Emergency Department (ED) congestion can be better understood by examining overall system impacts, in particular inpatient admissions and discharges. This study first investigates trends of inpatient admissions, volume of patients in the ED who have been admitted (ED “boarders”), length of stay, and bed resources of three major admitting services at our teaching institution. It was found that patients admitted to the General Internal Medicine (GIM) service constituted the majority of ED boarders by default rather than design, as GIM served as a safety net for specialty services. This study investigates operational factors that impact discharge and found that day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge rates. Based on these results, next, a system dynamics computer simulation was built to test the impact of various discharge smoothing strategies on the number of ED boarders. Next, this study uses the framework and tools of system dynamics methodology to design a conceptual model of the ED boarder problem that may be used as a generalizable roadmap to create sustainable improvements in ED congestion. Finally, this study introduces a novel real time metric of hospital operational discharge efficiency- daily discharge rate – to bring focus on the underlying causes of discharge variation and help indicate opportunities for improvement.

Developing countries face imminent choices for introducing needed, effective but expensive new vaccines, given the substantial immunization resources now available from international donors. Cost-effectiveness analysis (CEA) is a tool that decision-makers can use for efficiently allocating expanding resources. However, although CEA has been increasingly applied in developing-country settings since the 1990’s, its use lags behind that in industrialized countries. This thesis explored how CEA could be made more relevant for decision-making in developing countries through 1) identifying the limitations for using CEA in developing countries 2) identifying guidelines for CEA specific to developing countries 3) identifying the impact of donor funding on CEA estimation 4) identifying areas for enhancement in the 1996 “Reference Case” (a standard set of methods) recommended by the US Panel on Cost-Effectiveness in Health and Medicine, and 5) better understanding the decision-making environment in developing countries. Focusing on pediatric immunization in developing countries, thematic analysis was used to distill key concepts from 157 documents spanning health economics, clinical epidemiology and health financing. 11 key informants, researchers active in developing countries, were also interviewed to explore the production and use of evidence in public health decision-making. Results showed a divergence between industrialized and developing nations in the emphases of methodological difficulties, in the general application of CEA, and the types of guidelines available. Explicitly considering donor funding costs and effects highlighted the need to specify an appropriate perspective and address policy-related issues of affordability and sustainability. Key informant interviews also revealed that opinion-makers, international organizations and the presence of local vaccine manufacturing have significant influence on decision-making. It is suggested that CEA could be more useful with a broadened reference case framework that included multiple perspectives, sensitivity analysis exploring differential discount rates (upper limits exceeding 10% for costs, declining from 3% for benefits) and supplemental reports to aid decision-making (budgetary and sustainability assessments). This study has implications for improving health outcomes globally in the context of public-private collaborative health funding. Further research could explore defining an extra-societal (multi-country) perspective to aid in efficient allocation of immunization resources among countries.

Emergency Department (ED) congestion can be better understood by examining overall system impacts, in particular inpatient admissions and discharges. This study first investigates trends of inpatient admissions, volume of patients in the ED who have been admitted (ED “boarders”), length of stay, and bed resources of three major admitting services at our teaching institution. It was found that patients admitted to the General Internal Medicine (GIM) service constituted the majority of ED boarders by default rather than design, as GIM served as a safety net for specialty services. This study investigates operational factors that impact discharge and found that day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge rates. Based on these results, next, a system dynamics computer simulation was built to test the impact of various discharge smoothing strategies on the number of ED boarders. Next, this study uses the framework and tools of system dynamics methodology to design a conceptual model of the ED boarder problem that may be used as a generalizable roadmap to create sustainable improvements in ED congestion. Finally, this study introduces a novel real time metric of hospital operational discharge efficiency- daily discharge rate – to bring focus on the underlying causes of discharge variation and help indicate opportunities for improvement.

Introduction: This study compared societal costs of care between two settings of palliative care delivery and death (home versus hospital) in an integrated palliative care program in Toronto. Methods: 186 terminal cancer patients participated in the study. Total societal cost of end-of-life care was compared between patients who died in the home and patients who died in the hospital. Total societal cost of end-of-life care was modeled as a function of the number of days the patients spent at home during the palliative trajectory. Results: There was no statistically significant difference in total cost of end-of-life care between home death and hospital death patients (p>0.05). Furthermore, an additional day the patient spent at home led to a significant increase in the total cost of end-of-life care (p<0.05). Conclusion: The results demonstrated that from a societal perspective, providing palliative care under an integrated palliative care program at home may be just as expensive (if not more expensive) as caring for them in the hospital.

Context: A relatively recent focus on evidence based management has been influenced strongly by evidence based medicine. Healthcare administrators are encouraged to utilize similar principles to optimize their decision making. There are no known studies that address whether or not and how evidence is used by healthcare administrators in decision making practice and process. Objectives: This study explores how evidence is conceptualized by public hospital executives and whether or not, and how, evidence is brought to bear on strategic decision making. Design: The study undertook a qualitative design, using a grounded theory approach. The focus was to uncover how evidence is conceptualized by decision makers, whether or not and how evidence as defined is brought to bear, and under what conditions and why evidence is brought to bear. The study included four public hospitals in the Greater Toronto Area, two academic health sciences centres and two community teaching hospitals. Hospital CEOs were asked to identify three strategic decisions (one clinical expansion, one partnership, and one decision on prioritizing quality improvement). Interviews were conducted with 19 healthcare leaders and decision makers, and content analysis was undertaken for 64 supporting documents. Results: Strategic decision makers in this study bring an amalgam of evidence to bear on strategic decisions. Evidence comes from sources internal and external to the organization, and includes a series of types of evidence ranging from published research to local business evidence. The reasons for bringing evidence to bear are highly intertwined. Evidence was sought, developed, and brought to bear on decisions in a formalized manner, and was used in concert with conditions internal and externalto the organization, and informed by the decision maker characteristics. Conclusion: Evidence plays a prominent role in strategic decision making. Strategic decisions were supported by processes requiring evidence to be brought to bear.

