Challenges in implementing a budget-holding programme for primary care clinics.
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In 1990, Kupat Holim Clalit (KHC), Israel's largest sick fund, initiated a demonstration programme for transforming a number of primary care clinics in the Negev district of southern Israel into autonomous budget-holding units. Four programme components were implemented in the nine participating clinics: allocation of a fixed budget; expansion of day-to-day decision-making authority; establishment of a computerized information system to produce monthly reports on expenditure; and provision of incentives for budgetary control. The research findings are based on a four-year evaluation of the programme, which involved a longitudinal case study conducted with multiple research tools: in-depth interviews, a staff survey, and analysis of relevant documents. This article analyzes the challenges involved in implementing the demonstration programme. It examines clinic staff evaluation of the implementation process (e.g. overall staff had a positive attitude toward it); assesses staff satisfaction with clinic participation in the programme (while only 33% were satisfied, only 21% said they would like the clinic to revert to the pre-programme model) and factors influencing this satisfaction (among them intrinsic benefits, perception of the programme as fair and age); and discusses the lessons to be learnt from the programme regarding effective implementation of organizational change. The main lessons indicate the importance of certain factors in implementing such programmes: (a) long-term management commitment to the programme; (b) appointment of agents of change/programme administrators; (c) establishment of a formal agreement between the parties involved; (d) establishment of communication channels between the parties involved; (e) intrinsic benefits for staff, perceived as incentives to economize; (f) reliable data, perceived to be reliable by the parties involved; (g) staff participation in the process of change; and (h) involvement of the participating unit as a single entity. (+info)
A process evaluation of the National Cancer Institute's Data-based Intervention Research program: a study of organizational capacity building.
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This paper reports on a qualitative process evaluation of the Data-based Intervention Research (DBIR) program, that was funded by the National Cancer Institute (NCI) and operated in 21 states and the District of Columbia. The goal of DBIR was to build a foundation within state health agencies to ensure the translation of cancer control science into practice. NCI's objective reflected the readiness of cancer control research for public health application, the paucity of cancer control activity within public health settings and the recognition that state health agencies could play a critical role in the effective transfer of research results into public health practice. The qualitative process evaluation reported in this paper is based on one case study of four DBIR programs. The present study indicates that the four state health agencies executed the DBIR program with fidelity. Also, the four states offered a balanced assessment of NCI's role in enabling the state agency operation of DBIR, providing numerous citations illustrating how NCI successfully facilitated organizational capacity as compared to fewer mentions of ways NCI was less than successful. Thus, in funding the DBIR model, NCI was successful in raising state health agency capacity to implement cancer prevention and control programming. Implications for capacity building in state health departments are discussed. (+info)
The impact of the National Cancer Institute's Data-based Intervention Research program on state health agencies.
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To assist state health agencies adopt a new role in cancer prevention and control, the National Cancer Institute (NCI) initiated the Data-based Intervention Research (DBIR) program. The goal of DBIR was to stimulate data-driven activities and to build capacity for ongoing programs within state health agencies to ensure the translation of cancer prevention and control science into practice across the US. Each state funded under the DBIR program was required to conduct four phases of activity: identifying and analyzing relevant data, using these data to develop a state cancer control plan, and implementing and evaluating prevention and control interventions at the local level. This paper presents the results of survey of the 22 states that participated in the DBIR program. The survey is intended as a supplement to the case study also reported in this issue of Health Education Research. Results indicated that states were able to implement the DBIR model and they show the process to be useful to their cancer prevention efforts. DBIR had a major impact on how states will use data in future planning for cancer prevention and control. States had a number of recommendations for how NCI could improve its working relationships with state health agencies. (+info)
A successful tobacco cessation program led by primary care nurses in a managed care setting.
