case study on quality management in healthcare

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Case Study: The Implementation of Total Quality Management at the Charleston VA Medical Center's Dental Service

The views expressed in this article are those of the author and do not reflect the official policy or position of the U.S. Air Force, Department of Defense, or the Department of Veterans Affairs.

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Barry L. Matthews, Case Study: The Implementation of Total Quality Management at the Charleston VA Medical Center's Dental Service, Military Medicine , Volume 157, Issue 1, January 1992, Pages 21–24, https://doi.org/10.1093/milmed/157.1.21

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Total Quality Management (TQM) is an evolving management philosophy which has recently been introduced to the health care industry. TQM requires the use of a continuous process improvement methodology for delivered services. It was implemented at Charleston VAMC's Dental Service as a study to determine its effectiveness at the grassroots level. A modified Quality Circle was established within the clinical service under the guidance of Dr. Edward Deming's 14 principles. Top management support was not present. Many lessons were learned as process improvements were made. The overall success was limited due to the inability to address interdepartment process problems.

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The role of place on healthcare quality improvement: A qualitative case study of a teaching hospital

Affiliation.

• 1 Queen's Management School, Queen's University Belfast, Riddel Hall, 185 Stranmillis Road, Belfast, BT9 5EE, Northern Ireland, UK. Electronic address: [email protected].
• PMID: 29524869
• DOI: 10.1016/j.socscimed.2018.03.003

This article examines how the built environment impacts, and is impacted by, healthcare staff day to day practice, care outcomes and the design of new quality and patient safety (Q&PS) projects. It also explores how perceptions of the built environment affect inter-professional dynamics. In doing so, it contributes to the overlooked interplay between the physical, social, and symbolic dimensions associated with a hospital's place. The study draws on 46 in-depth semi-structured interviews conducted at a large teaching hospital in Portugal formed by two buildings. Interview transcripts were analysed inductively using thematic analysis. The major contribution of this study is to advance the understanding of the interactions among the different dimensions of place on Q&PS improvement. For example, findings indicate that some of the characteristics of the physical infrastructure of the hospital have a negative impact on the quality of care provided and/or significantly limit the initiatives that can be implemented to improve it, including refurbishment works. However, decisions on refurbishment works were also influenced by the characteristics of the patient population, hospital budget, etc. Likewise, clinicians' emotional reactions to the limitations of the buildings depended on their expectations of the buildings and the symbolic projections they attributed to them. Nevertheless, differences between clinicians' expectations regarding the physical infrastructure and its actual features influenced clinicians' views on Q&PS initiatives designed by non-clinicians.

Keywords: Case study; Healthcare quality management; Hospital; Patient safety; Place.

Copyright © 2018. Published by Elsevier Ltd.

Publication types

• Research Support, Non-U.S. Gov't
• Hospital Design and Construction*
• Hospitals, Teaching / statistics & numerical data*
• Organizational Case Studies
• Patient Safety
• Qualitative Research
• Quality Improvement / organization & administration*

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Please note you do not have access to teaching notes, integrated approach to healthcare quality management: a case study.

The TQM Magazine

ISSN : 0954-478X

Article publication date: 1 November 2006

The purpose of the paper is to develop an integrated quality management model, which identifies problems, suggests solutions, develops a framework for implementation and helps evaluate performance of health care services dynamically.

Design/methodology/approach

This paper uses logical framework analysis (LFA), a matrix approach to project planning for managing quality. This has been applied to three acute healthcare services (Operating room utilization, Accident and emergency, and Intensive care) in order to demonstrate its effectiveness.

The paper finds that LFA is an effective method of quality management of hospital‐based healthcare services.

Research limitations/implications

This paper shows LFA application in three service processes in one hospital. However, ideally this is required to be tested in several hospitals and other services as well.

Practical implications

In the paper the proposed model can be practised in hospital‐based healthcare services for improving performance.

Originality/value

The paper shows that quality improvement in healthcare services is a complex and multi‐dimensional task. Although various quality management tools are routinely deployed for identifying quality issues in health care delivery and corrective measures are taken for superior performance, there is an absence of an integrated approach, which can identify and analyze issues, provide solutions to resolve those issues, develop a project management framework (planning, monitoring, and evaluating) to implement those solutions in order to improve process performance. This study introduces an integrated and uniform quality management tool. It integrates operations with organizational strategies.

• Service operations
• Health services
• Quality management

Dey, P.K. and Hariharan, S. (2006), "Integrated approach to healthcare quality management: a case study", The TQM Magazine , Vol. 18 No. 6, pp. 583-605. https://doi.org/10.1108/09544780610707093

Emerald Group Publishing Limited

Copyright © 2006, Emerald Group Publishing Limited

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Total quality management: three case studies from around the world

With organisations to run and big orders to fill, it’s easy to see how some ceos inadvertently sacrifice quality for quantity. by integrating a system of total quality management it’s possible to have both.

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There are few boardrooms in the world whose inhabitants don’t salivate at the thought of engaging in a little aggressive expansion. After all, there’s little room in a contemporary, fast-paced business environment for any firm whose leaders don’t subscribe to ambitions of bigger factories, healthier accounts and stronger turnarounds. Yet too often such tales of excess go hand-in-hand with complaints of a severe drop in quality.

Food and entertainment markets are riddled with cautionary tales, but service sectors such as health and education aren’t immune to the disappointing by-products of unsustainable growth either. As always, the first steps in avoiding a catastrophic forsaking of quality begins with good management.

There are plenty of methods and models geared at managing the quality of a particular company’s goods or services. Yet very few of those models take into consideration the widely held belief that any company is only as strong as its weakest link. With that in mind, management consultant William Deming developed an entirely new set of methods with which to address quality.

Deming, whose managerial work revolutionised the titanic Japanese manufacturing industry, perceived quality management to be more of a philosophy than anything else. Top-to-bottom improvement, he reckoned, required uninterrupted participation of all key employees and stakeholders. Thus, the total quality management (TQM) approach was born.

All in Similar to the Six Sigma improvement process, TQM ensures long-term success by enforcing all-encompassing internal guidelines and process standards to reduce errors. By way of serious, in-depth auditing – as well as some well-orchestrated soul-searching – TQM ensures firms meet stakeholder needs and expectations efficiently and effectively, without forsaking ethical values.

By opting to reframe the way employees think about the company’s goals and processes, TQM allows CEOs to make sure certain things are done right from day one. According to Teresa Whitacre, of international consulting firm ASQ , proper quality management also boosts a company’s profitability.

“Total quality management allows the company to look at their management system as a whole entity — not just an output of the quality department,” she says. “Total quality means the organisation looks at all inputs, human resources, engineering, production, service, distribution, sales, finance, all functions, and their impact on the quality of all products or services of the organisation. TQM can improve a company’s processes and bottom line.”

Embracing the entire process sees companies strive to improve in several core areas, including: customer focus, total employee involvement, process-centred thinking, systematic approaches, good communication and leadership and integrated systems. Yet Whitacre is quick to point out that companies stand to gain very little from TQM unless they’re willing to go all-in.

“Companies need to consider the inputs of each department and determine which inputs relate to its governance system. Then, the company needs to look at the same inputs and determine if those inputs are yielding the desired results,” she says. “For example, ISO 9001 requires management reviews occur at least annually. Aside from minimum standard requirements, the company is free to review what they feel is best for them. While implementing TQM, they can add to their management review the most critical metrics for their business, such as customer complaints, returns, cost of products, and more.”

The customer knows best: AtlantiCare TQM isn’t an easy management strategy to introduce into a business; in fact, many attempts tend to fall flat. More often than not, it’s because firms maintain natural barriers to full involvement. Middle managers, for example, tend to complain their authority is being challenged when boots on the ground are encouraged to speak up in the early stages of TQM. Yet in a culture of constant quality enhancement, the views of any given workforce are invaluable.

AtlantiCare in numbers

5,000 Employees

$280m Profits before quality improvement strategy was implemented

$650m Profits after quality improvement strategy

One firm that’s proven the merit of TQM is New Jersey-based healthcare provider AtlantiCare . Managing 5,000 employees at 25 locations, AtlantiCare is a serious business that’s boasted a respectable turnaround for nearly two decades. Yet in order to increase that margin further still, managers wanted to implement improvements across the board. Because patient satisfaction is the single-most important aspect of the healthcare industry, engaging in a renewed campaign of TQM proved a natural fit. The firm chose to adopt a ‘plan-do-check-act’ cycle, revealing gaps in staff communication – which subsequently meant longer patient waiting times and more complaints. To tackle this, managers explored a sideways method of internal communications. Instead of information trickling down from top-to-bottom, all of the company’s employees were given freedom to provide vital feedback at each and every level.

AtlantiCare decided to ensure all new employees understood this quality culture from the onset. At orientation, staff now receive a crash course in the company’s performance excellence framework – a management system that organises the firm’s processes into five key areas: quality, customer service, people and workplace, growth and financial performance. As employees rise through the ranks, this emphasis on improvement follows, so managers can operate within the company’s tight-loose-tight process management style.

After creating benchmark goals for employees to achieve at all levels – including better engagement at the point of delivery, increasing clinical communication and identifying and prioritising service opportunities – AtlantiCare was able to thrive. The number of repeat customers at the firm tripled, and its market share hit a six-year high. Profits unsurprisingly followed. The firm’s revenues shot up from $280m to $650m after implementing the quality improvement strategies, and the number of patients being serviced dwarfed state numbers.

Hitting the right notes: Santa Cruz Guitar Co For companies further removed from the long-term satisfaction of customers, it’s easier to let quality control slide. Yet there are plenty of ways in which growing manufacturers can pursue both quality and sales volumes simultaneously. Artisan instrument makers the Santa Cruz Guitar Co (SCGC) prove a salient example. Although the California-based company is still a small-scale manufacturing operation, SCGC has grown in recent years from a basement operation to a serious business.

SCGC in numbers

14 Craftsmen employed by SCGC

800 Custom guitars produced each year

Owner Dan Roberts now employs 14 expert craftsmen, who create over 800 custom guitars each year. In order to ensure the continued quality of his instruments, Roberts has created an environment that improves with each sale. To keep things efficient (as TQM must), the shop floor is divided into six workstations in which guitars are partially assembled and then moved to the next station. Each bench is manned by a senior craftsman, and no guitar leaves that builder’s station until he is 100 percent happy with its quality. This product quality is akin to a traditional assembly line; however, unlike a traditional, top-to-bottom factory, Roberts is intimately involved in all phases of instrument construction.

Utilising this doting method of quality management, it’s difficult to see how customers wouldn’t be satisfied with the artists’ work. Yet even if there were issues, Roberts and other senior management also spend much of their days personally answering web queries about the instruments. According to the managers, customers tend to be pleasantly surprised to find the company’s senior leaders are the ones answering their technical questions and concerns. While Roberts has no intentions of taking his manufacturing company to industrial heights, the quality of his instruments and high levels of customer satisfaction speak for themselves; the company currently boasts one lengthy backlog of orders.

A quality education: Ramaiah Institute of Management Studies Although it may appear easier to find success with TQM at a boutique-sized endeavour, the philosophy’s principles hold true in virtually every sector. Educational institutions, for example, have utilised quality management in much the same way – albeit to tackle decidedly different problems.

The global financial crisis hit higher education harder than many might have expected, and nowhere have the odds stacked higher than in India. The nation plays home to one of the world’s fastest-growing markets for business education. Yet over recent years, the relevance of business education in India has come into question. A report by one recruiter recently asserted just one in four Indian MBAs were adequately prepared for the business world.

RIMS in numbers

9% Increase in test scores post total quality management strategy

22% Increase in number of recruiters hiring from the school

20,000 Increase in the salary offered to graduates

50,000 Rise in placement revenue

At the Ramaiah Institute of Management Studies (RIMS) in Bangalore, recruiters and accreditation bodies specifically called into question the quality of students’ educations. Although the relatively small school has always struggled to compete with India’s renowned Xavier Labour Research Institute, the faculty finally began to notice clear hindrances in the success of graduates. The RIMS board decided it was time for a serious reassessment of quality management.

The school nominated Chief Academic Advisor Dr Krishnamurthy to head a volunteer team that would audit, analyse and implement process changes that would improve quality throughout (all in a particularly academic fashion). The team was tasked with looking at three key dimensions: assurance of learning, research and productivity, and quality of placements. Each member underwent extensive training to learn about action plans, quality auditing skills and continuous improvement tools – such as the ‘plan-do-study-act’ cycle.

Once faculty members were trained, the team’s first task was to identify the school’s key stakeholders, processes and their importance at the institute. Unsurprisingly, the most vital processes were identified as student intake, research, knowledge dissemination, outcomes evaluation and recruiter acceptance. From there, Krishnamurthy’s team used a fishbone diagram to help identify potential root causes of the issues plaguing these vital processes. To illustrate just how bad things were at the school, the team selected control groups and administered domain-based knowledge tests.

The deficits were disappointing. A RIMS students’ knowledge base was rated at just 36 percent, while students at Harvard rated 95 percent. Likewise, students’ critical thinking abilities rated nine percent, versus 93 percent at MIT. Worse yet, the mean salaries of graduating students averaged $36,000, versus $150,000 for students from Kellogg. Krishnamurthy’s team had their work cut out.

