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Background: Patient and family engagement (PE) in healthcare planning and improvement achieves beneficial outcomes and is widely advocated, but a lack of resources is a critical barrier. Little prior research studied how organizations support engagement specifically in hospitals.Objective: We explored what constitutes hospital capacity for engagement.Methods: We conducted descriptive qualitative interviews and complied with criteria for rigour and reporting in qualitative research. We interviewed patient/family advisors, engagement managers, clinicians and executives at hospitals with high engagement activity, asking them to describe essential resources or processes. We used content analysis and constant comparison to identify themes and corresponding quotes and interpreted findings by mapping themes to two existing frameworks of PE capacity not specific to hospitals.Results: We interviewed 40 patient/family advisors, patient engagement managers, clinicians and corporate executives from nine hospitals (two < 100 beds, four 100 + beds, three teaching). Four over-arching themes about capacity considered essential included resources, training, organizational commitment and staff support. Views were similar across participant and hospital groups. Resources included funding and people dedicated to PE and technology to enable communication and collaboration. Training encompassed initial orientation and project-specific training for patient/family advisors and orientation for new staff and training for existing staff on how to engage with patient/family advisors. Organizational commitment included endorsement from the CEO and Board, commitment from staff and continuous evaluation and improvement. Staff support included words and actions that conveyed value for the role and input of patient/family advisors. The blended, non-hospital-specific framework captured all themes. Hospitals of all types varied in the availability of funding dedicated to PE. In particular, reimbursement of expenses and compensation for time and contributions were not provided to patient/family advisors. In addition to skilled engagement managers, the role of clinician or staff champions was viewed as essential.Conclusion: The findings build on prior research that largely focused on PE in individual clinical care or research or in primary care planning and improvement. The findings closely aligned with existing frameworks of organizational capacity for PE not specific to hospital settings, which suggests that hospitals could use the blended framework to plan, evaluate and improve their PE programs. Further research is needed to yield greater insight into how to promote and enable compensation for patient/family advisors and the role of clinician or staff champions in supporting PE. [ABSTRACT FROM AUTHOR]

Background: Substantial expenditures on health care safety programs have been justified by their goal of reducing health care associated–harm (adverse events), but adverse event rates have not changed over the past 4 decades. The objective of this study is to describe hospital-level factors that are relevant to safety in Canadian hospitals and the impact of these factors on hospital adverse events. Methods: This is a protocol for a national cohort study to describe the association between hospital-level factors and adverse events. We will survey at least 90 (35%) Canadian hospitals to describe 4 safety-relevant domains, chosen based on the literature and expert consultation, namely patient safety culture, safety strategies, staffing, and volume and capacity. We will retrospectively identify hospital adverse events from a national data source. We will evaluate organization-level factors using established scales and a survey, codesigned by the study team and hospital leaders. Hospital leaders, clinical unit leaders and front-line staff will complete the surveys once a year for 3 years, with an anticipated start date of winter 2022. We will use national health administrative data to estimate the rate and type of hospital adverse events corresponding to each 1-year survey period. Interpretation: Analysis of data from this project will describe hospital organizational factors that are relevant to safety and help identify organizational initiatives that improve hospital patient safety. In addition to biyearly reports to the leaders of the participating hospitals, we have a multifaceted and tailored dissemination strategy that includes integrating the knowledge users into the study team to increase the likelihood that our study will lead to improved hospital patient safety. [ABSTRACT FROM AUTHOR]

Background: Patient engagement (PE) in health‐care planning and improvement is a growing practice. We lack evidence‐based guidance for PE, particularly in hospital settings. This study explored how to optimize PE in hospitals. Methods: This study was based on qualitative interviews with individuals in various roles at hospitals with high PE capacity. We asked how patients were engaged, rationale for approaches chosen and solutions for key challenges. We identified themes using content analysis. Results: Participants included 40 patient/family advisors, PE managers, clinicians and executives from 9 hospitals (2 < 100 beds, 4 100 + beds, 3 teaching). Hospitals most frequently employed collaboration (standing committees, project teams), followed by blended approaches (collaboration + consultation), and then consultation (surveys, interviews). Those using collaboration emphasized integrating perspectives into decisions; those using consultation emphasized capturing diverse perspectives. Strategies to support engagement included engaging diverse patients, prioritizing what benefits many, matching patients to projects, training patients and health‐care workers, involving a critical volume of patients, requiring at least one patient for quorum, asking involved patients to review outputs, linking PE with the Board of Directors and championing PE by managers, staff and committee/team chairs. Conclusion: This research generated insight on concrete approaches and strategies that hospitals can use to optimize PE for planning and improvement. On‐going research is needed to understand how to recruit diverse patients and best balance blended consultation/collaboration approaches. Patient or public contribution: Three patient research partners with hospital PE experience informed study objectives and interview questions. [ABSTRACT FROM AUTHOR]

Background and aim: Many health systems attempt to develop integrated and population health-oriented systems of care, but knowledge of strategies and interventions to support this effort is lacking. We aimed to identify specific redesign strategies and interventions, and to present evidence of their effectiveness. Method: A modified scoping review process was carried out. Fifteen relevant examples of integrated care organizations that incorporated a broad population health approach in countries of the Organization for Economic Cooperation and Development described in 57 articles and reports were included in analysis. Results: Seven key redesign strategies and multiple redesign interventions have been identified and are described. Most commonly used redesign strategies included focusing on health and wellness, embracing intersectoral action and partnerships, addressing health in vulnerable groups, and addressing a wide range of determinants of health, including making improvements in health services. Redesign interventions included creative and innovative ways of addressing clinical and non-clinical issues such as establishing housing surgeries in primary care, establlishing vast social and provider networks to support patients with complex needs and also broadening of the scope of services, workforce redesign and other. Potential reductions in the utilization of care and costs could be derived by the wider adoption of these strategies and interventions. Conclusion: Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population- and individual-level. [ABSTRACT FROM AUTHOR]

The article focuses on the Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR) which aims to engage patients in research in a variety of roles, including identifying research questions, designing studies and contributing to decisions on recruitment, data collection and analysis of findings. It mentions that competencies, coupled with evidence of the benefits of patient-oriented research, are reinforce commitments to the patient oriented research agenda.

Background: With the knowledge that patient safety incidents can significantly impact patients, providers and health‐care organizations, greater emphasis on patient involvement as a means to mitigate risks warrants further research. Objective: To understand whether patient perceptions of patient safety play a role in patient involvement in factual and challenging patient safety practices and whether the constructs of the Health Belief Model (HBM) help to explain such perceptions. Design: Partial least squares (PLS) analysis of survey data. Setting and Participants: Four inpatient units located in two tertiary hospitals in Atlantic Canada. Patients discharged from participating units between November 2010 and January 2011. Intervention: None. Results: A total of 217 of the 587 patient surveys were returned for a final response rate of 37.0%. The PLS analysis revealed relationships between patient perceptions of threat and self‐efficacy and the performance of factual and challenging patient safety practices, explaining 46 and 42% of the variance, respectively. Discussion: The results from this study provide evidence for the constructs and relationships set forth by the HBM. Perceptions of patient safety were shown to influence patient likelihood for engaging in selected patient safety practices. While perceptions of barriers and benefits and threats were found to be a contributing factor to patient involvement in patient safety practices, self‐efficacy plays an important role as a mediating factor. Conclusions: Overall, the use of the HBM within patient safety provides for increased understanding of how such perceptions can be influenced to improve patient engagement in promoting safer health care. [ABSTRACT FROM AUTHOR]

Objective To assess which client events should be considered reportable and preventable in home care (HC) settings in the opinion of HC safety experts. Background Patient safety in acute care settings has been well documented; however, there are limited data about this issue in HC. While many organizations collect information about ‘incidents’, there are no standards for reporting and it is challenging to compare incident rates among organizations. Design A 29-item electronic survey that included potential HC safety issues was used in a two-round Delphi study. Setting and Participants Twenty-four pan-Canadian HC safety experts participated in an electronic survey. Main Outcome Measures Perceived reportability and preventability of patient safety events, HC. Results The events that were perceived as being most reportable and preventable included the following: a serious injury related to inappropriate client service plan (e.g. incomplete/inaccurate assessments, poor care plan design, flawed implementation); an adverse reaction requiring emergency room visit or hospitalization related to a medication-related event; a catheter-site infection (e.g. a new peritoneal dialysis infection or peritonitis); any serious event related to care or services that are contrary to current professional or other practice standards (e.g. incorrect treatment regimen, theft, retention of a foreign object in a wound, individual practicing outside scope or competence). Conclusion These data represent an important step in the development and validation of standard metrics about client safety in HC. The results address an expanding area of health services where there is a need to improve standardization and reporting. [ABSTRACT FROM AUTHOR]

