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1.  Managing boundaries in primary care service improvement: A developmental approach to communities of practice 
Effective implementation of change in healthcare organisations involves multiple professional and organisational groups and is often impeded by professional and organisational boundaries that present relatively impermeable barriers to sharing knowledge and spreading work practices. Informed by the theory of communities of practice (CoPs), this study explored the effects of intra-organisational and inter-organisational boundaries on the implementation of service improvement within and across primary healthcare settings and on the development of multiprofessional and multi-organisational CoPs during this process.
The study was conducted within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester—a collaborative partnership between the University of Manchester and local National Health Service organisations aiming to undertake applied health research and enhance its implementation in clinical practice. It deployed a qualitative embedded case study design, encompassing semistructured interviews, direct observation and documentary analysis, conducted in 2010–2011. The sample included practice doctors, nurses, managers and members of the CLAHRC implementation team.
The study showed that in spite of epistemic and status differences, professional boundaries between general practitioners, practice nurses and practice managers co-located in the same practice over a relatively long period of time could be successfully bridged, leading to the formation of multiprofessional CoPs. While knowledge circulated relatively easily within these CoPs, barriers to knowledge sharing emerged at the boundary separating them from other groups existing in the same primary care setting. The strongest boundaries, however, lay between individual general practices, with inter-organisational knowledge sharing and collaboration between them remaining unequally developed across different areas due to historical factors, competition and strong organisational identification. Manipulated emergence of multi-organisational CoPs in the context of primary care may thus be problematic.
In cases when manipulated emergence of new CoPs is problematic, boundary issues could be addressed by adopting a developmental perspective on CoPs, which provides an alternative to the analytical and instrumental perspectives previously described in the CoP literature. This perspective implies a pragmatic, situational approach to mapping existing CoPs and their characteristics and potentially modifying them in the process of service improvement through the combination of internal and external facilitation.
PMCID: PMC3514317  PMID: 23068016
Communities of practice; Professional boundaries; Organisational boundaries; Primary care; Service improvement; National Health Service; CLAHRC; UK
2.  Building effective service linkages in primary mental health care: a narrative review part 2 
Primary care services have not generally been effective in meeting mental health care needs. There is evidence that collaboration between primary care and specialist mental health services can improve clinical and organisational outcomes. It is not clear however what factors enable or hinder effective collaboration. The objective of this study was to examine the factors that enable effective collaboration between specialist mental health services and primary mental health care.
A narrative and thematic review of English language papers published between 1998 and 2009. An expert reference group helped formulate strategies for policy makers. Studies of descriptive and qualitative design from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted on factors reported as enablers or barriers to development of service linkages. These were tabulated by theme at clinical and organisational levels and the inter-relationship between themes was explored.
A thematic analysis of 30 papers found the most frequently cited group of factors was "partnership formation", specifically role clarity between health care workers. Other factor groups supporting clinical partnership formation were staff support, clinician attributes, clinic physical features and evaluation and feedback. At the organisational level a supportive institutional environment of leadership and change management was important. The expert reference group then proposed strategies for collaboration that would be seen as important, acceptable and feasible. Because of the variability of study types we did not exclude on quality and findings are weighted by the number of studies. Variability in local service contexts limits the generalisation of findings.
The findings provide a framework for health planners to develop effective service linkages in primary mental health care. Our expert reference group proposed five areas of strategy for policy makers that address organisational level support, joint clinical problem solving, local joint care guidelines, staff training and supervision and feedback.
PMCID: PMC3070626  PMID: 21435273
Narrative review; mental health services; primary health care; cooperative behaviour
3.  Parents' experiences of collaboration between welfare professionals regarding children with anxiety or depression - an explorative study 
Well-functioning collaboration between professionals in the welfare sector has a strong influence on the contacts with parents of children and adolescents suffering from mental illness, and it is a precondition for the availability of support for these parents. This paper describes how such parents perceive collaboration between professionals in mental health care, social services, and schools.
This was a small-scale qualitative study. Data were collected by in-depth interviews with seven parents of children and adolescents diagnosed with anxiety and depression. The families were selected from the Child and Adolescent Mental Health patient records kept by the Stockholm County Council (Sweden), and they all lived in a catchment area for Child and Adolescent Mental Health outpatient services in Stockholm.
Results and discussion
Our results suggest that when the encounter between parents and professionals is characterised by structure and trust, it is supportive and serves as a holding environment. Parents think that communication links and coordination between professionals from different organisations are needed in the collaboration, along with appropriately scheduled and well-performed joint meetings to create structure in the parent-professional encounter. Parents also think that establishment of trust in this interaction is promoted by individual professionals who are available, provide the parents with adequate information, are skilled, and show empathy and commitment.
