Expressions of Actor Power in Implementation: A Qualitative Case Study of a Health Service Intervention in South Africa

Abstract Background Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa. Methods A retrospective qualitative case study based on interviews with 34 actors in three ‘implementation units’ – a district hospital and surrounding primary health care services – of the district, selected as purposefully representing full, moderate and low implementation of the intervention some three years after it was first introduced. Data are analysed using Veneklasen and Miller’s typology of the forms of power – namely ‘power over’, ‘power to’, ‘power within’ and ‘power with’. Results Multiple expressions of actor power were evident during implementation and played a plausible role in shaping variable implementation, while the intervention itself acted to change power relations. The ability to mobilise collective action (power with) was a key dimension of successful implementation, but potentially poses a threat to hierarchical power (power over) at higher levels of the system, affecting sustainability. Conclusions A systematic approach to the analysis of power in implementation research may provide insights into the fate of interventions. Intervention designs need to consider how they shape power relations, especially where interventions seek to widen participation and responsiveness in local health systems.

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Community Efforts to Reduce Racial and Ethnic Health Disparities: Challenges and Facilitators Identified by 16 Multistakeholder Alliances

Medical Care Research and Review ◽

10.1177/1077558718776051 ◽

2018 ◽

Vol 77 (1) ◽

pp. 74-84 ◽

Cited By ~ 1

Author(s):

Jaime Hamil ◽

Juliet Yonek ◽

Yasmin Mahmud ◽

Raymond Kang ◽

Ariane Garrett ◽

...

Keyword(s):

Health Care ◽

Health Disparities ◽

Health Care Quality ◽

Ethnic Disparities ◽

The United States ◽

Care Quality ◽

Local Health ◽

Local Data ◽

Federal Policies ◽

Improve Health Care Quality

The Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) program aimed to improve health care quality and reduce racial and ethnic disparities in 16 diverse communities in the United States from 2006 to 2015; yet most communities failed to make substantive progress toward advancing health care equity by the program’s end. This qualitative analysis of key stakeholder interviews aims to identify the major contributors to success versus failure in addressing local health disparities during AF4Q and identified five major themes. Three themes highlight challenges related to collecting local data on racial and ethnic health disparities and transitioning from data collection to action. Two themes capture the critical contribution of stakeholder engagement and access to technical expertise to successful efforts. The challenges and facilitators experienced by these 16 AF4Q communities may help inform the disparities reduction efforts of other communities and guide state or federal policies to reduce health disparities.

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Exploring health system readiness for adopting interventions to address intimate partner violence: a case study from the occupied Palestinian Territory

Health Policy and Planning ◽

10.1093/heapol/czz151 ◽

2019 ◽

Vol 35 (3) ◽

pp. 245-256 ◽

Cited By ~ 3

Author(s):

Manuela Colombini ◽

Abdulsalam Alkaiyat ◽

Amira Shaheen ◽

Claudia Garcia Moreno ◽

Gene Feder ◽

...

Keyword(s):

Health Care ◽

Health System ◽

Health Systems ◽

Partner Violence ◽

Scale Up ◽

Successful Implementation ◽

Occupied Palestinian Territory ◽

System Readiness ◽

Palestinian Territory

Abstract Domestic violence (DV) against women is a widespread violation of human rights. Adoption of effective interventions to address DV by health systems may fail if there is no readiness among organizations, institutions, providers and communities. There is, however, a research gap in our understanding of health systems’ readiness to respond to DV. This article describes the use of a health system’s readiness assessment to identify system obstacles to enable successful implementation of a primary health-care (PHC) intervention to address DV in the occupied Palestinian Territory (oPT). This article describes a case study where qualitative methods were used, namely 23 interviews with PHC providers and key informants, one stakeholder meeting with 19 stakeholders, two health facility observations and a document review of legal and policy materials on DV in oPT. We present data on seven dimensions of health systems. Our findings highlight the partial readiness of health systems and services to adopt a new DV intervention. Gaps were identified in: governance (no DV legislation), financial resources (no public funding and limited staff and infrastructure) and information systems (no uniform system), co-ordination (disjointed referral network) and to some extent around the values system (tension between patriarchal views on DV and more gender equal norms). Additional service-level barriers included unclear leadership structure at district level, uncertain roles for front-line staff, limited staff protection and the lack of a private space for identification and counselling. Findings also pointed to concrete actions in each system dimension that were important for effective delivery. This is the first study to use an adapted framework to assess health system readiness (HSR) for implementing an intervention to address DV in low- and middle-income countries. More research is needed on HSR to inform effective implementation and scale up of health-care-based DV interventions.