Objective Incidence of adverse events (AEs) among home care patients and preventability ratings were estimated. Risk factors, AE types and factors associated with AEs were identified. Design This study used a stratified, randomized sample of home care patients discharged in the fiscal year 2004/05. Trained nurse reviewers completed retrospective chart abstractions; charts for cases that were positive for screening criteria suggesting the presence of AEs were reviewed by trained physicians to determine the presence of and preventability of AEs. Setting Three publicly funded home care programs in Ontario, Canada. Main outcome measures Prevalence and types of AEs; ratings of preventability. Results At least one screening criterion was positively identified in 286 (66.5%) of 430 cases. Physician reviewers identified 61 AEs in 55 (19.2%) of the 286 (12.8% of the 430) cases. The AE rate was 13.2 per 100 home care cases [95% confidence interval (CI): 10.4–16.6%, standard error 1.6%]. 32.7% (20 of 61 AEs) of the AEs were rated as having >50% probability of preventability; 6 deaths (10.9% of patients with an AE; 1.4% of all patients) occurred in AE-positive patients. The most common AEs were falls and adverse drug events. Conclusions Providing health care through home care programs creates unintended harm to patients. The incidence rate of AEs of 13.2% suggests a significant number of home care patients experience AEs, one-third of which were considered preventable. Improvements in patient and informal caregiver education, skill development and clinical planning may be useful interventions to reduce AEs. [ABSTRACT FROM PUBLISHER]

Patient safety has only recently been subjected to wide-spread systematic study. Healthcare differs from other high risk industries in being more diverse and multi-contextual, and less certain and regulated. Also many patient safety problems are low-frequency events associated with many, varied contributing factors. The subject of this paper is the epistemology of patient safety (the science of the method of finding out about patient safety). Patient safety research is considered here on the background of a risk management framework which requires researchers to: • Understand the context – as a subset of healthcare quality, services and systems research, with technical and human behavioural (cultural) components and a range of external and internal organisational influences, a wide range of research disciplines is necessary • Identify the risks – identify the things that go wrong and the frequency and nature of different types of incidents from sources such as medical record review, observational studies, audit, incident and medico-legal reports • Analyse the risks – deconstruct the things that go wrong, identifying contributing factors and trying to detect trends and patterns in contributing factors, detection, mitigation factors, ameliorating factors and actions taken to reduce risk • Evaluate the risks – decide on priorities, identifying preventive and corrective strategies and judging the risk- and cost-benefit of potential corrective strategies such as standardisation or simplification of a process or device • Manage the risk – evaluate and scope preventive and/or corrective strategies and then implement these, or place the problem on a risk register pending solution, or accept that what is needed is unaffordable • Communicate and consult – use interactive sessions, audit, on-going feedback, reminders and patient mediated prompts • Monitor and review the state of the problem – get baseline trends and patterns so that changes can be tracked and properly attributed to an intervention A hierarchy of levels of evidence has been proposed for clinical research and we argue that insufficient weighting has been given to lower ranked levels of research and to qualitative research, although critical interpretive synthesis is now gaining acceptance in mainstream thinking (e.g. by the Cochrane Collaboration). Fundamental challenges remain including how to grasp the elusive concept of patient safety, how to quantify, characterise and cost the problems, how to judge the extent to which harm can be attributed to errors, violations or system failures, how to identify contributing factors and the extent to which they can be implicated, how to judge whether incidents or their precursors are preventable, how to generate strong evidence to make healthcare safer and how to translate research into practice. Future directions include addressing the mundane as well as rare, dramatic events, and developing further research in non-hospital settings and in developing countries. In summary, a mixture of qualitative and quantitative methods, using information from all available data sources and combining retrospective, real time and prospective study designs, is necessary to address some of the more difficult patient safety problems. [ABSTRACT FROM AUTHOR]

Introduction: Community based primary health care (CBPHC) organizations are critical providers of integrated care for complex patients. Exemplar cases exist, but efforts to scale up and spread successful models continue to face major challenges. While scale and spread has become a popular topic, there are still significant gaps in our understanding of what components or activities of integrated care models should and can be spread from one locale or jurisdiction to the next, and to what degree we allow for local adaptation of those activities. Theory/Methods: To address this identified gap we developed a survey for managers and providers in CBPHC organizations that allows respondents to specify which activities require local adaptation for their scale up and spread and which need to be more standardized. The survey builds on learning from the iCOACH project, a study analyzing 9 integrated models of community-based primary health care (CBPHC) in Ontario, Quebec and New Zealand. To develop the survey we carried out 1) a targeted literature review identifying existing reviews of key activities of integrated CBPHC; 2) a workshop session with CBPHC managers and providers to validate the approach and aim of the survey; 3) mapping the findings of the literature review to coded qualitative data from the iCOACH study to validate identified activities; and 4) validation and initial testing of a pilot survey. Results: The literature review yielded 32activities of integrated CBPHC, each of which were found to be present in iCOACH case studies. The workshop session was run in January 2018 with 17 participants. from 3 case study sites. Participants identified all activities as important to models of integrated care; but reported varying needs for standardization or adaptation for specific elements. Discussion from the workshop was used to refine survey wording and structure. The draft survey was tested with managers and providers in CBPHC organizations using cognitive interviewing techniques to refine the instrument. Small scale testing of the survey will be undertaken with staff in 2 CBPHC sites. Discussion: Multiple methods were used to validate the key activities of integrated care; however, the ways in which these activities are implemented in scale and spread efforts are nuanced and context dependent. Conclusions: The survey tool developed will help us to unpack these nuances and contextual influences, with the aim of clarifying core versus peripheral activities of integrated care at different stages of the scale and spread process (e.g., whether early or later stages of adoption). Lessons learned: One critical finding from the symposium was that conceptualizations of fidelity and adaptation are widely varied and needs to be clearly stated in any assessment. Ensuring clarity of these terms was central to the development of this survey. Limitations: While the survey has strong content validity due to our development methodology, additional work will be required to test reliability and other components of validity prior to wider adoption of the survey. Suggestions for future research: Following testing in Canadian settings, we plan to deploy the survey to CBPHC organizations internationally. [ABSTRACT FROM AUTHOR]

Background: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We esti-mated the incidence of AEs among patients in Canadian acute care hospitals. Methods: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Sco-tia) and reviewed a random sample of charts for nonpsychi-atric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. Results: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confi-dence interval [CI] 5.7--9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%--41.8%) and death in 20.8% (95% CI 7.8%--33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women ex-perienced equal rates of AEs, patients who had AEs were sig-nificantly older than those who did not (mean age [and stan-dard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p= 0.016). Interpretation: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable. [ABSTRACT FROM AUTHOR]

ABSTRACT. Background. Problems with organizational culture, lack of or poor team communications, and conflict are often seen as barriers to improvement efforts. Methods. A survey measuring aspects of organizational culture was administered twice to staff in neonatal intensive care units participating in the Neonatal Intensive Care Unit Quality Improvement Collaborative Year 2000 collaborative. The surveys provided comparative data on coordination, teamwork and leadership, conflict management, unit leadership and unit culture. These data were summarized and fed back to NICU teams with guidance on their use. Interviews on the use of the survey were held with 12 medical directors and patient care leaders in 9 different NICUs. Results. The findings indicated that all the units contacted saw themselves as committed to undertaking the organizational survey and using the results. Some units shared the data widely and initiated changes. Other units limited the distribution of data to the unit leadership. There was no apparent relationship between scores on the survey and activities undertaken. Several respondents credited the survey with helping to promote discussions about organizational and team issues. Conclusions. Future use of the survey should include additional materials to assist in disseminating the results to staff. Pediatrics 2003;111:e419-e425. URL: http://www. pediatrics.org/cgi/content/full/111/4/e419; organizational culture, organizational survey, collaborative quality improvement, teamwork, NIC/Q 2000. [ABSTRACT FROM AUTHOR]

Quality improvement in health care, appropriately understood and applied, is one way to develop a sense of control over daily work. How can faculty members learn improvement methods, apply them to work and teach them to future health professionals? The paper outlines an improvement 'theory' and illustrates some ways it has been taught and learned by 10 interdisciplinary groups of faculty and students over the past 6 years. Eight domains constitute the content of improvement knowledge. They include: (1) health care as a system; (2) variation and measurement; (3) knowledge of the beneficiaries of health care services; (4) leading, following and making changes; (5) collaboration; (6) social context and accountability; (7) developing new locally useful knowledge; and (8) professional subject matter knowledge. Many lessons have been learned by 10 Local Interdisciplinary teams who have collaborated over the past 6 years including: (1) Systems knowledge is more effectively learned in the context of real work than in the classroom; (2) outcomes of care are beneficial sources of information to learn about the beneficiaries of care; and (3) the experience of collaboration with others-experts, colleagues, students and others-can be a learning tool in itself, especially in an inter-professional team. Involvement of students from multiple disciplines can enhance the impact of efforts to allocate resources in their organizations to building knowledge for improvement. [ABSTRACT FROM AUTHOR]