PMCID: PMC3817954  PMID: 24198739
patients' perceptions; collaboration; child and adolescent mental health; child welfare; holding environment
4.  Judgements about fellow professionals and the management of patients receiving palliative care in primary care: a qualitative study 
Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services.
To explore the influences on referrals within general and specialist community palliative care services.
Design of study
Qualitative, multiple-case study.
Three primary care trusts in the north-west of England.
Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals.
Judgements — positive and negative — about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional ‘game playing’ to achieve professionals' desired outcomes.
Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care.
PMCID: PMC2277112  PMID: 18494176
case study; interprofessional care; palliative care; primary health care; qualitative research
5.  Factors influencing professional decision making on unplanned hospital admission: a qualitative study 
The British Journal of General Practice  2012;62(604):e750-e756.
Unplanned admissions to hospital are a challenge for healthcare systems internationally. In the UK variation in unplanned admission rates across geographical areas, general practices and GPs remains largely unexplained.
To identify factors influencing professional decision making around unplanned hospital admission.
Design and setting
Qualitative study with a purposive sample of health and social care professionals from three primary care trusts, two acute hospitals, social services and an ambulance service in the South West of England.
Semi-structured interviews were conducted with 19 professionals. Interviews were audio-recorded and transcribed. Data were analysed thematically drawing on the constant comparative method.
The main factors influencing professional decision making around unplanned admissions were: lack of availability of seamless care on a 24/7 basis; ‘professional tribalism’ and poor information flow; service targets and performance management; commissioning culture and the impact of a ‘market approach’; and clinical governance structures, tolerance of risk and the role of peer support. A tension was perceived between the need to reduce unplanned admissions by tolerating more risk in primary care and a risk averse culture in secondary and emergency care.
Professional decision making that leads to unplanned admission to hospital is influenced by a range of organisational and individual health or social care professional factors. Finding ways to modify and ameliorate the effects of these systems and individual influences should be considered an important goal in the design of new interventions.
PMCID: PMC3481515  PMID: 23211178
decision making; emergency care; general practice; patient admission; qualitative research
6.  Service learning in Guatemala: using qualitative content analysis to explore an interdisciplinary learning experience among students in health care professional programs 
Interprofessional collaboration among health care professionals yields improved patient outcomes, yet many students in health care programs have limited exposure to interprofessional collaboration in the classroom and in clinical and service-learning experiences. This practice gap implies that students enter their professions without valuing interprofessional collaboration and the impact it has on promoting positive patient outcomes.
The aim of this study was to describe the interprofessional experiences of students in health care professional programs as they collaborated to provide health care to Guatemalan citizens over a 7-day period.
In light of the identified practice gap and a commitment by college administration to fund interprofessional initiatives, faculty educators from nursing, occupational therapy, and physical therapy conducted a qualitative study to explore a service-learning initiative focused on promoting interprofessional collaboration. Students collaborated in triads (one student from each of the three disciplines) to provide supervised health care to underserved Guatemalan men, women, children, and infants across a variety of community and health care settings. Eighteen students participated in a qualitative research project by describing their experience of interprofessional collaboration in a service-learning environment. Twice before arriving in Guatemala, and on three occasions during the trip, participants reflected on their experiences and provided narrative responses to open-ended questions. Qualitative content analysis methodology was used to describe their experiences of interprofessional collaboration.
An interprofessional service-learning experience positively affected students’ learning, their growth in interprofessional collaboration, and their understanding and appreciation of health care professions besides their own. The experience also generated feelings of gratitude for the opportunity to be a member of an interprofessional team and to serve those in need by giving of themselves.
The findings support service learning as a platform to encourage interprofessional collaboration among students in health care professional programs. The research will inform future service-learning experiences in which interdisciplinary collaboration is an outcome of interest.
PMCID: PMC3573825  PMID: 23430865
content analysis; interdisciplinary collaboration; service-learning; qualitative research
7.  Contemporary UK paramedical training and education. How do we train? How should we educate? 
Emergency Medicine Journal : EMJ  2005;22(5):375-379.
Methods: This was a qualitative naturalistic inquiry using an interpretative constructivist approach for 44 interviews with a range of ambulance staff. Stakeholder views on training and education were analysed and compared using the constant comparison method.
Results: Key emergent themes included: issues around prescribed programme entry levels and methods; the desire for a higher education curriculum with a balance between theory and practice; valid and reliable assessment methods; development of a supportive mentorship framework; an emphasis on self directed professional development with a focus on deskilling issues; and development of interprofessional collaborative links.