To tackle these issues, Krishnamurthy created an employability team, developed strategic architecture and designed pilot studies to improve the school’s curriculum and make it more competitive. In order to do so, he needed absolutely every employee and student on board – and there was some resistance at the onset. Yet the educator asserted it didn’t actually take long to convince the school’s stakeholders the changes were extremely beneficial.

“Once students started seeing the results, buy-in became complete and unconditional,” he says. Acceptance was also achieved by maintaining clearer levels of communication with stakeholders. The school actually started to provide shareholders with detailed plans and projections. Then, it proceeded with a variety of new methods, such as incorporating case studies into the curriculum, which increased general test scores by almost 10 percent. Administrators also introduced a mandate saying students must be certified in English by the British Council – increasing scores from 42 percent to 51 percent.

By improving those test scores, the perceived quality of RIMS skyrocketed. The number of top 100 businesses recruiting from the school shot up by 22 percent, while the average salary offers graduates were receiving increased by $20,000. Placement revenue rose by an impressive $50,000, and RIMS has since skyrocketed up domestic and international education tables.

No matter the business, total quality management can and will work. Yet this philosophical take on quality control will only impact firms that are in it for the long haul. Every employee must be in tune with the company’s ideologies and desires to improve, and customer satisfaction must reign supreme.

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Healthcare Quality Management: A Case Study Approach 1st Edition, Kindle Edition

Healthcare Quality Management: A Case Study Approach is the first comprehensive case-based text combining essential quality management knowledge with real-world scenarios. With in-depth healthcare quality management case studies, tools, activities, and discussion questions, the text helps build the competencies needed to succeed in quality management.

Written in an easy-to-read style, Part One of the textbook introduces students to the fundamentals of quality management, including history, culture, and different quality management philosophies, such as Lean and Six Sigma. Part One additionally explains the A3 problem-solving template used to follow the Plan-Do-Study-Act (PDSA) or Define, Measure, Analyze, Improve, and Control (DMAIC) cycles, that guides your completion of the problem-solving exercises found in Part Two. The bulk of the textbook includes realistic and engaging case studies featuring common quality management problems encountered in a variety of healthcare settings. The case studies feature engaging scenarios, descriptions, opinions, charts, and data, covering such contemporary topics as provider burnout, artificial intelligence, the opioid overdose epidemic, among many more.

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About the author.

Zachary Pruitt, PhD, MHA, CPH, is assistant professor and director of community practice at the University of South Florida College of Public Health.

Candace S. Smith, PhD, RN, NEA-BC, is chief nursing officer at Manatee Memorial Hospital.

Eddie Pérez-Ruberté, MS, is senior Lean project manager at BayCare Health Systems who leads the deployment of the Lean management system and culture. Eddie is a certified Lean expert and a certified Six Sigma Black Belt from the American Society for Quality. He also helps organizations implement Lean programs through his consulting company, Areito Group. Eddie is an instructor for the Institute of Industrial and Systems Engineers where he teaches Lean and Six Sigma and certifies students in these methodologies at multiple universities and healthcare organizations across the United States.

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• Open access
• Published: 13 May 2024

Nurse perceptions of practice environment, quality of care and patient safety across four hospital levels within the public health sector of South Africa

• Immaculate Sabelile Tenza 1 ,
• Alwiena J. Blignaut 1 ,
• Suria M. Ellis 2 &
• Siedine K. Coetzee 1  

BMC Nursing volume  23 , Article number:  324 ( 2024 ) Cite this article

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Improving the practice environment, quality of care and patient safety are global health priorities. In South Africa, quality of care and patient safety are among the top goals of the National Department of Health; nevertheless, empirical data regarding the condition of the nursing practice environment, quality of care and patient safety in public hospitals is lacking.

This study examined nurses’ perceptions of the practice environment, quality of care and patient safety across four hospital levels (central, tertiary, provincial and district) within the public health sector of South Africa.

This was a cross-sectional survey design. We used multi-phase sampling to recruit all categories of nursing staff from central ( n  = 408), tertiary ( n  = 254), provincial ( n  = 401) and district ( n  = 244 [large n  = 81; medium n  = 83 and small n  = 80]) public hospitals in all nine provinces of South Africa. After ethical approval, a self-reported questionnaire with subscales on the practice environment, quality of care and patient safety was administered. Data was collected from April 2021 to June 2022, with a response rate of 43.1%. ANOVA type Hierarchical Linear Modelling (HLM) was used to present the differences in nurses’ perceptions across four hospital levels.

Nurses rated the overall practice environment as poor (M = 2.46; SD = 0.65), especially with regard to the subscales of nurse participation in hospital affairs (M = 2.22; SD = 0.76), staffing and resource adequacy (M = 2.23; SD = 0.80), and nurse leadership, management, and support of nurses (M = 2.39; SD = 0.81). One-fifth (19.59%; n  = 248) of nurses rated the overall grade of patient safety in their units as poor or failing, and more than one third (38.45%; n  = 486) reported that the quality of care delivered to patient was fair or poor. Statistical and practical significant results indicated that central hospitals most often presented more positive perceptions of the practice environment, quality of care and patient safety, while small district hospitals often presented the most negative. The practice environment was most highly correlated with quality of care and patient safety outcomes.

There is a need to strengthen compliance with existing policies that enhance quality of care and patient safety. This includes the need to create positive practice environments in all public hospitals, but with an increased focus on smaller hospital settings.

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Improving the nurse practice environment, quality of healthcare and patient safety has become a global priority [ 1 ]. This is because countries worldwide are striving to provide universal health coverage (UHC) to their citizens, and quality and safe care has been prioritised in the agenda to achieve UHC [ 2 , 3 ]. Recently there has been an increase in scholarly attention on the relationship between the nurse practice environment, quality of healthcare and patient safety, with global consensus that a positive nurse practice environment contributes positively to these [ 4 ].

The nurse practice environment is defined as the organisational characteristics of a work context that facilitate or constrain professional nursing practice [ 5 ]. Quality of care is the degree to which health services for individuals and populations increase the likelihood of the desired health outcomes [ 6 ], and patient safety is a dimension of quality of care and is defined as the avoidance of unintended or unexpected harm to people during the provision of healthcare [ 1 ].

Studies on the nurse practice environment have focused on nurse participation in organisational affairs, staffing and resource adequacy, and nurse leadership, management, and support of nurses, nurse-physician collegial relations, and foundations of quality of care [ 7 , 8 , 9 ]. A recent meta-analysis [ 10 ] found consistent and significant associations between the practice environment and quality of care and patient safety, based on data from 1,368,420 patients in 22 countries (including South Africa), 141 nursing units, 165,024 nurses, and 2677 hospitals. Ten years ago, a South African article—the only one from Africa included in this meta-analysis—showed the following trends: 52.3% of nurses assessed their practice environment as either poor or fair, 20.7% rated the quality of care as either poor or fair, and 5.5% rated patient safety as inadequate or failing [ 11 ]. In all cases, the public sector had worse outcomes than the private sector; and the study concluded that the nurse practice environment was significantly associated with better nurse and patient outcomes [ 11 ]. No national study has since followed this, with most studies focusing on small-scale or single-site qualitative and quantitative descriptive studies. Furthermore the variables of interest were explored separately from each other, such as the influence of the nurse practice environment on nurse outcomes [ 12 , 13 ], professional nurses’ understanding of quality nursing care [ 14 ], with a primary focus on patient safety culture [ 13 , 15 , 16 , 17 ]. Quality of care and patient safety studies in South Africa reported negative experiences of health providers, but these were not linked with the practice environment, even with ample evidence of its influence. One significant issue is the existence of policy documents that govern quality of care and patient safety in the nation. These include the following: the Patient Rights Charter, the Batho Pele principles, the National Core Standards framework [ 18 ], the National Guideline for Patient Safety Incident Reporting [ 19 ], and the Ideal Facility Framework [ 20 ]. Despite the aforementioned governmental obligations, achieving quality in healthcare continues to be a struggle [ 21 ]. This has been evidenced by the reports of litigations experienced by public health hospitals [ 22 ]. A major concern of the National Department of Health is the sudden increase in expenditure related to medico-legal claims. In the 2020/2021 financial year, more than ZAR6.5 billion (US $343,496.02) was awarded in medicolegal claims in the public sector [ 23 ].

Nurses as frontline, street-level bureaucrats in the implementation of the policies related to quality of care and patient safety in healthcare have critical experience of the nurse practice environment, quality of care and patient safety, and their views could contribute to future improvements [ 5 ]. Given existing evidence that the nurse practice environment influences quality of care and patient safety, it is important to understand the current situation. While there are existing policies directing quality of care and patient safety, it is not known how having these policies in place shapes the nurse practice environment, perceived quality of care and patient safety. This article expands on the findings of a previous national study [ 11 ], which demonstrated that the public sector had a more negative nurse practice environment, quality of care and patient safety. To add to the body of knowledge, this study examines the public sector and four hospital levels: central, tertiary, provincial, and district (small, medium, and large) hospitals. Hence this national study sought to examine nurses' perceptions of the practice environment, quality of care and patient safety across four hospital levels within the public health sector of South Africa.

Theoretical framework

This study is based on the theoretical framework of Tvedt et al. [ 24 ], which is a system perspective based on the model of Donabedian and modified by Battles (2006) to show how hospital structures and practice environment features improve quality of care and patient safety [ 24 ]. These outcomes are specifically identified as quality of care, patient safety (work-related outcome measures), and low-frequency adverse events and self-care ability (patient-related outcome measures).

Study context

This study was conducted in all nine provinces of South Africa, namely, Northern Cape, Western Cape, Eastern Cape, Free State, North West, Gauteng, Limpopo, Mpumalanga, and KwaZulu-Natal. South Africa has a two-tier healthcare system, with a public and a private sector [ 18 , 25 ]. The public sector is state-funded and caters to the majority – 71% – of the population [ 19 , 25 ]. The private sector is largely funded through individual contributions to medical aid schemes or health insurance, and serves a minority of the population [ 20 , 25 ]. This study focused on the public sector hospitals as they cater for the majority of the population. There are five categories of hospitals in the public sector, including district, regional, tertiary, central, and specialised hospitals, which are categorised according to the nature and extent of services provided and size [ 26 ]. The first point of entry to the South African health system is through primary healthcare (PHC) facilities, often referred to as clinics. Patients are referred from PHC facilities to district hospitals, regional, tertiary and central hospitals or specialised hospitals [ 26 ]. District hospitals are categorised into small, medium, and large district hospitals. Small district hospitals have between 50 and 150 beds; medium district hospitals have between 150 and 300 beds; and large district hospitals have between 300 and 600 beds [ 26 ]. These hospitals serve a defined population within a health district and support PHC facilities, providing services that include in-patient, ambulatory health services as well as emergency health services [ 26 ]. A regional hospital has between 200 and 800 beds and receives referrals from several district hospitals. Regional hospitals provide health services on a 24-h basis to a defined regional population, limited to provincial boundaries [ 26 ]. A tertiary hospital has between 400 and 800 beds and receives referrals from regional hospitals not limited to provincial boundaries, and also provides specialist level services [ 26 ]. A central hospital has a maximum of 1200 beds, receives patients referred from more than one province, and provides tertiary hospital services; they may also provide national referral services, including conducting research. A central hospital is attached to a medical school as the main teaching platform [ 26 ].

Study design

This study had a cross-sectional descriptive design. The STROBE checklist of items that should be included in reports of cross-sectional studies was used to guide the study and the reporting thereof.

Population and sampling

Multi-phase sampling was applied in the public sector. Purposive sampling was applied to the selection of hospitals in the public sector. A total of 27 hospitals were included by selecting the largest central or tertiary hospital in every province, and the provincial and district hospital in closest proximity to the selected central or tertiary hospital. The district hospitals were further stratified into large ( n  = 2), medium ( n  = 3), and small ( n  = 4) hospitals. Specialist hospitals were excluded. All in-patient medical and surgical units were included. Total population sampling was applied to all categories of nursing staff (registered nurses, community service nurses, enrolled nurses [2-year diploma], and enrolled nursing auxiliaries [1-year certificate]), including temporary staff, in these selected units. Nurses had to have worked in the respective unit for at least three months, and student nurses were excluded. The total sample of participants was as follows: central n  = 408; tertiary, n  = 254; provincial, n  = 401; and district, n  = 244 [large n  = 81; medium n  = 83 and small n  = 80]). Data were collected from April 2021 to June 2022. A sample size calculation was performed in g-power using the F-tests as the Test Family and the ANOVA: Fixed effects, special, main effects and interactions as the Statistical test in order to take the structure of the data into account. The parameters were specified as follow: Effect size f as and large (0.4) and medium (0.25), α err prob as 0.05, Power (1-β err prob) as 0.95, Numerator df as 10, Number of groups 6. The total sample sizes calculated were 162 and 400, which is well below the realised sample size of 1307. Total population sampling was used and not a random sample, thus no generalisations are made beyond the study population of nurses from these hospitals.

Instruments

In accordance with the theoretical framework of Tvedt et al., the variables measured included practice environment, quality of care, self-care ability, patient safety, and adverse events [ 24 ] . The practice environment was measured using the Practice Environment Scale of the Nurse Work Index Revised (PES-NWI-R). It consists of 32 questions and is divided into five subscales measuring nurse participation in hospital affairs; nursing foundations for quality of care; nurse manager ability, leadership, and support of nurses; staffing and resource adequacy; and collegial nurse-physician relations. The questions are measured on a Likert scale from 1 to 4, where 1 represents strongly disagree and 4 strongly agree. A mean score of 2.5 or more is indicative of a positive practice environment. This tool was found to be valid and reliable in many countries, including South Africa [ 27 ].

