Hospital executive leadership: a critical component for improving care at the end of life

End-of-life care and its planning by individuals, in concert with their families and professional healthcare givers, pose important social, legal, and ethical issues. The authors evaluate the results of a multi-year (1997-2001) collaborative effort among representatives of Georgia healthcare providers, healthcare payers, and the general public that was designed to (a) improve end-of-life care through a community-focused field effort to increase public awareness, execution, and institutional management of advance directives and (b) impact institutional and state government systems and policies around end-of-life care. The authors conclude that a proactive presence of senior management is integral in implementing systematic change in hospital-based end-of-life care and offer practical recommendations to hospital leaders to affect real change in their institutions.     

The Educational Needs of Healthcare Managers and Executives in the Key Strategic Areas of Healthcare

Management approaches used by many healthcare organizations lag behind those of similar competitive industries. The authors of this article report findings from an exploratory study of executives' perceptions of training needs in managerial strategy. The authors asked executives to rate the level of knowledge required for each of five key areas in strategic management and then to assess actual levels of knowledge in the field. They found that (a) strategic management is vital in this competitive industry, (b) there is a disconnect between what healthcare managers should know and what they actually know about the tasks of strategic management, and (c) more resources need to be devoted to strategic management training and the development of managers at all levels of healthcare organizations.     

The struggle for equality in healthcare continues

All healthcare providers, both institutional and individual, must make every effort to ensure that every person who seeks their medical care is offered competent, sincere, and equal treatment options. Unfortunately, this ideal scenario does not take into account the lack of diversity among care providers and the lack of culturally competent policies within healthcare delivery settings. As a result, many care providers continue to follow racially biased treatment practices and many organizations continue to ignore their public trust of providing fair treatment to everyone, regardless of skin color, gender, economic capabilities, etc. Although developing and implementing a diversity plan and culturally competent policies is very complex practically, politically, and programmatically for traditional institutional care providers, it must be done. The key ingredient to this effort is the absolute commitment and support of the organization's governing bodies and executive management. Institutions can certainly volunteer and begin to develop such programs that foster recruitment, selection, and retention of culturally competent care providers to ensure that equal healthcare is received by their patient populations. However, many institutions are already besieged by too many healthcare challenges to volunteer for such an effort. The Joint Commission on Accreditation of Healthcare Organizations and the National Council of Quality Assurance can certainly help jumpstart this effort by establishing an accreditation standard that requires all healthcare providers to establish and practice culturally competent care within their organizations. Providers must also embrace the diversity that is a part of our society and must not let race or ethnicity be a determining factor in offering treatment options.     

Appropriateness of End-of-Life Care in People Dying With Dementia: Applying Quality Indicators on Linked Administrative Databases

ObjectivesDementia is a progressive incurable life-limiting illness. Previous research suggests end-of-life care for people with dementia should have a symptomatic focus with an effort to avoid burdensome interventions that would not improve quality of life. This study aims to assess the appropriateness of end-of-life care in people who died with dementia in Belgium and to establish relative performance standards by measuring validated population-level quality indicators.DesignWe conducted a retrospective observational study.Setting and ParticipantsWe included all persons deceased with dementia in 2015 in Belgium. Data from 8 administratively collected population-level databases was linked.MeasuresWe used a validated set of 28 quality indicators for end-of-life dementia care. We compared quality indicator scores across 14 healthcare regions to establish relative benchmarks.ResultsIn Belgium in 2015, 10,629 people died with dementia. For indicators of appropriate end-of-life care, people who died with dementia had on average 1.83 contacts with their family physician in the last week before death, whereas 68.4% died at home or in their nursing home of residence. For indicators of inappropriate end-of-life care, 32.4% were admitted to the hospital and 36.3% underwent diagnostic testing in the last 30 days before death, whereas 25.1% died in the hospital. In the last 30 days, emergency department admission varied between 19% and 31%, dispensing of gastric protectors between 18% and 42%, and antihypertensives between 40% and 53% between healthcare regions, with at least 25% of health regions below 46%.Conclusions and ImplicationsOur study found indications of appropriate as well as inappropriate end-of-life care in people with dementia, including high rates of family physician contact, as well as high percentages of diagnostic testing, and emergency department and hospital admissions. We also found high risk-adjusted variation for multiple quality indicators, indicating opportunity for quality improvement in end-of-life dementia care.     

