卫生服务体系发展不充分不平衡与有效治理：一个理论分析框架

新医改十年以来，我国卫生服务体系发展不充分不平衡问题仍较为突出，无法充分有效地适应新时代居民的健康需要。在国家治理现代化的大背景下，卫生服务体系的有效治理得到了广泛的呼吁。但是，目前尚未有成熟的理论分析框架。因此，建构卫生服务体系有效治理的理论分析框架具有重要的研究、政策和实践意义。首先，本研究通过文献综述、概念辨析，基于多学科视角界定了卫生服务体系发展不充分不平衡的层次和维度。其次，结合其与卫生治理的逻辑关系，初步探讨了有效治理的内涵逻辑、作用路径和机制，提出了一个“制度—结构—过程—结果”的理论分析框架。最后，基于卫生治理的三大作用靶点，为相关问题的研究和实践提供了新的思路。     

Research campaigns in the UK National Health Service: patient recruitment and questions of valuation

The National Institute for Health Research (NIHR) aims to improve national ‘health and wealth' by providing infrastructural support to enable clinical research in National Health Service settings in England and Wales. Cognisant of the consequences of studies' failure to achieve required numbers of participants, it also actively campaigns to promote patient awareness of research, and willingness to participate in trials. In this paper, we analyse recent NIHR campaigns and policies designed to encourage patients to participate in clinical research to interrogate how they are implicated in the national bioeconomy. In doing so we expand the notion of ‘clinical labour' to include the work of patient recruitment and highlight an emergent obligation on patients to contribute to research processes. Whereas once patient knowledge and experience may have been devalued, here we draw on the concept of ‘assetisation' (Birch 2012) to explore the emergent relationship between healthcare system and patient as research participant. We consider how patients' contribution goes beyond the provision of standardised objects of valuation so that patients themselves may be perceived as assets to, not only recipients of, the national healthcare system.     

Promoting patient–practitioner partnership in clinical training: a critical evaluation

This study provides a critical assessment of the application of the 'partnership' model of clinical interaction in an educational context, in the light of ethnographic research on education in complementary and alternative medicine (CAM). The concept of 'partnership' in healthcare practice is central to current health policy developments in the UK and the sense of patient empowerment in a more equitable practitioner–patient relationship is often cited as a reason why people are turning to CAM in ever greater numbers. After locating the concept of partnership in its policy and theoretical context (comparing it with traditional and consumer models), the study draws on ethnographic research with student osteopaths and homeopaths to explore the extent to which partnership can be achieved in clinical training situations. The implications for a working concept of professional expertise are subsequently discussed. I argue that the partnership model of clinical interaction is a useful point of departure for critically exploring issues in the patient–practitioner relationship in an educational context.     

It's not just what you say,it's also how you say it: Opening the ‘black box’ of informed consent appointments in randomised controlled trials

Randomised controlled trials (RCTs) represent the gold standard methodology for determining effectiveness of healthcare interventions. Poor recruitment to RCTs can threaten external validity and waste resources. An inherent tension exists between safeguarding informed decision-making by participants and maximising numbers enrolled. This study investigated what occurs during informed consent appointments in an ongoing multi-centre RCT in the UK. Objectives were to investigate: 1] how study staff presented study information to participants; 2] what evidence emerged as to how well-informed participants were when proceeding to randomisation or treatment selection; and 3] what aspects of the communication process may facilitate improvements in providing evidence of informed consent. Qualitative analysis of a purposive sample of 23 recruitment appointments from three study centres and involving several recruitment staff applied techniques of thematic, content and conversation analysis (CA). Thematic analysis and CA revealed variation in appointment content and structure. Appointments were mostly recruiter-led or participant-led, and this structure was associated with what evidence emerged as to how participants understood information provided and whether they were in equipoise. Participant-led appointments provided this evidence more consistently. Detailed CA identified communication techniques which, when employed by recruiters, provided evidence as to how participants understood the choices before them. Strategic use of open questions, pauses and ceding the floor in the interaction facilitated detailed and systematic exploration of each participant's concerns and position regarding equipoise. We conclude that the current focus on content to be provided to achieve informed consent should be broadened to encompass consideration of how information is best conveyed to potential participants. A model of tailored information provision using the communication techniques identified and centred on eliciting and addressing participants' concerns is proposed. Use of these techniques is necessary to make potential participants' understanding of key issues and their position regarding equipoise explicit in order to facilitate truly informed consent.     

