Despite the ongoing initiatives of quality improvement collaboratives in healthcare which reflect various multifaceted intervention packages, clear evidence of the effectiveness of the model itself is lacking. Little is known about the true impact of the collaborative approach on improvement outcomes or how specific components are actually implemented within participating organizations. This dissertation reports on empirical qualitative research undertaken to investigate “how” healthcare providers and management describe the experience of being involved in a collaborative network for quality improvement. Using a process evaluation of a sample QI collaborative, this research reveals that frontline staff do not feel the need to conform or be identical to their peer organizations; rather they feel that by participating with them that their high level of care is finally recognized. In addition, the existing communication structure is ineffective for staff engagement and a “QI bubble” seems to exist in terms of knowledge transfer and the idea of collaboration bears out more internally in increased intra-team cooperation than externally between organizations or units. Selected theoretical perspectives from the fields of sociology and organizational behaviour are used as an analytic framework from which the author posits that based on the findings from this case study that in fact collaboratives may not actually function by any of the commonly held assumptions of legitimization, communication and collaboration. A conceptual framework for how these constructs are related in terms of QI collaborative design is proposed for future testing. With further work and on-the-ground testing of this model and relational hypotheses, this research can help the QI community develop a more functional theory of collaborative improvement and use mixed methods evaluation to better understand complex QI implementation.

The central objective of this study is to examine the policy, legal, and constitutional implications resulting from the Chaoulli v. Quebec (2005 1 S.C.R. 791) both for the rights of Canadians within the scope of the publicly funded healthcare system and the configuration of that system. In examining the policy implications the thesis focuses on Quebecs Bill 33, Ralph Kleins Third Way proposal, and the development of national wait time benchmarks. In examining the legal implications the thesis focuses on the so-called copy-cat cases triggered by the Chaoulli case, namely Flora v. Ontario, Murray v. Alberta, and McCreith and Holmes v. Ontario. In examining the constitutional implications of Chaoulli the thesis focuses on the expansion of the interpretation of Section 7 of the Charter of Rights and Freedoms, and the elevation of timely access to healthcare to a Charter right. <p>The study concludes with some observations regarding how Canadas publicly funded healthcare system could evolve in the future and the role of the courts in the evolution of the system. It provides a warning that if appropriate and timely action is not taken by federal and provincial officials to minimize wait times in the publicly funded healthcare system, the implications of Chaoulli will continue to expand through future litigation and judicial decisions. One of the potential outcomes of such litigation and decisions is development of a two-tier or multi-tier healthcare system in Canada.

Globally, concern for natural resource depletion is growing. The healthcare industry is looking to improve healthcare environments by improving design and using better resources. The U.S. Green Building Council has created the Leadership in Energy and Environmental Design (LEED) standard that gives suggestions on how to best use energy, water, land, materials and provide a comfortable indoor environment. Many health centers have used this standard to build new health facilities. It is important that the LEED standards benefit the environment as well as healthcare staff. This study presents four case studies of LEED health centers whose medical staff and administrators evaluate the perceivable green building features applied to their facility. All facilities were given the Occupant Evaluation of LEED Certified Health Centers Survey. The Patrick Dollard Discovery Health Center, the Richard J. Lacks Cancer Center, the Angel Harvey Infant Welfare of Chicago, and the Pearland Pediatric centers received overall satisfactory scores from the occupants. Within the case studies variations in satisfaction occurred where LEED points were not received. There is no evidence that perceivable features used in the design and construction of LEED certified health centers decrease occupant satisfaction.

In this study I investigate how healthcare workers, involved in the Texas Medicaid program as healthcare providers, cope with four workplace constraints. Healthcare workers are constrained by: 1) the policies and practices of the Medicaid program, 2) their own individual and professional values towards indigent care, 3) the rules and policies of their own organization and business type, and 4) the Medicaid patients with whom they interact. I use structuration theory and sensemaking to better understand how these professionals cope with these challenging constraints.Using in depth interviews of 36 private and public healthcare professionals from four unique fields of service (i.e., dental, optical, pediatric, mental health) I applied a modified grounded theory approach to understand: 1) how professionals make sense of the four Medicaid constraints described above, 2) how sensemaking strategies help or hinder professional performance, and 3) how sensemaking communication shapes professional identity and work perceptions. Healthcare workers viewed Medicaid support staff as "flippant", "rude", incompetent, unhelpful, and unreliable. However, providers believed Medicaid was equal to or better than other insurance companies for speed and reliability of payment. While they unanimously identified with providing indigent healthcare, they also clashed with the Medicaid program as a vehicle for those services. Private practices framed Medicaid as a liability while public non-profit organizations relied on Medicaid as a primary source of revenue. Providers agreed that Medicaid patients had poor follow-through, a high no-show rate, were undisciplined, and crowded provider offices with unscheduled family members. Healthcare workers enacted self-reliance as individuals, by networking with other Medicaid providers, and by relying on in-house experts. They also engaged in discursive strategies by minimizing, blaming, and detaching. They viewed themselves as disciplinarians, problem-solvers, advocates, and benefactors. Theoretically, this study develops the concept of identity regions and reframes workplace constraints as necessary identity structures. It also suggests that how Medicaid patients behave may have a more damaging impact on whether providers are willing to work with Medicaid than low reimbursement rates.