Introduction: Currently, there is limited knowledge about operationally feasible strategies that help link the provision of integrated care with the population health approach1,2. The scope of integrated care needs to be expanded to bridge the gaps not only within the health system, but also between public health, health care and social care1,3. This broader focus for integrated health care would enable health systems to address the social determinants of health SDOH of populations4. Using results from an ongoing multi-case study investigating implementation of population health approach in Canada and abroad, we will present an analysis of strategies used by select Canadian primary care and speciality care organizations that have taken on the population health approach and link the provision of integrated care, and successfully tackle issues of inequity and the SDOHs. Methods: In this multi-case study we use field visits, interviews, document analysis and other resources to identify key strategies, barriers and enablers to implementation of the population health approach. Population health experts and health planners nominated potential cases that were then assessed against the criteria that identify population health systems. Integrated knowledge translation has been incorporated to link knowledge users and academic researchers throughout the study. The study draws on the expanded chronic care model, socioecological model and equity lenses. Expected results: The study will identify and provide evidence about the effectiveness of specific strategies, including creative approaches and innovations that help routinely screen for the SDOHs and integrate social supports into delivery of care. We will map out strategic partnerships and inter-sectoral collaborations designed to support integrated delivery of health promotion and disease prevention, health care services and social care. Discussion/conclusion: This study will contribute to the knowledge about the planning and implementation of population-based integrated systems of care that successfully address a range of SDOH. Findings may help inform relevant policy and strategy and are directly relevant to ICIC 2018 theme "Population Health Management", sub-themes: Tackling inequalities and the social determinants of health, Improving population health outcomes and Strategy development, partnerships & leadership. Potential suggestions for future research: As the population health approach is adopted across the continuum of care, future research needs to facilitate the spread and scale up of integrated care in the context of population health. [ABSTRACT FROM AUTHOR]

Introduction: Currently, there is limited knowledge about operationally feasible strategies that help link the provision of integrated care with the population health approach1,2. The scope of integrated care needs to be expanded to bridge the gaps not only within the health system, but also between public health, health care and social care1,3. This broader focus for integrated health care would enable health systems to address the social determinants of health SDOH of populations4. Using results from an ongoing multi-case study investigating implementation of population health approach in Canada and abroad, we will present an analysis of strategies used by select Canadian primary care and speciality care organizations that have taken on the population health approach and link the provision of integrated care, and successfully tackle issues of inequity and the SDOHs. Methods: In this multi-case study we use field visits, interviews, document analysis and other resources to identify key strategies, barriers and enablers to implementation of the population health approach. Population health experts and health planners nominated potential cases that were then assessed against the criteria that identify population health systems. Integrated knowledge translation has been incorporated to link knowledge users and academic researchers throughout the study. The study draws on the expanded chronic care model, socioecological model and equity lenses. Expected results: The study will identify and provide evidence about the effectiveness of specific strategies, including creative approaches and innovations that help routinely screen for the SDOHs and integrate social supports into delivery of care. We will map out strategic partnerships and inter-sectoral collaborations designed to support integrated delivery of health promotion and disease prevention, health care services and social care. Discussion/conclusion: This study will contribute to the knowledge about the planning and implementation of population-based integrated systems of care that successfully address a range of SDOH. Findings may help inform relevant policy and strategy and are directly relevant to ICIC 2018 theme "Population Health Management", sub-themes: Tackling inequalities and the social determinants of health, Improving population health outcomes and Strategy development, partnerships & leadership. Potential suggestions for future research: As the population health approach is adopted across the continuum of care, future research needs to facilitate the spread and scale up of integrated care in the context of population health. [ABSTRACT FROM AUTHOR]

Introduction: Varying models of integrated care have been successfully developed in different health systems to deliver value-based care; yet many of these models face challenges in scaleup and spread. One critical theme with limited consensus is the extent to which practices and programs should be standardized for effective spread. Barker 2016 argues that transfers of effective programs and practices into different settings are greatly facilitated by a detailed understanding of the core work and the supportive resources needed for effective programs in order to identify the "scalable unit". Other researchers see healthcare services as "complex adaptive systems"; scaling-up thus requires that the design of interventions be adapted to local contexts, In this view the straightforward replication of effective programs and practices is replaced with local sensemaking, focused experimentation, and participation by local actors in determining what works. This tension between the core elements of an intervention and an adaptable periphery is a key component in Damschroder's Consolidated Framework for Implementation Research. However, there is limited study of providers' and managers' views of standardization and little evaluation of the extent to which views on standardization or local adaptation support or hinder effective implementation. Methods: The iCoach Integrated Care for Older Adults with Complex Health Needs project has carried out a focused program of research exploring different models of integrated care in the Canadian provinces of Ontario and Quebec, and New Zealand. The research team, together with providers and managers engaged in the Ontario case studies are assessing views on where standardization of core activities, such as patient and family engagement, interprofessional team work, case management, leadership and governance are seen as desirable for spread. The team identified key activities and elements of integrated care from the literature. Using a workshop format, individual participants from four different organizations mapped out their views on a continuum of the desirable degree of standardization or adaptation for each activity that will support effective implementation and operations in their settings. [ABSTRACT FROM AUTHOR]

Background: Patient engagement (PE) in hospital planning and improvement is widespread, yet we lack evidence of its impact. We aimed to identify benefits and harms that could be used to assess the impact of hospital PE. Methods: We interviewed hospital-affiliated persons involved in PE activities using a qualitative descriptive approach and inductive content analysis to derive themes. We interpreted themes by mapping to an existing framework of healthcare performance measures and reported themes with exemplar quotes. Results: Participants included 38 patient/family advisors, PE managers and clinicians from 9 hospitals (2 < 100 beds, 4 100 + beds, 3 teaching). Benefits of PE activities included 9 impacts on the capacity of hospitals. PE activities involved patient/family advisors and clinicians/staff in developing and spreading new PE processes across hospital units or departments, and those involved became more adept and engaged. PE had beneficial effects on hospital structures/resources, clinician staff functions and processes, patient experience and patient outcomes. A total of 14 beneficial impacts of PE were identified across these domains. Few unintended or harmful impacts were identified: overextended patient/family advisors, patient/family advisor turnover and clinician frustration if PE slowed the pace of planning and improvement. Conclusions: The 23 self reported impacts were captured in a Framework of Impacts of Patient/Family Engagement on Hospital Planning and Improvement, which can be used by decision-makers to assess and allocate resources to hospital PE, and as the basis for ongoing research on the impacts of hospital PE and how to measure it. [ABSTRACT FROM AUTHOR]

Introduction: The implementation of integrated care involves efforts to engage health care providers in a vision of health care delivery that includes coordination and collaboration for the care of individual clients. The processes by which health care providers engage with an organizational vision for integrated care, and the challenges associated with encouraging health care providers to adopt integrated practices remain under-explored in the research literature. Theory/Method: This paper reports initial findings on health care provider engagement in efforts to implement integrated community-based primary health care from the iCOACH project (Integrated Care for Older Adults with Complex Health Needs). The research project draws on in-depth international case studies of organizations in 3 jurisdictions: Ontario, Canada (n=3), Quebec, Canada (n=3), and New Zealand (n=3). Drawing on the theory of institutional logics, this report will include data from health care provider and organizational management/leadership interviews across all 9 case studies. Results: Preliminary findings suggest that health care providers respond to organizations' visions for integrated care differently depending on whether they feel supported to practice in more integrated ways. Even within a single organization, health care providers may enact or resist the organizational vision (and thus institutional logic) toward integrated care depending on the extent to which they feel engaged. Managerial approaches were found to be of central importance, helping to determine the extent to which health care providers adopted more integrated practices in the provision of everyday care delivery. These findings were illustrated across case studies in each of the 3 study jurisdictions. Discussion: Although these qualitative data only represent preliminary analysis, they point to the importance of managerial engagement strategies to promote health care provider buy-in to an organizational vision of more integrated care. These early findings suggest that managers within health care organizations can act as either barriers or facilitators to implementing integrated care depending on whether and how the interact and work with health care providers. Conclusions: Managerial approaches to the engagement of health care providers are of primary importance for the implementation of integrated care. Further analysis of the iCOACH study data will provide more detailed examination of which managerial approaches promote integrated health care provider practice, and those which act as barriers to integrated primary health care. [ABSTRACT FROM AUTHOR]

Introduction: Policy makers in many countries are encouraging the development of integrated care strategies and the development of new models of integrated care. These new models require changes at a clinical or service level, organizational level and system level with strong leadership necessary at all three levels. Despite the key role of leadership in these efforts, there has been only limited study of what organizational leadership approach is successful in different contexts for integrated care. Theory/Methods: This paper analyses the organizational leadership behaviors and strategies in the iCOACH project (Integrated Care for Older Adults with Complex Health Needs) for 9 integrated care projects in 3 jurisdictions: New Zealand, and the Canadian provinces of Ontario and Quebec. Data are derived from interviews with leaders, policy makers and providers in these cases. We draw on institutional logics and institutional entrepreneurship theories to explore how leaders engaged external stakeholders and developed strategies to optimize the effectiveness of integrated care within and between their organizations in these different contexts. Results: There are concerted efforts to develop integrated care models of community based primary health care in all three jurisdictions. However, the policy environments vary in the latitude and resources provided to organizational leaders to develop organizational forms and networks. In Ontario and New Zealand there have been considerable variations in the nature of integrated care organizations and networks, while in Quebec the government has mandated new organizational forms and specified their relationships with other providers. Preliminary analysis of our data suggests that institutional entrepreneurship takes different forms in response to these environments, and other policy issues, such as the development of health care resources for Maori have also influenced the support and direction of integrated care. There is also variation in the entrepreneurial styles within and across these organizations, balancing the need for external stakeholder management and developing local capability for more integrated care based on the vision for the organization. Discussion: Leadership is a critical resource in the development of new organizational forms and in carrying out the negotiations needed to garner the resources and legitimacy necessary for effective organizations. However, leadership strategies can vary in different contexts, and the types of institutional entrepreneurship necessary for building these organizations varies as well. Conclusions: Understanding successful leadership strategies and entrepreneurial behaviors in different contexts helps to illuminate the similarities and differences across different policy and organizational environments. Lessons learned: While leadership is essential for integrated care, there is no single model that has been successful across the contexts we have studied. Limitations: The analysis of the data described here is still underway. Our data is derived from cases in three jurisdictions and these are likely not fully representative of the range of policy and organizational environments. Suggestions for future research: Further research on the leadership strategies that are successful in different environments is needed to confirm and extend the analysis from the 9 cases we have studied. [ABSTRACT FROM AUTHOR]