Quality of care was measured using the following question: In general, how would you describe the quality of nursing care delivered to patients on your unit/ward? The question was measured on a Likert scale from 1 to 5, where 1 represented excellent and 5 poor. Self-care ability was measured using one question (How confident are you that your patients and their caregivers can manage their care after discharge?), measured on a Likert scale from 1 to 4, where 1 represented very confident and 5 not at all confident.

Patient safety was measured using the following question: Please give your current practice setting an overall grade on patient safety. This was measured on a Likert scale from 1 to 5, where 1 represented excellent and 5 represented failing. The other eight items came from the Hospital Survey on Patient Safety Culture (HSOPSC) [ 28 ]. They were answered on a Likert scale from 1 to 5, where one represented strongly agree and five strongly disagree.

Finally, adverse events were measured by five questions on a five-point scale, where 1 represented never and 5 represented daily. These questions have been employed in multi-country research in South Africa [ 29 ], Europe [ 30 ], the United States of America [ 31 ], and Asia [ 32 ]. The specific outcomes have also been used in a meta-analysis [ 33 ]. The authors tried to control for response bias and subjectivity by asking neutrally worded questions, using anonymous surveys, ensuring that answer options were not leading, and that the order of the answers was randomised. i.e. the range for the practice environment was 1 = Strongly disagree.

4 = Strongly agree (ascending order), while quality of care and patient safety ranged from 1 = Excellent; 4 = Poor (descending order).

Data collection

Data collection took place between April 2021 and June 2022 after ethics approval and obtaining permission from relevant health departments. A team of trained field workers visited the hospitals to administer a paper-based survey to all of the consenting nurses in the hospitals, according to participation criteria. Upon arrival at each hospital, each unit manager was approached and a discussion was held between researcher, manager and staff regarding permission to do a survey among nurses in the unit. The discussion gave detailed information about the study, including the voluntary nature of participation, with an invitation to participate. The survey forms were given to the participants and they were allowed to complete them at a time convenient to them. The survey was completed anonymously, and participants were requested to return them in a sealed envelope via a sealed box with a post-box split, which was placed in all departments in the participating hospitals. The contents of these boxes were emptied by the researcher at the end of each day and removed a week later upon completion of data collection at the selected hospital.

Quantitative data analysis

Data was analysed using SPSS [ 34 ]. Descriptive statistics were used to analyse the demographic data, and data from each subscale representing the practice environment, quality of care and patient safety. These described frequencies, percentages, means and standard deviations. ANOVA type Hierarchical Linear Modelling (HLM), with p -values for all effects and interactions were calculated to present the differences in nurses’ perceptions of the practice environment, quality of care and patient safety across four hospital levels within the public health sector of South Africa, as the means of the different hospital levels and not the regression coefficients were important in the interpretation of the results. After the ANOVA type HLM, pair wise post-hoc comparisons were done to determine the statistically significant differences between the groups. Additionally, effect sizes were computed to determine which of these differences were important in practice. Where significant p - values lead to generalisations of results, effect sizes only indicate whether the differences in the sample groups were important in practice and are not used for generalisation if the p -values are not significant. Effect sizes were calculated and the magnitude of difference between the groups indicated as 0.2 = small, 0.5 = medium, 0.8 = large. Correlations between aspects of the nurse practice environment, quality of care and patient safety were also explored for the entire sample with 0.1. = small; 0.3 = medium and 0.5 = large relationships. Normality of the data was tested using the Kolmogorov–Smirnov test, but due to the unlikelihood of non-significant p -values in such a large sample size, more significance was ascribed to results from Q-Q plots. The points in the Q-Q plot lies close enough to the straight line to retain the assumption that the data distribution is normal for all variables [ 35 ].

Demographic data

We obtained a 43.1% response rate. As indicated in Table  1 , the majority of the participants were female ( n  = 1159; 88.7%), working on a full-time basis ( n  = 1158; 89.35%) and in the registered nurse/midwifery category ( n  = 593; 45.58%). Most nurses worked in the surgical units ( n  = 483; 36.95%), and we received most participation from the central level hospitals ( n  = 408; 31.22%).

• Nurse practice environment

The overall practice environment was not considered to be positive (M = 2.46; SD = 0.65), especially with regard to the subscales of nurse participation in hospital affairs (M = 2.22, SD = 0.76), staffing and resource adequacy (M = 2.23; SD = 0.80), and nurse manager ability, leadership, and support of nurses (M = 2.39; SD = 0.81), see Table  2 .

Table 3 provides an overview of responses to items on quality of care, patient safety, and adverse events.

• Quality of care

When asked about their perception of the quality of nursing care delivered to patients in their work setting, a third of participants (38.45%; n  = 486) indicated a negative outcome, and more than half of the nurses reported that they lacked confidence in patient or caregiver post-discharge care abilities (52.22%; n  = 658).

• Patient safety

As indicated in Table  3 , the overall grade for patient safety was rated as poor or failing by 19.59% ( n  = 248) of participants, and 430 participants (35.95%) agreed that there was a high reliance on temporary staff in their hospitals. In addition, more than half of the participants strongly agreed that their mistakes were held against them (64.38%; n  = 770), and that there was a lack of support for staff involved in patient safety errors (63.15%; n  = 749). Close to half felt that they could not question the decisions or actions of those in authority when related to patient safety issues (42.22%; n  = 505).

Adverse events

The subscale on adverse events examined the weekly and daily occurrence of adverse events. At least 21.32% ( n  = 252) of the participants experienced complaints weekly or daily, while 9.29% ( n  = 108) reported a weekly or daily incidence of hospital-acquired infections, and 7.77% ( n  = 93) weekly or daily medication errors.

Table 4 shows several effect sizes between the different levels of hospitals; however, only medium effect sizes will be reported on. Regarding the practice environment, there were medium practical effects between central hospitals and the small district hospitals for nurse participation in hospital affairs ( r  = 0.40; p  = 0.291), nursing foundations for quality of care ( r  = 0.44; p  = 0.469), and nurse manager ability, leadership, and support of nurses ( r  = 0.45; p  = 0.484), where central hospitals reported a more positive perception of these elements. There were also medium practical effects between provincial hospitals and the small district hospitals for nurse participation in hospital affairs ( r  = 0.40; p  = 0.211) and nursing foundations for quality of care ( r  = 0.43; p  = 0.398), where provincial hospitals reported a more positive perception of these elements of the practice environment.

Regarding the quality of care, there were medium practical effects with statistical significance between central hospitals and tertiary hospitals ( r  = 0.54; p  = 0.015) and small district hospitals ( r  = 0.51; p  = 0.061), where central hospitals reported better quality of care. Regarding patients’ self-care ability, there were medium practical effects between central hospitals and tertiary hospitals ( r  = 0.42; p  = 0.042) as well as medium district hospitals ( r  = 0.41; p  = 0.110) and small district hospitals ( r  = 0.56; p  = 0.007), where central hospitals reported more confidence in patients’ ability to manage their own care after discharge.

Regarding patient safety, there were medium practical effects between central hospitals and tertiary hospitals ( r  = 0.45; p  = 0.178), and also between medium district hospitals ( r  = 0.44; p  = 0.399), and small district hospitals ( r  = 0.51; p  = 0.178), where central hospitals reported higher grades of patient safety. Regarding staff feeling that their mistakes are held against them, there was a medium practical effect between small and medium district hospitals ( r  = 0.42; p  = 0.681), where small district hospitals reported that mistakes were held against them more often. There was also a medium practical effect between medium and large district hospitals regarding lack of support for staff involved in patient safety errors ( r  = 0.44; p  = 0.572), where small district hospitals reported less support for staff involved in patient safety errors. Finally, there was a medium practical effect between large and small district hospitals regarding the actions of hospital management showing that patient safety is a top priority ( r  = 0.40; p  = 0.856), where small district hospitals felt that the actions of hospital management showed that patient safety is a top priority.

Complaints were the only adverse event that had a medium practical effect, these effects being between provincial hospitals and large district hospitals ( r  = 0.57; p  = 0.056), and large district hospitals and small district hospitals ( r  = 0.60; p  = 0.114), where large district hospitals had a greater incidence of complaints.

As shown in Table  5 , all practice environment subscales showed medium to large negative correlations with the quality of nursing care delivered ( r  = -3.20 to r  = -4.28; p  = 0.00) and that patients and their caregivers can manage care after discharge ( r  = -0.282 to r  = -0.327; p  = 0.00). When considering the correlations of the practice environment on overall grade of patient safety, the practice environment had a large negative correlation ( r  = -0.405; p  = 0.00), especially regarding nurse foundations of quality of care ( r  = -0.411; p  = 0.00). Furthermore, medium negative correlations were noted between overall grade of patient safety and staffing and resources ( r  = -0.347; p  = 0.00) and nurse management, leadership, and support of nurses ( r  = -0.340; p  = 0.00), nurse participation ( r  = -0.323; p  = 0.00) and collegial nurse-physician relationships ( r  = -0.299; p  = 0.00). This shows that the more that participants agreed with positive statements about the nurse practice environment, the better they rated their quality of care, the more confidence they had in their patients’ post-discharge management, and the better they rated their overall grade on patient safety.

All practice environment items, except for collegial nurse-physician relationships, had medium negative correlations with the AHRQ item that the unit regularly reviews work processes to determine if changes are needed to improve patient safety ( r  = -0.221 to r  = -0.275; p  = 0.00). Furthermore, foundations of quality of care showed a medium negative correlation with staff speaking up when they see something that may negatively impact patient care ( r  = -0.226; p  = 0.00). Nurse participation ( r  = 0.235; p  = 0.00), leadership ( r  = 0.278; p  = 0.00), collegial nurse- physician relationship ( r  = 0.200; p  = 0.00), and the total practice environment scale ( r  = 0.259; p  = 0.00) all showed medium positive correlations with the AHRQ item ‘Staff feel like their mistakes are held against them’. All practice environment subscales exhibited medium correlations with the lack of support for staff involved in patient safety errors ( r  = 0.239 to r  = 0.315; p  = 0.00). Foundations of quality of care ( r  = -0.222; p  = 0.00), leadership, management, and support of nurses ( r  = -0.223; p  = 0.00), and the overall practice environment scale ( r  = -0.219; p  = 0.00) had negative medium correlations with discussing ways to prevent errors from happening again. All except the collegial nurse-physician relationship subscale of the practice environment showed medium negative correlations with staff feeling free to question the decisions or actions of those in authority ( r  = -0.222 to r  = -0.314; p  = 0.00). All practice environment subscales had medium correlations with the actions of hospital staff showing that patient safety is a top priority ( r  = -0.222 to r  = -0.362; p  = 0.00). To explain, the more that nurses agreed with positive practice environment items, the more they would agree to positive patient safety (AHRQ) items and the more they would disagree with negative patient safety (AHRQ) items.

Overall patient safety correlated positively and strongly with quality of nursing care delivered ( r  = 0.563; p  = 0.00), with a medium positive correlation with confidence in patients’ and caregivers’ post-discharge management ( r  = 0.357; p  = 0.00). Overall grade of patient safety also revealed a medium positive correlation with the unit regularly reviewing work processes ( r  = 0.258; p  = 0.00), staff feeling free to question the actions of those in authority ( r  = 0.222; p  = 0.00), and the actions of hospital management showing that patient safety is a top priority ( r  = 0.372; p  = 0.00). Regarding adverse events, overall grade of patient safety showed medium correlations with medication errors ( r  = 0.208; p  = 0.00) and patient falls ( r  = 0.223 p  = 0.00). This indicates that, as nurses rated overall patient safety more positively, they would also rate quality of care, confidence in post-discharge management, and positive items on patient safety (AHRQ) better, while at the same time leaning towards a lower incidence of adverse events occurring.

Another strong positive correlation was observed between quality of nursing care, and confidence that patients and their caregivers can manage care after discharge ( r  = 0.438; p  = 0.00), while medium positive correlations were noted between quality of nursing care and the unit reviewing work processes regularly ( r  = 0.273; p  = 0.00), staff speaking up if they see something that may negatively impact patient care ( r  = 0.209; p  = 0.00), staff feeling free to question the actions of those in authority ( r  = 0.210; p  = 0.00), and the actions of hospital management showing that patient safety is a top priority ( r  = 0.305; p  = 0.00). Regarding adverse events, quality of nursing care was correlated positively with medication errors ( r  = 0.230; p  = 0.00), patient falls ( r  = 0.237; p  = 0.00), and complaints ( r  = 0.249; p  = 0.00). This shows that the nurses rating the quality of care in their units as more positive would also have more confidence in their patients’ post-discharge management and agree more with positive patient safety items (AHRQ), while indicating a lower incidence of adverse events.

Confidence in post-discharge care and the actions of hospital management showing that patient safety is a top priority were also correlated positively on a medium level ( r  = 0.216; p  = 0.00). Regarding adverse events, confidence in post-discharge care was correlated positively with patient falls ( r  = 0.202; p  = 0.00), healthcare-associated infections ( r  = 0.206; p  = 0.00), and complaints ( r  = 0.211; p  = 0.00). To explain, this indicates that nurses with a higher rating in confidence in post-discharge management would also have a higher rating of their hospital management’s actions showing that patient safety is a top priority, while also rating the incidence of patient falls, healthcare-associated infections and complaints as occurring less often.