We analyze the patient flow of three community health clinics from the Seton group in Austin, Texas, using simulation tools. Our goal is to help the clinics find solutions to cope with increasing patient demand. Several scenarios for increasing efficiency are explored using an ARENA-based patient flow model. Multiple bottlenecks are identified and solutions are found to help the clinics minimize overall patient cycle time and to distribute the workload more evenly across the staff. This study demonstrates that healthcare service facilities may benefit from quantitative analysis, especially simulation tools, to improve their efficiency. / text

Collaboration is neither the ethos, nor the experience, of most professionals in health care. Nevertheless, the concept of collaboration has become increasingly popular in recent years, promising to enhance all aspects of work, academic, and political life. And while collaboration is a significant and complex phenomenon, it has not been clearly understood for its impact on health care professionals and their work, or for the factors that influence its success or failure. The purpose of the study was to explore the meaning of collaboration, as conveyed by the lived experience of health care professionals, as well as the interpersonal and interactional determinants and their impact on the outcomes of their collaboration. The conceptual paradigm of phenomenology and hermeneutic phenomenological methods guided the research. In-depth interviews were conducted with 10 health care professionals engaged in interprofessional practice in a novel community-based geriatric care program. The interviews were audiotaped and transcribed verbatim. Ricoeur’s procedural steps were used to analyze the transcripts. Acquiring the ‘real world’ experiences of health care professionals enabled the emergence of six themes: engaging in collective thinking and action to produce best outcomes and optimize clients’ health; responding to collaboration for self and other members as a continued work in progress; experiencing the personal and professional rewards as markers of success with collaboration; existing challenges create barriers that impede collaboration; experiencing the interactional dynamics of collaboration and their influences requires the interpersonal attributes of quality communication, openness, trust, and respect; and forming a common vision is necessary for collaboration but difficult to achieve. The findings of this study suggest that collaboration is a genuinely experiential phenomenon: it is a human process that requires leadership on the part of all health care professionals to negotiate and agree upon the processes that will enhance their relationships and are necessary for collaboration to unfold. This study produced a number of recommendations that can be offered to multiple stakeholders in the geriatric care setting, as well as extended to those in the other domains of health care.

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Healthcare in Sweden is in need of eHealth innovations to meet the requirements a highlydeveloped society. However to develop and implement eHealth in the healthcare system ischallenging because the system is experienced as complex, conservative and fragmented.In this thesis a qualitative single case study has been conducted to further investigate thechallenges of development and implementation of eHealth. This study demonstrates that itis challenging to understand the complexity of the healthcare system and this has animpact on eHealth development. Involvement of potential users and collaborationbetween stakeholders are seen as a suggested solution to understand this problem. Thisthesis has also shown that to involve users and collaborators is challenging as well.Further the study has shown that there are technological challenges in realizing eHealthin the healthcare system and there is a challenge to develop and implement informationsystems because of regulatory limitations. Despite years of experience in healthcare or ITdevelopmentmany of the respondents find that these factors challenge innovation efforts.

Collaboration is neither the ethos, nor the experience, of most professionals in health care. Nevertheless, the concept of collaboration has become increasingly popular in recent years, promising to enhance all aspects of work, academic, and political life. And while collaboration is a significant and complex phenomenon, it has not been clearly understood for its impact on health care professionals and their work, or for the factors that influence its success or failure. The purpose of the study was to explore the meaning of collaboration, as conveyed by the lived experience of health care professionals, as well as the interpersonal and interactional determinants and their impact on the outcomes of their collaboration. The conceptual paradigm of phenomenology and hermeneutic phenomenological methods guided the research. In-depth interviews were conducted with 10 health care professionals engaged in interprofessional practice in a novel community-based geriatric care program. The interviews were audiotaped and transcribed verbatim. Ricoeur’s procedural steps were used to analyze the transcripts. Acquiring the ‘real world’ experiences of health care professionals enabled the emergence of six themes: engaging in collective thinking and action to produce best outcomes and optimize clients’ health; responding to collaboration for self and other members as a continued work in progress; experiencing the personal and professional rewards as markers of success with collaboration; existing challenges create barriers that impede collaboration; experiencing the interactional dynamics of collaboration and their influences requires the interpersonal attributes of quality communication, openness, trust, and respect; and forming a common vision is necessary for collaboration but difficult to achieve. The findings of this study suggest that collaboration is a genuinely experiential phenomenon: it is a human process that requires leadership on the part of all health care professionals to negotiate and agree upon the processes that will enhance their relationships and are necessary for collaboration to unfold. This study produced a number of recommendations that can be offered to multiple stakeholders in the geriatric care setting, as well as extended to those in the other domains of health care.