This dissertation investigates how patient-perceived integrated care and manager commitment influence the improvement and integration of health care delivery. Using survey instruments, across three studies I examine potential mechanisms for improving health care delivery: patient perceptions of integrated care, a physician organization care management program, and manager commitment to a quality improvement program. In Chapter Two, I examine how patient-perceived integrated care relates to utilization of health services. I assess relationships between provider performance on 11 domains of patient-reported integrated care and rates of emergency department (ED) visits, hospital admissions, and outpatient visits. I find better performance on two of the surveyed dimensions of integrated care are significantly associated with lower ED visit rates: information flow to other providers in doctor’s office and responsiveness independent of visits. Better performance on three dimensions of integrated care is associated with lower outpatient visit rates: information flow to specialist, post-visit information flow to the patient, and continuous familiarity with patient over time. No dimension of integration is associated with hospital admission rates. In Chapter Three, I use the same patient sample to evaluate the achievement of integrated care by a care management program (CMP) from the perspective of older patients with multiple chronic conditions. Survey results suggest that patient perceptions of integrated care vary substantially among survey items and domains. CMP enrollment is significantly associated with greater patient perceptions of care integration in two domains: connecting patients to home services and being responsive independent of visits, domains that were targeted for improvement by the CMP. Enrollment in the CMP is not significantly associated with other domains of integration. In Chapter Four, I assess whether and how senior and middle manager commitment to a falls reduction quality improvement (QI) program is associated with the successful implementation of the program. Survey results suggest managers’ affective commitment to the program is positively associated with program implementation success across all manager levels surveyed (senior managers, middle managers, and assistant middle managers). Stronger frontline worker support for the falls QI program partially mediates the relationship between manager affective commitment and falls program implementation success for middle managers and assistant middle managers, but not for senior managers. Manager affective commitment to the falls program mediates the relationship between organizational support for the falls program and program implementation success across all manager levels. Together, these studies advance our understanding of how patient-perceived integrated care, care management programs, and manager commitment to a quality improvement program influence the integration and improvement of health care delivery. Findings demonstrate how patient reports of integration can be useful guides to improving health systems. Dissertation results also provide empirical evidence of a relationship between manager commitment—at both the middle and senior manager levels—and successful QI program implementation. In addition, these studies provide practical implications for physicians and hospital managers seeking ways to improve the quality and integration of health care delivery. / Health Policy

<p> Objective. To systematically evaluate and compare healthcare innovations in three geographically small nations, Ireland, Israel, and Switzerland, and to explore the factors that contribute to both innovations and diffusions of innovations. </p><p> Design. Systematic review of published articles. </p><p> Data Survey. CINAHL, ProQuest, PubMed Central, Google Scholar and Citation Lists. All articles published 2017 and earlier will be included in the search. </p><p> Review Method. Articles describing innovation in healthcare, diffusion in innovation, and/or innovation indicators in Israel, Switzerland, and Ireland were selected for review. Only scholarly journals were accepted. </p><p> Results. The data analysis for this systematic review followed the PRISMA guidelines that encapsulated the basic eight steps for systematic review process. Academic search engines were used to identify studies relevant to the topic under study. The CASP checklist was used to evaluate the quality of the study, along with determining whether the study met the eligibility criteria for this systematic review. Eighty-nine full text sources were included in the final assessment, and 57 of these were excluded from the final review because, while some appeared in scholarly journals, these were either webpages, conference papers, commentaries, interviews, or news related. The 32 remaining full text articles were included in the review. </p><p> In addition to the systematic literature review, six Subject Matter Experts were interviewed. Participants&rsquo; responses showed clear perspectives on the critical success factors v necessary for healthcare innovation to thrive within a country and an organization. Their responses overlapped in answering each of the research questions. The principal areas of concern included committed leadership, collaborative cultures, cost effectiveness, planning, and futureoriented thinking. These areas were the top critical success factors for healthcare innovation. However, these also represented concerns about and barriers to it. The absence of these factors potentially stalled innovation in a country. This stall occurred if that country lacked openness to new ideas or was extremely risk adverse. These various factors required further study to understand the overall effect on healthcare innovation in different contexts. </p><p> Conclusion. Small nations that innovate in healthcare benefit the most from government subsidies of research and development. Additionally, benefits accrue exponentially with strong global partnerships. The development of national and international partnerships occurred when existing internal information was shared at the beginning of the innovation process. Connecting healthcare stakeholders is necessary for improving innovation experts. Developing new methods of measuring innovation will significantly aid in understanding the influence of adaption and diffusion of innovations in healthcare systems. The implications of this study suggest that our understanding of innovation and innovation diffusions have the potential to lead to adaptations. However, we don&rsquo;t yet fully understand the most efficacious way to measure innovation and its impact on society.</p><p>