This national study sought to examine nurses' perceptions of the practice environment, quality of care and patient safety across four hospital levels within the public health sector of South Africa. In the participating hospitals we found that there was a negative nurse practice environment, and reports of poor quality of care and patient safety.

The findings on the perceived poor nurse practice environment in the public hospitals is of great concern. The recent South African Human Resources for Health Strategy 2030 advocates for the support of health personnel to deliver quality services [ 36 ]. The findings are worrying given that nurses are the backbone of the health system. A negative practice environment contributes to increased staff turnover and mental health challenges due to a stressful environment [ 37 ]. The challenges of unavailability of resources are common in public hospitals [ 38 ], but when coupled with poor leadership support could worsen the nurse outcomes. The finding on poor participation in hospital affairs indicates a lack of prioritisation of frontline nurses’ voices in hospital affairs; previous studies also found poor involvement of frontline nurses in policy decision making [ 39 , 40 ]. This could also mean that nurse managers may need empowerment on how to be supportive to staff and in improving prioritisation of frontline nurses’ voices in decision making. The implication of poor involvement of staff in hospital affairs usually includes retaliation, lack of a sense of belonging, and demotivation [ 41 ], and it also indicates weak leadership [ 42 ]. System level improvements, including relational leadership focused on prioritising staff involvement in decision making, could improve nursing practice environments in these hospitals [ 43 , 44 , 45 ]. Nurses’ perceptions of a negative practice environment have been reported in the literature. A study in Menoufia University Hospital, Egypt, reported that about 66.3% of nurses had a poor perception of the work environment [ 46 ]. Equally, a rapid review of literature on positive practice environment in the United Kingdom reported that most articles revealed a negative practice environment [ 47 ]. Nurse practice environment scholars concur that improving the nurse practice environment saves resources while building a culture of safety [ 48 ], and that prudent nurse managers should prioritise creating practice environments that are conducive to providing quality nursing care, as well as that managers should take the lead in impacting the elements of a positive practice environment [ 49 ]. In the context of our study, managers could be advocates for resources, nurse inclusion in hospital affairs, and provide strong leadership support.

The finding that almost half of the participating nurses rated the quality of care in their ward as poor is not new. A study in KwaZulu-Natal province in South Africa that explored nurses’ attitudes in providing care to patients revealed that they reported a poor incidence of nursing care to patients and deliberate disregard of essential patient care [ 50 ]. The study also noted that nurses attributed poor quality of nursing care to the attitudes of patients’ relatives or patients themselves, including unsupportive management behaviour. Maphumulo and Bhengu (2019) also report on poor quality of care [ 51 ]. As mentioned earlier, there are existing national policies to support quality and safety. For example, the Office of Health Standards Compliance set standards on quality in health care; additionally, in 2013 there was a nationwide quality improvement initiative called ideal facility [ 52 ]. Such initiatives focused on setting standards to assess each facility regarding compliance with set criteria for quality care in the facilities, started with the PHC clinics [ 53 ] and rolled out to hospital level. These results could mean that hospitals are not adhering to the set standards. Major challenges reported in the South African literature associated with poor quality of patient care include poor infrastructure [ 54 , 55 ], unavailability of medicine [ 56 , 57 ], shortage of staff, increased workload, shift work and long working hours [ 58 , 59 ]. These have contributed to an ongoing cycle of high staff turnover [ 60 ]. In line with international evidence, it would appear that the practice environment is closely linked to the quality of care [ 11 ].

The findings that nurses rated patient safety in their hospitals as poor could be due to their perceived patient safety culture. Evidence suggests that to achieve patient safety, strong leadership and a culture supportive of learning from errors (rather than a punitive approach) are critical ingredients [ 61 ]. In this study nurses reported that they experience a punitive reaction when reporting errors, and that they lacked support from their managers, and this is of great concern. Management response to errors is a critical determinant of patient safety culture; positive reactions to reported errors have been cited to encourage health providers to report them and subsequently improve patient care [ 62 ]. The findings resonate with recent South African studies that also found a poor patient safety culture in public hospitals [ 13 , 16 ]. A punitive reaction to reporting of adverse events remains a global challenge. A qualitative study conducted in South Korea on nurses’ experiences with disclosure of patient safety incidents found that nurses often prefer not to report patient safety incidents [ 63 ] due to the reaction expected from managers. An integrative review of literature from January 2010 to December 2020 using 31 papers revealed that a non-punitive reaction to patient safety incident reporting could improve patient safety and learning from errors [ 64 ]. Such strategies should be adopted in these participating hospitals.

The findings on weekly and daily reported adverse events and complaints resonate with the perceived poor patient safety. The finding that nurses perceived reactions to reported incidents as punitive could mean that more adverse events are not reported, for fear of the management reaction. Adverse events are a critical indicator of patient safety, hence weekly adverse events reported in a hospital should be a major concern. A qualitative study conducted in Palestine on nurses’ experience of the most common medical errors in the intensive care unit and coronary care unit demonstrated that they usually experience events like medication errors, nursing procedure errors, equipment errors, patient monitoring errors, intravenous medication errors, and resuscitation errors [ 65 ]. Similarly, in their study in Ghana Alhassan et al. (2019) noted that the type of errors nurses experience were wrong documentation, wrong intravenous fluid, and blood transfusion [ 66 ]. Furthermore, a study in Tehran, Iran on the types and causes of medication errors from nurses’ viewpoint indicated that about 64.55% of nurses reportedly made medication errors, and approximately 31.4% nearly experienced medication errors [ 67 ]. In the South African context reporting of adverse events remains a challenge, due to similar fear of reporting patient safety incidents, and evidence suggests that health providers often classify adverse events as minor to avoid reporting them [ 68 ]. A need to emphasise a just culture in the nursing environment will improve reporting of adverse events, and learning from these events will further reduce occurrences.

We also observed that when looking at comparison of effect sizes across hospitals, larger hospitals most often revealed better practice environments, quality of care and patient safety outcomes, while small district hospitals had the worst. These findings are not uncommon, as a Korean study also confirmed a strong relationship between practice environment and hospital sizes, concluding that the nurse practice environment varies with hospital size [ 69 ]. A distinct difference in the hospital categories compared is bed capacity, and complexity of conditions treated in each category, with more complex conditions seen in higher levels of hospitals. In the South African context, hospital categories also influence decisions on allocation and prioritisation of resources among the hospital categories, with more resources given to the larger hospitals [ 26 ]. Availability of resources plays a significant role in improving the nursing practice environment [ 70 ], and this is a possible contributor to a negative practice environment in small hospitals, since they often have fewer staff and resources [ 49 ]. We also found that central hospitals reported more confidence in patients’ ability to manage care after discharge than the smaller hospitals did; this could mean that central hospitals have prioritised teaching of their patients, thereby empowering them for post-discharge care. A 2020 study in the United Kingdom also reported that hospital size is a good predictor of efficient discharge processes [ 71 ].

The finding that patient safety in central hospitals was better than in small district hospitals is contrary to the assumption that large hospitals are busy and likely to be attending to complex patient conditions which could make them more prone to errors and unsafe practice [ 72 ]. In our study better safety in tertiary hospitals could be related to the fact that they are operated mostly by specialised health professionals who may be more knowledgeable than those in non-specialised hospitals, and that tertiary hospitals are teaching hospitals, often with ongoing training related to practice [ 26 , 73 ]. In the South African context to our knowledge this is the first study to link nurse practice environment, quality of care and patient safety in four hospital levels, and showing definite differences in nurses’ perceptions at these different levels of care. It followed a quantitative approach, and it would be interesting to further explore the reasons for the perceived practice environment, quality of care and patient safety using qualitative approaches in these hospitals. The findings of this study, specifically the variations in perceived nurse practice environment, quality of care and patient safety across hospital levels, imply an urgent need for mindfulness in resource allocation so as not to compromise care in the smaller hospitals.

The finding of strong correlations between the nurse practice environment, quality of care and patient safety is similar to those of other studies that also emphasised that a negative practice environment is associated with perceived poor quality of care and patient safety [ 48 , 49 , 74 , 75 ]. For our study it implies a need to intentionally improve the nurse practice environment, in order to influence quality of care and patient safety. It also means that quality of care and patient safety policies should deliberately consider the practice environment. This could start by involving nurses in policy development, so they can contribute to hospital affairs and the feasibility of the policies. This will also make them feel included as important role-players in the health system. Patient safety policies could also not focus on reporting of errors but consider system level contributors to errors; such practice will also address the reported challenges of punitive reactions to reported errors.

Limitations and strengths

Since this was a cross-sectional, self-reported survey, one of the limitations could be that the nurses may have had social-desirable bias in their responses, although the authors did try to control for this by asking neutrally worded questions, using anonymous surveys, ensuring that the answer options were not leading and that the order of the answers was randomised. There are several strengths of this study: firstly a contribution to knowledge of a link between nurse practice environment, quality in health care and patient safety in the South African context; often studies investigating these concepts are isolated. An additional strength is that we included a large sample size, representing all nine provinces of South Africa. To our knowledge this is the first study examining nurses' perceptions of the practice environment, quality of care and patient safety across four hospital levels within the public health sector of South Africa.

Recommendations

There are several recommendations from this study which could contribute to improvement to nurse practice environment, quality of care and patient safety. For example, there is a need to improve organisational culture with a focus on empowering leaders on leading compliance to existing policies, and on supportive leadership; this would lead to an improved nurse practice environment, quality of care and patient safety. A specific focus should be placed on support and empowerment of nurses working in more rural and smaller hospitals. Resource allocation to smaller hospitals should be reviewed, considering the added expenditure associated with remote locations and the added challenges in achieving economies of scale. Enabling positive nursing practice environments by means of enhanced nurse participation, non-punitive strategies of enhancing quality of care, leadership championing and better resource auditing will create environments nurses can thrive in, while also maximising patient outcomes in terms of quality of care and patient safety. In addition, there is an urgent need to review existing policies to identify how the nurse practice environment is enhanced or negatively affected by such policies, and intentionally examine and improve the link between nurse practice environment, quality of care and patient safety in the existing policies.

Nurses perceived the practice environment, quality of care and patient safety to be poor across four hospital levels within the public health sector of South Africa. Since there is a strong correlation between nurse practice environment, quality of care and patient safety, there is a need to review the existing policies on quality of care and patient safety and if and to what extent they enhance the nursing practice environment. In addition, strengthening compliance with existing policies that enhance quality of care and patient safety remains important, including the creation of a culture that supports a positive nurse practice environment characterised by manager support, nurse participation in hospital affairs and increased supply of resources, especially in smaller and more rural hospital settings.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Hospital Survey on Patient Safety Culture

National Department of Health

Practice Environment Scale of the Nurse Work Index Revised

Primary healthcare

Universal Health Coverage

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Acknowledgements

We would like to thank all the participants of this study; without their participation, this study would not be in existence.

Open access funding provided by North-West University. This work is based on the research supported in part by the National Research Foundation of South Africa (Grant Number 123541). All opinions, findings expressed, and conclusions arrived at, are solely those of the author and are not attributed to the National Research Foundation in any way.

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IST; AJB; SME and SKC, conceptualised the manuscript. SKC, AJB, and SME analysed the data. IST wrote the original draft of the manuscript. All authors reviewed and edited the manuscript. SKC is a primary investigator, project administrator and a recipient of funding of this study.

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This study has been performed following the Declaration of Helsinki [ 76 ] and has obtained ethical approval from the North-West University Health Research Ethics Committee, with ethics number (NWU-00033–19-A1). We also obtained permission to conduct the study from the health authorities and individual public health facilities in the nine provinces of South Africa. All participants were given a detailed information sheet, as well as a verbal explanation of the study. We also informed study participants of the voluntary and confidential nature of participation in the study. All participants signed an informed consent to participate in the study.

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Tenza, I.S., Blignaut, A.J., Ellis, S.M. et al. Nurse perceptions of practice environment, quality of care and patient safety across four hospital levels within the public health sector of South Africa. BMC Nurs 23 , 324 (2024). https://doi.org/10.1186/s12912-024-01992-z

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Performance Management and Quality Improvement: Definitions and Concepts

At a glance.

In the public health field, many initiatives and organizations focus on improving public health practice, using different terms. This page provides common definitions for public health performance management.

Definitions and concepts

There has been a rapidly growing interest in performance and quality improvement within the public health community, and different names and labels are often used to describe similar concepts or activities. Other sectors, such as industry and hospitals, have embraced a diverse and evolving set of terms but which generally have the same principles at heart (i.e., continuous quality improvement, quality improvement, performance improvement, six sigma, and total quality management).

In the public health field, an array of initiatives has set the stage for attention to improving public health practice, using assorted terms. The Turning Point Collaborative focused on performance management, the National Public Health Performance Standards Program created a framework to assess and improve public health systems, while the US Department of Health and Human Services has provided recommendations on how to achieve quality in healthcare . In 2011, the Public Health Accreditation Board launched a national voluntary accreditation program that catalyzes quality improvement but also acknowledges the importance of performance management within public health agencies. Regardless of the terminology, a common thread has emerged—one that focuses on continuous improvement and operational excellence within public health programs, agencies, and the public health system.

To anchor common thinking, below are links to some of the definitions that are frequently used throughout these pages.