Perspectives on clinical leadership: a qualitative study exploring the views of senior healthcare leaders in the UK

Introduction

Clinicians are being asked to play a major role leading the NHS. While much is written on about clinical leadership, little research in the medical literature has examined perceptions of the term or mapped the perceived attributes required for success.

Objective

To capture the views of senior UK healthcare leaders regarding their perception of the term `clinical leadership'' and the cultural backdrop in which it is being espoused.

Setting

UK Healthcare sector

Participants

Senior UK Healthcare leaders

Methods

Twenty senior healthcare leaders including a former Health Minister, NHS Executives, NHS Strategic Health Authority, PCT and Acute Trust chief executives and medical directors, Medical Deans and other key actors in the UK medical leadership arena were interviewed between 2010 and 2011 using a semi-structured interview technique. Using grounded theory, themes were identified and subsequently analysed in an attempt to answer the broad questions posed.

Main outcome measures

Not applicable for a qualitative research project

Results

A number of themes emerged from this qualitative study. First, there was evidence of changing attitudes among doctors, particularly trainees, towards becoming involved in clinical leadership. However, there was unease over the ambiguity of the term ‘clinical leadership’ and the implications for the future. There was, however, broad agreement as to the perceived attributes and skills required for success in healthcare leadership.

Conclusions

Clinical leadership is often perceived to be doctor centric and ‘Healthcare Leadership’ may be a more inclusive term. An understanding of the historical medico-political context of the leadership debate is required by all healthcare leaders to fully understand the challenges of changing healthcare culture. Whilst the broad attributes deemed essential for success as a healthcare leaders are not new, significant effort and investment, including a physical Healthcare Academy, are required to best utilise and harmonise the breadth of leadership talent in the NHS.     

ActCPG framework to learn about information user requirements of a clinical practice guideline

A clinical practice guideline is a knowledge uptake instrument that supports evidence-based decision making by clinicians. It represents a model of a clinical process that describes the sequence of actions, decisions and their outcomes, and the interface with other processes beyond the scope of a guideline. In domains outside healthcare, the computerization of business processes via information systems follows a very rigorous design labeled as the system development life cycle. Our argument is that the computerization of a clinical practice guideline is the equivalent of building an information system for a clinical process and therefore should follow a similarly rigorous design method. One of the first and also one of the most important steps in the system development life cycle is learning about user information requirements. This paper is about a user requirements elicitation and definition process customized to clinical practice guideline. We propose the novel ActCPG conceptual framework for elicitation of basic user requirements for developing computer-interpreted guidelines. This framework relies on Activity Theory to structure and decompose information coming from a clinical practice guideline and associated narrative. We illustrate operation of the ActCPG framework with an example of a practice guideline for a management of clinically obese children enrolled in the Children's Hospital of Eastern Ontario obesity program.     

Maternal-Fetal Surgery: The Fallacy of Abstraction and the Problem of Equipoise

When surgery is performed on pregnant women forthe sake of the fetus (MFS or maternal fetalsurgery), it is often discussed in terms of thefetus alone. This usage exemplifies whatphilosophers call the fallacy of abstraction: considering a concept as if it were separablefrom another concept whose meaning isessentially related to it. In light of theirpotential separability, research on pregnantwomen raises the possibility of conflictsbetween the interests of the woman and those ofthe fetus. Such research should meet therequirement of equipoise, i.e., a state ofgenuine uncertainty about the risks andbenefits of alternative interventions ornoninterventions. While illustrating thefallacy of abstraction in discussions of MFS,we review the rationale for explicitacknowledgment of the essential tie betweenfetus and pregnant woman. Next we examinewhether it is possible to meet the requirementof equipoise in research on MFS, focusing on afetal condition called myelomeningocele. Weshow how issues related to equipoise innonpregnant populations appear also in debatesregarding MFS. We also examine evidence insupport of claims that the requirement ofequipoise has been satisfied with respect to``the fetal patient' while considering risks andbenefits to gestating women only marginally ornot at all. After delineating challenges andpossibilities for equipoise in MFS research, weconclude with a suggestion for avoiding thefallacy of abstraction and achieving equipoiseso that research on MFS may be ethicallyconducted.     