Conclusion: This thematic review suggests that this UK ambulance service is in a transition stage, with significant organisational, professional, and cultural challenges. The dichotomies, boundaries, and development issues are part of the development of an emerging profession for which it is essential that the educational agenda is addressed.
PMCID: PMC1726764  PMID: 15843714
8.  Challenges of interprofessional collaboration in Iranian mental health services: A qualitative investigation 
Nurses and other members of health care team provide mental patients with health services through interprofessional collaboration which is a main strategy to improve health services. Nevertheless, many difficulties are evidently influencing interprofessional collaboration in Iranian context. This paper presented the results of a study aimed to explore the context.
Materials and Methods:
A qualitative study was conducted using in-depth interviews to collect data from 20 health professionals and 4 clients or their family members who were selected purposefully from the health centers affiliated with Isfahan University of Medical Sciences. Themes were identified using latent qualitative content analysis. Trustworthiness of the study was supported considering auditability, neutrality, consistency and transferability. The study lasted from 2010 to 2011.
Some important challenges were identified as protecting professional territory, medical oriented approach and teamwork deficits. They were all under a main theme emphasizing professionals’ divergent views. It could shed insight into underlying causes of collaboration gaps among nurses and other health professionals.
The three introduced themes implied difficulties mainly related to divergences among health professionals. Moreover, the difficulties revealed the need for training chiefly to improve their convergent shared views and approaches. Therefore, it is worthwhile to suggest interprofessional education for nurses and other professionals with special attention to improving interpersonal skills as well as mental health need-based services.
PMCID: PMC3696970  PMID: 23833601
Mental health services; interprofessional collaboration; challenges; Iran
9.  Access to primary health care for Australian young people: service provider perspectives. 
BACKGROUND: To adequately address the complex health needs of young people, their access to services, and the quality of services received, must be improved. AIMS: To explore the barriers to service provision for young people and to identify the training needs of primary healthcare service providers in New South Wales (NSW), Australia. DESIGN OF STUDY: A cross-sectional, qualitative study of the perspectives of a range of health service providers. SETTING: A range of primary healthcare organisations across NSW. METHODS: Samples of general practitioners (GPs), youth health workers, youth health coordinators, and community health centre staff were drawn from urban and rural clusters across NSW. Focus groups and interviews were used to identify barriers to service provision and the training needs of service providers. Data were tape recorded, transcribed, and analysed. RESULTS: Barriers to service provision among GPs and community health centre staff included inadequate time, flexibility, skills, and confidence in working with young people, and poor linkages with other relevant services. Training needs included better knowledge of and skills in adolescent health requirements, working with adolescents, and working with other services. Barriers to service provision for youth health workers and coordinators included lack of financial resources and infrastructure. There were few linkages between groups of service providers. CONCLUSION: Models of service provision that allow stronger linkages between service providers, sufficient time for consultation with young people, adequate training and support of health professionals, and flexibility of service provision, including outreach, should be explored and evaluated.
PMCID: PMC1314748  PMID: 14960219
10.  Qualitative research within trials: developing a standard operating procedure for a clinical trials unit 
Trials  2013;14:54.
Qualitative research methods are increasingly used within clinical trials to address broader research questions than can be addressed by quantitative methods alone. These methods enable health professionals, service users, and other stakeholders to contribute their views and experiences to evaluation of healthcare treatments, interventions, or policies, and influence the design of trials. Qualitative data often contribute information that is better able to reform policy or influence design.
Health services researchers, including trialists, clinicians, and qualitative researchers, worked collaboratively to develop a comprehensive portfolio of standard operating procedures (SOPs) for the West Wales Organisation for Rigorous Trials in Health (WWORTH), a clinical trials unit (CTU) at Swansea University, which has recently achieved registration with the UK Clinical Research Collaboration (UKCRC). Although the UKCRC requires a total of 25 SOPs from registered CTUs, WWORTH chose to add an additional qualitative-methods SOP (QM-SOP).
The qualitative methods SOP (QM-SOP) defines good practice in designing and implementing qualitative components of trials, while allowing flexibility of approach and method. Its basic principles are that: qualitative researchers should be contributors from the start of trials with qualitative potential; the qualitative component should have clear aims; and the main study publication should report on the qualitative component.
We recommend that CTUs consider developing a QM-SOP to enhance the conduct of quantitative trials by adding qualitative data and analysis. We judge that this improves the value of quantitative trials, and contributes to the future development of multi-method trials.
PMCID: PMC3599333  PMID: 23433341
11.  Evaluation of complex integrated care programmes: the approach in North West London 
Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect.
Study design
We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context.
