS (1948), up until the Coalition government reforms and their aftermath (2010-2020). The focus is on the two main policy actors and their complex relationship over time. As for the Canadian case study, the reform narrative is followed by analysis along three thematic axis: 1) the drivers and shapers of medical politics; 2) the strategies used by medical doctors and governments to deal with evolving context and 3) The implications for medical politics and healthcare reforms.

Public and patient engagement (PPE) is increasingly recognized in policy statements as essential to achieving transformation towards patient-centred, value-based, integrated care. Despite extensive research over two decades, important gaps and questions remain around how the efforts invested in engagement drive the changes needed to meet these objectives.We conducted a meta-narrative review of systematic and scoping reviews to understand persistent difficulties and uncertainties in this research domain. Thirty-eight reviews looking at studies of PPE in care, healthcare organizations and systems were appraised. We synthesized the expectations of PPE that prompted each review, the guiding ideas about how PPE comes about, main findings and the questions and gaps they raise.Four storylines are found in reviews: 1. Terminology is inconsistent and concepts are weak; 2. Outcomes of care can be improved 3. Influence on healthcare delivery and design is uncertain; 4. Characteristics of engagement efforts are consequential.Three assumptions underlie these storylines and appear as barriers to practice and research; alternative approaches based on collaborative governance and theories of change are proposed to understand and support engagement with transformative potential.

Responsive, integrated and sustainable health systems require that communities take an active role in service design and delivery. Much of the current literature focuses on provider-led initiatives to gain community input, raising concerns about power imbalances inherent in invited forms of participation. This paper provides an alternate view, exploring how, in a period following reforms, community actors forge network alliances to (re)gain legitimacy and capacities to coproduce health services with system providers.A longitudinal case study traced the network-building efforts over 3 years of a working group formed by citizens and community actors working with seniors, minorities, recent immigrants, youth and people with disabilities. The group came together over concerns about reforms that impacted access to health services and the ability of community groups to mediate access for vulnerable community residents. Data were collected from observation of the group's meetings and activities, documents circulated within and by the group, and semi-directed interviews. The first stage of analysis used social network mapping to reveal the network development achieved by the working group; a second traced network maturation, based on actor-network theory.Network mapping revealed how the working group mobilized existing links and created new links with health system actors to explore access issues. Problematization appeared as an especially important stage in network development in the context of reforms that disrupted existing collaborative relationships and introduced new structures and processes.Network-building strategies enable community actors to enhance their capacity for coproduction. A key contribution lies in the creation of 'organizational infrastructure'.The lead researcher was embedded over 3 years in the activities of the community groups and community residents. Several group members provided comments on an initial draft of this paper. To preserve the anonymity of the group, their names do not appear in the acknowledgements section.

Collective leadership arrangements in which two people jointly occupy a shared leadership role space are often thought to enable the bridging of competing demands and sources of expertise and legitimacy in pluralistic settings where multiple institutional logics coexist. This research investigates 20 co-leadership dyads in health care organizations to examine whether, when, and how co-leadership arrangements can enable the bridging of institutional logics. Empirical findings suggest that the potential for bridging through co-leadership arrangements is present, but that it may often be achieved through the assimilation of one side by the other rather than balanced integration of competing demands. We conclude that the challenge of collective leadership (and of co-leadership, in particular) may lie not only in developing smooth relations among multiple leaders and their followers, but also in maintaining and mobilizing the tensions that can make their collaboration most fruitful. We suggest that the collective leadership literature has often missed the significance of this central paradox: that collective leadership may be most needed where it is most difficult to achieve. When it seems to operate most smoothly, it is possible that it may not always be fulfilling its mission.

Purpose Despite growing attention to physician engagement there is a lack of literature to guide the development of physician-led interventions. A scoping review was conducted to describe physician-led strategies that have been implemented to promote increased physician engagement in acute care settings. Strategies are viewed through the theoretical lens of institutional work to advance the understanding about how the theory can be applied. The paper aims to discuss this issue. Design/methodology/approach Searches were conducted in English-language publications (2012–2017). Of 35 retained articles, 15 were from the gray literature; and 20 were peer reviewed. The review was guided by Arskey and O’Malley’s (2005) five-stage process. Findings Five themes reflecting different foci of physician-led activity were examined from the perspective of institutional work: systematically analyze context using participatory methods; work collaboratively toward locally defined, shared targets and build in processes to monitor progress; expand physicians’ role and capacity to include leadership toward shared organizational goals; promote appropriate rewards and incentives for work that builds engagement; and invest in opportunities for formal and informal communication and interaction. Practical implications Physicians considering action to increase their engagement in system improvement may benefit from analysis of local opportunities and barriers in selecting context-relevant activities that will motivate participation and build engagement through a balance of institutional work. Originality/value The paper considers the potential for physicians to initiate and support activity that will increase their engagement. It provides pragmatic strategies for designing intervention and research using the theoretical lens of institutional work.

