Incident reporting systems offer rich opportunities for learning from errors in health care. However, little attention has been given to understanding how the implementation of reporting system characteristics impact analysis and communication activities. This research explored the characteristics of reporting systems that promote analysis and communication activities. Ten characteristics were identified through a comprehensive literature review. Two reporting systems were then compared to assess how differences in the implementation of the characteristics impact the contents of the database. The results demonstrated that differences in the characteristics’ implementation have an effect on the ability to extract information essential to analysis activities. Next, the reporting processes of the two systems were mapped onto a hierarchical framework to highlight how the characteristics influence the communication of incident information across the health care system. The presented work furthers the understanding of characteristics needed to design reporting systems more effective at promoting learning.

Introduction: Peripherally Inserted Central Catheters (PICCs) are commonly used in medium or long-term infusion therapy. This study aims to assess the costs associated with PICCs and its determinants. Methods: A retrospective cohort of patients with PICCs inserted at the Hospital for Sick Children between Jan.1, 2008 and Dec.31, 2008, were reviewed and followed until their PICCs were removed. Cost analysis, theoretical cost comparison with peripheral intravenous therapy (PIV), and multiple linear regressions were applied from the societal perspective. Findings: The average total cost is $2763.75/catheter/day, including inpatient ward cost. Age, male, ward, home care, catheter dwell days, and complications were found to be significant factors influencing the total cost. PICCs can become a cost saving device, compared to PIV, but is affected by several factors. Conclusion: Information gleaned from this study will inform decision makers maximizing the benefits of better resource allocation.

How clinicians detect and differentiate near misses from adverse events in health care is poorly understood. This study adopted a constructivist grounded theory approach and utilized document analysis and semi-structured interviews with 24 managers (middle and senior) and clinicians to examine the processes and factors associated with recognizing and recovering and learning from near misses in daily clinical practice. While safety science suggests that near misses are sources of learning to guide improvement efforts, the study identified how clinicians and managers cognitively downgrade and accept near misses as a routine part of daily practice. Such downgrading reduces the visibility of near misses and creates a paradoxical effect of promoting collective vigilance and increased safety while also encouraging violations in clinical practice. Three approaches to correcting and/or learning from near misses emerged: “doing a quick fix,” “going into the black hole,” and “closing off the swiss-cheese holes”; however, minimal organizational learning occurs. From these findings, two key paradoxes that undermine organization-level learning require further attention: (a) near misses are pervasive in everyday practice but many remain undetected and are missed learning opportunities, and (b) collective vigilance serves as both safety net and safety threat. Study findings suggest that organizational efforts are required to determine which near misses need to be reported. Organizations need to shift the culture from one of “doing a quick fix” to one that learns from near misses in daily practice; they should reinforce the benefits and reduce the risks of collective vigilance, and further encourage learning at the clinical microsystem level. Future research is required to provide insight into how individual, social, and organizational factors influence the recognition, recovery, and instructional value of near misses and safety threats in health care organizations’ daily practice.

Technological position is a dimension along which organizations can either differentiate from or mimic the behavior of other organizations in the technological landscape. This paper is aimed at providing empirical evidence of the specific ways in which an organization’s technological position choice is impacted by the tension that arises from technological co-location; the information available to the focal firm; and the focal firm’s usage of such information. In this dissertation I examine the factors influencing technological agglomerations in technological positions in the technological landscape. I further examine how the organization’s experience impacts its strategic positioning choice while facing the tradeoff between the expected derivatives of co-location - opportunities and competition. I argue and find that an organization strategically positions itself in the technological landscape based not only on the information it has gathered on its technological environment but also using its own experience and information. Further, my findings show that the organization’s technological positioning choice reflects the tension between opportunity and competition, which questions the notion of isomorphism.

The objectives of this thesis are to: 1) obtain a snapshot of callers of 211 Toronto, a free information and referral service, understanding how representative they are of Toronto’s general population; 2) understand how 211 Toronto callers seeking health-related information use the information they obtain when contacting the service and their overall level of satisfaction, and; 3) better understand the experience and information needs of recent immigrants struggling to navigate an unfamiliar health care system. The study had three phases: 1) a cross-sectional phone interview with 211 Toronto callers; 2) a follow-up phone interview of 211 Toronto callers who had asked health-related questions; and, 3) qualitative interviews with callers who were Spanish speakers from Latin American countries. Participants were randomly selected adult callers living within the boundaries of Toronto’s Census Metropolitan Area (CMA). Respondents were compared with the general adult population living in Toronto’s CMA, using 2001 Census data, to identify under- or overrepresented population groups. A sub-set of callers who had asked health-related questions was followed up to understand how they had used the information received and their level of satisfaction with the service. Qualitative interviews were conducted with callers who were recent immigrants and native Spanish speakers from Latin America to explore their post-migration experiences. Recent immigrants experience significant information challenges. Health-related questions reflect the multifaceted nature of the concept of health in the experience of users. Negative experiences with the health care system are common. Recent immigrants have access to disorganized, confusing, often poor quality information. 211 Toronto represents an efficient and effective way to gain access to information but does not achieve its full potential. Newcomers should receive timely, appropriate, and reliable information on existing health and health-related services as soon as possible after they relocate to Canada. Appropriate information should also be made available to potential immigrants in their countries of origin. Information and communication technologies should be used to support newcomers, increasing the efficiency and effectiveness of services such as 211 Toronto.