Theory and discussion
This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them.
We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important.
PMCID: PMC3653284  PMID: 23687478
integrated; evaluation; delivery; complexity
12.  Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner—qualitative and summative findings 
Emergency Medicine Journal : EMJ  2007;24(9):625-629.
To identify collaborative instances and hindrances and to produce a model of collaborative practice.
A 12‐month (2005–2006) mixed methods clinical case study was carried out in a large UK ambulance trust. Collaboration was measured through direct observational ratings of communication skills, teamwork and leadership with 24 multi‐professional emergency care practitioners (ECPs), interviews with 45 ECPs and stakeholders, and an audit of 611 patients
Using a generic qualitative approach, observational records and interviews showed that ECPs' numerous links with other professions were influenced by three major themes as follows. (i) The ECP role: for example, “restricted transport codes” of communication, focus on reducing admissions, frustrations about patient tasking and conflicting views about leadership and team work. (ii) Education and training: drivers for multi‐professional clinically focussed graduate level education, requirements for skill development in minor injury units (MIUs) and general practice, and the need for clinical supervision/mentorship. (iii) Cultural perspectives: a “crew room” blue collar view of inter‐professional working versus emerging professional white collar views, power and communication conflicts, and a lack of understanding of the ECPs' role. The quantitative findings are reported elsewhere.
The final model of collaborative practice suggests that ECPs are having an impact on patient care, but that improvements can be made. We recommend the appointment of ECP clinical leads, degree level clinically focussed multi‐professional education, communication skills training, clinical supervision and multi‐professional ECP appointments.
PMCID: PMC2464628  PMID: 17711937
emergency; ambulance; collaboration; leadership; team; communication
13.  Integrated working between residential care homes and primary care: a survey of care homes in England 
BMC Geriatrics  2012;12:71.
Older people living in care homes in England have complex health needs due to a range of medical conditions, mental health needs and frailty. Despite an increasing policy expectation that professionals should operate in an integrated way across organisational boundaries, there is a lack of understanding between care homes and the National Health Service (NHS) about how the two sectors should work together, meaning that residents can experience a poor "fit" between their needs, and services they can access. This paper describes a survey to establish the current extent of integrated working that exists between care homes and primary and community health and social services.
A self-completion, online questionnaire was designed by the research team. Items on the different dimensions of integration (funding, administrative, organisational, service delivery, clinical care) were included. The survey was sent to a random sample of residential care homes with more than 25 beds (n = 621) in England in 2009. Responses were analysed using quantitative and qualitative methods.
The survey achieved an overall response rate of 15.8%. Most care homes (78.7%) worked with more than one general practice. Respondents indicated that a mean of 14.1 professionals/ services (other than GPs) had visited the care homes in the last six months (SD 5.11, median 14); a mean of .39 (SD.163) professionals/services per bed. The most frequent services visiting were district nursing, chiropody and community psychiatric nurses. Many (60%) managers considered that they worked with the NHS in an integrated way, including sharing documents, engaging in integrated care planning and joint learning and training. However, some care home managers cited working practices dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents, a lack of willingness by NHS professionals to share information, and low levels of respect for the experience and knowledge of care home staff.
Care homes are a hub for a wide range of NHS activity, but this is ad hoc with no recognised way to support working together. Integration between care homes and local health services is only really evident at the level of individual working relationships and reflects patterns of collaborative working rather than integration. More integrated working between care homes and primary health services has the potential to improve quality of care in a cost- effective manner, but strategic decisions to create more formal arrangements are required to bring this about. Commissioners of services for older people need to capitalise on good working relationships and address idiosyncratic patterns of provision to care homes.The low response rate is indicative of the difficulty of undertaking research in care homes.
PMCID: PMC3534387  PMID: 23151009
14.  Chain DTC Diabetes: new payment system to stimulate integrated care in the Netherlands 
To examine if the free negotiable chain diagnosis treatment combination (DTC) will stimulate (cost) effective and well organised diabetes care by integrated care groups.
The chain DTC diabetes contains the care in accordance with the medical care standard of the Dutch Diabetes Federation. The care group negotiates the price of the DTC with the insurer. This should stimulate the professionals involved to collaborate as efficient as possible and the insurer to negotiate the lowest price possible.
Case description
By order of the Ministry of Health, ZonMw (The Netherlands organisation for health research and development) has carried out a program with 10 diabetes care groups, who have experimented the past two years with the chain DTC diabetes and with the organising of integrated care.
