The purpose of this paper is to describe and understand the effects of the accreditation process on organizational control and quality management practices in two Quebec primary-care health organizations.
A multiple-case longitudinal study was conducted taking a mixed qualitative/quantitative approach. An analytical model was developed of the effects of the accreditation process on the type of organizational control exercised and the quality management practices implemented. The data were collected through group interviews, semi-directed interviews of key informers, non-participant observations, a review of the literature, and structured questionnaires distributed to all the employees working in both institutions.
The accreditation process has fostered the implementation of consultation mechanisms in self-assessment teams. Improving assessments of client satisfaction was identified as a prime objective but, in terms of the values promoted in organizations, accreditation has little effect on the perceptions of employees not directly involved in the process. As long as not all staff members have integrated the basis for accreditation and its outcomes, the accreditation process appears to remain an external, bureaucratic control instrument.
This study provides a theoretical model for understanding organizational changes brought about by accreditation of primary services. Through self-assessment of professional values and standards, accreditation may foster better quality management practices.
Primary health care (PHC) renewal was designed explicitly to attend to the multidimensional factors impacting on health, including the social determinants of health. These determinants are central considerations in the development of integrated, cross-sectoral, and multi-jurisdictional policies such as those that inform models of shared mental health care for children. However, there are complex theoretical challenges in translating these multidimensional issues into policy. One of these is the rarely discussed interrelationships among the social determinants of health and identities such as race, gender, age, sexuality, and social class within the added confluence of geographic contexts. An intersectionality lens is used to examine the complex interrelationships among the factors affecting child mental health and the associated policy challenges surrounding PHC renewal. The authors argue that an understanding of the intersections of social determinants of health, identity, and geography is pivotal in guiding policy-makers as they address child mental health inequities using a PHC renewal agenda.
Erratum In: Can J Nurs Res. 2010 Dec;42(4):2 p preceding table of contents
This article relates the results of descriptive exploratory research conducted through interviews with 297 young immigrant families and 40 health and social workers on the primary health problems encountered by the families and on how they resolved these problems. Families and workers rank problems in different orders of priority. While families give priority to the health problems of their children, workers give priority to the problems encountered by the mothers, and in particular, mental health problems. Families and workers alike express a desire for help from the health and social service system for these problems. For families, this help would come from family doctors and nurses. These health providers are subsequently consulted; when they are not, language is determined to be the main obstacle to accessibility. Difficulties related to cultural compatibility of services are seen as more numerous by workers than by families.
To understand the key challenges to adoption of advanced features of electronic medical records (EMRs) in office practice, and to better understand these challenges in a Canadian context.
Health care providers and staff in 5 primary care offices.
Level of EMR adoption was assessed, and field notes from interviews and discussion groups were qualitatively analyzed for common challenges and themes across all sites.
Fifty-seven interviews and 4 discussion groups were conducted from November 2011 to January 2012. Electronic medical record adoption scores ranged from 2.3 to 3.0 (out of a theoretical maximum of 5). Practices often scored lower than expected on use of decision support, providing patients with access to their own data, and use of practice-reporting tools. Qualitative analysis showed there were ceiling effects to EMR adoption owing to how the EMR was implemented, the supporting eHealth infrastructure, lack of awareness or availability of EMR functionality, and poor EMR data quality.
Many practitioners used their EMRs as "electronic paper records" and were not using advanced features of their EMRs that could further enhance practice. Data-quality issues within the EMRs could affect future attempts at using these features. Education and quality improvement activities to support data quality and EMR optimization are likely needed to support practices in maximizing their use of EMRs.
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Computer-based patient record systems have become very common in the primary health service, but their effects have seldom been documented. Three surveys were carried out in the municipality of Sør-Varanger, in 1993, 1994 and 1995, to discover how such a system has affected the running of the municipal medical centres. The most significant changes were organisational. Certain tasks changed hands, others were dispensed with, and new ones were added. Information on patients became more readily available, and services to the public were improved. Many more patients received an answer to questions concerning information in the case record, and far fewer forms had to be filled in manually. Despite this, computerisation had seemingly led to little change in effectiveness, and the total load of work remained the same. The survey also showed that simple extensions to the system could produce marked improvements.
Nurse practitioners in Canada have experienced many of the problems facing those in the UK. In this paper, first presented at this year's meeting of the Commonwealth Nurses' Federation, the authors explain the events.
To assess whether the model of service delivery affects the equity of the care provided across age groups.
One hundred thirty-seven practices, including traditional fee-for-service practices, salaried community health centres (CHCs), and capitation-based family health networks and health service organizations.
To compare the quality of care across age groups using multilevel linear or logistic regressions. Health service delivery measures and health promotion were assessed through patient surveys (N = 5111), which were based on the Primary Care Assessment Tool, and prevention and chronic disease management were assessed, based on Canadian recommendations for care, through chart abstraction (N = 4108).
Older individuals reported better health service delivery in all models. This age effect ranged from 1.9% to 5.7%, and was larger in the 2 capitation-based models. Individuals aged younger than 30 years attending CHCs had more features of disadvantage (ie, living below the poverty line and without high school education) and were more likely than older individuals to report discussing at least 1 health promotion subject at the index visit. These differences were deemed an appropriate response to greater needs in these younger individuals. The prevention score showed an age-sex interaction in all models, with adherence to recommended care dropping with age for women. These results are largely attributable to the fact that maneuvers recommended for younger women are considerably more likely to be performed than other maneuvers. Chronic disease management scores showed an inverted U relationship with age in fee-for-service practices, family health networks, and health service organizations but not in CHCs.
The salaried model might have an organizational structure that is more conducive to providing appropriate care across age groups. The thrust toward adopting capitation-based payment is unlikely to have an effect on age disparities.
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Alberta's integrated approach to chronic disease management programming embraces client-centred care, supports self-management and facilitates care across the continuum. This paper presents strategies implemented through collaboration with primary care to improve care of individuals with chronic conditions, evaluation evidence supporting success and lessons learned from the Alberta perspective.
The Alumni Program is a novel approach to the continuing care and preventive treatment of clients with "chronic" mental illness. This approach demands a different conceptualization of outpatient psychiatric intervention. The infectious disease model has been deliberately replaced with a chronic illness model that more accurately reflects the course and natural history of psychiatric illness. The Alumni Program is similar to the approach employed with other chronic medical conditions like arthritis, asthma, or diabetes. The program has complementary roles for both specialty psychiatric clinicians and family practitioners. In addition, the program empowers clients and their families to play a key role in their own ongoing adaptation and adjustment to chronic illness while striving for optimal wellness.
The Ambulatory Sentinel Practice Network (ASPN) is a network of primary health care practices across the United States and Canada offering (1) a laboratory for the study of populations under the care of primary care providers, and (2) surveillance of primary care problems and services. This paper reports the methods and policies developed and used by ASPN to conduct studies and describes the initial sentinel practices.