Key definitions

• Riley et al, "Defining Quality Improvement in Public Health", JPHMP, 2010, 16(10), 5-7.
• Public Health Accreditation Board Acronyms and Glossary of Terms, Version 2022 [PDF]

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Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design

• Mekides Geta 1 ,
• Geta Asrade Alemayehu 2 ,
• Wubshet Debebe Negash 2 ,
• Tadele Biresaw Belachew 2 ,
• Chalie Tadie Tsehay 2 &
• Getachew Teshale 2  

BMC Pediatrics volume  24 , Article number:  310 ( 2024 ) Cite this article

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Metrics details

Integrated Community Case Management (ICCM) of common childhood illness is one of the global initiatives to reduce mortality among under-five children by two-thirds. It is also implemented in Ethiopia to improve community access and coverage of health services. However, as per our best knowledge the implementation status of integrated community case management in the study area is not well evaluated. Therefore, this study aimed to evaluate the implementation status of the integrated community case management program in Gondar City, Northwest Ethiopia.

A single case study design with mixed methods was employed to evaluate the process of integrated community case management for common childhood illness in Gondar town from March 17 to April 17, 2022. The availability, compliance, and acceptability dimensions of the program implementation were evaluated using 49 indicators. In this evaluation, 484 mothers or caregivers participated in exit interviews; 230 records were reviewed, 21 key informants were interviewed; and 42 observations were included. To identify the predictor variables associated with acceptability, we used a multivariable logistic regression analysis. Statistically significant variables were identified based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value. The qualitative data was recorded, transcribed, and translated into English, and thematic analysis was carried out.

The overall implementation of integrated community case management was 81.5%, of which availability (84.2%), compliance (83.1%), and acceptability (75.3%) contributed. Some drugs and medical equipment, like Cotrimoxazole, vitamin K, a timer, and a resuscitation bag, were stocked out. Health care providers complained that lack of refreshment training and continuous supportive supervision was the common challenges that led to a skill gap for effective program delivery. Educational status (primary AOR = 0.27, 95% CI:0.11–0.52), secondary AOR = 0.16, 95% CI:0.07–0.39), and college and above AOR = 0.08, 95% CI:0.07–0.39), prescribed drug availability (AOR = 2.17, 95% CI:1.14–4.10), travel time to the to the ICCM site (AOR = 3.8, 95% CI:1.99–7.35), and waiting time (AOR = 2.80, 95% CI:1.16–6.79) were factors associated with the acceptability of the program by caregivers.

Conclusion and recommendation

The overall implementation status of the integrated community case management program was judged as good. However, there were gaps observed in the assessment, classification, and treatment of diseases. Educational status, availability of the prescribed drugs, waiting time and travel time to integrated community case management sites were factors associated with the program acceptability. Continuous supportive supervision for health facilities, refreshment training for HEW’s to maximize compliance, construction clean water sources for HPs, and conducting longitudinal studies for the future are the forwarded recommendation.

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Integrated Community Case Management (ICCM) is a critical public health strategy for expanding the coverage of quality child care services [ 1 , 2 ]. It mainly concentrated on curative care and also on the diagnosis, treatment, and referral of children who are ill with infectious diseases [ 3 , 4 ].

Based on the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommendations, Ethiopia adopted and implemented a national policy supporting community-based treatment of common childhood illnesses like pneumonia, Diarrhea, uncomplicated malnutrition, malaria and other febrile illness and Amhara region was one the piloted regions in late 2010 [ 5 ]. The Ethiopian primary healthcare units, established at district levels include primary hospitals, health centers (HCs), and health posts (HPs). The HPs are run by Health Extension Workers (HEWs), and they have function of monitoring health programs and disease occurrence, providing health education, essential primary care services, and timely referrals to HCs [ 6 , 7 ]. The Health Extension Program (HEP) uses task shifting and community ownership to provide essential health services at the first level using the health development army and a network of woman volunteers. These groups are organized to promote health and prevent diseases through community participation and empowerment by identifying the salient local bottlenecks which hinder vital maternal, neonatal, and child health service utilization [ 8 , 9 ].

One of the key steps to enhance the clinical case of health extension staff is to encourage better growth and development among under-five children by health extension. Healthy family and neighborhood practices are also encouraged [ 10 , 11 ]. The program also combines immunization, community-based feeding, vitamin A and de-worming with multiple preventive measures [ 12 , 13 ]. Now a days rapidly scaling up of ICCM approach to efficiently manage the most common causes of morbidity and mortality of children under the age of five in an integrated manner at the community level is required [ 14 , 15 ].

Over 5.3 million children are died at a global level in 2018 and most causes (75%) are preventable or treatable diseases such as pneumonia, malaria and diarrhea [ 16 ]. About 99% of the global burden of mortality and morbidity of under-five children which exists in developing countries are due to common childhood diseases such as pneumonia, diarrhea, malaria and malnutrition [ 17 ].

In 2013, the mortality rate of under-five children in Sub-Saharan Africa decreased to 86 deaths per 1000 live birth and estimated to be 25 per 1000live births by 2030. However, it is a huge figure and the trends are not sufficient to reach the target [ 18 ]. About half of global under-five deaths occurred in sub-Saharan Africa. And from the top 26 nations burdened with 80% of the world’s under-five deaths, 19 are in sub-Saharan Africa [ 19 ].

To alleviate the burden, the Ethiopian government tries to deliver basic child care services at the community level by trained health extension workers. The program improves the health of the children not only in Ethiopia but also in some African nations. Despite its proven benefits, the program implementation had several challenges, in particular, non-adherence to the national guidelines among health care workers [ 20 ]. Addressing those challenges could further improve the program performance. Present treatment levels in sub-Saharan Africa are unacceptably poor; only 39% of children receive proper diarrhea treatment, 13% of children with suspected pneumonia receive antibiotics, 13% of children with fever receive a finger/heel stick to screen for malaria [ 21 ].

To improve the program performance, program gaps should be identified through scientific evaluations and stakeholder involvement. This evaluation not only identify gaps but also forward recommendations for the observed gaps. Furthermore, the implementation status of ICCM of common childhood illnesses has not been evaluated in the study area yet. Therefore, this work aimed to evaluate the implementation status of integrated community case management program implementation in Gondar town, northwest Ethiopia. The findings may be used by policy makers, healthcare providers, funders and researchers.

Method and material

Evaluation design and settings.

A single-case study design with concurrent mixed-methods evaluation was conducted in Gondar city, northwest Ethiopia, from March 17 to April 17, 2022. The evaluability assessment was done from December 15–30, 2021. Both qualitative and quantitative data were collected concurrently, analyzed separately, and integrated at the result interpretation phase.

The evaluation area, Gondar City, is located in northwest Ethiopia, 740 km from Addis Ababa, the capital city of the country. It has six sub-cities and thirty-six kebeles (25 urban and 11 rural). In 2019, the estimated total population of the town was 338,646, and 58,519 (17.3%) were under-five children. In the town there are eight public health centers and 14 health posts serving the population. All health posts provide ICCM service for more than 70,852 populations.

Evaluation approach and dimensions

Program stakeholders.

The evaluation followed a formative participatory approach by engaging the potential stakeholders in the program. Prior to the development of the proposal, an extensive discussion was held with the Gondar City Health Department to identify other key stakeholders in the program. Service providers at each health facility (HCs and HPs), caretakers of sick children, the Gondar City Health Office (GCHO), the Amhara Regional Health Bureau (ARHB), the Minister of Health (MoH), and NGOs (IFHP and Save the Children) were considered key stakeholders. During the Evaluability Assessment (EA), the stakeholders were involved in the development of evaluation questions, objectives, indicators, and judgment criteria of the evaluation.

Evaluation dimensions

The availability and acceptability dimensions from the access framework [ 22 ] and compliance dimension from the fidelity framework [ 23 ] were used to evaluate the implementation of ICCM.

Population and samplings

All under-five children and their caregivers attended at the HPs; program implementers (health extension workers, healthcare providers, healthcare managers, PHCU focal persons, MCH coordinators, and other stakeholders); and ICCM records and registries in the health posts of Gondar city administration were included in the evaluation. For quantitative data, the required sample size was proportionally allocated for each health post based on the number of cases served in the recent one month. But the qualitative sample size was determined by data saturation, and the samples were selected purposefully.

The data sources and sample size for the compliance dimension were all administrative records/reports and ICCM registration books (230 documents) in all health posts registered from December 1, 2021, to February 30, 2022 (three months retrospectively) included in the evaluation. The registries were assessed starting from the most recent registration number until the required sample size was obtained for each health post.

The sample size to measure the mothers’/caregivers’ acceptability towards ICCM was calculated by taking prevalence of caregivers’ satisfaction on ICCM program p  = 74% from previously similar study [ 24 ] and considering standard error 4% at 95% CI and 10% non- responses, which gave 508. Except those who were seriously ill, all caregivers attending the ICCM sites during data collection were selected and interviewed consecutively.

The availability of required supplies, materials and human resources for the program were assessed in all 14HPs. The data collectors observed the health posts and collected required data by using a resources inventory checklist.

A total of 70 non-participatory patient-provider interactions were also observed. The observations were conducted per each health post and for health posts which have more than one health extension workers one of them were selected randomly. The observation findings were used to triangulate the findings obtained through other data collection techniques. Since people may act accordingly to the standards when they know they are observed for their activities, we discarded the first two observations from analysis. It is one of the strategies to minimize the Hawthorne effect of the study. Finally a total of 42 (3 in each HPs) observations were included in the analysis.

Twenty one key informants (14 HEWs, 3 PHCU focal person, 3 health center heads and one MCH coordinator) were interviewed. These key informants were selected since they are assumed to be best teachers in the program. Besides originally developed key informant interview questions, the data collectors probed them to get more detail and clear information.

Variables and measurement

The availability of resources, including trained healthcare workers, was examined using 17 indicators, with weighted score of 35%. Compliance was used to assess HEWs’ adherence to the ICCM treatment guidelines by observing patient-provider interactions and conducting document reviews. We used 18 indicators and a weighted value of 40%.

Mothers’ /caregivers’/ acceptance of ICCM service was examined using 14 indicators and had a weighted score of 25%. The indicators were developed with a five-point Likert scale (1: strongly disagree, 2: disagree, 3: neutral, 4: agree and 5: strongly agree). The cut off point for this categorization was calculated using the demarcation threshold formula: ( \(\frac{\text{t}\text{o}\text{t}\text{a}\text{l}\, \text{h}\text{i}\text{g}\text{h}\text{e}\text{s}\text{t}\, \text{s}\text{c}\text{o}\text{r}\text{e}-\,\text{t}\text{o}\text{t}\text{a}\text{l}\, \text{l}\text{o}\text{w}\text{e}\text{s}\text{t} \,\text{s}\text{c}\text{o}\text{r}\text{e}}{2}) +total lowest score\) ( 25 – 27 ). Those mothers/caregivers/ who scored above cut point (42) were considered as “satisfied”, otherwise “dissatisfied”. The indicators were adapted from the national ICCM and IMNCI implementation guideline and other related evaluations with the participation of stakeholders. Indicator weight was given by the stakeholders during EA. Indicators score was calculated using the formula \(\left(achieved \,in \%=\frac{indicator \,score \,x \,100}{indicator\, weight} \right)\) [ 26 , 28 ].

The independent variables for the acceptability dimension were socio-demographic and economic variables (age, educational status, marital status, occupation of caregiver, family size, income level, and mode of transport), availability of prescribed drugs, waiting time, travel time to ICCM site, home to home visit, consultation time, appointment, and source of information.

The overall implementation of ICCM was measured by using 49 indicators over the three dimensions: availability (17 indicators), compliance (18 indicators) and acceptability (14 indicators).

Program logic model

Based on the constructed program logic model and trained health care providers, mothers/caregivers received health information and counseling on child feeding; children were assessed, classified, and treated for disease, received follow-up; they were checked for vitamin A; and deworming and immunization status were the expected outputs of the program activities. Improved knowledge of HEWs on ICCM, increased health-seeking behavior, improved quality of health services, increased utilization of services, improved data quality and information use, and improved child health conditions are considered outcomes of the program. Reduction of under-five morbidity and mortality and improving quality of life in the society are the distant outcomes or impacts of the program (Fig.  1 ).

Integrated community case management of childhood illness program logic model in Gondar City in 2022

Data collection tools and procedure

Resource inventory and data extraction checklists were adapted from standard ICCM tool and check lists [ 29 ]. A structured interviewer administered questionnaire was adapted by referring different literatures [ 30 , 31 ] to measure the acceptability of ICCM. The key informant interview (KII) guide was also developed to explore the views of KIs. The interview questionnaire and guide were initially developed in English and translated into the local language (Amharic) and finally back to English to ensure consistency. All the interviews were done in the local language, Amharic.

Five trained clinical nurses and one BSC nurse were recruited from Gondar zuria and Wegera district as data collectors and supervisors, respectively. Two days training on the overall purpose of the evaluation and basic data collection procedures were provided prior to data collection. Then, both quantitative and qualitative data were gathered at the same time. The quantitative data were gathered from program documentation, charts of ICCM program visitors and, exit interview. Interviews with 21 KIIs and non-participatory observations of patient-provider interactions were used to acquire qualitative data. Key informant interviews were conducted to investigate the gaps and best practices in the implementation of the ICCM program.

A pretest was conducted to 26 mothers/caregivers/ at Maksegnit health post and appropriate modifications were made based on the pretest results. The data collectors were supervised and principal evaluator examined the completeness and consistency of the data on a daily basis.