Data sources
The program will be evaluated by the RIVM (The National Institute for Public Health and the Environment) on the basis of quantitative and qualitative data. The quantitative data comprise the medical outcome and the organising process of integrated care. The qualitative data comprise open-ended interviews with involved professionals, insurers and patients about their experiences and satisfaction with this way of organising, paying and consuming integrated care.
Preliminary conclusions
The DTC has indeed facilitated the forming of diabetes care groups. The quality of care seems to be improved, the costs differ between the groups and the place of the patient in the care process differs as well. (Final results expected around November 2009.)
The chain DTC seems to be a good instrument for improving diabetes care. Applicability for other chronic diseases provokes questions about the total macro costs for chronic care, paying and organising care for multi morbidity and the transition between prevention and care.
PMCID: PMC2807072
diabetes; diagnosis treatment combination; payment system
15.  Integration of primary health services: being put together does not mean they will work together 
BMC Research Notes  2014;7:66.
This paper reports on an Australian experience of co-locating a range of different primary health services into one building, with the aim of providing integrated services. It discusses some of the early challenges involved with moving services together and reasons why collaborative and integrated working relationships to improve the clients’ journey, may remain elusive.
Ethnographic observational data was collected within a GP plus site as part of day-to-day interactions between the research officer and health professionals. This involved observations of team processes within and across teams at the site. Observations were thematically analysed using a social anthropological approach.
Three main themes arose from the analysis: Infrastructural impediments to collaboration; Territorialism; and Interprofessional practice (IPP) simply not on the agenda. The experience of this setting demonstrates that dedicated staff and resources are needed to keep IPP on the agenda of health service organisations. This is especially important where organisations are attempting to implement new models of collaborative and co-located services. Furthermore, it shows that establishing IPP within newly co-located services is a process that needs time to develop, as part of teams building trust with each other in new circumstances, in order to eventually build a new cultural identity for the co-located services.
Co-located health service systems can be complex, with competing priorities and differing strategic plans and performance indicators to meet. This, coupled with the tendency for policy makers to move on to their next issue of focus, and to shift resources in the process, means that adequate time and resources for IPP are often overlooked. Shared interprofessional student placements may be one way forward.
PMCID: PMC3915222  PMID: 24479605
Interprofessional practice; Territorialism; Co-location; Community mental health; Primary health care
16.  Collaboration between general practitioners and mental health care professionals: a qualitative study 
Collaboration between general practice and mental health care has been recognised as necessary to provide good quality healthcare services to people with mental health problems. Several studies indicate that collaboration often is poor, with the result that patient' needs for coordinated services are not sufficiently met, and that resources are inefficiently used. An increasing number of mental health care workers should improve mental health services, but may complicate collaboration and coordination between mental health workers and other professionals in the treatment chain. The aim of this qualitative study is to investigate strengths and weaknesses in today's collaboration, and to suggest improvements in the interaction between General Practitioners (GPs) and specialised mental health service.
This paper presents a qualitative focus group study with data drawn from six groups and eight group sessions with 28 health professionals (10 GPs, 12 nurses, and 6 physicians doing post-doctoral training in psychiatry), all working in the same region and assumed to make professional contact with each other.
GPs and mental health professionals shared each others expressions of strengths, weaknesses and suggestions for improvement in today's collaboration. Strengths in today's collaboration were related to common consultations between GPs and mental health professionals, and when GPs were able to receive advice about diagnostic treatment dilemmas. Weaknesses were related to the GPs' possibility to meet mental health professionals, and lack of mutual knowledge in mental health services. The results describe experiences and importance of interpersonal knowledge, mutual accessibility and familiarity with existing systems and resources. There is an agreement between GPs and mental health professionals that services will improve with shared knowledge about patients through systematic collaborative services, direct cell-phone lines to mental health professionals and allocated times for telephone consultation.
GPs and mental health professionals experience collaboration as important. GPs are the gate-keepers to specialised health care, and lack of collaboration seems to create problems for GPs, mental health professionals, and for the patients. Suggestions for improvement included identification of situations that could increase mutual knowledge, and make it easier for GPs to reach the right mental health care professional when needed.
PMCID: PMC3123285  PMID: 21600067
17.  Results after one year introduction of disease oriented payments in the Netherlands 
The purpose of our study was to show the first results after introduction of disease oriented payments for diabetes mellitus type II in the Netherlands.
In 2010 disease oriented payment for diabetes mellitus type II was introduced nationwide in the Netherlands. In disease oriented payment, care for disease groups is organised by a care group that organises both general and more specialised care, and that negotiate a lumpsum for each patient with the health insurer. The care groups can either provide care themselves or sub-contract other providers. Included services within the care program are based on national health care standards. Aim of disease oriented payments is to improve care for chronically ill, by stimulating multidisciplinary collaboration between health care providers.