Purpose The purpose of this paper is to articulate cutting-edge conceptions of the relationship between local processes in the here-and-now, and the broader influences on those processes, that are both organic and overtly designed, and to discern the implications of this relationship for future research, policy and practice. Design/methodology/approach A focused and structured approach was taken to give effect to this purpose by reviewing the chosen articles in this collection, which from the 2018 Organizational Behavior in Health Care conference papers. Findings Research in coordination within and across health care boundaries increasingly recognizes: the multilevel influences on human action and interaction in health care delivery; the challenge of balancing individual or local agency with overt interventions; the everchanging the local circumstances of healthcare delivery; and the need to foster reflexivity, that is, self-improvement capacity, in healthcare organizations. Research limitations/implications Interventions to improve care coordination must be grounded in the reality of changing local circumstances and incentives for action from the broader environment. Originality/value This paper articulates the implied tension in health care delivery between individual and local agency, and imposed structures that may contradict, but are at the same time necessary, to foster such agency.

BackgroundOptimising health professionals’ contribution is an essential step in effective and efficient health human resources utilisation. However, despite the considerable efforts made to implement advanced practice nursing roles, including those in primary care settings (PHCNP), the optimisation of these roles remains variable. In this investigation, we report on the subjective work experience of a group of PHCNPs in the province of Quebec (Canada).MethodsWe used Giddens’ structuration theory to guide our study given its’ facilitation of the understanding of the dynamic between structural constraints and actors’ actions. Using a qualitative descriptive study design, and specifically both individual and focus group interviews, we conducted our investigation within three health care regions in Quebec during 2016–2017.ResultsForty-one PHCNPs participated. Their descriptions of their experience fell into two general categories. The first of these, their perception of others’ inadequate understanding and valuing of their role, included the influence of certain work conditions, perceived restrictions on professional autonomy and the feeling of being caught between two professional paradigms. The second category, the PHCNPs’ sense of engagement in their work, included perspectives associated with the specific conditions in which their work is situated, for example, the fragility of the role depending on the particular clinic/s in which they work or on the individuals with whom they work. This fragility was also linked with certain health care reforms that had been implemented in Quebec (e.g., legislation requiring greater physician productivity).ConclusionSeveral new insights emerged, for example, the sense of role fragility being experienced by PHCNPs. The findings suggest an overarching link between the work context, the meaning attributed by PHCNPs to their work and their engagement. The optimisation of their role at the patient care level appears to be influenced by elements at the organisational and health system context levels. It appears that role optimisation must include the establishment of work environments and congruent health context structures that favour the implementation and deployment of new professional roles, work engagement, effective collaboration in interprofessional teams, and opportunities to exercise agency. Further research is necessary to evaluate initiatives that endeavour to achieve these objectives.

PurposeThe purpose of this paper is to explore the appropriation of control rooms based on value-based integrated performance management tools implemented in all publicly funded health organizations in Quebec (Canada) as a form of legitimate sociomaterial work.Design/methodology/approachMulti-site organizational ethnographic case studies in two Integrated health and social services centers, with narrative process analysis of triangulated qualitative data collected through non-participant observation (163 h), individual semi-structured interviews (N = 34), and document review (N = 143).FindingsThree types of legitimate sociomaterial work are accomplished when actors appropriate control rooms: 1) reformulating performance management work; 2) disrupting accountability work and; 3) effecting value-based integrated performance management. Each actor (tools, institutions and people) follows recurrent institutional work-paths: tools consistently engage in disruptive work; institutions consistently engage in maintaining work, and people consistently engage in creation work. The study reveals the potential of performance management tools as “effective integrators” of the technological, managerial, policy and delivery levels of data-driven health system performance and improvement.Practical implicationsThis paper draws on theoretically informed empirical insights to develop actionable knowledge around how to better design, implement and adapt tool-driven health system change: 1) Packaging the three agents of data-driven system change in health care: tools, institutions, people; 2) Redefining the search for performance in health care in the context of value creation, and; 3) Strengthening clinical and managerial relevance in health performance management practice.Originality/valueThe authors aim to stimulate new and original scholarship around the under-theorized concept of sociomaterial work, challenging theoretical, ontological and practical conceptions of work in healthcare organizations and beyond.