Introduction: Current investments in integrated care have predominantly focused on downstream strategies designed to reduce the fragmentation of healthcare services. Yet, there is a growing recognition that integrated care strategies must also move upstream and focus on health and wellness at the population level. Progress in this area has been slow, but a number of early adopters of the population health approach in integrated care provide insights into key approaches. This research identifies early initiatives, identifies common design components, and analyzes the lessonslearned. Theory/Methods: We undertook a scoping review of the international literature to define and describe the broad range of initiatives underway using Arskey & O'Malley's five stage scoping review methodology. Literature included academic and grey literature amongst developed OECD countries between the years 2000 and 2015. These papers were abstracted by two reviewers, thematic elements were identified by the team and the evidence synthesized. Results: Thirty-three papers were identified, describing 14 different initiatives taking place in eight different countries around the world. Most of the initiatives were initiated and lead by healthcare system providers (largely within primary care) who interfaced with local social services in order to meet the health needs of a target population. In some cases integrated care strategies were initiated and lead by public health or some other sector that then linked with healthcare. Target populations most often included seniors but also included other subpopulations including families living in high deprivation neighbourhoods, and mothers and children. Beyond healthcare, these initiatives often focused on such determinants of health as physical and social environments, personal health practices, education and literacy, and income. Discussion: There is a growing need to attend to population health within the context of healthcare delivery, rather than as a set of initiatives divorced from front-line practitioners. Several population health oriented integrated care strategies are underway around the world. These initiatives often face implementation challenges in creating robust partnerships across organizations and the alignment of vision, mandates, roles & responsibilities among partners. In addition, governance challenges and funding incentives must be addressed to support program success. Leadership, use of technology and community engagement are major enablers for success. Conclusions: Health systems in the industrialized world face increasing concerns about aging populations and the growing burden of chronic disease. Population health-oriented integrated care strategies have become an important part of sustainable health system reform. By studying early population health oriented integrated care initiatives, lessons learned from implementation can inform the broader thinking in reorienting models of care. Lessons learned: In the context of daily pressures to deliver care, it can be challenging to integrate population health based approaches, but these may be critical for managing chronic conditions. Limitations: This scoping review is limited to those initiatives reported in the literature. The literature is heterogeneous in terms of focus and methods so detailed comparisons between programs is limited. Suggestions for future research: Additional comparative case study research would help to elaborate on the strategies and mechanism for integrating population health approaches into integrated care. [ABSTRACT FROM AUTHOR]

Introduction: The implementation of integrated care involves efforts to engage health care providers in a vision of health care delivery that includes coordination and collaboration for the care of individual clients. The processes by which health care providers engage with an organizational vision for integrated care, and the challenges associated with encouraging health care providers to adopt integrated practices remain under-explored in the research literature. Theory/Method: This paper reports initial findings on health care provider engagement in efforts to implement integrated community-based primary health care from the iCOACH project (Integrated Care for Older Adults with Complex Health Needs). The research project draws on in-depth international case studies of organizations in 3 jurisdictions: Ontario, Canada (n=3), Quebec, Canada (n=3), and New Zealand (n=3). Drawing on the theory of institutional logics, this report will include data from health care provider and organizational management/leadership interviews across all 9 case studies. Results: Preliminary findings suggest that health care providers respond to organizations' visions for integrated care differently depending on whether they feel supported to practice in more integrated ways. Even within a single organization, health care providers may enact or resist the organizational vision (and thus institutional logic) toward integrated care depending on the extent to which they feel engaged. Managerial approaches were found to be of central importance, helping to determine the extent to which health care providers adopted more integrated practices in the provision of everyday care delivery. These findings were illustrated across case studies in each of the 3 study jurisdictions. Discussion: Although these qualitative data only represent preliminary analysis, they point to the importance of managerial engagement strategies to promote health care provider buy-in to an organizational vision of more integrated care. These early findings suggest that managers within health care organizations can act as either barriers or facilitators to implementing integrated care depending on whether and how the interact and work with health care providers. Conclusions: Managerial approaches to the engagement of health care providers are of primary importance for the implementation of integrated care. Further analysis of the iCOACH study data will provide more detailed examination of which managerial approaches promote integrated health care provider practice, and those which act as barriers to integrated primary health care. Lessons Learned: The key lesson learned is that health care providers respond differently to a single managerial approach. Organizational leaders should anticipate different reactions from health care providers within a given organizational context, and anticipate the need for different engagement strategies when seeking to implement integrated care. Limitations: This abstract represents preliminary analysis, and further analysis is required to provide a more detailed presentation of (a) specific care provider reactions to managerial strategies, (b) the influence of other features of organizational contexts, and (c) how to promote better health care provider buy-in to organization vision. Future Research: Further analysis will examine in detail the reactions of health care providers to specific managerial strategies, presenting their adoption of more integrated ways of providing primary health care in different organizational contexts. [ABSTRACT FROM AUTHOR]

Background: Health systems in many countries see person‐centred care as a critical component of high‐quality care but many struggle to operationalize it in practice. We argue that models such as adaptive leadership can be a critical lever to support person‐centred care, particularly for people who have multiple complex care needs. Objective: To reflect on two concepts: person‐centred care and adaptive leadership and share how adaptive leadership can advance person‐centred care at the front‐line care delivery level and the organizational level. Findings: The defining feature of adaptive leadership is the separation of technical solutions (ie applying existing knowledge and techniques to problems) from adaptive solutions (ie requiring shifts in how people work together, not just what they do). Addressing adaptive challenges requires identifying key assumptions that may limit motivations for change and the behaviours influenced by these assumptions. Thus, effective care for patients, particularly those with multiple complex care needs, often entails helping care providers and patients to examine their relationships and behaviours not just identifying technical solutions. Addressing adaptive challenges also requires a supportive and enabling organizational context. We provide illustrative examples of how adaptive leadership principles can be applied at both the front line of care and the organization level in advancing person‐centred care delivery. Conclusions: Advancing person‐centred care at both the clinical and organizational levels requires a growth mindset, a willingness to try (and fail) and try again, comfort in being uncomfortable and a commitment to figure things out, in partnership, in iterative ways. Patients, caregivers, care providers and organizational leaders all need to be adaptive leaders in this endeavour. [ABSTRACT FROM AUTHOR]

Background: Integrated care systems coordinate services for individuals and populations, linking health and community care providers and engaging patients and families to improve outcomes. Many jurisdictions have identified better integration as a key strategy for improving healthcare system performance. But these policies supporting integration are often inconsistent and require local adaptation and alignment to support implementation. This paper reports the experience of 9 community-based primary care organizations in three jurisdictions (the provinces of Ontario and Quebec in Canada, and New Zealand). Detailed case studies of these organizations identify the challenges of integration, the leadership and organizational strategies to foster integrated care, and the unintended consequences of policy frameworks, regulation, funding and program design. Theory and Methods: Results are pulled from the 9 case studies and include document analysis and key informant interviews with providers and organizational managers/leaders from each of the case sites, as well as interviews with policy-makers from each of the three jurisdictions. Qualitative thematic analysis was used to code interview transcripts and documents using both a deductive approach, based on the Context for Integrating Care theoretical framework developed to guide this study, as well as an inductive, data-driven approach. After coding, single case analysis methods will be used to understand tensions at each of the 9 cases, and cross-case analysis methods will be used to compare across the 9 cases. As we are still completing data collection, results presented below are based on preliminary analysis of findings generated from coding a sub-sample of available data. Results: Preliminary data analysis identified common challenges faced by leaders trying to integrate care across programs and organizations. These challenges include inadequate information sharing, often due to limited IT infrastructure and connectivity, inadequate time and human resources to launch new programs, high rates of HR turnover (in some cases), and confusion over "who owns the patient" with regard to integrated practice across multiple organizations. Beyond these organizational level challenges, leaders face a host of funding and policy issues. While funders and regulators in each jurisdiction have provided resources and supports for integration, these supports often take the form of one-time project funding that may not be sustainable over the longer term. Regulatory requirements often vary between programs in different sectors, raising local conflicts about integrating programs. As a result policy frameworks may be inconsistent and not conducive to integrating care, leading organizations to integrate in spite of policy rather than because of it. Policy and regulation thus have unintended consequences, creating tensions for leaders, undermining efforts to integrate care that require managing separate funding streams, conflicting regulatory regimes, and other complexities. Early analysis suggests that lack of sustained funding results in organizations behaving opportunistically rather than strategically, leading to potentially inefficient program designs. Discussion: Preliminary analysis suggests that in the face of these tensions, leaders often rely on past and present inter-organizational partnerships and the opportunities offered by fragmented funding programs to develop more integrated models of care for their patients. Leaders seek to present a coherent image to both funders and patients despite substantial organizational complexity that may create inefficiencies and frustrations for clients and staff. Developing a shared vision and sharing scarce resources have been key strategies in some of these cases to enable partners to secure funding for more integrated programs and provide a more coordinated care experience for patients and their families. Further analysis will illustrate how leaders brought individuals with differing perspectives and goals together from across the spectrum of health and social care to develop more integrated approaches to service. Conclusions: Our findings suggest that strong leadership is needed to navigate the tensions of integrating care. At the organizational level, leaders need to be able to identify and manage these tensions early to avoid inefficient and ineffective program design. Policy makers, in turn, need to assess the unintended consequences of fragmented funding and overlapping program designs, acknowledging the challenges these present for organizational leaders in health care. Finally, investment is needed in strategies to more systematically support and develop leadership capabilities for building collaboration and integration throughout the health system. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