Selection of patients, health care utilization, organisation of care and self management needs were analysed with the aid data from written structured questionnaires from the National Panel of people with Chronic Illness or Disability (n=275) and data from electronic medical records of general practitioners (n=1144). Diabetes patients with and without disease oriented payment were compared.
Results and conclusions
Our first results show no evidence of selection of patients within disease oriented payments. And hardly any differences in the care between diabetes patients with and without disease oriented payments. Diabetes patients within disease oriented payments tended to go less often to a dietician after the introduction of disease oriented payments. It seems that patients within disease oriented payments receive part of their care from less specialist health care providers. Also, care to diabetes patients within disease oriented payment was only to a limited degree provided according to a programmatic approach.
PMCID: PMC3617746
disease oriented payments; chronically ill; diabetes mellitus type II; the Netherlands
18.  A Case Study of Early Experience with Implementation of Collaborative Care in the Veterans Health Administration 
Population Health Management  2010;13(6):331-337.
Primary care remains critically important for those who suffer from mental disorders. Although collaborative care, which integrates mental health services into primary care, has been shown to be more effective than usual care, its implementation has been slow and the experience of providers and patients with collaborative care is less well known. The objective of this case study was to examine the effects of collaborative care on patient and primary care provider (PCP) experiences and communication during clinical encounters.
Participating physicians completed a self-administered visit reconstruction questionnaire in which they logged details of patient visits and described their perceptions of the visits and the influence of collaborative care. Audio recordings of visits were analyzed to assess the extent of discussion about colocated mental health services and visit time devoted to mental health topics.
The main outcome measures were the extent of discussion and recommendation for collaborative care during clinical visits and providers' experiences based on their responses to the visit reconstruction questionnaire. Providers surveyed expressed enthusiasm about collaborative care and cited the time constraint of office visits and lack of specialty support as the main reasons for limiting their discussion of mental health topics with patients. Despite the availability of mental health providers at the same clinic, PCPs missed many opportunities to address mental health issues with their patients. Ongoing education for PCPs regarding how to conduct a “warm handoff” to colocated providers will need to be an integral part of the implementation of collaborative care. (Population Health Management 2010;13:331–337)
PMCID: PMC3135899  PMID: 21090989
19.  Translating research into practice in Leeds and Bradford (TRiPLaB): a protocol for a programme of research 
The National Institute for Health Research (NIHR) has funded nine Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). Each CLAHRC is a partnership between higher education institutions (HEIs) and the NHS in nine UK regional health economies. The CLAHRC for Leeds, York, and Bradford comprises two 'research themes' and three 'implementation themes.' One of these implementation themes is Translating Research into Practice in Leeds and Bradford (TRiPLaB). TRiPLaB aims to develop, implement, and evaluate methods for inducing and sustaining the uptake of research knowledge into practice in order to improve the quality of health services for the people of Leeds and Bradford.
TRiPLaB is built around a three-stage, sequential, approach using separate, longitudinal case studies conducted with collaborating NHS organisations, TRiPLaB will select robust innovations to implement, conduct a theory-informed exploration of the local context using a variety of data collection and analytic methods, and synthesise the information collected to identify the key factors influencing the uptake and adoption of targeted innovations. This synthesis will inform the development of tailored, multifaceted, interventions designed to increase the translation of research findings into practice. Mixed research methods, including time series analysis, quasi-experimental comparison, and qualitative process evaluation, will be used to evaluate the impact of the implementation strategies deployed.
TRiPLaB is a theory-informed, systematic, mixed methods approach to developing and evaluating tailored implementation strategies aimed at increasing the translation of research-based findings into practice in one UK health economy. Through active collaboration with its local NHS, TRiPLaB aims to improve the quality of health services for the people of Leeds and Bradford and to contribute to research knowledge regarding the interaction between context and adoption behaviour in health services.
PMCID: PMC2889856  PMID: 20492651
20.  Collaborations for Leadership in Applied Health Research and Care: lessons from the theory of communities of practice 
The paper combines the analytical and instrumental perspectives on communities of practice (CoPs) to reflect on potential challenges that may arise in the process of interprofessional and inter-organisational joint working within the Collaborations for Leaderships in Applied Health Research and Care (CLAHRCs)--partnerships between the universities and National Health Service (NHS) Trusts aimed at conducting applied health research and translating its findings into day-to-day clinical practice.