INTRODUCTION AND OBJECTIVE:With a median follow–up of 16 years the European Randomized Study of Screening for Prostate Cancer (ERSPC) shows a relative reduction of prostate cancer (PCa) specific mo...

Summary Inhibition of the extracellular signal-regulated kinases ERK1 and ERK2 (ERK1/2) offers a promising therapeutic strategy in cancers harboring activated RAS/RAF/MEK/ERK signaling pathways. Here, we describe an orally bioavailable and selective ERK1/2 inhibitor, ASN007, currently in clinical development for the treatment of cancer. In preclinical studies, ASN007 shows strong antiproliferative activity in tumors harboring mutations in BRAF and RAS (KRAS, NRAS, and HRAS). ASN007 demonstrates activity in a BRAFV600E mutant melanoma tumor model that is resistant to BRAF and MEK inhibitors. The PI3K inhibitor copanlisib enhances the antiproliferative activity of ASN007 both in vitro and in vivo due to dual inhibition of RAS/MAPK and PI3K survival pathways. Our data provide a rationale for evaluating ASN007 in RAS/RAF-driven tumors as well as a mechanistic basis for combining ASN007 with PI3K inhibitors., Graphical abstract, Highlights ASN007 is a reversible ATP-competitive inhibitor of ERK1 and ERK2 kinase activity The presence of RAS/RAF pathway mutations predicts enhanced efficacy of ASN007 ASN007 demonstrates strong efficacy in a resistant melanoma PDX model Combination with a PI3K inhibitor enhances ASN007 antitumor activity in several tumors, Portelinha et al. describe a selective ERK1/2 kinase inhibitor, ASN007, with antitumor activity against several solid tumors and lymphomas. Moreover, the authors show that PI3K inhibition enhances the activity of ASN007.

Resumo O grupo de colaboradores do LARIISA realiza pesquisa e desenvolvimento de soluções tecnológicas para apoio à tomada de decisão em sistemas de saúde desde 2009. Dentre as soluções produzidas está o GISSA®, sistema em nuvem resultado da evolução científica e tecnológica do projeto LARIISA. O objetivo do presente artigo é descrever a trajetória de evolução do GISSA®, ferramenta tecnológica que apoia a Estratégia de Saúde da Família no nordeste do Brasil, apontando desafios, caminhos e potencialidades. Trata-se de um estudo descritivo e exploratório, baseado em fontes secundárias do IBGE, INMET, SINAN, SIM e SINASC, com análise quantitativa a partir de modelos de aprendizagem de máquina aplicados na criação de microserviços em saúde digital. Operando nas regiões nordeste e sudeste, o GISSA® disponibiliza informações que qualificam o processo de tomada de decisão de gestores de saúde e, consequentemente, contribui para aperfeiçoar a gestão do sistema de saúde municipal. Abstract The LARIISA collaborators group has been conducting research and development of technological solutions to support decision-making in health systems since 2009. GISSA, a cloud system resulting from the scientific and technological evolution of the LARIISA project, is among the solutions produced. This paper aims to describe the developing trend of GISSA©, a technological tool supporting the Family Health Strategy in northeastern Brazil, pointing out challenges, paths, and potentialities. This is a descriptive and exploratory study, based on secondary sources from the IBGE, INMET, SINAN, SIM, and SINASC, with quantitative analysis based on machine-learning techniques applied to create digital health microservices. Operating in the northeast and southeast regions, GISSA© provides information that qualifies health managers’ decision-making process, improving the municipal health system’s management.