Policy PointsConsiderable investments have been made to build high‐performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions.There is significant variation in the degree of implementation of structural features of high‐performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation. Context: Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high‐performing primary care systems. Methods: A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high‐performing primary care systems to describe each case and assess changes over time. Findings: The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation. Conclusions: Progress toward building high‐performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research. [ABSTRACT FROM AUTHOR]

Background: Patient engagement (PE) in planning or improving hospital facilities or services is one approach for improving healthcare delivery and outcomes. To provide evidence on hospital capacity needed to support PE, we described the attributes of hospital PE capacity associated with clinical quality measures.Methods: We conducted a cross-sectional survey of general and specialty hospitals based on the Measuring Organizational Readiness for Patient Engagement framework. We derived a PE capacity index measure, and with Multiple Correspondence Analysis, assessed the association of PE capacity with hospital type, and rates of hand-washing, C. difficile infection rates and 30-day readmission.Results: Respondents (91, 66.4%) included general: < 100 beds (48.4%), 100+ beds (27.5%), teaching hospitals (11.0%) and specialty (13.2%) hospitals. Most featured PE in multiple clinical and corporate departments. Most employed PE in a range of Planning (design/improve facilities 94.5%, develop strategic plans 87.9%), Evaluation/Quality Improvement (accreditation 91.2%, develop QI plans 90.1%) and Service Delivery activities (develop information/communication aids 92.3%). Hospitals enabled PE with multiple supports (median 12, range 0 to 25), most often: 76.9% strategic plan recognizes PE, 74.7% patient/family advisory council, and 69.2% pool of patient volunteers; and least often: 30.0% PE staff, 26.4% PE funding and 16.5% patient reimbursement or 3.3% compensation. Hospitals employed a range of less (inform, consult) and more (involve, partner) active modes of engagement. Two variables accounted for 29.6% of variance in hospital PE capacity index measure data: number of departments featuring PE and greater use of active engagement modes. PE capacity was not associated with general hospital type or clinical quality measures.Conclusions: Hospitals with fewer resources can establish favourable PE conditions by deploying PE widely and actively engaging patients. Healthcare policy-makers, hospital executives and PE managers can use these findings to allocate PE resources. Future research should explore how PE modes and methods impact clinical outcomes. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue, including one on cancer patients that are attending an outpatient cancer clinic, and another on coordination for caring of cancer patients.

Background: Ongoing challenges to healthcare integration point toward the need to move beyond structural and process issues. While we know what needs to be done to achieve integrated care, there is little that informs us as to how. We need to understand how diverse organizations and professionals develop shared knowledge and beliefs - that is, we need to generate knowledge about normative integration. We present a cognitive perspective on integration, based on shared mental model theory, that may enhance our understanding and ability to measure and influence normative integration. The aim of this paper is to validate and improve the Mental Models of Integrated Care (MMIC) Framework, which outlines important knowledge and beliefs whose convergence or divergence across stakeholder groups may influence inter-professional and inter-organizational relations.Methods: We used a two-stage web-based modified Delphi process to test the MMIC Framework against expert opinion using a random sample of participants from Canada's National Symposium on Integrated Care. Respondents were asked to rate the framework's clarity, comprehensiveness, usefulness, and importance using seven-point ordinal scales. Spaces for open comments were provided. Descriptive statistics were used to describe the structured responses, while open comments were coded and categorized using thematic analysis. The Kruskall-Wallis test was used to examine cross-group agreement by level of integration experience, current workplace, and current role.Results: In the first round, 90 individuals responded (52% response rate), representing a wide range of professional roles and organization types from across the continuum of care. In the second round, 68 individuals responded (75.6% response rate). The quantitative and qualitative feedback from experts was used to revise the framework. The re-named "Integration Mindsets Framework" consists of a Strategy Mental Model and a Relationships Mental Model, comprising a total of nineteen content areas.Conclusions: The Integration Mindsets Framework draws the attention of researchers and practitioners to how various stakeholders think about and conceptualize integration. A cognitive approach to understanding and measuring normative integration complements dominant cultural approaches and allows for more fine-grained analyses. The framework can be used by managers and leaders to facilitate the interpretation, planning, implementation, management and evaluation of integration initiatives. [ABSTRACT FROM AUTHOR]

The success of integrated care interventions is highly dependent on the internal and collective capabilities of the organizations in which they are implemented. Yet, organizational capabilities are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. Assessing these capabilities can contribute to understanding why some integrated care interventions are more effective than others. We identified, organized, and assessed survey instruments that measure the internal and collective organizational capabilities required for integrated care delivery. We conducted an expert consultation and searched Medline and Google Scholar databases for survey instruments measuring factors outlined in the Context and Capabilities for Integrating Care Framework. A total of 58 instruments were included in the review and assessed based on their psychometric properties, practical considerations, and applicability to integrated care efforts. This study provides a bank of psychometrically sound instruments for describing and comparing organizational capabilities. Greater use of these instruments across integrated care interventions and studies can enhance standardized comparative analyses and inform change management. Further research is needed to build an evidence base for these instruments and to explore the associations between organizational capabilities and integrated care processes and outcomes. [ABSTRACT FROM AUTHOR]

The success of integrated care interventions is highly dependent on the internal and collective capabilities of the organizations in which they are implemented. Yet, organizational capabilities are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. Assessing these capabilities can contribute to understanding why some integrated care interventions are more effective than others. We identified, organized, and assessed survey instruments that measure the internal and collective organizational capabilities required for integrated care delivery. We conducted an expert consultation and searched Medline and Google Scholar databases for survey instruments measuring factors outlined in the Context and Capabilities for Integrating Care Framework. A total of 58 instruments were included in the review and assessed based on their psychometric properties, practical considerations, and applicability to integrated care efforts. This study provides a bank of psychometrically sound instruments for describing and comparing organizational capabilities. Greater use of these instruments across integrated care interventions and studies can enhance standardized comparative analyses and inform change management. Further research is needed to build an evidence base for these instruments and to explore the associations between organizational capabilities and integrated care processes and outcomes. [ABSTRACT FROM AUTHOR]

Presents a response by G. Ross Baker, Peter G. Norton and Virginia Flintoft to a letter to the editor about their article "The Canadian Adverse Events Study: The Incidence of Adverse Events Among Hospital Patients in Canada."

Background: Variations in the performance of healthcare organizations may be partly explained by differing "stocks" of intellectual capital (IC), and differing approaches and capacities for leveraging IC. This study synthesizes what is currently known about the conceptualization, management and measurement of IC in healthcare through a review of the literature.Methods: Peer-reviewed papers on IC in healthcare published between 1990 and 2014 were identified through searches of five databases using the following key terms: intellectual capital/assets, knowledge capital/assets/resources, and intangible assets/resources. Articles deemed relevant for inclusion underwent systematic data extraction to identify overarching themes and were assessed for their methodological quality.Results: Thirty-seven papers were included in the review. The primary research method used was cross-sectional questionnaires focused on hospital managers' perceptions of IC, followed by semi-structured interviews and analysis of administrative data. Empirical studies suggest that IC is linked to subjective process and performance indicators in healthcare organizations. Although the literature on IC in healthcare is growing, it is not advanced. In this paper, we identify and examine the conceptual, theoretical and methodological limitations of the literature.Conclusions: The concept and framework of IC offer a means to study the value of intangible resources in healthcare organizations, how to manage systematically these resources together, and their mutually enhancing interactions on performance. We offer several recommendations for future research. [ABSTRACT FROM AUTHOR]

