Request for Proposals (RFP014) for Synthesis Research - Governance Choices and Health Care Quality: A Focus on Patient Safety
Funding and General Information
Deadline for applications: April 30, 2003 (must be courier stamped
April 29 for next day delivery).
Up to $600,000 have been set aside in this competition for the
support of up to 4 projects. Maximum funds per project: $200,000.
Funding is expected to begin in the fall of 2003. Project final
reports must be submitted by February 2005.
Synthesis is the identification, review, analysis and appraisal
of the best available existing knowledge. In this competition,
projects must:
- include published literature, "grey" (unpublished)
literature, the practical experience of policy/decision makers
and/or the knowledge of experts in the field;
- consider international sources and not be restricted to English
and French sources;
- state the policy implications of the evidence studied to patient
safety governance in Canada.
Background
Health care quality1 has gained increasing
attention in health policy and health care practice in recent years.
Integral to that focus has been a concern with patient safety2 and
the prevention of adverse events (medical error)3.
Initial research on adverse events in health care emerged in the
1950s and 1960s, grew with the publication of the Harvard Medical
Practice Study in 1991 and subsequent research in Australia, the
United Kingdom and the United States.
Numerous OECD countries,
including Canada, Denmark, the Netherlands, Sweden and New Zealand,
have recognized that their health care systems are prone to medical
error, and that measures need to be taken to reduce the risk of
such error. An Institute of Medicine Report 4 estimated
that in the United States, between 44,000 and 98,000 deaths occur
each year as a result of medical errors. In the United Kingdom,
it is estimated that adverse events resulting in harm occur in
approximately 10% of patient admissions, or about 850,000 times
a year. The 1995 Quality in Australian Health Care Study5 reported
that 16.6% of admissions were associated with adverse events, and
of these, 51% were considered highly preventable. In Canada, there
is currently a lack of data on the incidence of adverse events
in health care, but work is underway that will begin to address
this need for information. The Canadian Institute for Health Information
(CIHI)
and the Canadian Institutes for Health Research (CIHR)
recently initiated a jointly funded research study to examine the
extent of adverse events in Canadian acute-care hospitals. The
results, expected in 2004, will provide baseline data and a reference
point for patient safety activities in Canadian hospitals.
Recent health care policy literature has identified governance
choices as a primary issue of concern for any future reforms of
the Canadian health care system6. Broadly,
governance can be defined as the interaction of processes, institutions
and traditions that determines how decisions are made on issues
of public concern7. In democracies,
governance is most often shared between a number of actors, including
citizens at large, the private sector, civil society and government.
In this environment, governments and other actors are challenged
to choose "governing" or "policy instruments" that
successfully address certain public problems or social issues 8.
The choices governments make in this regard contribute to shaping
how other actors participate in decision-making.
On any given issue, these instruments can include both voluntary
and mandatory codes and standards; accountability and reporting
mechanisms; leadership and coordination strategies; self-regulation
regimes; fiscal and other incentives; and opportunities for consumer
or public involvement. More specifically, in the area of health
care quality, some of these instruments have included certification
and licensure of professions; incidence reporting systems; patient
complaints mechanisms; accreditation of health services; continuing
professional education; systems coordination bodies; legal liability
and tort law; and institutional/sectoral quality improvement initiatives.
Objective
The objective of this synthesis research is to explore the impact
of governance choices on improvements in quality and safety, both
in health and in other sectors. Health Canada needs information
on the effectiveness of these governance choices in order to support
its ongoing policy development.
Research Questions
- What are the current definitions, concepts and trends related
to governance and health care quality in general, and patient
safety in particular, in Canada and in other countries?
Include a scan of existing definitions and conceptual frameworks for governance
in the health care system. Examine the most prevalent trends through the
1990s to the present, as well as new and emerging trends. Include:
- methods by which effective governance has been defined and
measured;
- how trends in governance have been applied to the health care
system, with respect to health care quality and patient safety;
and,
- existing evidence and data which could be used to measure nationally
the state of health care quality and patient safety (for example,
incidence studies, system performance data, and other methods
such as patient surveys)
- What evidence exists in sectors outside the health sector
to link governance choices to improvements in quality and safety,
in Canada and in other countries ?
What frameworks/approaches and indicators exist to assess the effectiveness
of governance choices in improving quality and safety? What are the advantages
and limitations of these approaches and how can they be applied to patient
safety in Canada? What evidence associates effective governance with specific
governance instruments? What examples exist of effective and ineffective
governance choices and the methods by which such effectiveness was measured?
What are the characteristics of governance choices which have been associated
with improvements in quality and safety?
- What are the key examples of governance arrangements related
to patient safety that exist outside Canada? Which of these
can be considered most effective in improving patient safety?
Identify the scope of actions they have taken in relation to patient safety,
and whether these actions are limited to certain care settings, health care
professions and/or procedures/treatments. Identify short, medium and long-term
priorities for patient safety, the changes (or proposals for change) which
have emerged related to governance choices, the extent to which these (proposed)
changes have addressed current trends in health care delivery, including:
new technologies and treatments; newly regulated and unregulated health care
professions; the growing diversity of care settings; the growth in multi-disciplinary
teams of providers and reports on national incidence. Finally, identify other
factors which have driven recent changes (or proposals for change) in patient
safety governance.