Interprofessional collaboration (IPC) is central to effective care. This practice is structured by an array of laws, regulations and policies but the literature on their impact on IPC is scarce. This study aims to illustrate the gap between the texts and clinicians' knowledge of the legal framework using an anonymous web-based survey. The survey, sent to nurses and physicians in Quebec, Canada, focused on the IPC legal framework, legal knowledge sources and IPC perceptions or beliefs. The primary outcome was to determine the gap between the law and understanding of the law. The secondary outcome was to identify legal knowledge sources for clinicians in Quebec. A total of 267 participants filled in the survey. For knowledge acquisition, 40% of physicians turned to insurers whereas 43% of nurses turned to their regulatory body. Only 30% of physicians correctly identified what activity is reserved for physicians while 39% of nurses correctly identified their reserved activity. Regarding legal perceptions, 28% of physicians and 39% of nurses thought IPC could increase their liability. These participants have a higher tendency to name liability-related issues as barriers to IPC. These results show an important discrepancy between clinicians' knowledge about law and policies, and the actual texts themselves. This gap can lead to misinterpretations of the law by clinicians, ineffective policy changes by policymakers and can perpetuate ineffective implementation of IPC.

This article relates institutional theory to the concept of organizational legitimacy with cognitive, moral, and pragmatic dimensions, to analyse how a Dutch national policy reform – aimed at expanding the social responsibility for sick leave and disability toward non-state organizations – is understood and enacted locally. Based on interviews in 52 organizations, the study highlights that implementing welfare state reform is predominantly based on pragmatic reasoning, and justified by specific moral and cognitive interpretations. The findings reveal that implementing reform is active institutional work by – paradoxically – restricted local agency, with disciplinary effects on a narrow range of actors.

Cet article porte sur le rôle stratégique des cadres intermédiaires dans les organisations pluralistes du secteur de la santé. Il vise à rendre compte de la complexité de leur travail stratégique en période de changements. L’analyse a permis d’établir trois attributs du strategizing3, c’est-à-dire des activités qui sont influencés par la nature imposée ou participative du changement : 1) la création d’un réseau d’alliances; 2) la négociation des valeurs; et 3) les micro pratiques quotidiennes., This article explores the strategic role played by middle managers in pluralist health sector organizations. It aims to capture the complexity of their strategy work during periods of change. The analysis identifies three attributes of strategizing, seen as activities influenced by the imposed or participative nature of change: 1) the creation of a network of alliances; 2) the negotiation of values; and 3) daily micro-practices., En este artículo se analiza el papel estratégico de los cuadros intermedios en organizaciones pluralistas del sector salud. Su objetivo es dar cuenta de la complejidad de su trabajo estratégico en períodos de cambio. El análisis permitió establecer tres atributos de la elaboración de estrategias, es decir, de las actividades que son influenciadas por la naturaleza impuesta o participativa del cambio: 1) la creación de una red de alianza; (2) la negociación de los valores; y (3) las micro prácticas diarias.

Bien que le concept d’innovation responsable (IR) gagne en popularite, aucune synthese d’etudes empiriques n’existe pour informer son developpement. Cet article presente les resultats d’une meta-ethnographie dont l’objectif etait de modeliser pourquoi et comment differentes IR ayant une incidence sur les determinants de la sante avaient ete developpees. Dix-sept etudes qualitatives, publiees entre 2000 et 2018, ont ete analysees afin d’elaborer ce modele. Ce dernier suggere que les IR sont orientees vers un bien commun, mais que les acteurs cherchent aussi par ces projets a satisfaire leurs interets propres. Les processus de developpement des IR impliquent des activites de nature manageriale, cognitive-technologique et normative-politique qui permettent de prendre des decisions pragmatiques et de creer un espace protecteur pour ces IR. Cette etude confirme la pertinence de plusieurs notions theoriques de l’IR, mais identifie egalement des aspects qui echappent aux logiques normatives qui prevalent actuellement dans la litterature. Codes JEL : O31, O350

Background: The European Randomized study of Screening for Prostate Cancer (ERSPC) has previously demonstrated that prostate-specific antigen (PSA) screening decreases prostate cancer (PCa) mortality. Objective: To determine whether PSA screening decreases PCa mortality for up to 16 yr and to assess results following adjustment for nonparticipation and the number of screening rounds attended. Design, setting, and participants: This multicentre population-based randomised screening trial was conducted in eight European countries. Report includes 182 160 men, followed up until 2014 (maximum of 16 yr), with a predefined core age group of 162 389 men (55-69 yr), selected from population registry. Outcome measurements and statistical analysis: The outcome was PCa mortality, also assessed with adjustment for nonparticipation and the number of screening rounds attended. Results and limitations: The rate ratio of PCa mortality was 0.80 (95% confidence interval [CI] 0.72-0.89, p 20 ng/ml (9.9% compared with 4.1% in the second round, p

