Many patients, particularly older patients, interact with multiple providers while accessing health care services in a variety of different settings over extended periods of time. Understanding older patients' experiences of their journeys through the health system is critical to improving service integration and quality of care. In this study, we have summarized the experiences of four patients living with chronic obstructive pulmonary disease as they interacted with the health care system over a three-month period following hospital discharge. Guided by case study methodology, we gathered data through semi-structured interviews and patient logs. Three overarching themes - social support, system navigation, and access - emerged from the data. Attending to provider-patient and provider-provider communication, and to patient social support and self-care needs, could improve integration and care outcomes. Achieving what patients perceive as an integrated and effective system will require time and commitment.
BackgroundThe objective of this systematic review of diverse evidence was to examine the relationship between health system governance and workforce outcomes. Particular attention was paid to how governance mechanisms facilitate change in the workforce to ensure the effective use of all health providers.MethodsIn accordance with standard systematic review procedures, the research team independently screened over 4300 abstracts found in database searches, website searches, and bibliographies. Searches were limited to 2001–2012, included only publications from Canada, the United Kingdom, the Netherlands, New Zealand, Australia, and the United States. Peer- reviewed papers and grey literature were considered. Two reviewers independently rated articles on quality and relevance and classified them into themes identified by the team. One hundred and thirteen articles that discussed both workforce and governance were retained and extracted into narrative summary tables for synthesis.ResultsSix types of governance mechanisms emerged from our analysis. Shared governance, Magnet accreditation, and professional development initiatives were all associated with improved outcomes for the health workforce (e.g., decreased turnover, increased job satisfaction, increased empowerment, etc.). Implementation of quality-focused initiatives was associated with apprehension among providers, but opportunities for provider training on these initiatives increased quality and improved work attitudes. Research on reorganization of healthcare delivery suggests that changing to team-based care is accompanied by stress and concerns about role clarity, that outcomes vary for providers in private versus public organizations, and that co-operative clinics are beneficial for physicians. Funding schemes required a supplementary search to achieve adequate depth and coverage. Those findings are reported elsewhere.ConclusionsThe results of the review show that while there are governance mechanisms that consider workforce impacts, it is not to the extent one might expect given the importance of the workforce for improving patient outcomes. Furthermore, to successfully implement governance mechanisms in this domain, there are key strategies recommended to support change and achieve desired outcomes. The most important of these are: to build trust by clearly articulating the organization’s goal; considering the workforce through planning, implementation, and evaluation phases; and providing strong leadership.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-479) contains supplementary material, which is available to authorized users.
Changes to how registered nurses and health care aides enact their role will require a clear vision by unit managers and their staff of their role accountabilities, and the gap between ideal and actual practice.
Overall, evidence of effective strategies for improving outcomes is mixed. While financial incentives play a key role in enhancing outcomes, they need to be considered as only one strategy within an incentives package. There is stronger evidence that improving the work place environment and instituting mechanisms for work-life balance need to be part of an overall strategy to improve outcomes for health care practitioners.
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