Context: A relatively recent focus on evidence based management has been influenced strongly by evidence based medicine. Healthcare administrators are encouraged to utilize similar principles to optimize their decision making. There are no known studies that address whether or not and how evidence is used by healthcare administrators in decision making practice and process. Objectives: This study explores how evidence is conceptualized by public hospital executives and whether or not, and how, evidence is brought to bear on strategic decision making. Design: The study undertook a qualitative design, using a grounded theory approach. The focus was to uncover how evidence is conceptualized by decision makers, whether or not and how evidence as defined is brought to bear, and under what conditions and why evidence is brought to bear. The study included four public hospitals in the Greater Toronto Area, two academic health sciences centres and two community teaching hospitals. Hospital CEOs were asked to identify three strategic decisions (one clinical expansion, one partnership, and one decision on prioritizing quality improvement). Interviews were conducted with 19 healthcare leaders and decision makers, and content analysis was undertaken for 64 supporting documents. Results: Strategic decision makers in this study bring an amalgam of evidence to bear on strategic decisions. Evidence comes from sources internal and external to the organization, and includes a series of types of evidence ranging from published research to local business evidence. The reasons for bringing evidence to bear are highly intertwined. Evidence was sought, developed, and brought to bear on decisions in a formalized manner, and was used in concert with conditions internal and externalto the organization, and informed by the decision maker characteristics. Conclusion: Evidence plays a prominent role in strategic decision making. Strategic decisions were supported by processes requiring evidence to be brought to bear.

Introduction: This study compared societal costs of care between two settings of palliative care delivery and death (home versus hospital) in an integrated palliative care program in Toronto. Methods: 186 terminal cancer patients participated in the study. Total societal cost of end-of-life care was compared between patients who died in the home and patients who died in the hospital. Total societal cost of end-of-life care was modeled as a function of the number of days the patients spent at home during the palliative trajectory. Results: There was no statistically significant difference in total cost of end-of-life care between home death and hospital death patients (p>0.05). Furthermore, an additional day the patient spent at home led to a significant increase in the total cost of end-of-life care (p<0.05). Conclusion: The results demonstrated that from a societal perspective, providing palliative care under an integrated palliative care program at home may be just as expensive (if not more expensive) as caring for them in the hospital.

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.

A growing demand for services and expensive innovative technologies is threatening the sustainability of healthcare systems worldwide. Decision makers in this environment struggle to set priorities appropriately, particularly because they lack consensus about which values should guide their decisions; this is because there is no agreement on best practices in priority setting. Decision makers (or ‘leaders’) who want to evaluate priority setting have little guidance to let them know if their efforts were successful t. While approaches exist that are grounded in different disciplines, there is no way to know whether these approaches lead to successful priority setting. The purpose of this thesis is to present a conceptual framework and an evaluation tool for successful priority setting. The conceptual framework is the result of the synthesis of three empirical studies into a framework of ten separate but interconnected elements germane to successful priority setting: stakeholder understanding, shifted priorities/reallocation of resources, decision making quality, stakeholder acceptance and satisfaction, positive externalities, stakeholder engagement, use of explicit process, information management, consideration of values and context, and revision or appeals mechanism. The elements specify both quantitative and qualitative dimensions of priority setting and relate to both process and outcome aspects. The evaluation tool is made up of three parts: a survey, interviews, and document analysis, and specifies both quantitative and qualitative dimensions and relates to both procedural and substantive dimensions of priority setting. The framework and the tool were piloted in a meso-level urban hospital. The pilot test confirmed the usability of the tool as well as face and content validity (i.e., the tool measured relevant features of success identified in the conceptual framework). The tool can be used by leaders to evaluate and improve priority setting.

In Ontario, access to publicly funded home care services is managed by Community Care Access Centres (CCACs). CCAC case managers are responsible for assessing all potential clients and prioritizing the allocation of services. The objectives of this thesis were to: 1) describe the types of decisions made by CCAC organizations and by individual case managers concerning the allocation of nursing, personal support and homemaking services to long-term adult clients with no mental health issues; and 2) to describe and assess the factors and values that influence these decisions. We conducted two case studies in which qualitative data were collected through 39 semi-structured interviews and a review of relevant documents from an urban and a rural area CCAC. A modified thematic analysis was used to identify themes related to the types of priority setting decisions and the associated factors and values. An internet-based survey was then designed based on these results and answered by 177 case managers from 8 of the 14 CCACs. The survey contained discrete choice experiments to examine the relative importance of client attributes and values to prioritization choices related to personal support and homemaking services, as well as questions that examined case managers’ attitudes towards priority setting. We found that both the rural and the urban CCACs utilized similar forms of priority setting and that case managers made the majority of these decisions during their daily interactions with clients. Numerous client, CCAC, and external factors related to the values of safety, independence and client-focused care were considered by case managers during needs assessment and service plan development. The relative importance of the selected client attributes in defining need for personal support and homemaking services was tested and found to be significantly affected by the location of the case manager (rural or urban area), years of experience in home care, and recent experience providing informal care. Case managers allocated services in the spirit of equal service for equal need and in consideration of operational efficiency. We also identified a number of case manager-related, client-related and external factors that interfered with the achievement of horizontal equity.