Background: While responsible innovation in health (RIH) suggests that health innovations could be purposefully designed to better support health systems, little is known about the system-level challenges that it should address. The goal of this paper is thus to document what is known about health systems’ demand for innovations. Methods: We searched 8 databases to perform a scoping review of the scientific literature on health system challenges published between January 2000 and April 2016. The challenges reported in the articles were classified using the dynamic health system framework. The countries where the studies had been conducted were grouped using the human development index (HDI). Frequency distributions and qualitative content analysis were performed. Results: Up to 1391 challenges were extracted from 254 articles examining health systems in 99 countries. Across countries, the most frequently reported challenges pertained to: service delivery (25%), human resources (23%), and leadership and governance (21%). Our analyses indicate that innovations tend to increase challenges associated to human resources by affecting the nature and scope of their tasks, skills and responsibilities, to exacerbate service delivery issues when they are meant to be used by highly skilled providers and call for accountable governance of their dissemination, use and reimbursement. In countries with a low and medium HDI, problems arising with infrastructure, logistics and equipment were described in connection with challenges affecting procurement, supply and distribution systems. In countries with a medium and high HDI, challenges included a growing demand for drugs and new technology and the management of rising costs. Across all HDI groups, the need for flexible information technologies (IT) solutions to reach rural areas was underscored. Conclusion: Highlighting challenges that are common across countries, this study suggests that RIH should aim to reduce the cost of innovation production processes and attend not only to the requirements of the immediate clinical context of use, but also to the vulnerabilities of the broader system wherein innovations are deployed. Policy-makers should translate system-level demand signals into innovation development opportunities since it is imperative to foster innovations that contribute to the success and sustainability of health systems.

Antiandrogens inhibit the androgen receptor and have an important role in the treatment of prostate cancer. This review provides a historical perspective on the development and clinical benefit of antiandrogens in the treatment of prostate cancer.We searched PubMed® for clinical trials with the search terms antiandrogens and prostate cancer combined with drug names for antiandrogens. This article represents a collaboration of clinical investigators who have made critical scientific contributions leading to the approval of antiandrogens for treating patients with prostate cancer.Antiandrogens differ in chemical structure and exert varying efficacy and safety profiles. The unfavorable therapeutic index of steroidal antiandrogens led to replacement by safer nonsteroidal agents. Flutamide, nilutamide and bicalutamide, which were designed to target the androgen receptor, were developed primarily for use in combination with castration to provide combined androgen blockade. Modest clinical benefits were observed with the combination of first generation antiandrogens and castration vs castration alone. With increased knowledge of androgen receptor structure and its biological functions a new generation of antiandrogens without agonist activity was designed to provide more potent inhibition of the androgen receptor. Randomized clinical trials in patients with metastatic, castration resistant prostate cancer showed significant survival benefits, which led to the approval of enzalutamide in August 2012. Apalutamide was recently approved while darolutamide is not yet approved in the United States. These next generation antiandrogens are being actively tested in earlier disease states such as nonmetastatic prostate cancer. Evolving knowledge of resistance mechanisms to androgen receptor targeted treatments will stimulate research and drug discovery for additional compounds. Further testing in nonmetastatic castration resistant prostate cancer as well as castration sensitive disease states will hopefully augment our ability to treat a broader spectrum of patients with prostate cancer.Antiandrogens have already provided important benefits for prostate cancer treatment. Greater knowledge about the structural and functional biology of the androgen receptor in prostate cancer will facilitate further discovery and development of further improved antiandrogens with enhanced clinical activity in patients with advanced metastatic disease. Testing these new agents earlier in the course of prostate cancer may further improve the survival and quality of life of patients with current local and/or systemic treatment modalities.