Hepatitis C is the most common blood-borne viral illness in the North America. Chronic hepatitis C infection may lead to cirrhosis of the liver, liver failure and liver cancer. In North America, injection drug use is the most important risk factor for infection and substance abusing populations are disproportionately affected by the disease. Antiviral therapy exists and approximately 50% of infected individuals can be cured. The aim of this thesis was to provide information to help clinicians and policy-makers minimize the impact of hepatitis C in substance abusers. The thesis is comprised of three studies. The first assessed the rate of progression to cirrhosis for those acquiring infection through injection drug use, using a meta-analysis of 44 studies from the published literature. We estimated that fibrosis progression occurs at a rate of 8.1 per 1000 person-years (95% Credible Region (CR), 3.9 to 14.7) corresponding to a 20-year cirrhosis prevalence of 14.8% (95% CR, 7.5 to 25.5). The second study measured the association between successful antiviral therapy and quality of life. We demonstrated that sustained responders to therapy had higher scores on the hepatitis-specific Medical Outcomes Survey Short-Form-36 (SF-36), Health Utilities Index Mark 2/3 (HUI2/3), and time-tradeoff (TTO) than treatment failures, an average of 3.7 years following antiviral therapy. The third study assessed rates of adherence to antiviral therapy and rates of sustained response in current or former iii substance abusers on methadone maintenance. We demonstrated that while use of illicit substances prior to therapy negatively affected adherence, rates of sustained response were comparable to non-substance abusing populations. Our work indicates the future burden of disease in current and former substance abusers, demonstrates that antiviral therapy can be successful in this population, and indicates that the benefits of successful therapy may extend beyond decreased disease burden to improved quality of life.

Patient satisfaction is a key outcome measure being examined by researchers exploring the relationships between patient outcomes and hospital structure and care processes. Only a few non-generalizable studies, however, have explored the relationship of nurse staffing and patient satisfaction with nursing care in emergency departments of hospitals. This dissertation aims to address that gap. Using more than 182,000 patient satisfaction surveys collected over a five-year period from 153 emergency departments (EDs) in 107 hospitals throughout Ontario, this study explores the relationship between nurse staffing and patient perceptions of nursing care in a range of Canadian ED settings, including urban and rural, community and academic, and small and large healthcare institutions with varying sizes and case mix. Using an established conceptual framework for investigating the relationship between nurse staffing and patient outcomes, nineteen nurse staffing variables were initially investigated. Ultimately, however, only five staffing variables were used in the multi-level regression analyzes. These five variables included registered nurse (RN) proportion, RN agency proportion, percent full-time nurse worked hours, RN worked hours per patient length of stay and registered practical nurse (RPN) worked hours per length of stay. Emergency department case mix index, patient age and gender, hospital peer group, size, wait times, cleanliness of the emergency department, physician courtesy, and year of measurement were controlled to account for their effect on the relationship between nursing staffing and patient satisfaction in the ED. The study revealed a subset of six patient satisfaction variables representing the overall variation in patient satisfaction with nursing care in the ED. Although RN proportion and RPN worked hours per length of stay were found to have a statistical association with patient satisfaction in the ED, the association was weak and not administratively actionable. Interpersonal and environmental factors such as physician and nurse courtesy, ED cleanliness and timeliness, however, were areas which hospital administrators should consider since they were highly associated with patient satisfaction in EDs.

The overall goal of this research study is to determine if there is a correlation between electronic health (e-Health) adoption, e-Health investment and better health outcomes in a hospital setting. To carry out this research, data with respect to e-Health spending, e-Health adoption and relevant health outcome indicator results for Ontario hospitals were analyzed to determine if there is a correlation between the variables. There were significant positive correlations between e-Health adoption and investment variables; indicating that higher e-Health investment is associated with greater e-Health adoption. There were significant correlations between variables related to e-Health adoption, investment and certain health outcomes. For example, increased e-Health adoption was significantly and negatively correlated with variables related to Length of Stay (LOS), which suggests that increased e-Health adoption is associated with lower LOS. This study attempts to create a foundation upon which Return On Investment (ROI) may be calculated for e-Health technology.

Background: Older Canadian women are not meeting recommended calcium intake levels and therefore require calcium supplementation to maintain bone mass. Objective: To examine factors associated with calcium supplementation among older community-dwelling women, using the Health Belief Model (HBM) as a conceptual framework. Methods: Data previously collected from Ontario community-dwelling women aged 65 to 90 years (n=798) were analyzed. Multivariable logistic regression was utilized to determine HBM factors associated with calcium supplement use. Results: About half (54%) of women reported taking calcium supplements. Positive correlates of calcium supplementation included: perceived osteoporosis susceptibility, perceived calcium benefits, natural health product use, residing in Toronto and general osteoporosis management factors (discussion with a physician or pharmacist, osteoporosis screening, falls history and preventive health check-ups); a negative correlate included: use of etidronate therapy. Conclusion: Only half of older women were taking calcium supplements. Discussions with healthcare practitioners may help to improve recommended calcium intake levels.

The objective of this study was to assess Primary Care Physicians’ attitudes towards adoption of the Diagnostic Assessment Program-Electronic Pathway Solution (DAP-EPS), an electronic tool for improving cancer diagnostic processes. The implementation of DAP-EPS is a provincial activity supported by Cancer Care Ontario in collaboration with the Canadian Cancer Society. We conducted an online survey of Ontario PCPs. To guide our study, we used an integrated theoretical framework combining the Technology Acceptance Model and Diffusion of Innovation. Study results suggested a strong influence of perceived usefulness of the DAP-EPS tool on physicians’ attitudes towards adoption of the tool. The results also found that perceived usefulness was more important than perceived ease-of-use within the PCP context. The study revealed that perceived usefulness is the main predictor of physicians’ attitudes. The findings also suggested that the management and implementation team should emphasize the usefulness of the DAP-EPS to increase adoption among PCPs.