Data management and analysis

For analysis, quantitative data were entered into epi-data version 4.6 and exported to Stata 14 software for analysis. Narration and tabular statistics were used to present descriptive statistics. Based on established judgment criteria, the total program implementation was examined and interpreted as a mix of the availability, compliance, and acceptability dimensions. To investigate the factors associated with ICCM acceptance, a binary logistic regression analysis was performed. During bivariable analysis, variables with p-values less than 0.25 were included in multivariable analysis. Finally, variables having a p-value less than 0.05 and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) were judged statistically significant. Qualitative data were collected recorded, transcribed into Amharic, then translated into English and finally coded and thematically analyzed.

Judgment matrix analysis

The weighted values of availability, compliance, and acceptability dimensions were 35, 40, and 25 based on the stakeholder and investigator agreement on each indicator, respectively. The judgment parameters for each dimension and the overall implementation of the program were categorized as poor (< 60%), fair (60–74.9%), good (75-84.9%), and very good (85–100%).

Availability of resources

A total of 26 HEWs were assigned within the fourteen health posts, and 72.7% of them were trained on ICCM to manage common childhood illnesses in under-five children. However, the training was given before four years, and they didn’t get even refreshment training about ICCM. The KII responses also supported that the shortage of HEWs at the HPs was the problem in implementing the program properly.

I am the only HEW in this health post and I have not been trained on ICCM program. So, this may compromise the quality of service and client satisfaction.(25 years old HEW with two years’ experience)

All observed health posts had ICCM registration books, monthly report and referral formats, functional thermometer, weighting scale and MUAC tape meter. However, timer and resuscitation bag was not available in all HPs. Most of the key informant finding showed that, in all HPs there was no shortage of guideline, registration book and recording tool; however, there was no OTP card in some health posts.

“Guideline, ICCM registration book for 2–59 months of age, and other different recording and reporting formats and booklet charts are available since September/2016. However, OTP card is not available in most HPs.”. (A 30 years male health center director)

Only one-fifth (21%) of HPs had a clean water source for drinking and washing of equipment. Most of Key-informant interview findings showed that the availability of infrastructures like water was not available in most HPs. Poor linkage between HPs, HCs, town health department, and local Kebele administer were the reason for unavailability.

Since there is no water for hand washing, or drinking, we obligated to bring water from our home for daily consumptions. This increases the burden for us in our daily activity. (35 years old HEW)

Most medicines, such as anti-malaria drugs with RDT, Quartem, Albendazole, Amoxicillin, vitamin A capsules, ORS, and gloves, were available in all the health posts. Drugs like zinc, paracetamol, TTC eye ointment, and folic acid were available in some HPs. However, cotrimoxazole and vitamin K capsules were stocked-out in all health posts for the last six months. The key informant also revealed that: “Vitamin K was not available starting from the beginning of this program and Cotrimoxazole was not available for the past one year and they told us they would avail it soon but still not availed. Some essential ICCM drugs like anti malaria drugs, De-worming, Amoxicillin, vitamin A capsules, ORS and medical supplies were also not available in HCs regularly.”(28 years’ Female PHCU focal)

The overall availability of resources for ICCM implementation was 84.2% which was good based on our presetting judgment parameter (Table  1 ).

Health extension worker’s compliance

From the 42 patient-provider interactions, we found that 85.7%, 71.4%, 76.2%, and 95.2% of the children were checked for body temperature, weight, general danger signs, and immunization status respectively. Out of total (42) observation, 33(78.6%) of sick children were classified for their nutritional status. During observation time 29 (69.1%) of caregivers were counseled by HEWs on food, fluid and when to return back and 35 (83.3%) of children were appointed for next follow-up visit. Key informant interviews also affirmed that;

“Most of our health extension workers were trained on ICCM program guidelines but still there are problems on assessment classification and treatment of disease based on guidelines and standards this is mainly due to lack refreshment training on the program and lack of continuous supportive supervision from the respective body.” (27years’ Male health center head)

From 10 clients classified as having severe pneumonia cases, all of them were referred to a health center (with pre-referral treatment), and from those 57 pneumonia cases, 50 (87.7%) were treated at the HP with amoxicillin or cotrimoxazole. All children with severe diarrhea, very severe disease, and severe complicated malnutrition cases were referred to health centers with a pre-referral treatment for severe dehydration, very severe febrile disease, and severe complicated malnutrition, respectively. From those with some dehydration and no dehydration cases, (82.4%) and (86.8%) were treated at the HPs for some dehydration (ORS; plan B) and for no dehydration (ORS; plan A), respectively. Moreover, zinc sulfate was prescribed for 63 (90%) of under-five children with some dehydration or no dehydration. From 26 malaria cases and 32 severe uncomplicated malnutrition and moderate acute malnutrition cases, 20 (76.9%) and 25 (78.1%) were treated at the HPs, respectively. Of the total reviewed documents, 56 (93.3%), 66 (94.3%), 38 (84.4%), and 25 (78.1%) of them were given a follow-up date for pneumonia, diarrhea, malaria, and malnutrition, respectively.

Supportive supervision and performance review meetings were conducted only in 10 (71.4%) HPs, but all (100%) HPs sent timely reports to the next supervisory body.

Most of the key informants’ interview findings showed that supportive supervision was not conducted regularly and for all HPs.

I had mentored and supervised by supportive supervision teams who came to our health post at different times from health center, town health office and zonal health department. I received this integrated supervision from town health office irregularly, but every month from catchment health center and last integrated supportive supervision from HC was on January. The problem is the supervision was conducted for all programs.(32 years’ old and nine years experienced female HEW)

Moreover, the result showed that there was poor compliance of HEWs for the program mainly due to weak supportive supervision system of managerial and technical health workers. It was also supported by key informants as:

We conducted supportive supervision and performance review meeting at different time, but still there was not regular and not addressed all HPs. In addition to this the supervision and review meeting was conducted as integration of ICCM program with other services. The other problem is that most of the time we didn’t used checklist during supportive supervision. (Mid 30 years old male HC director)

Based on our observation and ICCM document review, 83.1% of the HEWs were complied with the ICCM guidelines and judged as fair (Table  2 ).

Acceptability of ICCM program

Sociodemographic and obstetric characteristics of participants.

A total of 484 study participants responded to the interviewer-administered questionnaire with a response rate of 95.3%. The mean age of study participants was 30.7 (SD ± 5.5) years. Of the total caregivers, the majority (38.6%) were categorized under the age group of 26–30 years. Among the total respondents, 89.3% were married, and regarding religion, the majorities (84.5%) were Orthodox Christian followers. Regarding educational status, over half of caregivers (52.1%) were illiterate (unable to read or write). Nearly two-thirds of the caregivers (62.6%) were housewives (Table  3 ).

All the caregivers came to the health post on foot, and most of them 418 (86.4%) arrived within one hour. The majority of 452 (93.4%) caregivers responded that the waiting time to get the service was less than 30 min. Caregivers who got the prescribed drugs at the health post were 409 (84.5%). Most of the respondents, 429 (88.6%) and 438 (90.5%), received counseling services on providing extra fluid and feeding for their sick child and were given a follow-up date.

Most 298 (61.6%) of the caregivers were satisfied with the convenience of the working hours of HPs, and more than three-fourths (80.8%) were satisfied with the counseling services they received. Most of the respondents, 366 (75.6%), were satisfied with the appropriateness of waiting time and 431 (89%) with the appropriateness of consultation time. The majority (448 (92.6%) of caregivers were satisfied with the way of communicating with HEWs, and 269 (55.6%) were satisfied with the knowledge and competence of HEWs. Nearly half of the caregivers (240, or 49.6%) were satisfied with the availability of drugs at health posts.

The overall acceptability of the ICCM program was 75.3%, which was judged as good. A low proportion of acceptability was measured on the cleanliness of the health posts, the appropriateness of the waiting area, and the competence and knowledge of the HEWs. On the other hand, high proportion of acceptability was measured on appropriateness of waiting time, way of communication with HEWs, and the availability of drugs (Table  4 ).

Factors associated with acceptability of ICCM program

In the final multivariable logistic regression analysis, educational status of caregivers, availability of prescribed drugs, time to arrive, and waiting time were factors significantly associated with the satisfaction of caregivers with the ICCM program.

Accordingly, the odds of caregivers with primary education, secondary education, and college and above were 73% (AOR = 0.27, 95% CI: 0.11–0.52), 84% (AOR = 0.16, 95% CI: 0.07–0.39), and 92% (AOR = 0.08, 95% CI: 0.07–0.40) less likely to accept the program as compared to mothers or caregivers who were not able to read and write, respectively. The odds of caregivers or mothers who received prescribed drugs were 2.17 times more likely to accept the program as compared to their counters (AOR = 2.17, 95% CI: 1.14–4.10). The odds of caregivers or mothers who waited for services for less than 30 min were 2.8 times more likely to accept the program as compared to those who waited for more than 30 min (AOR = 2.80, 95% CI: 1.16–6.79). Moreover, the odds of caregivers/mothers who traveled an hour or less for service were 3.8 times more likely to accept the ICCM program as compared to their counters (AOR = 3.82, 95% CI:1.99–7.35) (Table  5 ).

Overall ICCM program implementation and judgment

The implementation of the ICCM program in Gondar city administration was measured in terms of availability (84.2%), compliance (83.1%), and acceptability (75.3%) dimensions. In the availability dimension, amoxicillin, antimalarial drugs, albendazole, Vit. A, and ORS were available in all health posts, but only six HPs had Ready-to-Use Therapeutic Feedings, three HPs had ORT Corners, and none of the HPs had functional timers. In all health posts, the health extension workers asked the chief to complain, correctly assessed for pneumonia, diarrhea, malaria, and malnutrition, and sent reports based on the national schedule. However, only 70% of caretakers counseled about food, fluids, and when to return, 66% and 76% of the sick children were checked for anemia and other danger signs, respectively. The acceptability level of the program by caretakers and caretakers’/mothers’ educational status, waiting time to get the service and travel time ICCM sites were the factors affecting its acceptability. The overall ICCM program in Gondar city administration was 81.5% and judged as good (Fig.  2 ).

Overall ICCM program implementation and the evaluation dimensions in Gondar city administration, 2022

The implementation status of ICCM was judged by using three dimensions including availability, compliance and acceptability of the program. The judgment cut of points was determined during evaluability assessment (EA) along with the stakeholders. As a result, we found that the overall implementation status of ICCM program was good as per the presetting judgment parameter. Availability of resources for the program implementation, compliance of HEWs to the treatment guideline and acceptability of the program services by users were also judged as good as per the judgment parameter.

This evaluation showed that most medications, equipment and recording and reporting materials available. This finding was comparable with the standard ICCM treatment guide line [ 10 ]. On the other hand trained health care providers, some medications like Zink, Paracetamol and TTC eye ointment, folic acid and syringes were not found in some HPs. However the finding was higher than the study conducted in SNNPR on selected health posts [ 33 ] and a study conducted in Soro district, southern Ethiopia [ 24 ]. The possible reason might be due to low interruption of drugs at town health office or regional health department stores, regular supplies of essential drugs and good supply management and distribution of drug from health centers to health post.

The result of this evaluation showed that only one fourth of health posts had functional ORT Corner which was lower compared to the study conducted in SNNPR [ 34 ]. This might be due poor coverage of functional pipe water in the kebeles and the installation was not set at the beginning of health post construction as reported from one of ICCM program coordinator.

Compliance of HEWs to the treatment guidelines in this evaluation was higher than the study done in southern Ethiopia (65.6%) [ 24 ]. This might be due to availability of essential drugs educational level of HEWs and good utilization of ICCM guideline and chart booklet by HEWs. The observations showed most of the sick children were assessed for danger sign, weight, and temperature respectively. This finding is lower than the study conducted in Rwanda [ 35 ]. This difference might be due to lack of refreshment training and regular supportive supervision for HEWs. This also higher compared to the study done in three regions of Ethiopia indicates that 88%, 92% and 93% of children classified as per standard for Pneumonia, diarrhea and malaria respectively [ 36 ]. The reason for this difference may be due to the presence of medical equipment and supplies including RDT kit for malaria, and good educational level of HEWs.

Moreover most HPs received supportive supervision and performance review meeting was conducted and all of them send reports timely to next level. The finding of this evaluation was lower than the study conducted on implementation evaluation of ICCM program southern Ethiopia [ 24 ] and study done in three regions of Ethiopia (Amhara, Tigray and SNNPR) [ 37 ]. This difference might be due sample size variation.

The overall acceptability of the ICCM program was less than the presetting judgment parameter but slightly higher compared to the study in southern Ethiopia [ 24 ]. This might be due to presence of essential drugs for treating children, reasonable waiting and counseling time provided by HEWs, and smooth communication between HEWs and caregivers. In contrast, this was lower than similar studies conducted in Wakiso district, Uganda [ 38 ]. The reason for this might be due to contextual difference between the two countries, inappropriate waiting area to receive the service and poor cleanness of the HPs in our study area. Low acceptability of caregivers to ICCM service was observed in the appropriateness of waiting area, availability of drugs, cleanness of health post, and competence of HEWs while high level of caregiver’s acceptability was consultation time, counseling service they received, communication with HEWs, treatment given for their sick children and interest to return back for ICCM service.