While policy-makers in many jurisdictions are paying increasing attention to health workforce issues, human resources remain at best only partially aligned with population health needs. This paper explores the governance of human resources during the pandemic, looking at the Quebec health system as a revelatory case. We identify three issues related to health human resource (HHR) policies: working conditions, recognition at work and scope of practice. We empirically probe these issues based on an analysis of popular media, policy reports and participant observation by the lead authors in various forums and research projects. Using an integrated model of HHR, we identify major vulnerabilities in this domain. Persistent labour shortages, endemic deficiencies in working environments and inequity across occupational categories limit the ability to address critical HHR issues. We propose three ways to eliminate HHR vulnerabilities: reorganize work through participatory initiatives, implement joint policy making to rebalance power across the health workforce, and invest in the development of capacities at all system levels. \ud \ud \ud

Around the world, the COVID-19 pandemic has prompted radical transformations in health policy and the organisation of health and care services. In many countries, policymakers have rushed to re-organise care services to meet the ‘surge demand’ and ‘waves’ of COVID-19 infection and disease. Such strategies signal important and sweeping changes in the organisation of both ‘COVID’ and ‘non-COVID’ care, whilst asking more fundamental questions about the long-term organisation of care ‘after COVID’. This includes, for example, unprecedented patterns and levels of funding; new ways of governing, managing and leading services; and the reconfiguration of clinical teams and frontline care delivery. In some contexts, COVID-19 has exposed the fragilities and vulnerabilities of long held ways of organising care, especially where services operate at the very brink of resource constraints or at near full capacity. In others, it has shown how services are organised to be more resilient and adaptive to unanticipated pressures and surge demand. This introductory chapter reviews the themes of the edited collection in terms of policy learning, governance in hospital organisations, professions and professionalism, technologies and governmentalities, and organisational responses to COVID-19.

The LARIISA collaborators group has been conducting research and development of technological solutions to support decision-making in health systems since 2009. GISSA, a cloud system resulting from the scientific and technological evolution of the LARIISA project, is among the solutions produced. This paper aims to describe the developing trend of GISSA©, a technological tool supporting the Family Health Strategy in northeastern Brazil, pointing out challenges, paths, and potentialities. This is a descriptive and exploratory study, based on secondary sources from the IBGE, INMET, SINAN, SIM, and SINASC, with quantitative analysis based on machine-learning techniques applied to create digital health microservices. Operating in the northeast and southeast regions, GISSA© provides information that qualifies health managers' decision-making process, improving the municipal health system's management.O grupo de colaboradores do LARIISA realiza pesquisa e desenvolvimento de soluções tecnológicas para apoio à tomada de decisão em sistemas de saúde desde 2009. Dentre as soluções produzidas está o GISSA®, sistema em nuvem resultado da evolução científica e tecnológica do projeto LARIISA. O objetivo do presente artigo é descrever a trajetória de evolução do GISSA®, ferramenta tecnológica que apoia a Estratégia de Saúde da Família no nordeste do Brasil, apontando desafios, caminhos e potencialidades. Trata-se de um estudo descritivo e exploratório, baseado em fontes secundárias do IBGE, INMET, SINAN, SIM e SINASC, com análise quantitativa a partir de modelos de aprendizagem de máquina aplicados na criação de microserviços em saúde digital. Operando nas regiões nordeste e sudeste, o GISSA® disponibiliza informações que qualificam o processo de tomada de decisão de gestores de saúde e, consequentemente, contribui para aperfeiçoar a gestão do sistema de saúde municipal.

Background As part of reforms in 2015, the Ministry of Health and Social Services in Quebec, Canada mandated the national implementation of control rooms, making health system actors accountable for implementing value-based performance management. Objective To explore how do organizational actors appropriate control rooms as managerial tools to influence value-based performance in health systems. Design Multi-site organizational ethnographic case studies (N = 2) and narrative process analysis of triangulated qualitative data collected through non-participatory observations (179.5 h), individual semi-structured interviews (N = 34), and document review (N = 143). Results The process of appropriating control rooms plays a crucial role in achieving value-based performance management. Appropriating unfolds along three paths (cognitive, structural, technical) over three phases (implementing, testing, adapting). Implementing control rooms both produces and emerges from improvement capacities within healthcare organizations. Testing tools reveals that incompatibilities between tools, structures and values give rise to value-driven distributed clinical leadership. Adapting tools relies on the adaptability of organizations towards the value system driving the tools, rather than on the adaptability of tools to organizational design. Conclusion There is no “one-size-fits-all” framework to design and support the successful appropriation of control rooms towards achieving value-based performance. However, we believe that consideration for the three distinct phases of appropriation and leveraging the right mechanism to support each phase is a first important step in reviving value in healthcare governance.

