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IntroductionAs an increasing number of people are living with more than 1 long-term condition, identifying effective interventions for the management of multimorbidity in primary care has become a matter of urgency. Interventions are challenging to evaluate due to intervention complexity and the need for adaptability to different contexts. A process evaluation can provide extra information necessary for interpreting trial results and making decisions about whether the intervention is likely to be successful in a wider context. The 3D (dimensions of health, drugs and depression) study will recruit 32 UK general practices to a cluster randomised controlled trial to evaluate effectiveness of a patient-centred intervention. Practices will be randomised to intervention or usual care.Methods and analysisThe aim of the process evaluation is to understand how and why the intervention was effective or ineffective and the effect of context. As part of the intervention, quantitative data will be collected to provide implementation feedback to all intervention practices and will contribute to evaluation of implementation fidelity, alongside case study data. Data will be collected at the beginning and end of the trial to characterise each practice and how it provides care to patients with multimorbidity. Mixed methods will be used to collect qualitative data from 4 case study practices, purposively sampled from among intervention practices. Qualitative data will be analysed using techniques of constant comparison to develop codes integrated within a flexible framework of themes. Quantitative and qualitative data will be integrated to describe case study sites and develop possible explanations for implementation variation. Analysis will take place prior to knowing trial outcomes.Ethics and disseminationStudy approved by South West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via a final report, peer-reviewed publications and practical guidance to healthcare professionals, commissioners and policymakers.Trial registration numberISRCTN06180958.

This book is a must-have resource for private practice owners in hearing healthcare. Author Gyl Kasewurm, AuD, known in the audiology field as \"Dr. Gyl\", has owned and operated a practice for thirty-five years, generating ten times the annual revenue of a typical practice, despite being in a town of only 12,000 people. Readers will benefit from her unique expertise and insight whether they are just starting a new practice or current practice owners looking to implement new strategies to take their business to the next level.

Background A widespread assumption across health systems suggests that greater clinicians’ involvement in governance and management roles would have wider benefits for the efficiency and effectiveness of healthcare organisations. However, despite growing interest around the topic, it is still poorly understood how managers with a clinical background might specifically affect healthcare performance outcomes. The purpose of this review is, therefore, to map out and critically appraise quantitatively-oriented studies investigating this phenomenon within the acute hospital sector. Methods The review has focused on scientific papers published in English in international journals and conference proceedings. The articles have been extracted through a Boolean search strategy from ISI Web of Science citation and search source. No time constraints were imposed. A manual search by keywords and citation tracking was also conducted concentrating on highly ranked public sector governance and management journals. Nineteen papers were identified as a match for the research criteria and, subsequently, were classified on the basis of six items. Finally, a thematic mapping has been carried out leading to identify three main research sub-streams on the basis of the types of performance outcomes investigated. Results and contribution The analysis of the extant literature has revealed that research focusing on clinicians’ involvement in leadership positions has explored its implications for the management of financial resources, the quality of care offered and the social performance of service providers. In general terms, the findings show a positive impact of clinical leadership on different types of outcome measures, with only a handful of studies highlighting a negative impact on financial and social performance. Therefore, this review lends support to the prevalent move across health systems towards increasing the presence of clinicians in leadership positions in healthcare organisations. Furthermore, we present an explanatory model summarising the reasons offered in the reviewed studies to justify the findings and provide suggestions for future research.

No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0–35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8–14.4), presence of allied health professionals (15.3; 95% CI 5.4–25.2) and/or specialist physicians (19.6; 95% CI 8.3–30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0–12.4) and average organizational access to the practice (4.9; 95% CI 2.6–7.2). The number of physicians (1.2; 95% CI 0.6–1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1–2.5) were modestly associated with high-quality care. We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.

In response to systemic challenges facing the US healthcare system, many medical students, residents and practicing physicians are pursuing a Master in Business Administration (MBA) degree. The value of such proposition remains poorly defined. The aim of this review is to analyze current literature pertaining to the added value of MBA training for physician executives (PEs). We hypothesized that physicians who supplement their clinical expertise with business education gain a significant competitive advantage. A detailed literature search of four electronic databases (PubMed, SCOPUS, Embase and ERIC) was performed. Included were studies published between Jan 2000 and June 2017, focusing specifically on PEs. Among 1580 non-duplicative titles, we identified 23 relevant articles. Attributes which were found to add value to one’s competitiveness as PE were recorded. A quality index score was assigned to each article in order to minimize bias. Results were tabulated by attributes and by publication. We found that competitive domains deemed to be most important for PEs in the context of MBA training were leadership ( n   =  17), career advancement opportunities ( n   =  12), understanding of financial aspects of medicine ( n   =  9) and team-building skills ( n   =  10). Among other prominent factors associated with the desire to engage in an MBA were higher compensation, awareness of public health issues/strategy, increased negotiation skills and enhanced work–life balance. Of interest, the learning of strategies for reducing malpractice litigation was less important than the other drivers. This comprehensive systemic review supports our hypothesis that a business degree confers a competitive advantage for PEs. Physician executives equipped with an MBA degree appear to be better equipped to face the challenge of the dynamically evolving healthcare landscape. This information may be beneficial to medical schools designing or implementing combined dual-degree curricula.