Understanding community engagement in end-of-life care: developing conceptual clarity

Over the past decade, public health approaches to end-of-life care have received increased literature, policy and practice focus. These developments recognise the significance of community engagement activities and their contribution to end-of-life care. In the United Kingdom, community engagement is a priority for the majority of hospices. Nevertheless, there exists some ambiguity about the range of different practice that exists under this heading, the principles underpinning it and the outcomes for the work. Conceptual clarity is an essential next step in the development of this emergent field. The aim of this paper is to present a definition and a conceptual model of community engagement for end-of-life care services and the communities they serve. A spectrum of community engagement in end of life care is presented, derived from models in the general community engagement literature. Types of engagement extend on a continuum from informing through consulting, co-producing, collaborating to empowerment, with the later levels capable of achieving more penetrating health and social change. The factors that affect the type and nature of engagement are represented in boxes at either end, demonstrating that it is not the influence of a single factor, but the overall balance of factors that determines the quality and outcomes of the engagement work. This spectrum is designed to aid professional services and the communities they serve to embark on community engagement projects with an open awareness of the requirements and key components underpinning their success and a shared understanding and language.     

Integrated care in action: opening the “black box” of implementation

The aim of this contribution is to explain how healthcare professionals implement policies for integrated care. More specifically, we aim to understand how these policies are received, interpreted and executed by primary care professionals. By opening the “black box” of policy implementation, we also explain how and why the process of implementation of the same policy diverges in practice. The research is framed according to both the neo‐institutional and the change management perspectives. The empirical investigation is conducted through a documental analysis and a multiple‐embedded case study. The results show that three forces affect and explain differences in the implementation processes: the unstable level of internal communication among the professionals involved, the limited use of power to resist to change and the poor learning process on the part of both the professionals and policy makers. The pressure of external institutions does not play a role in shaping the process. Through our study, we further knowledge about how healthcare professionals implement policies for integrated care, and we believe this is interesting, according to emerging evidence that variations in the effectiveness of policy outcomes may be explained by choices and potential distortions made during the initial stages of the policy implementation process. Copyright © 2015 John Wiley & Sons, Ltd. StartCopTextCopyright © 2015 John Wiley & Sons, Ltd.     

Shared care: the barriers encountered by community-based palliative care teams in Ontario, Canada

To meet the complex needs of patients requiring palliative care and to deliver holistic end-of-life care to patients and their families, an interprofessional team approach is recommended. Expert palliative care teams work to improve the quality of life of patients and families through pain and symptom management, and psychosocial spiritual and bereavement support. By establishing shared care models in the community setting, teams support primary healthcare providers such as family physicians and community nurses who often have little exposure to palliative care in their training. As a result, palliative care teams strive to improve not only the end-of-life experience of patients and families, but also the palliative care capacity of primary healthcare providers. The aim of this qualitative study was to explore the views and experiences of community-based palliative care team members and key-informants about the barriers involved using a shared care model to provide care in the community. A thematic analysis approach was used to analyse interviews with five community-based palliative care teams and six key-informants, which took place between December 2010 and March 2011. Using the 3-I framework, this study explores the impacts of Institution-related barriers (i.e. the healthcare system), Interest-related barriers (i.e. motivations of stakeholders) and Idea-related barriers (i.e. values of stakeholders and information/research), on community-based palliative care teams in Ontario, Canada. On the basis of the perspective of team members and key-informants, it is suggested that palliative care teams experience sociopolitical barriers in an effort to establish shared care in the community setting. It is important to examine the barriers encountered by palliative care teams to address how to better develop and sustain them in the community.     