This thesis presents an attempt to assess how prediction about patients' expected stay in the operating room, intensive care and postoperative surgical units could be used in the process of scheduling of patients for cardiac surgery. The study was carried out in the setting of the University of Ottawa Heart Institute (OHI) where current scheduling practices and the process of flow of patients through surgery were studied. Data were collected from all patients who underwent cardiac surgery at the University of Ottawa Heart Institute during the 1994 and 1995 calendar years. Information of interest is the relation of demographic, clinical and procedural factors for each patient to the time of operation, length of stay in the intensive care unit after surgery, length of postoperative stay until discharge from the hospital and in-hospital mortality after surgery. As a result of the analysis of the University of Ottawa Heart Institute surgical scheduling system and patient data we (i) understood how the current system is operating, (ii) developed and assessed models for predicting length of stay in ICU after cardiac surgery. (Abstract shortened by UMI.)

Abstract Not Available.

Day surgery is a rapidly growing alternative mode of treating patients. Instead of a two to three day stay in the hospital, the patient arrives the morning of surgery, is operated on and returns home the same evening. There are restrictions on the type of patient and type of procedure that can be done in day surgery. It also has been shown that day surgery is a much less costly method of treating patients, provided the patients and the procedure meet the day surgery requirements. This study was conducted at the University of Alberta Hospital in Edmonton, Alberta. It looked at six procedures that meet the day surgery requirements (Dilatation and Curettage, Laparoscopy, Non-Recurrent Inguinal Hernia, Breast Biopsy, Cataracts and Haemorrhoids) and the cost associated with each procedure both on an inpatient and day surgery basis. A sample of medical records for each procedure was examined and information concerning Nursing, Supply, Drug and Test costs, as well as, length of stay was extracted. Hotel service costs were obtained from various departments and the remaining costs, including Administration and Plant, were obtained from the Hospital's annual return to the government. The costs were added up to give a procedure cost for each procedure on an inpatient and day surgery basis. Then using data derived from the medical records, including age and complications, an eligibility rate (the percentage of patients eligible for day surgery) was derived. This was multiplied by the total number of that particular procedure performed in 1980 and was then multiplied by the procedure cost. The final result was the savings that would have possible if a greater percentage of procedures had on a day surgery basis. The results show that significant savings can be expected by substituting day for inpatient surgery, providing a number of inpatient beds are closed to correspond with the increase in day surgery.

The method whereby fees are set for medical services is of significant relevance to the operation and overall total cost of a health care delivery system. Until the advent of medical insurance, the setting of fees was traditionally a matter for the profession. Although many of the early medical insurance organisations were physician sponsored, the profession began to lose its autonomy as these insurance bodies became involved in the process. With the introduction of medicare the setting of fees became a joint government and profession matter with fees, for medical benefit purposes, being set by negotiation. It may be argued that by 1978 the Government had assumed responsibility for medical fee setting in many Provinces. The purpose of this paper is to review the conduct of fee negotiations in five provinces---Alberta (in depth), British Columbia, Saskatchewan, Ontario and Quebec---up until 1978. In the first chapter the purpose is further defined and explained, while in the second the method to be followed is developed. The third chapter is devoted to a review of literature relevant to physician behaviour in relation to fees and income. As an introduction to the chapters dealing with the individual Provinces the fourth chapter develops a set of possible objectives for the profession and the government in the fee negotiation process; this reference set is provided to allow the reader to access the conduct of negotiations in each Province. The individual provinces are dealt with one by one in Chapters V to IX. In the final chapter the conduct of fee negotiations is discussed.

