BackgroundCancer program delivery, like the rest of health care in Canada, faces two ongoing challenges: to coordinate a pan-Canadian approach across complex provincial jurisdictions, and to facilitate the rapid translation of knowledge into clinical practice. Communities of practice, or CoPs, which have been described by Etienne Wenger as a collaborative learning platform, represent a promising solution to these challenges because they rely on bottom-up rather than top-down social structures for integrating knowledge and practice across regions and agencies. The communities of practice model has been realized in the corporate (e.g., Royal Dutch Shell, Xerox, IBM, etc) and development (e.g., World Bank) sectors, but its application to health care is relatively new. The Canadian Partnership Against Cancer (CPAC) is exploring the potential of Wenger's concept in the Canadian health care context. This paper provides an in-depth analysis of Wenger's concept with a focus on its applicability to the health care sector.DiscussionEmpirical studies and social science theory are used to examine the utility of Wenger's concept. Its value lies in emphasizing learning from peers and through practice in settings where innovation is valued. Yet the communities of practice concept lacks conceptual clarity because Wenger defines it so broadly and sidelines issues of decision making within CoPs. We consider the implications of his broad definition to establishing an informed nomenclature around this specific type of collaborative group. The CoP Project under CPAC and communities of practice in Canadian health care are discussed.SummaryThe use of communities of practice in Canadian health care has been shown in some instances to facilitate quality improvements, encourage buy in among participants, and generate high levels of satisfaction with clinical leadership and knowledge translation among participating physicians. Despite these individual success stories, more information is required on how group decisions are made and applied to the practice world in order to leverage the potential of Wenger's concept more fully, and advance the science of knowledge translation within an accountability framework.
Different types of inpatients "consume" differing amounts of hospital resources, and it is important to be able to measure these differences in resource consumption. An equitable methodology for funding hospitals must take into account differences in case mix between facilities. An ability to examine these differences in case mix and resource utilization allows hospitals to focus efforts to improve efficiency. A standardized methodology for measuring resource consumption is critical to funding and resource allocation both at a global and organizational level. This study was undertaken to determine whether or not the Canadian system for measuring resource consumption, Canadian Institute for Health Information (CIHI) RIWs, was reflective of the relative cost differences between inpatient cases at the Greater Victoria Hospital Society (GVHS) and to identify RIWs with a significant difference in comparison to GVHS cost weights. A regression analysis was performed on the more than 30,000 inpatient cost profile records from the GVHS 1995-96 cost and patient activity data. The scope of the analysis was restricted to the 424 Case Mix Groups (CMGs) that had a minimum composition of five patient profiles. Comparisons of GVHS cost weights to CIHI RIWs yielded mostly positive results. With the noted exception of about 20 CMGs, there was a high correlation between the CIHI RIW and the GVHS actual cost weights. Hence, the GVHS cost weights can be viewed with confidence as representative of the relative cost differences between typical RIW value CMGs and actual costs.
Background:The Screening Mammography Program of British Columbia (SMPBC) implemented voluntary, facilitated referral to diagnostic imaging ("Fast Track") after testing 5 interventions to reduce time from an abnormal screening mammogram to diagnosis. The purpose of this study was to compare time intervals for patients evaluated through the Fast Track process with patients who were not.Methods: Data were extracted from the SMPBC database for women with abnormal screens conducted from January 1, 2003 to June 30, 2005 (N=40,292). After exclusions, 39,607 screens were analyzed. Median and 90 th percentile times were calculated from abnormal screen to diagnosis and for three subintervals: abnormal screen to notification, notification to first assessment, and first assessment to diagnosis.Results: One third of abnormal screens were investigated through Fast Track imaging facilities. Overall, the median time from abnormal screen to diagnosis was 8 days faster for Fast Track compared with non-Fast Track. There was no clinically significant difference in time from abnormal screen to notification. The median time from notification to first assessment was 1.1 weeks (Fast Track) compared with 2.4 weeks (non-Fast Track), a reduction of 9 days or 54% in the interval targeted by the Fast Track strategy. The time interval distribution from first assessment to diagnosis was significantly different only for those having a core biopsy (average 3 days faster for Fast Track).Interpretation: Facilitated referral to diagnostic imaging reduces average time from notification of abnormal screen to first assessment by more than half. Additional strategies are needed to address diagnostic investigation beyond initial imaging procedures.