Caregivers who achieved primary, secondary, and college and above were more likely accept the program services than those who were illiterate. This may more educated mothers know about their child health condition and expect quality service from healthcare providers which is more likely reduce the acceptability of the service. The finding is congruent with a study done on implementation evaluation of ICCM program in southern Ethiopia [ 24 ]. However, inconsistent with a study conducted in wakiso district in Uganda [ 38 ]. The possible reason for this might be due to contextual differences between the two countries. The ICCM program acceptability was high in caregivers who received all prescribed drugs than those did not. Caregivers those waited less than 30 min for service were more accepted ICCM services compared to those more than 30 minutes’ waiting time. This finding is similar compared with the study conducted on implementation evaluation of ICCM program in southern Ethiopia [ 24 ]. In contrary, the result was incongruent with a survey result conducted by Ethiopian public health institute in all regions and two administrative cities of Ethiopia [ 39 ]. This variation might be due to smaller sample size in our study the previous one. Moreover, caregivers who traveled to HPs less than 60 min were more likely accepted the program than who traveled more and the finding was similar with the study finding in Jimma zone [ 40 ].

Strengths and limitations

This evaluation used three evaluation dimensions, mixed method and different data sources that would enhance the reliability and credibility of the findings. However, the study might have limitations like social desirability bias, recall bias and Hawthorne effect.

The implementation of the ICCM program in Gondar city administration was measured in terms of availability (84.2%), compliance (83.1%), and acceptability (75.3%) dimensions. In the availability dimension, amoxicillin, antimalarial drugs, albendazole, Vit. A, and ORS were available in all health posts, but only six HPs had Ready-to-Use Therapeutic Feedings, three HPs had ORT Corners, and none of the HPs had functional timers.

This evaluation assessed the implementation status of the ICCM program, focusing mainly on availability, compliance, and acceptability dimensions. The overall implementation status of the program was judged as good. The availability dimension is compromised due to stock-outs of chloroquine syrup, cotrimoxazole, and vitamin K and the inaccessibility of clean water supply in some health posts. Educational statuses of caregivers, availability of prescribed drugs at the HPs, time to arrive to HPs, and waiting time to receive the service were the factors associated with the acceptability of the ICCM program.

Therefore, continuous supportive supervision for health facilities, and refreshment training for HEW’s to maximize compliance are recommended. Materials and supplies shall be delivered directly to the health centers or health posts to solve the transportation problem. HEWs shall document the assessment findings and the services provided using the registration format to identify their gaps, limitations, and better performances. The health facilities and local administrations should construct clean water sources for health facilities. Furthermore, we recommend for future researchers and program evaluators to conduct longitudinal studies to know the causal relationship of the program interventions and the outcomes.

Data availability

Data will be available upon reasonable request from the corresponding author.

Abbreviations

Ethiopian Demographic and Health Survey

Health Center/Health Facility

Health Extension Program

Health Extension Workers

Health Post

Health Sector Development Plan

Integrated Community Case Management of Common Childhood Illnesses

Information Communication and Education

Integrated Family Health Program

Integrated Management of Neonatal and Childhood Illness

Integrated Supportive Supervision

Maternal and Child Health

Mid Upper Arm Circumference

Non-Government Organization

Oral Rehydration Salts

Outpatient Therapeutic program

Primary health care unit

Rapid Diagnostics Test

Ready to Use Therapeutic Foods

Sever Acute Malnutrition

South Nation Nationalities People Region

United Nations International Child Emergency Fund

World Health Organization

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Acknowledgements

We are very grateful to University of Gondar and Gondar town health office for its welcoming approaches. We would also like to thank all of the study participants of this evaluation for their information and commitment. Our appreciation also goes to the data collectors and supervisors for their unreserved contribution.

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Geta Asrade Alemayehu, Wubshet Debebe Negash, Tadele Biresaw Belachew, Chalie Tadie Tsehay & Getachew Teshale

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All authors contributed to the preparation of the manuscript. M.G. conceived and designed the evaluation and performed the analysis then T.B.B., W.D.N., G.A.A., C.T.T. and G.T. revised the analysis. G.T. prepared the manuscript and all the authors revised and approved the final manuscript.

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Geta, M., Alemayehu, G.A., Negash, W.D. et al. Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design. BMC Pediatr 24 , 310 (2024). https://doi.org/10.1186/s12887-024-04785-0

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Article sidebar, article details, main article content, assessment of health facility access to care, surveillance and response readiness and readiness score for malaria elimination in four counties, kenya, 2023, j.g. murangiri, f.o. odhiambo, r.j. kosgei, a.b. kihara.

Objectives : To determine capacity for; surveillance and response; access to care and readiness score for malaria elimination  implementation amongst the sampled health facilities.

Design : A retrospective cross-sectional study that used routinely collected Malaria program data using a District-Level Readiness for  Elimination of Malaria Tool (DREAM-IT) tool, adopted by the Ministry of Health and modified to fit the country’s context.

Settings : Four  malaria elimination target counties in Kenya namely; Kirinyaga, Nyandarua, Laikipia and Nyeri.

Subject : Healthcare workers in twenty- four sampled health facilities offering outpatient and inpatient malaria services across all levels of care. Interventions : Implementation  of malaria elimination strategy in Kenya.

Main outcome measures : Health facility readiness and score in Access to care (Case management), Surveillance and response for malaria elimination implementation. 

Results : Most of the study health facilities were  government- owned (public) and level 2. Kirinyaga recorded the best performance in case management. Surveillance and response was  performed over 50% in Kirinyaga and Nyandarua, and was poorly performed in less than 40% in Nyeri and Laikipia.

Conclusion : In  elimination settings, a case-based surveillance system with increased sensitivity and specificity as part of broader strengthening of the  passive surveillance systems is key. High-quality and prompt case management that allows testing and treatment of all suspected and  confirmed malaria cases respectively should be put in place to reduce transmission, especially in lower-level health facilities where  majority of people seek care. More investments in health systems in readiness for malaria elimination implementation in Kenya is  required. 

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Introduction: Reducing unplanned hospital admissions in chronic patients at risk is a key area for action due to the high healthcare and societal burden of the phenomenon. The inconclusive results of preventive strategies in patients with chronic respiratory disorders and comorbidities are explainable by multifactorial but actionable factors. The current protocol (January 2024 to December 2025) relies on the hypothesis that intertwined actions in four dimensions: i) management change, ii) personalisation of the interventions based on early detection/treatment of acute episodes and enhanced management of comorbidities, iii) mature digital support, and iv) comprehensive assessment, can effectively overcome most of the limitations shown by previous preventive strategies. Accordingly, the main objective is to implement a novel integrated care preventive service for enhanced management of these patients, as well as to evaluate its potential for value generation. Methods and analysis: At the end of 2024, the specifics of the novel service will be defined through the articulation of its four main components: i) Enhanced lung function testing through oscillometry, ii) Continuous monitoring of indoor air quality as a potential triggering factor, iii) Digital support with an adaptive case management approach, and iv) Predictive modelling for early identification and management of exacerbations. During 2025, the novel service will be assessed using a Quintuple Aim approach. Moreover, the Consolidated Framework for Implementation Research will be applied to assess the implementation. The service components will be articulated through four sequential six-months Plan-Do-Study-Act cycles. Each cycle involves a targeted co-creation process following a mixed-methods approach with the active participation of patients, health professionals, managers, and digital experts. Ethics and dissemination: The Ethics Committee for Human Research at Hospital Clinic de Barcelona approved the protocol on June 29, 2023 (HCB/2023/0126). Before any procedure, all patients in the study must sign an informed consent form. Registration: NCT06421402 . Keywords: COPD, Severe Asthma, Digital Support, Integrated Care, Quintuple Aim, Service Assessment

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The Ethical Committee for Human Research at Hospital Clinic de Barcelona approved the core study protocol of K-Health in Air on June 29, 2023 (HCB/2023/0126). The study design adheres to data minimisation principles, ensuring that only essential data are collected and utilised. The study will be conducted in compliance with the Helsinki Declaration (Stronghold Version, Brazil, October 2013) and in accordance with the protocol and the relevant legal requirements (Biomedical Research Act 14/2007 of July 3). All patients in the study must sign an informed consent form before any procedure. The participants can withdraw their consent at any time without altering their relationship with their doctor or harming their treatment. The One Beat watch does not hold medical device certification and will be utilized solely for data collection and exploring potential patterns informing exacerbations, not for decision-making within the study. Any future application derived from this research must ensure that the technology aligns with medical device regulations.

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Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis

Dr. catherine hudon.

1 Département de médecine de famille et de médecine d’urgence, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC, Canada

2 Centre de recherche du CHUS, 12e Avenue Nord Porte 6, Sherbrooke, QC, Canada

Maud-Christine Chouinard

3 Faculté des sciences infirmières, Université de Montréal, Pavillon Marguerite-d’Youville, 2375 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada

Mathieu Bisson

Astrid brousselle.

4 School of Public Administration, University of Victoria, Public Administration, HSD building, Room A302, Victoria, BC, Canada

Mireille Lambert

5 Centre intégré universitaire de santé et services sociaux du Saguenay–Lac-Saint-Jean, 930 rue Jacques-Cartier E, Chicoutimi, QC, Canada

Alya Danish

Charo rodriguez.

6 Department of Family Medicine, McGill University, 5858, Chemin de la Côte-des-Neiges, Montreal, QC, Canada

Véronique Sabourin

7 Patient partner, CA

Introduction:

Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use.

A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada).

Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers’ access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use.

Conclusion and discussion:

This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.

Introduction

Individuals with chronic conditions sometimes have complex healthcare needs, due to mental health comorbidities and/or social vulnerabilities [ 1 ] and become frequent users of healthcare services [ 2 , 3 , 4 ]. Organizing services to improve care for these patients with complex needs is a priority for healthcare systems [ 4 ] and requires an integration of clinical services offered by health and social care professionals, as well as community-based ones [ 5 ]. Models of integrated care such as case management [ 6 ] improve the quality of care, patient satisfaction, access to care, and care transitions [ 7 , 8 ], and reduce the probability of hospitalization, when compared with usual care [ 9 ].

Case management programs (CMP) for frequent users of healthcare services with complex needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost [ 10 , 11 , 12 ]. Case management is a dynamic, systematic and collaborative approach used to ensure, coordinate, and integrate care and services for a clientele. The case manager is a key practitioner or navigator (often a nurse or a social worker) who evaluates, plans, implements, coordinates, and prioritizes services based on individuals’ needs, and offers self-management support in close collaboration with health, social and community partners [ 13 ].

A majority of studies have reported the effectiveness of CMP with indicators such as improvement in patient satisfaction and quality of life, and reduction of healthcare services use, ED visits, hospitalization rates, and cost [ 10 , 11 , 12 ]. Although the evidence in support of CMP is strong, there remains a paucity of evidence about the implementation process that lead to these outcomes in local contexts [ 14 ]. The aim of this study was to identify characteristics of CMP, and the contexts where they are implemented, that help to improve patient self-management, experience of integrated care, and healthcare services use.

Methodology

Design of the study.

This was a case study, more specifically a multiple embedded case study with a mixed-methods design [ 15 ]. Such a methodology appears the most appropriate for an implementation analysis in a complex system, and to study cases, with varied contexts, as they evolve over time [ 15 , 16 ]. In addition to allowing for an in-depth analysis of each case, the analysis strategies used in this design help to systematically compare trends observed between cases. It is recommended that four to ten cases be considered [ 17 ] in the multiple case study logic of theoretical replication [ 15 ]. This study included six cases, where each case was the CMP implemented in each hospital. The three different units of analysis that were interwoven to obtain an in depth understanding of each case were: 1) the hospital (organizational ‘macro’ level); 2) the CMP itself for frequent users of services (‘meso’ level) and 3) the individual (‘micro’ level), more particularly patients who are frequent users.

Context of the study

The study was realized in the Saguenay-Lac-Saint-Jean region of Quebec, a province in Canada. This region is the third largest territory in Quebec and has a very low average population density of 2.9 inhabitants per square kilometre. Much of the population is French-speaking and less than 1% are immigrants. Compared to the whole Quebec population, the residents of the Saguenay-Lac-Saint-Jean region have lower educational attainment and experience more mental health conditions [ 18 ]. In the province of Quebec, regions are divided into administrative sectors referred to as County Regional Municipalities (CRM). In the Saguenay subregion, one of these CRM is served by three hospitals, and in the Lac-Saint-Jean subregion, three of these CRM are each served by a hospital.

Case management program

In 2008, the Saguenay-Lac-Saint-Jean health and social services agency mandated the six hospitals of its territory to implement CMP for frequent users of healthcare services. Between 2009 and 2015, six CMP, the cases included in this study, were deployed by stakeholders’ committees made up of a coordinator, managers, services coordinators and case managers. CMP aimed to improve self-management support and integrated care, and decrease ED use, hospitalizations as well as healthcare cost. Case managers (a nurse or a social worker or both in dyad) in each of the six hospitals were recruited and trained to the case management approach. The training enabled the case managers to identify patients with complex care needs, assess their specific needs, and develop the individualized service plans (ISP) to respond to those needs in collaboration with the patient, their relatives and other actors involved in the implementation of the ISP, including nurses, social workers, family physicians, pharmacists, and representatives of community organizations.