The development of artificial intelligence (AI) systems to support diagnostic decision-making is rapidly expanding in health care. However, important challenges remain in executing algorithmic systems at the frontlines of clinical practice. Hence, most often, these systems have not been trained with local data nor do they fit with context-specific patterns of care. This research examines the implementation of an AI-based decision support system (DSS) in the emergency department of a large Academic Health Center (AHC) in Canada, focusing specifically on the question of end-user adoption. Based in an interpretative perspective, the study analyzes the perceptions of healthcare managers, AI developers, physicians and nurses on the DSS, so as to make sense of the main barriers to its adoption by emergency physicians. The study points to the importance of considering interconnections between technical, human and organizational factors to better grasp the unique challenges raised by AI systems in health care. It further emphasizes the need to investigate actors' perceptions of AI in order to develop strategies to adequately test and adapt AI systems, and ensure that they meet the needs of health professionals and patients. This research is particularly relevant at a time when considerable investments are being made to develop and deploy AI-based systems in health care. Empirically probing the conditions under which AI-based systems can effectively be integrated into processes and workflow is essential for maximizing the benefits these investments can bring to the organization and delivery of care.

The RAS/RAF/MEK/ERK pathway is aberrantly activated in approximately 30% of human cancers. Selective inhibitors of MEK or BRAF have shown clinical activity in both solid tumors and hematologic malignancies, but responses are typically transient due to acquired resistance and feedback activation of ERK1/2. We developed a potent, selective ERK1/2 inhibitor, ASN007, with anti-tumor activity in both solid tumors and lymphoma models with BRAF and RAS mutations and also in a melanoma PDX model resistant to BRAF and MEK inhibitors. ASN007 synergizes with PI3K inhibitors both in vitro and in vivo. Our data show that the selective ERK1/2 inhibitor ASN007, alone or in combination with PI3K inhibitors, may offer a new therapeutic option for patients with RAS or MAPK pathway activated cancers.

This chapter aims to understand how organizational actors in Academic Health Centres (AHCs) mobilize transformative capacities through the process of expanding the academic mission across the care continuum in the enactment of a policy reform. Using a realist evaluation approach, a single qualitative embedded case study was conducted in Quebec, Canada. Empirical data collected through document review and semi-structured interviews with key informants were first categorized as context, intervention, mechanism or outcome, and then sub-categorized as forms of institutional work. This study reveals that the development of transformative capacities through policy reform aiming to expand the academic mission across boundaries is a heterogeneous, nonlinear and relational process. Further research could explore the role of relational work in aligning actors across hierarchical boundaries through large-scale health system transformation.

As the increasingly employed concept of “governmentality” refers to diverse ideas, the authors present a state of the science assessment of its use in the study of healthcare networks. The review covers 17 databases over a 42-year period between 1975 and 2017 and identifies 1673 records, of which 98 are fully assessed and 38 meet inclusion criteria. It shows three usages of the concept: as an epistemology, as a framework, and as a specific form of governance. The review contributes to clarifying the usage, definitions, and concepts of governmentality in the existing literature on healthcare networks. The authors argue for the value of this multi-level theoretical ensemble to improve understanding of healthcare networks, particularly in relation to the implementation of mandated reforms across healthcare boundaries.

Background Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a “Wiki-suite” (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders. Objective The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools. Methods Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools. Results Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit. Conclusions This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada. Trial Registration ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245. International Registered Report Identifier (IRRID) DERR1-10.2196/17363