Oral cancer is a major health problem worldwide (over 300,000 new cases identified each year) with numbers projected to climb steadily. Although the site is easily accessed, it is most often detected at late-stage, leading to high mortality and morbidity rates that have shown little change for decades. Much of the projected increase in this disease will occur in low- and middle-income countries with very limited resources. Oral cancer is a good target for employing systems models for prevention and intervention. It shares etiology with many cancers (tobacco usage, alcohol consumption, diet, and infection) so prevention approaches have a universal application. Common challenges exist in both developing and wealthier countries: low awareness of health care professionals, low public awareness, low priority within public health, inequities in care, infrastructure and human resources deficits, system fragmentation and lack of coordinated advocacy and leadership. Approaches tend to be treatment rather than prevention focused. There is a need for development of new strategies for management of the disease. The objective of this presentation is to describe a population health-focused approach taken in British Columbia to improve oral cancer control that has drawn together provincial resources, integrating them into a comprehensive system of structures and players. The effort spans the continuum of care (prevention, early detection, diagnosis and treatment of the disease) working through multiple approaches, at multiple levels and across multiple sectors. Its growth is guided through partnerships and networks with health professionals and societies, by social marketing and epidemiological surveillance, and by technology development for early detection, risk assessment and cancer treatment within an ongoing NIH-funded longitudinal study. The approach has grown around an opportunistic screening network of dentist and ENT surgeons that has existed in British Columbia for ∼27 years. This network is linked through a centralized oral biopsy service to referral resources to facilitate patient management. We have engaged and empowered this network through a combination of approaches (focus groups of community dental health professionals, continuing education forums, news releases, journal publications, and social marketing strategies) with an aim to increase awareness of the importance of screening activity and to build social norms among dental professionals to enhance their ownership of this domain. In collaboration with the College of Dental Surgeons of British Columbia, a Guideline was released in 2008 to move activities from an ad hoc to a standardized, quality controlled approach, with formal integration of screening into the regular oral exam for each patient. This has resulted in increased screening among dental professionals who have seen the guideline, among whom 84% screen as part of routine exams, compared to 65% of those not aware of the guideline. A second offshoot of activity within the program is the development within the Oral Biopsy Service of an Oral Leukoplakia and Dysplasia Registry that will link to the British Columbia Cancer Registry to track the impact of changes in practice on outcomes. This project is supported by the Canadian Partnership Against Cancer (CPAC) with input from other provincial oral biopsy services across Canada. This will allow for development of parallel dental network and registry structures to better define the natural history of the disease and improve its management at a national level. We expect to reach 2/3 of the BC population through a strengthened dental office network and referral pathway. However, access to this network remains a challenge for the remaining population. Tailored strategies are being developed in partnership with the South Asian community, the Vancouver First Nations community, the Downtown Eastside in Vancouver, and rural BC. Since developing countries share many of the same barriers to health care utilization with these underserved communities, we have opened dialogues with international partners to gain input and provide knowledge exchange around facilitators and barriers to screening activities in low-resource settings. This increased screening activity has been coupled to the development of a streamlined referral pathway for risk assessment in dysplasia clinics for standardized risk assessment and follow-up of high-risk patients (an NIH-NIDC-funded initiative). These clinics use technology developed within an ongoing longitudinal study to identify and assess high-risk lesions: optical devices to improve clinical visualization; high-throughput computer microscopy systems to predict future behavior of early lesions in a cost-effective fashion, using subtle histological and cytological indicators; and molecular markers of risk. The impact of this technology on driving change in clinical practice is already apparent. Optical fluorescence technology has been used to detect occult disease in patients going to surgery. Its use to guide surgical margin delineation has resulted in a marked reduction in recurrence rates ∼10 fold or more (from ∼25% recurrence to close to zero) that is now being explored in multicenter randomized control trial for device efficacy supported by the Terry Fox Research Institute. This initiative promises to facilitate the better management of early disease detected within the system, and provides a structure for rigorous assessment of these innovations as well as a foundation for knowledge translation and scale-up. Conclusion: We are engaged in trials of innovative technology, social mobilization, and knowledge translation to support system-wide change for equitable population-based control of oral cancer in British Columbia. This effort is a model that demonstrates how resources can be pulled together and optimized to provide a centralized structure for shaping new approaches to detection, management, and prevention of disease. Citation Information: Cancer Prev Res 2010;3(12 Suppl):PL05-04.
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