Previous research has established a consensus that in-hospital adverse events are ubiquitous, cause significant harm to patients, and have important financial consequences. However, information on the extent, consequences and costs of adverse events in Canada is limited. For example, there is, as yet, no published study that has investigated the costs of adverse events in a Canadian context. This dissertation aims to redress this situation by providing Ontario-based estimates of the impact of eleven nursing sensitive adverse events on cost, death, readmission, and ambulatory care use within 90 days after hospitalization. This dissertation also aims to contribute more broadly to the patient safety literature by quantifying the impact of diagnostic coding error in administrative data on estimates of the excess costs attributable to adverse events. Given the increasing importance of these estimates in Canada and elsewhere for hospital payment policy and for assessments of the business case for patient safety, this is an important gap in the literature. Each of the adverse events was associated with positive excess costs, ranging from $29,501 (metabolic derangement) to $66,412 (pressure ulcers). Extrapolation from the study hospitals yielded a provincial estimate of $481 million in annual excess costs attributable to the adverse events, which represents 2.8 percent of Ontario’s total hospital expenditures. Several of the adverse events were also associated with significant excess rates of death, readmission, and ambulatory care use. These results suggest that there are economic as well as ethical reasons to improve patient safety in Ontario hospitals. Estimates of adverse event costs were highly sensitive to coding error. The excess cost of adverse events is likely to be significantly underestimated if the error is ignored. This finding, coupled with the observation that the likelihood of error is ignored in most studies, suggests that previous assessments of the business case for patient safety may have been biased against the cost effectiveness of patient safety improvements. Furthermore, the observed extent of institutional level variation in adverse event coding indicates that administrative data are an inadequate basis for adverse event payment policies or for public reporting of adverse event rates.

Objectives: To determine the level of adoption and which characteristics are most strongly associated with the adoption of a clinical innovation in Mental Health and Addiction Service organizations in Ontario, one year after dissemination. Methods: This cross-sectional study included a voluntary quantitative mail-out survey, using a self administered questionnaire that was sent to 260 mental health and addiction service organizations in Ontario. Linear regression analysis was conducted to identify significant predictors of the overall adoption-decision of the best practice recommendations. Results: Individuals’ tenure within the organization and the provision of screening (organizational variable) was identified to be predictors of adoption for the organization. Conclusions: The results of this study demonstrated the majority of the organizations are on the path towards a finale decision of adopting or rejecting the recommendations. The results also demonstrate the importance of individual characteristics and organizational characteristics in identifying predictors of adoption.

Information technology [IT] that enables electronic access to patient health records has been widely recognized as a promising means to improve the quality of care for patients with chronic diseases, and reduce health care costs through better health information delivery and encouragement of self-management. IT applied to assist chronic disease management is inadequately studied in Canadian health care settings. This thesis describes the development and modest pilot implementation of an electronic tool, the Diabetes Complication Surveillance System [DCSS]. The DCSS was conceived as a self-monitoring tool that facilitates regular checks on conditions of diabetes patients, including acute and long-term complications. The DCSS is relatively unusual, as it facilitates glycemic control and also allows patients to address the long-term complications of diabetes. The development of the DCSS involved literature reviews and consultations with clinician experts. Questionnaire results from the pilot provided positive feedback.

Objectives: The concept of clinical champions has been widely promoted, yet empirically underdeveloped in health services literature. The objectives of this study are to investigate the role of the clinical champion and how it contributes to effective patient safety change. Methods: Case study design was used to examine the role of champions in the implementation of rapid response teams in two hospitals. Central themes were derived through qualitative analysis of semi-structured interviews with key informants. Results: Analysis revealed a typology of champions: clinical, managerial, and executive. Champions engaged in five core activities: disseminating knowledge, advocating, building relationships, navigating boundaries, and facilitating consensus. Individuals became champions by informal emergence or by formal appointment combined with informal emergence. Conclusions: This study furthered understanding of patient safety champions by revealing types, activities, and modes of emergence. Findings will allow health care professionals to use an evidence-based approach to identifying and supporting champions.

