As strange and unsettling as 2016 has been (Brexit, the U.S. federal election, scary-clown epidemic), there is solace in drawing the year to a close with another issue of Healthcare Quarterly brimming with articles on topics of vital concern to contemporary healthcare.
Improving System Performance
Long-term capacity planning: one would be hard pressed to find a system administrator who does not believe in it. But what of the process of such planning? James Shaw and his colleagues begin to unlock that mystery by discussing the planning principles that arose out of a symposium with leaders of Ontario's local health integration networks. The authors report that the resulting principles, such as the development of a long-term vision and continuous stakeholder engagement, are already being "built into" the province's health ministry's planning activities (e.g., a provincial dementia strategy).
Training the system-performance lens onto hospitals specifically, Les Vertesi considers the measurement of performance and quality in light of institutions' varying operating environments. Mining CIHI's Discharge Abstract Database, Vertesi queries reliance on the average length of stay (ALOS) marker, as well as how inpatient days associated with transfers-in are factored. His analysis clarifies the importance of both planned and unplanned patient ratios for understanding hospitals' performance and ability to meet quality improvement and financial targets.
Electronic health records (EHRs) hold massive potential for care coordination. Josephine McMurray and her co-authors tackle the matter of EHR interoperability – in other words, how multiple care providers in "expanded circles of care" can access, exchange, interpret and act on the data in this aptly characterized "technical Tower of Babel." Discussing the results of a workshop on the topic held in the Waterloo–Wellington health network, the authors illuminate participants' calls for more research on several topics, including regulatory and legislative environments, as well as standardization.
Safer Patient Care
Medical device reprocessing (MDR) is a given, but improving practices requires knowing more about how to evaluate it. In their article, Bailey Lorv et al. relate the creation and impact of an MDR quality management framework at Trillium Health Partners. Their 10 key performance indicators include patient safety incidents, delayed surgical cases and decontamination time. The authors see their framework – "tool for continuous and purposeful evaluation of MDR" – as a basis on which they and others can now build.
Much in the patient-safety domain depends – as McMurray et al. and Lorv et al. show – not just on data gathering, but purposeful data use. Undertaking their study at Toronto's University Health Network, Hibak Mahamed et al. examined the use of incident reporting systems (IRSs) to improve patient safety. Their scrutiny of an IRS for Clostridium difficile infection identified four main hurdles: limited data input, lack of review-committee diversity, lack of measurable action items and variable feedback wait time. While brief, the authors' comments on how to address these concerns are enlightening.
Innovations in Primary Care
Our next article could profitably be read alongside Vertesi's observations on the escalation of unplanned hospital admissions. Lynette Krebs and her team dissect low-acuity emergency department (ED) presentations to understand the link between having a primary care physician (PCP) and ED use – and how to "divert" non-urgent patients. One of Krebs et al.'s most noteworthy findings is that while a sizeable majority (74.4%) of ED patients had a PCP, only 18.6% of them saw their PCP before presenting at the ED. It is clearly not enough to link patients to PCPs in order to steer them away from the ED; other strategies, such as increasing patients' "attachment" to their physicians, are needed.
Diagnosis and management of dementia at the primary-care level often falls short of goals and ideals. Ontario's emerging primary care collaborative memory clinics (PCCMCs), the subject of Linda Lee and her co-authors' paper, is an innovative response to that problem. Pivoting on the principle of person-centred care, this physician-led clinic type "represents an ideal chronic disease management approach in that it triages patients based on need." The impressive results include increased capacity, reduced wait times, efficient use of resources and greater patient satisfaction.
Next up, P. Tony Singh considers the impact of advanced access scheduling on a unique population: members of the Canadian Armed Forces (CAF). Aimed at improving continuity, access and patient satisfaction, the six-month pilot project he describes took place at a CAF clinic in Ottawa. Singh is forthright about the major turbulence the project encountered (in some cases created); however, once the data were analyzed, six "crucial lessons" – that surely could be extrapolated to other patient cohorts – emerged, involving planning around human resources, rostering and technology-enhanced scheduling.
Strategies for Challenging Behaviours
Caring for seniors with dementia who exhibit challenging behaviours is the goal of the Behavioural Supports Ontario (BSO) program. Of the BSO's three models of care, however, which is the most effective? Michelle Grouchy et al. attempt to find the answer. Focusing on individuals in long-term care facilities, the authors discovered that in-home BSO teams significantly "outperform" mobile teams. Their superiority is felt in critical areas such as care planning and provision, resident outcomes and lowering rates of restraint and inappropriate antipsychotic use.
From the behavioural challenges of a largely elderly population, we conclude with those affecting younger people. In 2011, Healthcare Quarterly published an article (https://www.longwoods.com/content/22584) documenting the behavioural gains brought about by workshops for staff and families to address the behavioural needs of children with autism. In this issue of the journal, one of that paper's authors – Shawn Reynolds – and Brea Chouinard return to the topic to assess durability. Their principal finding is that parents continued to use the skills they had learned. Parents also underscored the importance of having an impartial facilitator and capacity building. Despite the very small sample size on which Reynolds and Chouinard drew, their conclusions point the way to future research aimed at addressing the behavioural complexities of this challenging population.
– The Editors
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