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We conducted a descriptive study of a tobacco cessation program sponsored by a health maintenance organization (HMO) and led by primary care nurses. The tobacco cessation program was conducted at 20 primary care clinics in northeastern and central Pennsylvania. We gauged the successfulness of the program by the patients' self-reported quit rates at 1 year. We also examined the association between quit rates and compliance with scheduled counseling visits, the impact of the availability of an HMO pharmacy benefit that supported the costs of nicotine replacement therapy, and the quit rates among patients with HMO insurance versus those with insurance other than managed care. Of 1,695 patients enrolled in the program from July 1993 to March 1996, 1,140 completed 1 year of follow-up. Of these, 348 (30.5%) reported they had quit using tobacco. Among the 810 HMO enrollees who participated in the program, the quit rate was 280 (34.6%); among the 330 non-HMO participants, the quit rate was 69 (20.9%), a statistically significant difference (P < 0.001). For all patients, keeping more than four visits with the program nurse was associated with a significantly higher likelihood of quitting (317/751 [42.2%] versus 32/389 [8.2%]; P < 0.001). Non-HMO patients were less likely than HMO enrollees to keep four or more visits (165 [50%] versus 586 [72.3%]; P < 0.001). We were unable to detect a difference in quit rates among those with and those without a pharmacy benefit (196/577 [34%] versus 84/233 [36.1%]). These data are limited by their descriptive nature and the lack of information about other factors important in determining the quit rate among program participants. Nevertheless, they suggest that HMOs can successfully sponsor nurse-led tobacco cessation programs in multiple primary care settings and achieve 1-year quit rates significantly higher than the 15% quit rate reported in the medical literature. In addition, successfully quitting tobacco use appeared to be associated with use of counseling visits but not with use of a pharmacy benefit to pay for nicotine replacement therapy. Even though tobacco cessation programs have the best chance of benefitting HMO enrollees, patients not enrolled in managed care plans also appear to benefit significantly. This finding has important implications for developing future strategies--including the role of managed care organizations, the need to defray the costs of nicotine replacement therapy, and the best approach to provide counseling to patients--to meet the Healthy People 2000 goal of reducing tobacco smoking. (+info)
Conducting a literature review on the effectiveness of health care interventions.
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The dramatic increase in the volume of research based information means that effective policy makers must be able to conduct and interpret literature reviews. This article sets out the steps that should be followed in doing so. They are: explicitly defining the question; locating relevant literature; assessing the quality of studies and deciding whether they should be included; synthesizing and re-analyzing the results; and presenting them in a clear and concise manner. The article identifies the leading sources of information, including electronic databases and useful Internet addresses and describes briefly how each stage should be conducted, highlighting the strengths and weaknesses of different approaches and the ways in which bias may be introduced. (+info)
Trauma emergency unit: long-term evaluation of a quality assurance programme.
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OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme. (+info)
Revisiting community participation.
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Community participation in health is a complex entity that has been examined extensively in the literature and continues to be of great interest among community health workers. The genesis of the idea and its conceptual development are primarily attributed to large multinational health institutions, particularly the World Health Organization. However, the implementation of community participation is the ultimate responsibility of local health programme initiators. It is therefore at the local level where day to day realities of incorporating community participation into health service delivery are confronted. This paper reviews the value of community participation in health and provides a detailed examination of the challenges facing its implementation and sustainability. In 1978, the World Health Organization placed community participation squarely at the centre of their strategy to achieve Health For All By The Year 2000. As the year 2000 nears, it is time to critically re-examine the notion of community participation and the most pressing challenges to its viability. (+info)
A critical review of priority setting in the health sector: the methodology of the 1993 World Development Report.
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The 1993 World Development Report, Investing in Health, suggests policies to assist governments of developing countries in improving the health of their populations. A new methodology to improve government spending is introduced. Epidemiological and economic analyses from the basis for a global priority setting exercise, leading to a recommended essential public health and clinical services package for low- and middle-income countries. Ministries of Health in many countries have expressed an interest in designing a national package of essential health services, using the methodology. Given the apparent importance attached to the study and its far reaching potential consequences, this article provides an overview of the method, the main issues and problems in estimating the burden of disease as well as the cost-effectiveness of interventions. Strengths and weaknesses in the databases, value judgements and assumptions are identified, leading to a critical analysis of the validity of the priority setting exercise on the global level. (+info)