Context Medical trainees demonstrate a reluctance to ask for help unless they believe it is absolutely necessary, a situation which could impact on the safety of patients. This study aimed to develop a theoretical exploration of the pressure on medical trainees to be independent and to generate theory-based approaches to the implications for patient safety of this pressure towards independent working. Methods In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase 2, 36 in-depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. Results Participants conceived that the pressure towards independence in clinical work originated in trainees’ desire to lay claim to the identity of a doctor (as a member of a group of autonomous high achievers), and in organisational issues such as heavy workloads and constant evaluations. Discussion The identity and organisational issues related to the pressure towards independence were explored through the lenses of established theories from education and psychology. Consideration of Lave and Wenger’s situated learning theory suggests that giving attention to the ‘independent doctor’ ideal, through measures such as involving trainees when their supervisors ask for help, could impact the safety of teaching team practice. Amalberti et al.’s migration model explains how pressures to maximise productivity and individual gain may cause teaching teams to migrate beyond the boundaries of safe practice and suggests that managing triggers (such as workload and high-stakes evaluations) for violations of safe practice might improve safety. Implementation and evaluation of these theory-based approaches to the safety of teaching team practice would contribute to a better understanding of the links between trainee independence and patient safety. [ABSTRACT FROM AUTHOR]

BACKGROUND: Concern about the link between clinical supervision and safe, quality health care has led to widespread increases in the supervision of medical trainees. The effects of increased supervision on patient care and trainee education are not known, primarily because the current multifacted and poorly operationalized concept of clinical supervision limits the potential for evaluation. OBJECTIVE: To develop a conceptual model of clinical supervision to inform and guide policy and research. DESIGN, SETTING, AND PARTICIPANTS: Observational fieldwork and interviews were conducted in the Emergency Department and General Internal Medicine in-patient teaching wards of two academic health sciences centers associated with an urban Canadian medical school. Members of 12 Internal Medicine and Emergency Medicine teaching teams (n=88) were observed during regular clinical activities (216 hours). Sixty-five participants (12 physicians, 28 residents, 17 medical students, 8 nurses) also completed interviews about supervision. Field notes and interview transcripts were analyzed for emergent themes using grounded theory methodology. RESULTS: The term "clinical oversight" was developed to describe patient care activities performed by super- visors to ensure quality of care. "Routine oversight" (preplanned monitoring of trainees' clinical work) can expose supervisors to concerns that trigger "responsive oversight" (a double-check or elaboration of trainees' clinical work). Supervisors sometimes engage in "backstage oversight" (oversight of which the trainee is not directly aware). When supervisors encounter a situation that exceeds a trainee's competence, they move beyond clinical oversight to "direct patient care". CONCLUSIONS: This study elaborates a typology of clinical oversight activities including routine, responsive, and backstage oversight. This new typology provides a framework for clinical supervision policy arid for research to evaluate the relationship between supervision and safety. [ABSTRACT FROM AUTHOR]

Although implementation models broadly recognize the importance of social relationships, our knowledge about applying social network analysis (SNA) to formative, process, and outcome evaluations of health system interventions is limited. We explored applications of adopting an SNA lens to inform implementation planning, engagement and execution, and evaluation. We used Health Links, a province-wide program in Canada aiming to improve care coordination among multiple providers of high-needs patients, as an example of a health system intervention. At the planning phase, an SNA can depict the structure, network influencers, and composition of clusters at various levels. It can inform the engagement and execution by identifying potential targets (e.g., opinion leaders) and by revealing structural gaps and clusters. It can also be used to assess the outcomes of the intervention, such as its success in increasing network connectivity; changing the position of certain actors; and bridging across specialties, organizations, and sectors. We provided an overview of how an SNA lens can shed light on the complexity of implementation along the entire implementation pathway, by revealing the relational barriers and facilitators, the application of network-informed and network-altering interventions, and testing hypotheses on network consequences of the implementation. [ABSTRACT FROM AUTHOR]

Objective To develop a conceptual framework of the influences on medical trainees' decisions regarding requests for clinical support from a supervisor. Design Phase 1: members of teaching teams in internal and emergency medicine were observed during regular clinical activities (216 hours) and subsequently completed brief interviews. Phase 2:36 in-depth interviews were conducted using videotaped vignettes to probe tacit influences on decisions to request support. Data collection and analysis used grounded theory methods. Setting Three teaching hospitals in an urban setting in Canada. Participants 124 members of teaching teams on general internal medicine wards and in the emergency department, comprising 31 attending physicians, 57 junior and senior residents, 28 medical students, and eight nurses. Purposeful sampling to saturation was conducted. Results Trainees' decisions about whether or not to seek clinical support were influenced by three issues: the clinical question (clinical importance, scope of practice), supervisor factors' (availability, approachability), and trainee factors (skill, desire for independence, evaluation). Trainees perceived that requesting frequent/ inappropriate support threatened their credibility and used rhetorical strategies to preserve credibility. These strategies included building a case for the importance of requests, saving requests for opportune moments, making a plan before requesting support, and targeting requests to specific team members. Conclusions Trainees consider not only clinical implications but also professional credibility when requesting support from clinical supervisors. Exposing the complexity of this process provides the opportunity to make changes to training programmes to promote timely supervision and provides a framework for further exploration of the impact of clinical training on quality of care of patients. [ABSTRACT FROM AUTHOR]

Background: Studying implementation of integrated models of community-based primary health care takes a "whole systems" multidisciplinary approach to capture micro (patient/carer and provider), meso (organization) and macro (system/policy) factors. In new research studying the implementation of these integrated models intended to improve care for older adults with complex care needs, our project team adopted four theoretical perspectives to capture micro, meso and macro factors influencing implementation. Problem Statement: Four theoretical and disciplinary perspectives were adopted to guide data collection and analysis. These perspectives were guided by 1) Wagner's Chronic Care Model as related to Ham's 10 Dimensions of High Performing Chronic Care Systems addressing patient/caregiver and provider level perspectives; 2) the Organizational Context and Capabilities for Integrating Care framework capturing organizational and provider level perspectives; and 3) the Health Policy Monitor survey methodology covering system and policy level perspectives. The different perspectives capture a wide breadth of concepts; however there is also significant conceptual overlap across those frameworks. The nature of this overlap requires clarification in order to: 1) ensure efficient data collection at the case sites; and 2) guide inter-disciplinary data analysis. Theory/Methods: Concept mapping was used to identify connections between the concepts across perspectives. Novak and Canas (2007)'s methods and software CmapTools were used to first generate a descriptive map. We explored the conceptual links of the map using data from 1 case studies in Ontario collected as part of the iCOACH project. Results: The concept map reveals many links across policy/system, organizational, provider and patient/carer theoretical perspectives. Examination of the overlap between concepts related to care coordination reveals different meanings, approaches, and implementations, depending on from which perspective you start. For instance, from a policy perspective care coordination is related to how services are delivered and delivery arrangements, the organizational perspective highlights inter-organizational linkages and collaboration, the provider perspective focuses on teamwork and community linkages, and the patient and carer perspective emphasizes the experience of coordinated care. Conclusions: Our analysis reveals that while concepts from different theoretical perspectives and disciplines may be similar in definition, each perspective offers a different meaning, value and driver associated with similar concepts. This analysis highlights the importance of developing a "whole system" perspective, and how concept mapping can be used to guide this approach to data collection and analysis. [ABSTRACT FROM AUTHOR]

Introduction: Interventions aimed at integrating care have become widespread in healthcare; however, there is significant variability in their success. Differences in organizational contexts and associated capabilities may be responsible for some of this variability. This study develops and validates a conceptual framework of organizational capabilities for integrating care, identifies which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts. Theory/Methods: The Context and Capabilities for Integrating Care (CCIC) Framework was developed through a literature review, and revised and validated through interviews with leaders and care providers engaged in integrated care networks in Ontario, Canada. Interviews involved openended questions and graphic elicitation. Quantitative content analysis was used to summarize the data. Results: The CCIC Framework consists of eighteen organizational factors in three categories: Basic Structures, People and Values, and Key Processes. The three most important capabilities shaping the capacity of organizations to implement integrated care interventions include Leadership Approach, Clinician Engagement and Leadership, and Readiness for Change. The majority of hypothesized relationships among organizational capabilities involved Readiness for Change and Partnering, emphasizing the complexity, interrelatedness and importance of these two factors to integrated care efforts. Discussion: The quantitative content analysis of participant interviews suggests that the social and psychological context for integrating care should not be neglected in research and practice. Five of the nine organizational capabilities deemed most important to integrating care are from the "People and Values" domain of the framework. An understanding of the subjective context, and associated organizational capabilities such as leadership approach, clinician engagement, organizational culture, and readiness for change, may be of equal, if not greater, importance to study as the objective contextual factors such as physical features, resources, and organizational/network design. Organizational leaders can use the framework to determine readiness to integrate care, develop targeted change management strategies, and select appropriate partners with overlapping or complementary profiles on key capabilities. Conclusions: We developed a consolidated research- and practice-informed framework to guide the implementation of integrated care interventions and to help focus measurement of organizational context and capabilities. We also prioritized the most important organizational capabilities and explored their inter-relationships via interviews with key informants. Lessons Learned: Participants' views and experiences did not always align with the initial framework's structure and wording. Based on the results, we made modifications to terminology. Participants also identified complex, often non-linear relationships among capabilities that require additional study in future research. Limitations: The validation results presented are based on a sample of 29 participants in one Canadian province. Although participants came from diverse organizations and differed in approaches to integrating care, the limited scope of the sample indicates that the results may not be widely generalizable. Suggestions for Future Research: Additional research is needed to empirically test the proposed framework, with a focus on the hypothesized relationships. Research needs to move beyond general statements about variations in the performance of integrated care interventions being due, for example, to "culture" or "leadership", to more specific assessments of these capabilities. [ABSTRACT FROM AUTHOR]