Introduction: Integrated care models for older adults are increasingly implemented in modern healthcare systems. They usually involve complex coordination and collaborations between multiple actors operating at different levels of the healthcare system. Several groups of actors such as policymakers (at the strategic level), managers (at the tactical level), providers (at the operational level), patients and caregivers, are simultaneously involved in the implementation of integrated care. Exploring their convergent and divergent perspectives may deepen our understanding of the values prioritised by these respective groups of actors in the successful implementation of integrated care. Aim: To explore the implementation of a province-wide community-based integrated healthcare model for older adults in Quebec by comparing the perspectives of policymakers, managers, providers, patients and caregivers. Theory and methods: A qualitative multiple-case study, consisting of 97 semi-structured interviews with different actors - policymakers (n=11); managers (n=34), health and social care providers (n=29), older adult patients (n=14) and caregivers (n=9) - as well as document analysis. Thematic analysis of the views of these five groups of actors were compared along the lines of the six dimensions of the Rainbow Model of Integrated Care (Valentijn, 2015). Results/discussion: In this centralised province-wide integrated care model, there are strong convergent perspectives of policymakers, managers and providers regarding the professional, organisational, systemic, functional and normative dimensions of integration. Our results showed the limited participation of patients and caregivers in the implementation process, since they had little information on those dimensions. Although policymakers, managers and providers often adhere to the same principles, differences are sometimes observed at the level of implementation. For instance, they all viewed the "continuity" item as a central element where organizational structures must support service trajectories. However, several providers report that the poor harmonization of the operating rules between the organizations and the lack of knowledge of the various programs create a lack of fluidity. Among the six dimensions, the clinical dimension was illuminated by all perspectives, with the most divergence between actors. Providers appeared to mediate between policymakers/managers, and patients/caregivers. For example, patients and caregivers offered insights into the perceived difficulties of meeting their needs. Policymakers and managers viewed the centrality of patient needs as empowering patients/caregivers to receive the services they felt most strongly about. Meanwhile, providers were mostly concerned with the capacity of the healthcare system to balance patient needs with the limited resources available. Conclusion: Centralised province-wide integration appears to have systemic, organizational, functional, and normative effects, but clinical effects are more uncertain as evidenced by the observed divergences in perspectives of actors. Lessons learned: Additional implementation efforts are needed to improve clinical integration in centralised healthcare systems. Limitations: Coordinating data analysis and interpretation was complicated by the high volume of interviews across the different perspectives. Suggestions for future research: Are systemic effects precursors of clinical changes or, on the contrary, does their importance explain the lack of clinical effects?

Background To identify the strategies and contextual factors that enable optimal engagement of patients in the design, delivery, and evaluation of health services. Methods We searched MEDLINE, EMBASE, CINAHL, Cochrane, Scopus, PsychINFO, Social Science Abstracts, EBSCO, and ISI Web of Science from 1990 to 2016 for empirical studies addressing the active participation of patients, caregivers, or families in the design, delivery and evaluation of health services to improve quality of care. Thematic analysis was used to identify (1) strategies and contextual factors that enable optimal engagement of patients, (2) outcomes of patient engagement, and (3) patients’ experiences of being engaged. Results Forty-eight studies were included. Strategies and contextual factors that enable patient engagement were thematically grouped and related to techniques to enhance design, recruitment, involvement and leadership action, and those aimed to creating a receptive context. Reported outcomes ranged from educational or tool development and informed policy or planning documents (discrete products) to enhanced care processes or service delivery and governance (care process or structural outcomes). The level of engagement appears to influence the outcomes of service redesign—discrete products largely derived from low-level engagement (consultative unidirectional feedback)—whereas care process or structural outcomes mainly derived from high-level engagement (co-design or partnership strategies). A minority of studies formally evaluated patients’ experiences of the engagement process (n = 12; 25%). While most experiences were positive—increased self-esteem, feeling empowered, or independent—some patients sought greater involvement and felt that their involvement was important but tokenistic, especially when their requests were denied or decisions had already been made. Conclusions Patient engagement can inform patient and provider education and policies, as well as enhance service delivery and governance. Additional evidence is needed to understand patients’ experiences of the engagement process and whether these outcomes translate into improved quality of care. Registration N/A (data extraction completed prior to registration on PROSPERO). Electronic supplementary material The online version of this article (10.1186/s13012-018-0784-z) contains supplementary material, which is available to authorized users.

This paper aims to contribute to a better understanding of multilevel governance processes. We do so by focusing on the in-depth examination of the institutional changes recently implemented in the...

The issue of translational education of healthcare professionals is a major one. It is clear that a great degree of upskilling is already required and, to keep pace with the science, this must be ongoing. Stakeholders need to achieve this together - with agreed-on standards across the board so that no patient is denied a suitable, virtually tailor-made treatment due to a lack of knowledge or understanding on behalf of the healthcare professional treating and diagnosing him or her. A key partner in tackling this is the healthcare community, and one way to achieve the goal is through increased EU-wide investment in translational education and training of healthcare professionals.