Sampling Challenges in Nursing Home Research

BackgroundResearch on end-of-life care in nursing homes is hampered by challenges in retaining facilities in samples through study completion. Large-scale longitudinal studies in which data are collected on-site can be particularly challenging.ObjectivesTo compare characteristics of nursing homes that dropped from the study to those that completed the study.MethodsOne hundred two nursing homes in a large geographic 2-state area were enrolled in a prospective study of end-of-life care of residents who died in the facility. The focus of the study was the relationship of staff communication, teamwork, and palliative/end-of-life care practices to symptom distress and other care outcomes as perceived by family members. Data were collected from public data bases of nursing homes, clinical staff on site at each facility at 2 points in time, and from decedents’ family members in a telephone interview.ResultsSeventeen of the 102 nursing homes dropped from the study before completion. These non-completer facilities had significantly more deficiencies and a higher rate of turnover of key personnel compared to completer facilities. A few facilities with a profile typical of non-completers actually did complete the study after an extraordinary investment of retention effort by the research team.ConclusionNursing homes with a high rate of deficiencies and turnover have much to contribute to the goal of improving end-of-life care, and their loss to study is a significant sampling challenge. Investigators should be prepared to invest extra resources to maximize retention.     

Improving knowledge transfer on chronic respiratory diseases: A canadian perspective. How to translate recent advances in respiratory diseases into day-to-day care

Background: Chronic diseases represent an increasing burden for health care systems. Ongoing research efforts provide regularly new scientific evidence on how optimize current medical care. In regard to respiratory diseases, as for other health problems, optimal management of these conditions has been summarized in recent consensus guidelines but implementation of these recommendations is still poor. Not only are the key-messages of such guidelines often unknown to the practitioner and the patient but even when it is, they are often insufficiently integrated into current care, often related to behavioral, organizational and communication barriers.Methods: Literature review on the topic of Clinical Practice Guidelines implementation and reference to recent projects aimed at improving management of asthma in the province of Quebec and elsewhere, as models for such implementation process.Results: The basic principles of an effective translation of current knowledge into day-to-day care are known, but healthcare delivery structures, practice tools and resources, and regional/local leadership should be available to make it happen. Ideally, implementation requires a multidisciplinary effort of care providers, specialists, general practitioners, allied health professionals, patients and their family. The general public, health administrators and policy makers should also be aware of the consequences of poor management of these diseases and be supportive of the proposed initiatives. Finally, these last should be adequately evaluated to ensure their effectiveness and determine if they should be improved. Recently projects performed in Quebec have proposed disease management models to identify asthma care gaps and improve translation of current Guidelines into day-to-day care.Conclusions: Although the human and socio-economical burden of chronic diseases is still increasing, their current management is still often deficient. In the recent decades, Practice Guidelines have been developed to guide Practitioners towards optimal care, but implementation of these Guides is still poor. Recent Canadian and International initiatives have proposed valid models to help address current care gaps.     

Efficacy of Advance Care Planning: A Systematic Review and Meta-Analysis

ObjectiveTo systematically review the efficacy of advance care planning (ACP) interventions in different adult patient populations.DesignSystematic review and meta-analyses.Data SourcesMedline/PubMed, Cochrane Central Register of Controlled Trials (1966 to September 2013), and reference lists.Study SelectionRandomized controlled trials that describe original data on the efficacy of ACP interventions in adult populations and were written in English.Data Extraction and SynthesisFifty-five studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed using the PEDro scale by 2 independent reviewers. Meta-analytic techniques were conducted using a random effects model. Analyses were stratified for type of intervention: ‘advance directives’ and ‘communication.’Main Outcomes and MeasuresPrimary outcome measures were completion of advance directives and occurrence of end-of-life discussions. Secondary outcomes were concordance between preferences for care and delivered care, knowledge of ACP, end-of-life care preferences, quality of communication, satisfaction with healthcare, decisional conflict, use of healthcare services, and symptoms.ResultsInterventions focusing on advance directives as well as interventions that also included communication about end-of-life care increased the completion of advance directives and the occurrence of end-of-life care discussions between patients and healthcare professionals. In addition, interventions that also included communication about ACP, improved concordance between preferences for care and delivered care and may improve other outcomes, such as quality of communication.ConclusionsACP interventions increase the completion of advance directives, occurrence of discussions about ACP, concordance between preferences for care and delivered care, and are likely to improve other outcomes for patients and their loved ones in different adult populations. Future studies are necessary to reveal the effective elements of ACP and should focus on the best way to implement structured ACP in standard care.     