The paper discusses seminal theoretical literature on CoPs as well as previous empirical research on the role of these communities in healthcare collaboration, which is organised around the following three themes: knowledge sharing within and across CoPs, CoP formation and manageability, and identity building in CoPs. It argues that the multiprofessional and multi-agency nature of the CLAHRCs operating in the traditionally demarcated organisational landscape of the NHS may present formidable obstacles to knowledge sharing between various professional groupings, formation of a shared 'collaborative' identity, and the development of new communities within the CLAHRCs. To cross multiple boundaries between various professional and organisational communities and hence enable the flow of knowledge, the CLAHRCs will have to create an effective system of 'bridges' involving knowledge brokers, boundary objects, and cross-disciplinary interactions as well as address a number of issues related to professional and organisational identification.
The CoP approach can complement traditional 'stage-of-change' theories used in the field of implementation research and provide a basis for designing theory-informed interventions and evaluations. It can help to illuminate multiple boundaries that exist between professional and organisational groups within the CLAHRCs and suggest ways of crossing those boundaries to enable knowledge transfer and organisational learning. Achieving the aims of the CLAHRCs and producing a sustainable change in the ways applied health research is conducted and implemented may be influenced by how effectively these organisations can navigate through the multiple CoPs involved and promote the development of new multiprofessional and multi-organisational communities united by shared practice and a shared sense of belonging--an assumption that needs to be explored by further empirical research.
PMCID: PMC3130688  PMID: 21699712
21.  Revitalizing Care Program in UK Healthcare: Does It Add Up? 
Global Advances in Health and Medicine  2014;3(Suppl 1):BPA10.
The National Health Service (NHS) is a publicly funded health service in the United Kingdom that provides free point-of-use services for UK residents. In England, the NHS annual budget currently equates to £106 million. As the global financial climate has changed, so too has the real-terms budget available to meet spiralling healthcare costs in the United Kingdom. There is now unprecedented pressure on NHS Trusts to provide efficiency savings while maintaining the same levels of clinical service availability. In this climate, concerns arise regarding how best to ensure maintenance of the quality of service users experience of their care in addition to efficacy and efficiency targets.
Barts Health NHS Trust is the largest healthcare trust in the United Kingdom. A collaboration of stakeholders was established in 2010 to ensure an increased focus on the provision of compassionate care in all patient services as part of enhancing the overall patient experience. This initiative incorporated the implementation of the HeartMath Revitalizing Care Program in order to build staff resilience and enable workers to more efficiently manage their work and personal stress. Additionally, the project implementation enabled the first trial of the HeartMath Revitalizing Care Program within the context of NHS England services.
Using a pilot program model, the HeartMath Revitalizing Care Program was provided in four departments in the Trust from August to October 2011. Pilot areas included three clinical wards and one reception area. Over the 3-month period, 97 staff members participated in the workshops. Evaluation of the project was conducted using pre and post measures at two time points through the completion of the Personal and Organizational Quality Assessment – Revised 4 Scale (POQA-R4) and review of staff turnover, sickness absence rates, and complaints.
The evaluation indicated that the participants demonstrated improvements in nine of the 10 personal qualities categories. These changes were statistically significant in eight areas, with fatigue and calmness showing the greatest evidence of change. Only one area in the rating of organizational qualities showed a statistically significant change, which was expected due to the short timeframe of the post-project evaluation. The results of the pre-post comparison of staff turnover, sickness absence, and complaints were inconclusive.
The completion of the pilot project clearly demonstrated both a direct benefit for staff and the transferability of the HeartMath Revitalizing Care program to the UK health provider context. Further evaluation is required to determine the impact of building staff resilience on improving service-user's experience of care.
PMCID: PMC3923287
Personal and Organizational Quality Assessment; resilience; stress reduction; HeartMath; biofeedback
22.  Social organization of self-management support of persons with diabetes: A health systems comparison 
Identify important organizational elements for providing self-management support (SMS).
Semi-structured qualitative interviews conducted in two healthcare systems.
Kaiser Permanente Northern California and the Danish Health Care System.
36 managers and healthcare professionals in the two healthcare systems.
Main outcome measures
Elements important to providing self-management support to persons with diabetes.
Healthcare professionals’ provision of SMS was influenced by healthcare system organization and their perceptions of SMS, the capability and responsibility of healthcare systems, and their roles in the healthcare organization. Enabling factors for providing SMS included: strong leadership; aligned incentives; use of an integrated health information technology (HIT) system; multidisciplinary healthcare provider teams; ongoing training for healthcare professionals; outreach; and quality goals. Barriers to providing SMS included lack of collaboration between providers and skeptical attitudes towards prevention and outreach.
Conclusions and implications
Implementation of SMS can be improved by an understanding of the elements that enhance its provision: (1) initiatives seeking to improve collaboration and integration between providers; (2) implementation of an integrated HIT system; and (3) ongoing training of healthcare professionals.
