Rapid, Bottom-Up Design of a Regional Learning Health System in Response to COVID-19.
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ABSTRACT:
SUBMITTER: Beck AF
PROVIDER: S-EPMC7885665 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:IntroductionChina has made considerable progress with health system reforms in recent years. Rural China, however, has lagged behind as the diversity of needs of China's 3,000 rural counties were not always well addressed by national top-down reforms. China's Rural Health Reform Project Health XI (HXI) piloted a hybrid process of top down and bottom up implementation of health system reforms which were tailored to rural county level needs and covered a population of more than 21 million. Different studies provide evidence that HXI counties have achieved substantial benefits given the relatively limited investment. The Effectiveness of HXI subsequently raises the question how the hybrid approach may have resulted in effective implementation of interventions. We answer this question to advance understanding of hybrid approaches in general and in the rural Chinese context in particular, where the bottom-up elements might match poorly with the traditional organisational culture and learning style.Materials & methodsWe conducted an in-depth qualitative analysis in three 'best practice' counties, performing document-analyses, observations, semi-structured individual and group interviews. In alignment with the research question, this study is of an explorative nature and follows a sequence of deductive and inductive steps.ResultsHXI struggled initially as counties had difficulties to take initiative and autonomously select and adapt their own reforms. The initial reforms required multiple improvement iterations before achieving the planned results. The effectiveness of these bottom up reform processes has been aided by tight top down supervision and extensive domestic expert involvement. County level leadership is seen as essential to align the top down and bottom up structures and processes. Where successful, HXI has changed mind-sets and counties developed generic health improvement capabilities.ConclusionTailoring innovations to fit local needs formed a severe challenge for the three 'best practice' counties studied. A 'change of mindset' to actively take initiative and assume autonomy was needed to advance. Top down supervision and extensive support of experts was required to overcome the barriers. The studied counties finally achieved sustainable improvements and developed double loop learning capabilities beyond HXI objectives. Taken together, the above findings suggest that the continuum of healthcare reform implementation approaches in which hybrid approaches reside-from bottom up to top down-has two dimensions: a content dimension and a procedural dimension. Enabled by top down procedures, counties were able to bottom up tailor the content of best practice innovations to fit local needs.
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Project description:This opinion piece focuses on global health action by hands-on bottom-up practice: initiation of an organizational framework and securing financial efficiency are - however - essential, both clearly a domain of well-trained public health professionals. Examples of action are cited in the four main areas of global threats: planetary climate change, global divides and inequity, global insecurity and violent conflicts, and global instability and financial crises. In conclusion, a stable health systems policy framework would greatly enhance success. However, such organizational framework dries out if not linked to public debates channeling fresh thoughts and controversial proposals: the structural stabilization is essential but has to serve not to dominate bottom-up activities. In other words, a horizontal management is required, a balanced equilibrium between bottom-up initiative and top-down support. Last but not least, rewarding voluntary and charity work by public acknowledgment is essential.
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Project description:BackgroundRepeat Rapid Response Team (RRT) calls are associated with increased in-hospital mortality risk and pose an organisation-level resource burden. Use of Non-Technical Skills (NTS) at calls has the potential to reduce potentially preventable repeat calling. NTS are usually improved through training, although this consumes time and financial resources. Re-designing the Rapid Response System (RRS) to promote use of NTS may provide a feasible alternative.MethodsA pre-post observational study was undertaken to assess the effect of an RRS re-design that aimed to promote use of NTS during RRT calls. The primary outcome was the proportion of admissions each month subject to repeat RRT calling, and the average number of repeat calls per admission each month was the secondary outcome of interest. Univariate and multivariable interrupted time series analyses compared outcomes between the two study phases.ResultsThe proportion of admissions with repeat calls each month increased across both phases of the study period, but the increase was lower in the post re-design phase (change in regression slope -0.12 (standard error 0.07) post versus pre re-design). The multivariable model predicted a 6% reduction (95% confidence interval -15.1-3.1; P = 0.19) in the proportion of admissions having repeat calls at the end of the post redesign phase study compared to the predicted proportion in the absence of the re-design. The average number of calls per admission was also predicted to decrease in the post re-design phase, with an estimated difference of -0.07 calls per admission (equivalent to one fewer repeat call per 14 patients who had RRT calls) at the end of the post re-design phase (95% confidence interval -0.23-0.08, P = 0.35).ConclusionThis study of an RRS re-design showed modest, but not statistically significant, reductions in the proportion of admissions with repeat calls and the mean number of repeat calls per admission. Given the economic and workforce capacity issues that all health care systems now face, even small improvements in the RRS may have lasting impact across the organisation. For the potential interest of RRS managers, this paper presents a pragmatic, low-cost initiative intended to enhance communication and cooperation at RRT calls.
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Project description:IntroductionThe health systems needed to improve their learning capacities during the COVID-19 pandemic. Iran is one of the countries massively struck by the pandemic. This study aimed to explore whether and how the policy interventions made by Iran's policymakers at the national level to control COVID-19, could improve the rapid learning characteristics of the health system.MethodsA guide to clarify rapid learning health system (RLHS) characteristics was developed. The guide was used by two independent authors to select the policy interventions that could improve RLHS characteristics, then, to analyze the content of the selected policy interventions. In each stage, results were compared and discussed by all three authors. Final results were presented based on different RLHS characteristics and the potential mechanisms of contribution.ResultsFive hundred policy interventions were developed during the first 7 months of the outbreak. Thirty-one policy interventions could potentially improve RLHS characteristics (6.2%). Two characteristics, such as the timely production of research evidence and the appropriate decision support were addressed by selected policy interventions. Policies, that could improve learning capacities, focused on decision-maker groups more than user groups or researcher groups.ConclusionsMost of the developed policy interventions during the first months of the epidemic did not address the learning capacities of the health system. To improve health system functions, improving RLHS characteristics of the health system, especially in patient-centered and data linkage characteristics, is recommended.
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