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Statistical measures of customer satisfaction for health care quality assurance: a case study

International Journal of Health Care Quality Assurance ◽

10.1108/09526860110366214 ◽

2001 ◽

Vol 14 (1) ◽

pp. 6-14 ◽

Cited By ~ 59

Author(s):

M.A.A. Hasin ◽

Roongrat Seeluangsawat ◽

M.A. Shareef

Keyword(s):

Health Care ◽

Quality Assurance ◽

Customer Satisfaction ◽

Health Care Quality ◽

Care Quality ◽

Health Care Quality Assurance ◽

Statistical Measures

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Translating research into maternal health care policy: a qualitative case study of the use of evidence in policies for the treatment of eclampsia and pre-eclampsia in South Africa

Health Research Policy and Systems ◽

10.1186/1478-4505-6-12 ◽

2008 ◽

Vol 6 (1) ◽

Cited By ~ 29

Author(s):

Karen Daniels ◽

◽

Simon Lewin

Keyword(s):

South Africa ◽

Health Care ◽

Maternal Health ◽

Health Care Policy ◽

Qualitative Case Study ◽

Maternal Health Care ◽

Care Policy

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Perceptions of Local Health Care Quality in 7 Rural Communities with Telemedicine

The Journal of Rural Health ◽

10.1111/j.1748-0361.2005.tb00066.x ◽

2005 ◽

Vol 21 (1) ◽

pp. 79-85 ◽

Cited By ~ 38

Author(s):

Thomas S. Nesbitt ◽

James P. Marcin ◽

Martha M. Daschbach; ◽

Stacey L. Cole

Keyword(s):

Health Care ◽

Rural Communities ◽

Health Care Quality ◽

Care Quality ◽

Local Health ◽

Local Health Care

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Measuring Regional Performance in the Italian NHS: Are Disparities Decreasing?

Social Indicators Research ◽

10.1007/s11205-021-02775-8 ◽

2021 ◽

Author(s):

Silvia Bruzzi ◽

Enrico Ivaldi ◽

Marta Santagata

Keyword(s):

Health Care ◽

Health Systems ◽

Health Care Quality ◽

Health Care Systems ◽

Care Quality ◽

Regional Disparities ◽

Future Research ◽

Regional Health ◽

Regional Health Care ◽

Composite Indexes

AbstractGiven the regional disparities that historically characterize the Italian context, in this paper we propose a framework to evaluate the regional health care systems’ performance in order to contribute to the debate on the relationship between decentralisation of health care and equity. To investigate the regional health systems performance, we refer to the OECD Health Care Quality Indicators project to construct of a set of five composite indexes. The composite indexes are built on the basis of the non-compensatory Adjusted Mazziotta-Pareto Index, that allows comparability of the data across units and over time. We propose three indexes of health system performance, namely Quality Index, Accessibility Index and Cost-Expenditure Index, along with a Health Status Index and a Lifestyles Index. Our framework highlights that regional disparities still persist. Consistently with the evidence at the institutional level, there are regions, particularly in Southern Italy, which record lower levels of performance with high levels of expenditure. Continuous research is needed to provide policy makers with appropriate data and tools to build a cohesive health care system for the benefit of the whole population. Even if future research is needed to integrate our framework with new indicators for the calculation of the indexes and with the identification of new indexes, the study shows that a scientific reflection on decentralisation of health systems is necessary in order to reduce inequalities.

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Embedding the Pillars of Quality in Health Information Technology Solutions Using “Integrated Patient Journey Mapping” (IPJM): Case Study (Preprint)

10.2196/preprints.17416 ◽

2019 ◽

Author(s):

Stephen McCarthy ◽

Paidi O'Raghallaigh ◽

Simon Woodworth ◽

Yoke Yin Lim ◽

Louise C Kenny ◽

...