As part of a multiple-case study, the objective of this single-case study is to examine the impact of the accreditation process offered by the Canadian Council on Health Services Accreditation (CCHSA) on one health care organization. The main hospital of the organisation selected has been accredited for a little over 50 years. Quantitative and qualitative data was collected for methodological triangulation. Two questionnaires were distributed; interviews and focus groups were conducted on site. A previously developed conceptual framework on the dimensions of change was used for the analysis. Some changes within the organization were traced back to the accreditation process and they were mainly at the organizational level, affecting processes and organizational structures. In addition, the accreditation self-assessment phase offers an opportunity to increase social capital, but the quantity and type acquired depends on the composition of the self-assessment team and the follow-up done after the accreditation survey.

Objective. To demonstrate that participation in the CCHSA accreditation process helps HCOs to be more reactive to change, improving quality and safety, and that accreditation also helps health care organizations to develop their organizational learning processes. The hospital's culture is of a hierarchical nature (x&macr; = 36.92), but with the help of organizational initiatives, strong leadership, and accreditation, it is evolving towards a group culture. The hospital has a high commitment towards information and analysis, however, employees do not always perceive themselves as receiving adequate training and education for quality improvement. Accreditation has helped the hospital through its merger. It has affected the hospital at an individual, group, organizational, and external partnerships level. The self-assessment phase was highly effective in encouraging cohesion and collaboration, the emergence of a multidisciplinary approach to care, community involvement, and the development of organizational learning. The first post-merger accreditation's report encouraged the development of an organization wide quality framework which focuses on quality of care, efficiency, and patient safety. Most key values and initiatives are in place for the hospital to be a Learning Organization. A shift in organizational culture towards a group and developmental culture, as well as a stronger commitment towards QI education and training, are still necessary. (Abstract shortened by UMI.)

A geographic information system was used to measure geographical access to general surgical services in the Champlain Local Health Integration Network. An origin-destination matrix approach was used with discharge data for Champlain residents using the Ontario Road Network file and OC Transpo trip planner for public transportation trips with in the city of Ottawa. GIS showed that adding surgical services to the Renfrew Victoria Hospital would be the best location to achieve the goal of reduced drive times for Champlain LHIN residents. However, this hospital was ill suited to take on additional surgeries due to high occupancy rates, a lack of space and surgeons. Differences in neighbourhoods' geographical access (drive and transit time) to the General Campus of the Ottawa Hospital were found. However, it was the more affluent neighbourhoods and neighbourhoods with lower percent of recent immigrants that had longer drive times and transit times.

Background: Systematic reviews (SRs) are increasingly viewed as useful decision-making tools yet the extent of SR publication bias is under-explored. Through my thesis, I aimed to investigate the extent of SR publication bias. Methods: A conceptual model was derived from literature searches and one-on-one interviews and three studies were conducted: a cross-sectional study of 296 SRs indexed in MEDLINE and published in November 2004, an international survey of 625 corresponding or first authors of a published SR in 2005, and a retrospective cohort study of 411 Cochrane protocols from Issues 2-4, 2000 and Issue 1,2001 that were followed until Issue 1,2008 in The Cochrane Library. Main findings: The interviewees reported 40 unpublished SRs and the conceptual model showed that publication bias can permeate all steps of the publication process, from conceptualization to ultimate effect on health outcomes. The cross-sectional study identified favourable results in 57.7% of Cochrane reviews and 64.3% of non-Cochrane reviews with a meta-analysis of the primary outcome and non-Cochrane reviews were twice as likely to have positive conclusions as Cochrane reviews (p-value&le;0.05). In the international survey, participants reported 1405 published (median: 2.0, range: 1-150) and 199 unpublished (median: 2.0, range: 1-53) SRs. In the retrospective cohort study, 19.1% (71/372) of eligible Cochrane protocols remained unpublished and the median time to publication was 2.4 years (range: 0.15-8.96). A shorter time to publication was associated with the Cochrane review being subsequently updated versus not updated (n=100/372 Cochrane reviews that were updated, hazard ratio: 1.80 [95% confidence interval: 1.39-2.33 years]) and a longer time to publication was associated with the Cochrane review having two published versus one protocol (n=10/372 Cochrane reviews with two published protocols, 0.33 [0.12-0.90 years]). General conclusions: Over 300 unpublished SRs were identified through the interviews conducted for the conceptual model and the three studies that comprised my thesis. Possible solutions for minimizing or avoiding SR publication bias include registration of SRs at inception, educating the research community about the importance of publishing SRs, and having a general online open-access journal with rapid peer review that is dedicated to only publishing the results of SRs (including their updates).