医院公信力对患者抱怨行为层次的影响

本研究旨在探讨医院公信力对医疗服务抱怨行为层次的影响,以期为医疗公信力的践行提供理论依据。331名有过不满意就诊或住院医疗服务抱怨经历的患者参与了线上问卷调查。结果显示:(1)医院公信力对一般抱怨水平和是否向第三方抱怨有正向影响;(2)医院公信力对一般抱怨水平和是否向第三方机构抱怨的影响机制不同,对一般抱怨水平高低的影响主要通过患者就诊的不满意度,而对是否向第三方抱怨则通过抱怨的预期收益影响;(3)医院公信力对是否向第三方抱怨的影响效果(0.301)要大于其对患者一般抱怨水平的影响效果(0.060);(4)医院公信力也会通过对医疗服务质量的期望落差、患者对医生的信任对一般抱怨水平与是否向第三方抱怨同时产生影响,但相比其直接通过患者就诊不满意度、抱怨的预期收益的影响要小,尤其是通过患者对医生的信任产生的间接影响很小。这表明医院公信力践行离不开微观层次的抱怨管理,一方面可能通过基于关系的医患沟通培训提升医生沟通技能及抱怨管理人事来改善患者对医疗服务的信任,另一方面更应该通过改善医疗服务报怨管理制度与机构设立来提升。     

The fiscal crisis in the health sector: Patterns of cutback management across Europe

PurposeThe article investigates trends in health sector cutback management strategies occurred during the ongoing financial and fiscal crisis across Europe.SettingA European-wide survey to top public healthcare managers was conducted in ten different countries to understand their perception about public sector policy reactions to the financial and economic crisis; answers from 760 respondents from the healthcare sector (30.7% response rate) were analyzed.MethodA multinomial logistic regression was used to assess the characteristics of respondents, countries’ institutional healthcare models and the trend in public health resources availability during the crisis associated to the decision to introduce unselective cuts, targeted cuts or efficiency savings measures.ResultsDifferentiated responses to the fiscal crisis that buffeted public finances were reported both across and within countries. Organizational position of respondents is significant in explaining the perceived cutback management approach introduced, where decentralized positions detect a higher use of linear cuts compared to their colleagues working in central level organizations. Compared to Bismark-like systems Beveridge-like ones favour the introduction of targeted cuts. Postponing the implementation of new programmes and containing expenses through instruments like pay freezes are some of the most popular responses adopted, while outright staff layoffs or reduction of frontline services have been more selectively employed.ConclusionTo cope with the effects of the fiscal crisis healthcare systems are undergoing important changes, possibly also affecting the scope of universal coverage.     

Dying cases in emergency places: caring for the dying in emergency departments

In an ageing society, like the UK, where long-term illness dominates healthcare, there has been a change in the way that the end-of-life is approached and experienced. Advancing technology, inadequate knowledge and inconsistency in palliative care services have complicated the ability to recognise imminent dying and many people access emergency services at the end-of-life. Drawing on ethnographic research exploring end-of-life care in one large Emergency Department (ED), the authors examine the spaces of dying and death, which are created in a place designed to save life, and not necessarily to provide supportive and palliative care. Despite the high need for attention in an emergency crisis, this study shows that the approach taken to care for someone at the end-of-life, and consequently the space in which they are cared for, often falls short of the expectations of the dying patient and their relatives. It is argued that the dying body is seen as dirty and polluted in the sterile, controlled, clinical environment and is therefore 'matter out of place'. Attempts are made to conceal or remove the dying patient, the bereaved relatives and the deceased body protecting the natural order of the ED. Consequently, the individual supportive and palliative care needs of the dying are often overlooked. This paper highlights the needs of patients as death nears in the ED and argues that the critical decisions made in the ED have a significant impact on the quality of care experienced by patients, who spend the last few hours of their life there.     

Human immunodeficiency virus/acquired immunodeficiency syndrome training from a union perspective.

The authors developed a union sponsored 2-day human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) "train the trainer" program for healthcare workers in the San Francisco Bay Area. The program incorporated the "education for action" approach in an effort to respond to the inadequacies in many traditional, institutional trainings. Service Employees International Union (SEIU) and Labor Occupational Health Program (LOHP) conducted the HIV/AIDS "train the trainer" program for approximately 100 healthcare workers in county public hospitals and community health clinics. After completing the program, these workers went back to their healthcare facilities, or community organizations, and led additional classes on HIV/AIDS transmission and prevention for approximately 600 more people. The goal of the program was to empower healthcare workers to: 1) identify the occupational risks associated with exposure to blood and potentially infectious body fluids at the workplace; 2) develop strategies to reduce those risks; 3) discuss their feelings about caring for an HIV/AIDS patient; and, 4) conduct HIV/AIDS workshops at the workplace.     