Context: During the last decade, Canada's provinces and territories have embarked on primary care reform toward high-performing systems. A paper entitled "Towards Primary Care Strategy" identified 12 features of high-performing primary healthcare systems. Objective: This study examines the evolution of primary care systems across Canada between 2013 and 2021. Study design and Analysis: A multiple comparative case-study approach was used to explore changes in the 13 Canadian jurisdictions. Each case consisted of: (1) qualitative interviews with academics, provincial leaders, and healthcare professionals) and 2) a document and literature review of policies and innovations. Data for each case were thematically analyzed using the 12 features of high-performing primary care to describe each case and assess changes over time. This was followed by cross-case analyses. Setting: Canada. Population studied: Primary care systems. Intervention/Instrument: Evolution of primary care systems. Outcome measures: Progress in the 12 features of high-performing primary care systems. Results: We found that British Columbia, Alberta, Ontario, and Quebec have made the most significant progress toward primary care transformation in Canada, although no jurisdiction has achieved all attributes. There has been considerable progress in adopting health information technology across the country. Four jurisdictions have established a policy direction for primary care. Some jurisdictions have or are implementing collaborative primary care governance models. More jurisdictions are involved in patient enrollment and supporting quality improvement training. Experimentation with new interprofessional team models and funding arrangements continues. However, more investments are needed for wide-scale implementation of primary care governance mechanisms, interprofessional teams and funding arrangements, patient engagement, comprehensive performance measurement systems, leadership development, systematic evaluation, and building research capacity. Conclusion: The pace of primary care transformation has been slow in Canada. While there has been some progress toward high-performing systems, each jurisdiction has distinct opportunities to advance primary care to the level of best-performing countries. Further funding investments are needed by federal and provincial/territorial governments and by regional health authorities for primary care transformation. [ABSTRACT FROM AUTHOR]

Aim: To rigorously review the literature on the prosocial workplace behaviours of nurses. Background: Prosocial workplace behaviours, predominantly organisational citizenship behaviours have been theoretically and empirically found to promote individual and group level performance in various industries. However, little consensus exists in the literature regarding the impact of nurses' workplace behaviours on the work environment and organisational performance. Evaluation: An integrative literature review was conducted on studies between 1980 and 2016. Nineteen articles were included related to nurses' prosocial behaviours and performance. Results: A positive relationship was noted between workplace behaviours and individual level performance and unit level performance. Albeit multifactorial, leadership and the social structure of the work environment are important factors contributing to the workplace behaviour–performance relationship. Conclusions: Prosocial behaviours influence the social functioning of the work environment and offer insights into the delivery of quality care. Implications for Nursing Management: Nurse managers should recognize the influence of leadership style and characteristics in the work environment that encourage employee participation in prosocial behaviours. These additional voluntary efforts by nursing staff may improve organisational effectiveness and quality of care. Inclusion of these behaviours in performance reviews and as cultural norms may help to foster a more collaborative work environment. [ABSTRACT FROM AUTHOR]

Purpose: This scoping review examines what is known about the processes of quality improvement (QI) teams, particularly related to how teams impact outcomes. The aim is to provide research-informed guidance for QI leaders and to inform future research questions.Data Sources: Databases searched included: MedLINE, EMBASE, CINAHL, Web of Science and SCOPUS.Study Selection: Eligible publications were written in English, published between 1999 and 2016. Articles were included in the review if they examined processes of the QI team, were related to healthcare QI and were primary research studies. Studies were excluded if they had insufficient detail regarding QI team processes.Data Extraction: Descriptive detail extracted included: authors, geographical region and health sector. The Integrated (Health Care) Team Effectiveness Model was used to synthesize findings of studies along domains of team effectiveness: task design, team process, psychosocial traits and organizational context.Results Of Data Synthesis: Over two stages of searching, 4813 citations were reviewed. Of those, 48 full-text articles are included in the synthesis. This review demonstrates that QI teams are not immune from dysfunction. Further, a dysfunctional QI team is not likely to influence practice. However, a functional QI team alone is unlikely to create change. A positive QI team dynamic may be a necessary but insufficient condition for implementing QI strategies.Conclusions: Areas for further research include: interactions between QI teams and clinical microsystems, understanding the role of interprofessional representation on QI teams and exploring interactions between QI team task, composition and process. [ABSTRACT FROM AUTHOR]

Background: The concept of "mechanism" is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand).Methods: In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC.Results: We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions.Conclusions: We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation. [ABSTRACT FROM AUTHOR]

Complex adaptive systems (CAS) theory views healthcare as numerous sub-systems characterized by diverse agents that interact, self-organize, and continuously adapt. We apply this complexity science perspective to examine the extent to which CAS theory is a useful lens for designing and implementing health policies. We present the case of Health Links, a “low rules” policy intervention in Ontario, Canada aimed at stimulating the development of voluntary networks of health and social organizations to improve care coordination for the most frequent users of the healthcare system. Our sample consisted of stakeholders from regional governance bodies and organizations partnering in Health Links. Qualitative interview data were coded using the key complexity concepts of sensemaking, self-organization, interconnections, coevolution, and emergence. We found that the complexity-compatible policy design successfully stimulated local dynamics of flexibility, experimentation, and learning and that important mediating factors include leadership, readiness, relationship-building, role clarity, communication, and resources. However, we saw tensions between preferences for flexibility and standardization. Desirable developments occurred only in some settings and failed to flow upward to higher levels, resulting in a piecemeal and patchy landscape. Attention needs to be paid not only to local dynamics and processes, but also to regional and provincial levels to ensure that learning flows to the top and informs decision-making. We conclude that implementation of complexity-compatible policies needs a balance between flexibility and consistency and the right leadership to coordinate the two. Complexity-compatible policy for integrated healthcare is more than simply ‘letting a thousand flowers bloom’. [ABSTRACT FROM AUTHOR]

Purpose: A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience.Data Sources: International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies.Study Selection: Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English.Data Extraction: Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes.Results Of Data Synthesis: A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.Conclusions: This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators. [ABSTRACT FROM AUTHOR]

Introduction: Despite the widespread adoption of integrated care initiatives, achieving integrated care goals remains elusive. One continuing challenge is the frequent mismatch between measurement frameworks and goals. Existing literature describes conceptual frameworks or measurement domains without identifying specific measures, or, alternatively, reviews existing measures and measuring tools without explicating how these measures could be used or how they fit together in a performance measurement framework. We sought to develop a performance measurement framework for integrated care initiatives with linked measures that can be adapted to different initiatives and settings and which informs strategy and guides decision-making. Aims Objectives Theory or Methods: We conducted a scoping a review of peer-reviewed studies and grey literature articles to identify performance measurement frameworks, measurement domains and measures for integrated care. Measures were abstracted and categorized based on structure, process and outcomes; outcomes were further classified based on quadruple aim domains. Thematic analysis was conducted based on recommended measurement domains and subdomains in the literature. This was summarized in an overarching performance measurement framework using a logic model format. Further mapping and analysis of measures was conducted onto the proposed measurement framework based on discussion between study authors and feedback from local policy-makers Highlights or Results or Key Findings The initial scoping review search found over 2600 articles; of these, 278 were deemed potentially relevant and screened, resulting in the inclusion of 70 articles. A total of 340 measures of integrated care were found in these 70 articles. Most of these measures were existing outcome measures; and these measures were not directly linked to integrated care initiatives. A performance measurement framework was constructed including process and outcome measurement domains and subdomains. Process measures were divided into 1) measures of key integrated care activities including personalized care, coordinated care, and interprofessional collaboration, and 2) critical outputs including patient empowerment, communication, continuity of care, planned care, and access. Outcomes domains were mapped to the quadruple aim and included user experience (patient, caregiver), provider experience, health outcomes (system-level, person-level), and cost/utilization. Few measures were found that tapped policy environment, context and initiative structure components. Conclusions: Despite the substantial literature on integrated care measurement, many current measures are poorly suited to the task of measuring integrated care. We propose a performance measurement framework for integrated care initiatives that provides a conceptually grounded and useful approach for evaluating integrated care. Implications for applicability/transferability sustainability and limitations: Performance measurement of integrated care initiatives is a complex task. We propose a performance measurement framework and linked performance measures that can be utilized to guide implementation and development, informing practitioners, policy makers, funders and evaluators who seek to assess the performance of integrated care efforts. [ABSTRACT FROM AUTHOR]