This study explored the current state of eHealth policy in Latin American and the Caribbean (LAC). It is based on a novel methodological approach to the conduct of systematic reviews of documents that are not always published in peer-reviewed journals. 33 countries were included in the study and 19 ICT and 7 eHealth policies were identified. A hybrid inductive and deductive content analysis approach was used to provide an in- depth analysis and comparison of existing national eHealth policies in LAC. The study found that there has been considerable progress in the establishment of ICT policies in the LAC region, but less so for eHealth policy specifically. The findings suggest that the establishment of a strategic framework that may guide and support decisions and choices in the development of national eHealth policies, could prove to be an essential tool in the successful implementation of eHealth in LAC.

Objective: To identify principles and rules used by stakeholders in making limit-setting decisions for publicly funded dental care. Methods: A purposive sample, including administrators, academics, funders, clinicians and community representatives was surveyed using a 28-item questionnaire, in the first round of a proposed three-round modified Delphi study. Using open and closed-ended questions participants made and explained decisions on prioritizing populations and services. Open-ended text was analyzed with a thematic qualitative approach using open and axial coding. Results: Consensus emerged on two rationing principles; achieving equity and providing essential care. Rules for eligibility were defined as the inability to pay and/or assume full personal responsibility for securing dental care. Inclusion/exclusion of treatment categories rested on relieving pain/infection, preventing disease and maintaining/restoring function. Conclusions: Stakeholders presented principles and rules that suggest extending the distribution of publicly funded dental care to include, at a minimum, essential services for those unable to afford care.

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.

Priority setting for expensive biopharmaceuticals is one of the most important challenges for publicly funded health systems. One of the drivers of rising healthcare expenditures is pharmaceuticals (i.e., drugs). Moreover, people are living longer and their expectation of, and demand for, health care, drugs, and services are continually increasing. The overall aim of this research was to describe and evaluate reimbursement decisions for six expensive biopharmaceuticals across five countries in order to ascertain if the processes were legitimate and fair. I conducted qualitative case studies of six expensive biopharmaceuticals in order to describe and evaluate the priority setting activities of eight committees across five countries, including Canada, England and Wales, Australia, Israel and the United States. Data sources included: 1) 32 documents and 2) 56 interviews with informants. The recommendations process of each committee partially met the four conditions of ‘accountability for reasonableness’. My main finding is that, while a number of values were considered by committees when making reimbursement decisions, committees tended to focus on values of evidence, effectiveness and efficiency, but not the full range of relevant values. Thus, these contexts did not fully meet the conditions of legitimacy and fairness. I have provided an in-depth description of the eight committees’ priority setting activities regarding the study drugs, as well as committee members’, patients’ and industry representatives’ views regarding the process. I developed practical guidance for leaders for improving reimbursement decisions for expensive biopharmaceuticals, the implementation of which would enhance the fairness and legitimacy of priority setting. This study has demonstrated that in order to create a fair and legitimate drug reimbursement process, we need to ensure the incorporation of a wide range of values, and the involvement of multiple stakeholder groups within the deliberative and appeals/revisions processes.

Objectives: To determine the level of adoption and which characteristics are most strongly associated with the adoption of a clinical innovation in Mental Health and Addiction Service organizations in Ontario, one year after dissemination. Methods: This cross-sectional study included a voluntary quantitative mail-out survey, using a self administered questionnaire that was sent to 260 mental health and addiction service organizations in Ontario. Linear regression analysis was conducted to identify significant predictors of the overall adoption-decision of the best practice recommendations. Results: Individuals’ tenure within the organization and the provision of screening (organizational variable) was identified to be predictors of adoption for the organization. Conclusions: The results of this study demonstrated the majority of the organizations are on the path towards a finale decision of adopting or rejecting the recommendations. The results also demonstrate the importance of individual characteristics and organizational characteristics in identifying predictors of adoption.