PMCID: PMC3443944  PMID: 22839353
Denmark; diabetes mellitus; general practice; health system; international comparison; patient education; self-management support
23.  Opportunities for improving the nation's health through collaboration with the mass media. 
Public Health Reports  1990;105(3):219-223.
Understanding the mass media is a prerequisite to gaining the cooperation of those who control access to media time and space to improve the coverage of health issues about which the public needs, and often wants, to know. To address the complexities of the mass media and how they influence the public's health, a group of Public Health Service agencies, foundations, and research institutions collaborated to review recent changes in the mass media and public health sectors and to recommend steps for increased interaction. These included broadening strategies to include paid advertising, media advocacy, and other tactics beyond public service campaigns; increasing awareness within the public health sector of the media's perspective on health; working collaboratively with media professionals and organizations, including the minority media; and developing guidelines for public-private sector partnerships. These recommendations, and factors affecting the roles of the media and public health communities in informing the public about health, are described in this paper. A complete discussion of these recommendations and related issues can be found in "Mass Media and Health," edited by Caroline McNeil and Elaine Bratic Arkin, a forthcoming publication of the Office of Disease Prevention and Health Promotion, Public Health Service.
PMCID: PMC1579999  PMID: 2113678
24.  Developing European guidelines for training care professionals in mental health promotion 
BMC Public Health  2012;12:1114.
Although mental health promotion is a priority mental health action area for all European countries, high level training resources and high quality skills acquisition in mental health promotion are still relatively rare. The aim of the current paper is to present the results of the DG SANCO-funded PROMISE project concerning the development of European guidelines for training social and health care professionals in mental health promotion.
The PROMISE project brought together a multidisciplinary scientific committee from eight European sites representing a variety of institutions including universities, mental health service providers and public health organisations. The committee used thematic content analysis to filter and analyse European and international policy documents, scientific literature reviews on mental health promotion and existing mental health promotion programmes with regard to identifying quality criteria for training care professionals on this subject. The resulting PROMISE Guidelines quality criteria were then subjected to an iterative feedback procedure with local steering groups and training professionals at all sites with the aim of developing resource kits and evaluation tools for using the PROMISE Guidelines. Scientific committees also collected information from European, national and local stakeholder groups and professional organisations on existing training programmes, policies and projects.
The process identified ten quality criteria for training care professionals in mental health promotion: embracing the principle of positive mental health; empowering community stakeholders; adopting an interdisciplinary and intersectoral approach; including people with mental health problems; advocating; consulting the knowledge base; adapting interventions to local contexts; identifying and evaluating risks; using the media; evaluating training, implementation processes and outcomes. The iterative feedback process produced resource kits and evaluation checklists linked with each of these quality criteria in all PROMISE languages.
The development of generic guidelines based on key quality criteria for training health and social care professionals in mental health promotion should contribute in a significant way to implementing policy in this important area.
PMCID: PMC3553026  PMID: 23270332
Mental health promotion; Training; Best practice guidelines
25.  Collaborative working within UK NHS secondary care and across sectors for COPD and the impact of peer review: qualitative findings from the UK National COPD Resources and Outcomes Project 
We investigated the effects on collaborative work within the UK National Health Service (NHS) of an intervention for service quality improvement: informal, structured, reciprocated, multidisciplinary peer review with feedback and action plans. The setting was care for chronic obstructive pulmonary disease (COPD).
Theory and methods
We analysed semi-structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control sites, as part of a UK randomised controlled study, the National COPD Resources and Outcomes Project (NCROP), using Scott's conceptual framework for action (inter-organisational, intra-organisational, inter-professional and inter-individual). Three areas of care targeted by NCROP involved collaboration across primary and secondary care.
Hospital respiratory department collaborations with commissioners and hospital managers varied. Analysis suggested that this is related to team responses to barriers. Clinicians in unsuccessful collaborations told ‘atrocity stories’ of organisational, structural and professional barriers to service improvement. The others removed barriers by working with government and commissioner agendas to ensure continued involvement in patients' care. Multidisciplinary peer review facilitated collaboration between participants, enabling them to meet, reconcile differences and exchange ideas across boundaries.
The data come from the first randomised controlled trial of organisational peer review, adding to research into UK health service collaborative work, which has had a more restricted focus on inter-professional relations. NCROP peer review may only modestly improve collaboration but these data suggest it might be more effective than top-down exhortations to change when collaboration both across and within organisations is required.
PMCID: PMC2948684  PMID: 20922063
collaboration; inter-organizational; inter-professional; quality improvement; respiratory disease

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