Keyword(s):

Health Care ◽

Information Technology ◽

Health Service ◽

Health Information ◽

Health Care Quality ◽

Care Quality ◽

Multidisciplinary Teams ◽

Patient Journey ◽

Connected Health

BACKGROUND Health information technology (HIT) and associated data analytics offer significant opportunities for tackling some of the more complex challenges currently facing the health care sector. However, to deliver robust health care service improvements, it is essential that HIT solutions be designed by parallelly considering the 3 core pillars of health care quality: clinical effectiveness, patient safety, and patient experience. This requires multidisciplinary teams to design interventions that both adhere to medical protocols and achieve the tripartite goals of effectiveness, safety, and experience. OBJECTIVE In this paper, we present a design tool called <i>Integrated Patient Journey Mapping</i> (IPJM) that was developed to assist multidisciplinary teams in designing effective HIT solutions to address the 3 core pillars of health care quality. IPJM is intended to support the analysis of requirements as well as to promote empathy and the emergence of shared commitment and understanding among multidisciplinary teams. METHODS A 6-month, in-depth case study was conducted to derive findings on the use of IPJM during <i>Learning to Evaluate Blood Pressure at Home</i> (LEANBH), a connected health project that developed an HIT solution for the perinatal health context. Data were collected from over 700 hours of participant observations and 10 semistructured interviews. RESULTS The findings indicate that IPJM offered a constructive tool for multidisciplinary teams to work together in designing an HIT solution, through mapping the physical and emotional journey of patients for both the current service and the proposed connected health service. This allowed team members to consider the goals, tasks, constraints, and actors involved in the delivery of this journey and to capture requirements for the digital touchpoints of the connected health service. CONCLUSIONS Overall, IPJM facilitates the design and implementation of complex HITs that require multidisciplinary participation. CLINICALTRIAL

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Interprofessional, multitiered daily rounding management in a high-acuity hospital

International Journal of Health Care Quality Assurance ◽

10.1108/ijhcqa-09-2019-0158 ◽

2020 ◽

Vol 33 (6) ◽

pp. 447-461

Author(s):

Pracha Peter Eamranond ◽

Arti Bhukhen ◽

Donna DiPalma ◽

Schawan Kunuakaphun ◽

Thomas Burke ◽

...

Keyword(s):

Health Care ◽

Health Care Quality ◽

High Reliability ◽

Care Quality ◽

Total Quality ◽

Content Type ◽

Hospital Safety ◽

High Acuity ◽

Hospital Systems

PurposeThe purpose of this explanatory case study is to explain the implementation of interprofessional, multitiered lean daily management (LDM) and to quantitatively report its impact on hospital safety.Design/methodology/approachThis case study explained the framework for LDM implementation and changes in quality metrics associated with the interprofessional, multitiered LDM, implemented at Saint Francis Hospital and Medical Center (SFHMC) at the end of 2018. Concepts from lean, Total Quality Management (TQM) and high reliability science were applied to develop the four tiers and gemba rounding components of LDM. A two-tailed t-test analysis was utilized to determine statistical significance for serious safety events (SSEs) comparing the intervention period (January 2019–December 2019) to the baseline period (calendar years 2017 and 2018). Other quality and efficiency metrics were also tracked.FindingsLDM was associated with decreased SSEs in 2019 compared to 2017 and 2018 (p ≤ 0.01). There were no reportable central line-associated blood stream infection (CLABSI) or catheter-associated urinary tract infection (CAUTI) for first full calendar quarter in the hospital's history. Hospital-acquired pressure injuries were at 0.2 per 1,000 patient days, meeting the annual target of <0.5 per 1,000 patient days. Outcomes for falls with injury, hand hygiene and patient experience also trended toward target. These improvements occurred while also observing a lower observed to expected length of stay (O/E LOS), which is the organizational marker for hospital’s efficiency.Research limitations/implicationsLDM may contribute greatly to improve safety outcomes. This observational study was performed in an urban, high-acuity, low cost hospital which may not be representative of other hospitals. Further study is warranted to determine whether this model can be applied more broadly to other settings.Practical implicationsLDM can be implemented quickly to achieve an improvement in hospital safety and other health-care quality outcomes. This required a redistribution of time for hospital staff but did not require any significant capital or other investment.Social implicationsAs hospital systems move from a volume-based to value-based health-care delivery model, dynamic interventions using LDM can play a pivotal role in helping all patients, particularly in underserved settings where lower cost care is required for sustainability, given limited available resources.Originality/valueWhile many hospital systems promote organizational rounding as a routine quality improvement process, this study shows that a dynamic, intense LDM model can dramatically improve safety within months. This was done in a challenging urban environment for a high-acuity population with limited resources.

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