Developing a marketing function in public healthcare systems: a framework for action

The scope of this paper is to analyse the contribution that a marketing function can bring to the wide variety of healthcare organizations operating in public health systems (PHSs). While extensive research on marketing applied to healthcare services has been elaborated in competitive and managed care contexts, marketing is a rather new issue in PHSs and little research has been conducted to assess its relevance and benefits in these environments. This study tackles that gap and is based on a review of the current literature in order to provide answers to the following points: - definition of the scopes of marketing and of the elements that affect its incorporation in the healthcare sector; - conceptualization of the possible approaches to marketing by health organizations operating in PHSs; - discussion of the resulting framework for action.     

A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines.

Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diffusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the effectiveness of various behaviour change strategies. The framework emphasises the need for preimplementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies. The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more effectively. Clearly, the effectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies.     

Meeting pragmatism halfway: making a pragmatic clinical trial protocol

Pragmatic clinical trials (PCTs) are today an increasingly prominent means of measuring the ‘effectiveness’ of healthcare interventions in ‘real world’ clinical settings, in order to produce evidence on which to base regulatory and clinical decision‐making. Although several sociological studies have shown persuasively how PCTs are co‐constructed within particular healthcare systems in which they are based, they have tended to focus on relatively later stages in careers of trials. The paper contributes to literature by considering how the ‘real world’ of the UK National Health Service (NHS) is incorporated into the design of a research protocol. Drawing on a meeting held just prior to patient recruitment for a PCT in maternal health, the paper analyses a trial collective's efforts to purify the messy domain of NHS clinical care into the orderly confines of the protocol (Law 2004), which meant satisfying demands for both scientific and social robustness (c.f. Nowotny et al. 2001). The findings show how efforts to inscribe robustness into the PCT protocol were themselves mediated through epistemic and regulatory conventions surrounding protocols as devices in healthcare research. Finally it is argued that meetings constitute an important epistemic instrument through which to settle various emerging tensions in PCT protocol design.     

Patient involvement in general practice care: a pragmatic framework

This paper presents a pragmatic framework to guide decisions on involving people in general practice care. Patient involvement may be defined as: enabling patients to take an active role in deciding about and planning their healthcare. It can be located at different levels of care, including the patient-clinician contact or episode of care, and the patient population served by a care provider, or the regional or national population. The involvement of patients depends on considerations that include the aim of patient involvement, the type of health decision, and the type of patient. With respect to the aims, the fundamental question is whether involvement is seen as desirable in itself, or whether it is expected to result in favourable consequences. We suggest that patients' ability and willingness to be involved should determine the level of involvement. The concept of involving patients is relatively new, and new approaches are required to overcome obstacles for its implementation in healthcare.     

A new privacy framework for the management of chronic diseases via mHealth in a post-Covid-19 world

Aim

New challenges are being faced by global healthcare systems such as an increase in the elderly population, budget cuts as well as the ongoing Covid-19 pandemic. As pressures mount on healthcare systems to provide treatment to patients, mHealth is seen as one of the possible solutions to addressing these challenges. Given the sensitivity of health data, the rapid development of the mHealth sector raises privacy concerns. The aims of this research were to investigate privacy threats/concerns in the context of mHealth and the management of chronic diseases and to propose a novel privacy framework to address these concerns.

Subject and method

The study adopted a modified version of the engineering design process. After defining the problem, information was gathered through literature reviews, and analyses of existing regulatory (privacy) frameworks and past research on privacy threats/concerns. Requirements for a new framework were then specified leading to its development and comparison with existing frameworks.

Results

A novel future-proof privacy framework was developed and illustrated. Using existing regulatory frameworks for privacy and privacy threats/concerns from research studies, privacy principles and their resulting requirements were identified. Furthermore, mechanisms and associated technologies needed to implement the privacy principles/requirements into a functional prototype were also identified. A comparison of the proposed framework with existing frameworks, showed that it addressed privacy threats/concerns in a more comprehensive manner.

Conclusion

This research makes a valuable contribution to protecting privacy in mHealth. The novel framework developed is an improvement on existing frameworks. It is also future-proof since its foundations are built on regulatory frameworks and privacy threats/concerns existing at the time of its deployment/revision.