Introduction: Discussions of integrated care have ranged in focus from large-scale health system transformations, to discrete interventions intended to enhance local continuity of care. Beyond these variations in scale and focus, literature on integrated care has used a variety of conceptual frameworks to explain various activities and elements necessary to achieve integrated care. Existing frameworks have helped to advance research and practice; yet the complexity of changing practice required to achieve integrated care across the policy, organizational, and clinical levels complicates efforts to represent or implement these innovations in straightforward ways. Aims Objectives Theory or Methods: In this paper, we present a novel strategy for conceptualizing integrated care as developing through a series of milestones observable at the organizational level. Based on analysis of four integrated care organizational case studies in Canada and New Zealand, we outline how this approach to conceptualizing integrated care both resolves the tension of crossing the macro, meso, and micro levels of analysis, and generates new practical insights to guide policy and practice. Methods consist of qualitative interviews, observation, and document analysis across cases, and qualitative data were analyzed temporally to identify milestones as indicated by participants over time. Highlights or Results or Key Findings: We define a milestone as the occurrence of a salient event that is perceived by respondents to facilitate or disrupt efforts towards the development of integrated care. We synthesize these events at the organizational level, suggesting that the organizational level of analysis is the most appropriate level to represent the significance of these milestones. Our analysis identified six categories of milestone: (1) Strategic relational milestones, referring to building relationships between stakeholders. (2) Strategic process change milestones, referring to efforts to improve quality in practice. (3) Structural (intra-organizational) milestones, referring to changes in organizational structure. (4) Structural (inter-organizational) milestones, referring to changes in the legal, operational, or leadership structures that facilitate relationships between organizations. (5) Environmental milestones, referring to changes in the social or natural environment. (6) Political milestones, referring to changes in the control and allocation of resources. Conclusions: Our results generate a new conceptual framework for understanding the achievement of integrated care as occurring through a series of milestones. This approach enhances the focus on achieving integrated care "in the wild", in the actual environments in which leaders, clinicians, policymakers, patients, and caregivers work to implement integrated care. Implications for applicability/transferability sustainability and limitations: Our model emphasizes two practical points. First, that there is no single series of sequential steps that must be taken to achieve integrated care. Second, that policy efforts to support integrated care ought to encourage organizations and their collaborators to work toward milestones that facilitate the development of integrated care. [ABSTRACT FROM AUTHOR]

Introduction: This study explores the implementation of "Health Links", a provincial integrated care initiative aimed at transforming care systems for high needs patients in Ontario, Canada. Launched in 2012 with 19 early adopters, there are currently 54 operational Health Links in Ontario. Each Health Link consists of multiple providers and is led by a coordinating partner such as a hospital, primary care group, or community support agency. We explored the implementation of Health Links from the perspective of Local Health Integration Networks (LHINs). LHINs are regional planning and funding bodies that have played an active role in overseeing the implementation process. In this study, we aimed to understand how environmental and organizational contexts influence the implementation and success of Health Links. Theory/Methods: We conducted semi-structured telephone interviews with LHIN leaders directly engaged in overseeing and managing the Health Links within their boundaries. The interviews focused on the LHIN role in implementing and supporting the Health Links, achievements to date, key challenges, and perceived similarities, differences, and degrees of success and innovation among the Health Links in their region. Probing questions were used to clarify the nature and extent of influence of organizational or environmental factors on the participants' experiences and perceptions. The Context for Integrated Care (CIC) Framework (recently developed by the authors) was used as an analytical framework for data analysis. Interview transcripts were qualitatively analyzed in two successive rounds. In the first round, an open-ended, iterative approach was used to identify recurrent themes. In the second round, the dimensions of the CIC Framework were used to code the transcripts. Results: Fourteen interviews were conducted with 26 participants between August and September 2014, representing a 100% participation rate from all fourteen of Ontario's LHINs. Significant differences across Health Links were noted in target patient populations, primary care versus hospital leadership, perceived success in rural versus urban areas, and a flexible versus standardized approach to structuring and implementing the network. The response to the "lowrules", grass-roots style of implementation by the Ontario Ministry of Health and Long-Term Care was also varied, with some LHINs choosing to impose a prescriptive standardized approach across their Health Links and others embracing the flexibility and opportunity for local adaptation. Despite significant diversity across the LHINs, several common environmental challenges were identified including loss of momentum during the Health Link application and approval process, a lack of clarity regarding the role and accountability of LHINs, measurement limitations impacting evaluation, and sustainability of funding. When mapped on to the CIC Framework, which has an explicit focus on the organizational and network levels, the following factors were evoked most frequently: resources, leadership, primary care engagement, readiness to change, a strategic focus on improvement, and historical inter-organizational relationships. Discussion: Results of the qualitative analysis show that LHIN experiences implementing Health Links varied on a continuum that ranged from positive and eager to demonstrate impact to frustrated and change-fatigued. Despite differences in network structure, implementation approach and geography and demography, recurring themes were identified that reflect the potency of environmental and organizational factors on efforts to integrate services. The CIC Framework enabled a comprehensive analysis of organizational context. The results suggest that factors such as organizational culture, internal design, and work environment are less important to the implementation of integrated care initiatives than leadership, resources, and readiness for change. Although multiple perspectives are required before drawing firm conclusions about the relative importance of various factors, these results can be used to help prioritize key areas for discussion, measurement and/or change management. Conclusions: The results of this study have implications for policymakers, organizational leaders, and researchers. Policymakers should consider how best to balance flexibility and standardization in the implementation of new programs to support a diverse range of needs and capabilities. Rapid feedback and approval turn-around during the implementation process is crucial to maintain momentum, as is clarity of roles between levels of governance, a shared evaluation framework, and sustainability plans. Leaders must be attuned to the context of their organization, and partnering organizations, to enhance synergy and build on respective strengths. Finally, additional research is required to understand when and how specific contextual factors matter. Although generalizability is limited by the focus on one jurisdiction in Canada, given the diversity of the Health Links in terms of geography, target patient population, organizational partners, and integrated care model/intervention design, we expect that the results have some transferability to other settings. The research team is currently engaged in interviews with clinicians and leaders working directly within the Health Links. [ABSTRACT FROM AUTHOR]

Background: Early identification of patients at who have a higher risk for the occurrence of harm can provide patient safety improvement opportunities. Patient factors contribute to adverse event occurrence. The study aim was to identify a single, parsimonious model of home care patient factors that, regardless of location and differences in home care program management and design factors, could provide a means of locating patients at higher and lower risk of harm.Methods: Split modeling using secondary analyses of data from two recent Canadian home care patient safety studies was undertaken. Patient factors from the Minimum Data Set Resident Assessment Instrument (RAI) for Home Care and diagnoses consistent with ICD-10 and RAI-Mental Health assessment were used. Continuous and categorical measures of factors were considered. Adverse events were defined using World Health Organization taxonomy and measured on a dichotomous yes/no scale. Patient factors significantly associated (Pearson's Chi Square, p ≤ .05) with the occurrence of adverse events in both earlier studies were entered in forward selection regression analyses to locate factors predictive of adverse event occurrence.Results: Instrumental activities of daily living dependency and escalating co-morbidity counts are associated with patient vulnerability to adverse events.Conclusions: Instrumental activities of daily living dependency and burden of illness, both easily identifiable early in the episode of care, are significantly associated with the risk of adverse event occurrence, however there is regional variability in the relationships. [ABSTRACT FROM AUTHOR]

Introduction: Many studies have investigated the process of healthcare implementation to understand better how to bridge gaps between recommended practice, the needs and demands of healthcare consumers, and what they actually receive. However, in the implementation of integrated communitybased and integrated health care, it is still not well known which approaches work best. Methods: We conducted a systematic review and metanarrative synthesis of literature on implementation frameworks, theories and models in support of a research programme investigating CBPHC for older adults with chronic health problems. Results: Thirty-five reviews met our inclusion criteria and were appraised, summarised, and synthesised. Five metanarratives emerged 1) theoretical constructs; 2) multiple influencing factors; 3) development of new frameworks; 4) application of existing frameworks; and 5) effectiveness of interventions within frameworks/models. Four themes were generated that exposed the contradictions and synergies among the metanarratives. Person-centred care is fundamental to integrated CBPHC at all levels in the health care delivery system, yet many implementation theories and frameworks neglect this cornerstone. Discussion: The research identified perspectives central to integrated CBPHC that were missing in the literature. Context played a key role in determining success and in how consumers and their families, providers, organisations and policy-makers stay connected to implementing the best care possible. Conclusions: All phases of implementation of a new model of CBPHC call for collaborative partnerships with all stakeholders, the most important being the person receiving care in terms of what matters most to them. [ABSTRACT FROM AUTHOR]

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of the population. Across the world CBPHC is at varying stages of development and few standard models exist. In order to scale up and spread successful models of care it is important to study what works and why. The first step is to select 'appropriate' cases to study. In this commentary we reflect on our journey in the selection of CBPHC models for older adults, revealing the limited utility of sourcing the empirical literature; the difficulty in identifying "successful" models to study when outcomes of importance differ across stakeholders; the value of drawing on clinical and organisational networks and experts; and the association between policy context and ease of case selection. Such insights have important implications for case study methodology in health services and policy research. [ABSTRACT FROM AUTHOR]