Abstract Background Antimicrobial stewardship (AMS) programs are yet to be widely implemented in veterinary practice and medical programs are unlikely to be directly applicable to veterinary settings. Objective To gain an in-depth understanding of the factors that influence effective AMS in veterinary practices in Australia. Methods A concurrent explanatory mixed methods design was used. The quantitative phase of the study consisted of an online questionnaire to assess veterinarians’ attitudes to antimicrobial resistance (AMR) and antimicrobial use in animals, and the extent to which AMS currently is implemented (knowingly or unknowingly). The qualitative phase used semi-structured interviews to gain an understanding of the barriers to and enablers of AMS in veterinary practices. Data were collected and entered into NVivo v.11, openly coded and analyzed according to mixed methods data analysis principles. Results Companion animal, equine, and bovine veterinarians participated in the study. Veterinary practices rarely had antimicrobial prescribing policies. The key barriers were a lack of AMS governance structures, client expectations and competition between practices, cost of microbiological testing, and lack of access to education, training and AMS resources. The enablers were concern for the role of veterinary antimicrobial use in development of AMR in humans, a sense of pride in the service provided, and preparedness to change prescribing practices. Conclusion and Clinical Importance Our study can guide development and establishment of AMS programs in veterinary practices by defining the major issues that influence the prescribing behavior of veterinarians.

Background Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP ‘works’ when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams. Methods We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semi-structured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms. Results The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP’s underlying goal of organisational control. Conclusions Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future.

Under economic pressure, medicine is increasingly being subjected to the efficiency principles of “Taylorism.” But applying standardization to certain vital aspects of medicine can result in inappropriate and unresponsive care, as well as clinician burnout. Frederick Taylor, a son of Philadelphia aristocrats who lived at the turn of the last century, became known as the “father of scientific management” — the original “efficiency expert.” He believed that the components of every job could and should be scientifically studied, measured, timed, and standardized to maximize efficiency and profit. Central to Taylor’s system is the notion that there is one best way to do every task and that it is the manager’s responsibility to ensure that no worker deviates from it. “In the past, the man has been first; in the future, the system must be first,” . . .

Background Hospital governance is broadening its orientation from cost and production controls towards ‘improving performance on clinical outcomes’. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a ‘black-box’ thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems. Methods This study draws both on a quick scan amongst country coordinators in OECD’s Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals. Results This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems. Conclusions Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making.

Background Good inventory management practices in the health facilities are one of the critical aspects that influence the availability of essential medicines (EMs). This study aimed to assess EMs availability and inventory management practices at health centers (HCs) of Adama town, Ethiopia. Method Institution based cross sectional survey was conducted among six HCs in Adama Town from March 19 to April 12, 2017. Self-administered questionnaire and observational checklists were used to collect quantitative information. Eleven tracer drugs (TDs) that were selected by the Federal ministry of health and included in the TD list of the HCs were used to assess the availability of EMs at the time of the survey; and during the past 12 months. The data were entered and analyzed using SPSS version 21. The accuracy of record keeping was assessed using inventory management assessment tool (IMAT) indicators. Result Five HCs had Essential drug list and the procurement was made as per the list. Out of six HCs, four of them procured EMs from both pharmaceutical fund and supply agency (PFSA) of Ethiopia and private suppliers. Stock status of PFSA and transportation were the major challenges during the procurement process. The overall average availability of TDs on the day of the survey was 76.3%. Average length of stock out days for TDs during the past 12 months from each HC was 40.6 days. Among the TDs assessed at HCs, oral rehydrating salt was stock outed for 144 days while paracetamol was stock outed only for 1.4 days. The discrepancy of TDs between physical count and on bincard for which physical inventory less than the balance on bincard ranges from 0 to 33.3%. Conclusion The availability of EMs was low and there was also poor inventory management practice in some of the HCs during the study period.