     

Health workers at the core of the health system: framework and research issues

This paper presents a framework for the health system with health workers at the core. We review existing health-system frameworks and the role they assign to health workers. Earlier frameworks either do not include health workers as a central feature of system functioning or treat them as one among several components of equal importance. As every function of the health system is either undertaken by or mediated through the health worker, we place the health worker at the center of the health system. Our framework is useful for structuring research on the health workforce and for identifying health-worker research issues. We describe six research issues on the health workforce: metrics to measure the capacity of a health system to deliver healthcare; the contribution of public- vs. private-sector health workers in meeting healthcare needs and demands; the appropriate size, composition and distribution of the health workforce; approaches to achieving health-worker requirements; the adoption and adaption of treatments by health workers; and the training of health workers for horizontally vs. vertically structured health systems.     

Hospital medicine maturity framework: proposing a novel framework for defining stages of hospital medicine in Canada

While hospitalists and hospital medicine programs are proliferating across Canada, there is little written about them. In this article, the authors propose a conceptual framework for defining stages of development and maturity of hospitalist programs in the Canadian healthcare context. In developing this framework, they have not only relied on personal experience as practising hospitalists and healthcare consultants but have also consulted with leaders of hospital medicine across Canada.     

A critical analysis of the Australian Defence Force policy on maternal health care

Objective: To critically analyse the Australian Defence Force (ADF) policy on maternal health care: Health Directive No 235 – Management of pregnant members in the Australian Defence Force. Method: Bacchi's ‘What's the problem represented to be’ framework was used to analyse Health Directive No 235. This paper critically examines the representation of pregnancy and birth, the resulting effects and considers alternate representations. Results: The ADF's policy on maternal healthcare considers pregnancy as a health issue that requires specialist intervention and care, also known as the medicalisation of birth. Current research emphasises women‐centred care; a model of care not contained in the ADF policy. Conclusion: The problematisation of pregnancy in the ADF restricts women's choices regarding their maternal healthcare provider. This is contrary to the healthcare rights of Australians and likely contributes to health inequalities of ADF women. Implications for public health: A research gap regarding ADF women's knowledge and wishes regarding their maternal health care has been identified. Future research can inform any alterations to the ADF policy on maternal healthcare.     

An integrative framework for HIPAA-compliant I*IQ healthcare information systems

Currently the healthcare industry in the US is not only contending with relentless pressures to lower costs while maintaining and increasing the quality of service but is also under a stringent timeline to become compliant with the health insurance, portability and accountability act (HIPAA) regulatory requirements. Robust healthcare information systems (HCIS) become critical to enabling healthcare organizations address these challenges. Hence, it becomes an imperative need that the information that is captured, generated and disseminated by these HCIS be of the highest possible integrity and quality as well as compliant with regulatory requirements. This paper addresses this need by proposing an integrative framework for HIPAA compliant, I*IQ HCIS. It bases this framework on an integration of the requirements for HIPAA compliance, the principles of information integrity, as well as the healthcare quality aims set forth by the Committee on the Quality of Healthcare in America.     

整合型医疗健康服务体系理论框架的核心要素与演变特点 ——基于系统综述

目的:归纳总结国内外整合型医疗健康服务体系理论框架的基本特征、主要维度及核心要素,分析演变特点及启示.方法:采用系统综述法检索并筛选文献,依据前期研究提出的制度整合、组织整合、专业整合、服务整合、核心功能整合、价值规范整合6个维度,利用主题框架法提取和分析文献资料.结果:纳入分析的66个理论框架中,12个聚焦单一维度、...     

Charles Taylor,hermeneutics and Social Imaginaries: a framework for ethics research

Hermeneutics, also referred to as interpretive phenomenology, has led to important contributions to nursing research. The philosophy of Charles Taylor has been a major source in the development of contemporary hermeneutics, through his ontological and epistemological articulations of the human sciences. The aim of this paper is to demonstrate that Taylor's ideas can further enrich hermeneutic inquiry in nursing research, particularly for investigations of ethical concerns. The paper begins with an outline of Taylor's hermeneutical framework, followed by a review of his key ideas relevant for ethics research. The paper ends with a discussion of my empirical research with critically ill children in Canada and France in relation to Taylor's ideas, chiefly Social Imaginaries. I argue that Taylor's hermeneutics provides a substantive moral framework as well as a methodology for examining ethical concerns.