In 2015, during the data collection of the study, the government of Quebec reorganized the healthcare system by merging local hospitals into larger regional entities in order to centralize health and social services. This resulted in an effort from a single CMP committee made up of a coordinator, a manager, a performance improvement consultant and case managers to standardize the program offered by the six hospitals. Members of the committee also discussed challenges and facilitators to the implementation of the CMP in this new context, as well as factors at the healthcare system level that could influence the case managers’ work. Criteria for enrolment were standardized, targeting patients with more than six ED visits or three hospitalizations in the previous year. Frequent users were identified electronically through hospital admissions and ED records. The provincial healthcare system reorganization had major impacts on clinical, professional, administrative, management and governance aspects of the healthcare system. For example, there was staff turnover at the case manager and manager level, which affected the implantation of CMP in many cases.

Conceptual framework

Two conceptual frameworks guided this study. First, given that we were interested in the implementation of CMP, we used Chaudoir et al. [ 19 ] which proposes five broad categories of factors to consider when evaluating the implementation of an innovation, namely: 1) structural and environmental-level factors; 2) organizational-level factors; 3) practitioner-level factors; 4) patient–level factors, and 5) innovation-level factors. Second, to examine patient experience of integrated care, the model proposed by the National Collaboration in Integrated Care and Support was used [ 20 ]. It consists of six dimensions of care integration based on patient experience: 1) consideration of patient and family needs, 2) communication with the patient and between practitioners, 3) access to information, 4) patient involvement in decision-making, 5) care planning, and 6) transitions between various professionals.

Participants

Key informants involved in the six CMP and healthcare services used by patients with complex health needs were recruited through purposeful sampling [ 21 ] in each hospital. Patients recruited were frequent users of hospital services, who had six visits to the ED or more, or three hospitalizations or more in the previous year.

Data collection

An implementation analysis strategy [ 22 ] guided the three methods of qualitative data collection and the method of quantitative data collection. While qualitative methods were used to inform self-management and patient experience of integrated care, quantitative data collection methods allowed the measurement of ED services use.

Qualitative data

Individual interviews and focus groups.

Semi-structured individual interviews (n = 56) and focus groups (n = 11) were conducted between December 2014 and May 2018 with 24 patients, 12 case managers and intermediate managers, 8 senior managers, 12 family physicians, 25 community stakeholders and 6 pharmacists, with interview guides, adapted for each type of actor, and addressed the five main categories of factors of the Chaudoir et al. framework of innovation implementation [ 19 ], and the six dimensions of patient experience [ 20 ]. Data saturation was not the goal for each group, but the diversity of actors engaged provided a complete representation of each case [ 23 ]. All individual interviews and focus groups were audio recorded and transcribed verbatim.

Participant observation

A member of the research team performed participant observation during one case management training session, individual case manager activities (n = 6) (e.g. evaluation of targeted patient needs, contacts with patients and their healthcare providers, ISP meetings), and quarterly meetings of the CMP committee of each of the six hospitals (n = 11). The member of the research team was invited to attend all committee meetings and share updates about the research project. These meetings were also an opportunity to consult committee members on how the research project could provide new knowledge that would help them. Data were collected using field notes [ 21 ].

Document analysis

Minutes of the CMP committee meetings were collected as they provided insight into the characteristics of the CMP and the CMP implementation, including challenges and means to overcome them [ 24 ].

Quantitative data

Clinical and administrative data.

Using the hospitals’ Magic Chronique computer software [ 25 ], the number of frequent users of ED was recorded monthly for each hospital beginning in December 2012 (the year preceding the start date of the study) and ending on May 2018. Data quality was controlled using an integrated model of information quality and a series of validation algorithms.

For each case, all qualitative data were analysed together as one data corpus using a deductive (themes based on the conceptual frameworks [ 19 , 20 ] and inductive (themes emerging from the data) thematic analysis [ 26 ]. All data sources were examined to identify characteristics of CMP, and their contexts that can be related (positively or negatively) to the examined outcomes, i.e. patient self-management, experience of integrated care, and healthcare services use. Qualitative data were managed by two authors who used NVivo V.11 server software (QSR International Pty). Other authors, including an experienced patient partner, participated in the analysis. Persistent observation, and methodological and investigator triangulation were used to ensure credibility [ 27 ].

The number of ED frequent users (six visits or more in the previous year) was tabulated for each hospital and represented in one graph to allow for visual comparison.

Integration of qualitative and quantitative data

Qualitative and quantitative results were compared for each case [ 28 ]. Qualitative data was analysed first, quantitative data second, then cross-analyses merged the two corpora of data [ 15 ]. A case history was written for each case ( Table 2 ) to summarize merged data [ 26 ]. To compare the six case records, three analytic techniques used in case study research were used, namely pattern comparison, search for competing explanations and construction of explanations [ 15 ]. Management, data reduction and cross case comparisons were conducted with NVivo V.11 software using matrix queries.

Case management program (CMP) implementation in each setting: case stories.

The study was approved by the ethics committee of the Centre for integrated health and social services of Saguenay-Lac-Saint-Jean (2014–015).

Table 1 provides the descriptive characteristics of each of the six CMP.

Characteristics of the six case management programs.

CMP: case management program; CRM: County regional municipality; ED: Emergency department; ISP: Individual service plan.

Figure 1 illustrates the evolution of the number of ED frequent users during the implementation of the CMP. While the number of frequent users increased considerably in the case A and increased slightly in the case D, an important decrease was observed for the case C and a slight decrease in the case F. These last two cases are considered “success stories”. The cases B and E remain relatively stable.

Number of ED frequent users* for each hospital.

* FU: 6 ED visits or more in the previous year.

Intra-case results

Table 2 merged qualitative and quantitative data to present case stories.

Cross-case results

Tables 3 , ​ ,4, 4 , ​ ,5 5 present the cross-case results. The outcomes (see the legend) are identified according to the five categories of Chaudoir et al. framework.

Structural, environmental, and organizational characteristics influencing integrated care, self-management and health services use for each case.

ISP: Individualized services plan.

Practitioner and patient characteristics influencing integrated care, self-management and health services use for each case.

CT: care trajectory; ED: emergency department.

Characteristics of the innovation (the CMP) influencing integrated care, self-management and health services use for each case.

Legend for Tables 3 , ​ ,4 4 and ​ 5 5

Outcomes associated with each CMP characteristic

• 1.1 Consideration of patient and family needs
• 1.2 Communication with the patient and between practitioners
• 1.3 Access to information
• 1.4 Patient involvement in decision-making
• 1.5 Care planning
• 1.6 Transitions between various health professionals and practitioners
• 2 Self-management
• 3 Health services use

In the tables, the arrows represent an increase (↑), a decrease (↓), or an effect on another outcome (→), while the + and – signs represent contextual factors having a positive or negative impact on the implantation of CMPs.

Cross-Case Synthesis

The skills, leadership and experience of the case manager seem to be the characteristics of the CMP that have the most positive influence on patient experience of integrated care, self-management and healthcare services use. The case manager’s leadership was critical in both successful cases (C and F), i.e. where we observed a decrease of ED visits. Their coordination, communication and networking skills improved integrated care by facilitating collaboration among professionals and also the transitions between health services, for which information access was a key. These improvements were also observed when the case manager was experienced, well-known in his/her workplace (C and F) and located near the providers (cases D, E, F).

Regarding the other characteristics of the CMP, four stand out from our cross-case analysis: 1) the individualized services plan (all cases), 2) patient and family needs assessment (all cases), 3) patient and family participation in decision-making (all cases), and 4) the self-management approach (cases C, D and F).

Our results suggest that where staff turnover and thus, health care team instability, was present due to organizational issues and the health system reorganization (cases B, D and E), negative impacts on care integration, especially regarding communication and care transitions, were observed. However, when case managers were well supported by their managers (cases B, E and F), they had the opportunity to create more personalized care trajectories. Therefore, patient transition through care pathways was optimized and their use of services was more appropriate. Reassurance of patients by their case manager appears to be particularly important for those with anxiety as it seems to have contributed to a reduction in their ED visits.

This study underscores the necessity of an experienced, knowledgeable, and well-trained case manager with strong interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve. These qualities improve care coordination which is one of the main components of CMP [ 30 , 31 ]. Similarly, Ross et al. pointed out that the case manager skills such as ability to develop good interpersonal relationships, problem-solving, negotiation and brokerage, prescribing qualifications play a key role to facilitate CMP implementation and improve outcomes [ 32 ]. Case manager training could include a focus on these skills. Indeed, a qualitative systematic review by Joo et al. revealed that insufficient training was a barrier to the case manager’s role [ 33 ]. Likewise, our results also underscored the importance of adequate training, but also that it can be challenging to ensure such training when there is a high turnover of case managers. Hong et al. provide a potential solution to this by suggesting that all care team members receive training, in order to build a relationship of trust with the patient [ 31 ].

To improve integrated care, although coordination by a skilled case manager is the core of case management, self-management support is important for CMP as a whole [ 14 , 34 , 35 ]. Self-management support seeks to improve patients’ knowledge and awareness of their care plan, self-efficacy, sense of control over their condition, and motivation to take more responsibility for their health [ 36 , 37 ]. To effectively provide this support, case managers should adopt an approach that is relevant, meaningful and centred on patient needs [ 32 ]. When the patient and caregiver manage the patient’s care adequately, their use of healthcare services is more appropriate and reduced rates of readmission are observed [ 38 ]. Furthermore, encouraging patients and their families to participate in decisions regarding the ISP better meets patient needs, promotes patient and family involvement in patient care and leads to fewer ED visits [ 35 , 39 , 40 ].

It could be argued that in-depth descriptions of the six CMP settings studied would be helpful to judge whether the results of this study are transferable to similar healthcare system settings [ 41 ]. However, given that the six CMP are heterogenous in terms of the populations they serve, their urban and rural environments, their size, the types of providers, among other key features (see Table 1 ), this aspect increases the theoretical transferability of the results. That said, this study’s findings should be considered in light of some limitations that could be addressed in future research. First, only one source of quantitative data (ED visits) was used to measure CMP efficacy. Second, the qualitative data did not provide much insight into the factors linked to the ‘patient’ category of outcomes outlined in the Chaudoir et al. conceptual framework. Third, the qualitative results are relevant to many contextual factors in the other five categories of outcomes, but only those regarding the outcomes of interest (i.e., patient experience of integrated care and integrated care) are reported. Fourth, the case managers’ activities were not measured and evaluated. To further increase the credibility of the results, survey studies could be conducted with validated questionnaires that assess the impact of CMP on patients and the results could be triangulated with those presented herein. Finally, exploring system or organization level outcomes could complete the picture of the impact of CMP on frequent users’ health outcomes.

Studying CMP as they unfold is crucial to building the knowledge base regarding the components of CMP and the roll-out required to improve integrated care. This study is one of few that explore the implementation of CMP for frequent users of ED services in hospital settings. Additional implementation studies conducted in differing contexts or healthcare systems would be useful to confirm and further enrich the findings. In this regard, Malebranche et al. recently suggested that further research was needed to better understand the advantages and disadvantages of implementing case management as primary care program versus predominantly ED or hospital-based one [ 42 ]. Teper et al.’s systematic review of CMP implementation in primary care settings identified common facilitators and barriers of CMP implementation in hospital settings including case managers’ skills, training, and relationship building and team communication practices [ 43 ]. In a systematic mixed studies review on the barriers of CMP implementation for people with dementia in community-based primary health care, Khanassov et al. also reported the importance of communication between case managers and other professionals and services [ 44 ]. Identifying contextual barriers to CMP implementation can help to select more effective implementation strategies resulting in increased positive outcomes [ 44 , 45 ].

Based on the results of the study, recommendations can be made to senior and intermediate managers and clinicians for the planning and implementation of CMP. Senior managers should ensure ongoing support for the implementation of CMP and information sharing among health professionals. They should ensure stability in the health and social care teams, especially to maintain an experienced case manager. They also have a responsibility to promote the culture of a person-centred approach, i.e. one that encourages the consideration of patients’ needs and shared decision-making. Intermediate managers should facilitate the skills, leadership and experience of the case manager, as well as his/her proximity to providers. They will need to focus on the case manager’s skills during the hiring process and provide quality training in case management with frequent users. In addition, intermediate managers should foster professional development by, for example, allowing time for the case manager to participate in a community of practice or co-development activities. Clinicians must consider the needs of patients and their families when implementing the CMP. They should also provide support to patients and encourage their autonomy and involve them and their families in decision-making.

This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve. Providers’ access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, also impact patient experience of integrated care, self-management and services use.

Acknowledgements

We would like to thank the following intermediate and senior managers (Myriam-Nicole Bilodeau, Martine Couture, Julie Labbé, Jean Morneau, Sylvie Massé, Mélanie Paradis, Caroline Savard and Marc Villeneuve), patient partners (Claude Spence, Gilles Gauthier), and clinicians (Marie-Ève Bergeron, Marc Bolduc, Audrey Corneau, Sylvain Gagnon, Julie Godbout and Cécilia Ruiz) who participated in the governance of this study and made valuable contributions. We also thank Paula L. Bush, PhD, for her substantive and editorial comments and revisions to a previous version of this manuscript.

Adelaide Belo, Senior Consultant – Internal Medicine, Coordinator of Integrated Care Team – Unidade Local de Saúde do Litoral Alentejano – Portugal and President of the Portuguese Association for Integrated Care -PAFIC.

One anonymous reviewer.

Competing Interests

The authors have no competing interests to declare.