Nurses’ perceptions of mental healthcare in primary-care settings in Kenya

Kenya maintains an extraordinary treatment gap for mental health services because the need for and availability of mental health services are extraordinarily misaligned. One way to narrow the treatment gap is task-sharing, where specialists rationally distribute tasks across the health system, with many responsibilities falling upon frontline health workers, including nurses. Yet, little is known about how nurses perceive task-sharing mental health services. This article investigates nurses’ perceptions of mental healthcare delivery within primary-care settings in Kenya. We conducted a cross-sectional study of 60 nurses from a public urban (n?=?20), private urban (n?=?20), and public rural (n?=?20) hospitals. Nurses participated in a one-hour interview about their perceptions of mental healthcare delivery. Nurses viewed mental health services as a priority and believed integrating it into a basic package of primary care would protect it from competing health priorities, financial barriers, stigma, and social problems. Many nurses believed that integrating mental healthcare into primary care was acceptable and feasible, but low levels of knowledge of healthcare providers, especially in rural areas, and few specialists, would be barriers. These data underscore the need for task-sharing mental health services into existing primary healthcare in Kenya.     

Preventing Needlestick Injuries in Healthcare Settings

The U.S. healthcare system requires radical, not incremental, change. Management issues in healthcare delivery are fundamentally different from those in the business world. Systems thinking forces a focus on corporate culture, about which there is little hard data. The use of cost/benefit analysis suffers from the lack of any accepted measure of long-term “benefit.” The authors make four observations: (1) corporate culture is both part of the cause and part of the cure for healthcare; (2) long-term financial and functional measures are necessary to make evidence-based decisions; (3) valid, nationwide data must be developed regarding the corporate culture of medicine; and (4) direct (unmodified) application of management theory or practices will not achieve sustainable improvements.     

Current HIV/AIDS end-of-life care in sub-Saharan Africa: a survey of models,services, challenges and priorities

Background

In response to increased global public health funding initiatives to HIV/AIDS care in Africa, this study aimed to describe practice models, strategies and challenges to delivering end-of-life care in sub-Saharan Africa.

Methods

A survey end-of-life care programs was conducted, addressing the domains of service aims and configuration, barriers to pain control, governmental endorsement and strategies, funding, monitoring and evaluation, and research. Both closed and qualitative responses were sought.

Results

Despite great structural challenges, data from 48 programs in 14 countries with a mean annual funding of US $374,884 demonstrated integrated care delivery across diverse settings. Care was commonly integrated with all advanced disease care (67%) and disease stages (65% offering care from diagnosis). The majority (98%) provided home-based care for a mean of 301 patients. Ninety-four percent reported challenges in pain control (including availability, lack of trained providers, stigma and legal restrictions), and 77% addressed the effects of poverty on disease progression and management. Although 85% of programs reported Government endorsement, end-of-life and palliative care National strategies were largely absent.

Conclusions

The interdependent tasks of expanding pain control, balancing quality and coverage of care, providing technical assistance in monitoring and evaluation, collaborating between donor agencies and governments, and educating policy makers and program directors of end-of-life care are all necessary if resources are to reach their goals.

     

No Time to Waste: An Appraisal of Value at the End of Life

ObjectivesThe use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined.MethodsMEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life.ResultsA total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed.ConclusionsMost patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.     

Dying in Germany - consequences of societal changes for palliative care and the health care system

The changes in the way people die and the new challenges in dealing with dying and death have not been realized to their full extent or discussed in respect to their implications and consequences for end-of-life care in Germany. The purpose of this problem analysis paper is to provide an overview of the most important societal changes and to address the consequences for end-of-life care in the German Health Care System from a public health nursing point of view. It will be demonstrated that an exclusive focus on fostering the development of palliative care as a form of specialized health care and thereby allowing only a few people access to qualified care at the end of life is not a sufficient approach. It will be rather necessary to make broad changes in all areas of health care in order to achieve a level of end-of-life care that is of high quality and appropriate to match people’s needs. The most important challenges to be managed in the German health care system will be presented and discussed.