Research must examine existing frameworks/approaches and the indicators used
to assess the effectiveness of patient safety governance choices outside
Canada in order to identify advantages and limitations of these approaches
and how they can be applied to the study of patient safety governance choices
within Canada. What evidence associates effective patient safety governance
with specific governance instruments? Based on an examination of examples
of effective and ineffective patient safety governance choices, what are
the most prevalent examples and by what methods was effectiveness measured?
What are the characteristics of governance arrangements which have been associated
with improvements in quality and safety?
Policy Contact
Applicants must get in touch with the policy contact at least
once during the development of the proposal. The policy contact
is responsible for ongoing interaction with researchers on the
policy issues and context. Policy inquiries should be directed
to John Topping, Senior Policy Analyst, Health Care Strategies
and Policy Directorate, Health Policy and Communications Branch,
Health Canada (tel: 613-952-6410, email: john_topping@hc-sc.gc.ca).
How to Apply
Applicants are required to register in order to obtain an application
form and a registration number which must be quoted on the application
form. Applicants are encouraged to consult the HPRP Guide
for Applicants before registering.
Inquiries regarding registration, eligibility/ineligibility, administrative
questions about time frames and budgets, application formatting
and content, the review process, and terms and conditions of the
Health Policy Research Program should be directed to the program
officer, Inger Abrams (tel: 613-952-8112, e-mail: inger_abrams@hc-sc.gc.ca).
Deadline for applications is April 30, 2003 (must be courier stamped
April 29 for next day delivery). Address for courier:
Inger Abrams
Health Canada
Rm 1532B, Jeanne Mance Building, Tunney's Pasture
Postal Locator 1915A
Ottawa ON K1A 0K9
Endnotes
1 The Canadian Council on Health Services
Accreditation (CCHSA)
has defined many of the fundamental concepts associated with health
care quality. These include: safety, which occurs when potential
risks and/or unintended results are avoided or minimized; effectiveness,
which occurs when services, interventions, or actions achieve optimal
results; appropriateness, which occurs when services meet
the needs of the client and/or community population, are proven
to produce benefits, and are based on established standards; consumer
participation, which occurs when the client and/or community
actively participates as a partner in decision-making, and in service
planning, delivery, and evaluation; access, which occurs
when the client and/or community easily obtains required or available
services in the most appropriate setting; and efficiency,
which occurs when resources (inputs) are brought together to achieve
optimal results (outputs) with minimal wastes, re-work and effort
(Canadian Council on Health Services Accreditation, October 2001. Submission
to the Commission on the Future of Health Care in Canada).
2 The state of continually working
toward the avoidance, management and treatment of unsafe acts within
the health care system (National Steering Committee on Patient
Safety, 2002. Building a Safer System: A National Integrated
Strategy for Improving Patient Safety in Canadian Health Care).
3 Injury related to health care practice,
rather than to an underlying disease process. An adverse event
is an unplanned and undesired harmful occurrence, directly associated
with care or services provided to a patient/client, such as an
adverse reaction to a medication or a negative outcome of treatment.
The occurrence may result from acts of commission (e.g., administration
of the wrong medication) or omission (e.g., failure to institute
the appropriate therapeutic intervention) and is related to problems
in practice, products, procedures, and other aspects of the system
(National Steering Committee on Patient Safety, 2002. Building
a Safer System: A National Integrated Strategy for Improving Patient
Safety in Canadian Health Care).
4 Kohn, L., Corrigan, J., & Donaldson,
M. (Eds.). (1999). To err is human: Building a safer health
system. Institute of Medicine. Washington, DC: National Academy
Press.
5 Wilson, R.M., Harrison, B.T., Gibberd,
R.W., & Hamilton, J.D. (1999). An analysis of the causes of
adverse events from the quality in Australian health care study. Medical
Journal of Australia, 170(9), 411-415.
6 For a discussion of governance and
its application in one area of health care reform, see Forest,
P.G., Gagnon, D., Abelson, J., Turgeon, J., & Lamarche, P.
(1999). Issues in the governance of integrated health systems.
Canadian Health Services Research Foundation. Ottawa: Library Series.
For a discussion focussed more on macro level governance
of health care, see Adams, D. (2001). Conclusions: Proposals for
advancing federalism, democracy and governance of the Canadian
health care system. In Duane Adams (Ed.), Federalism, Democracy
and Health Policy in Canada. Montreal and Kingston: McGill-Queen's
University Press.
7 Personal communication (with John
Graham), adapted from a definition by the Institute on Governance.
For a discussion on definitions of governance, see Plumptre, T., & Graham,
J. (2000). Governance in the new millenium: Challenges for Canada.
Ottawa: Institute on Governance.
8 Eliadis, F. Pearl. (2002). Foundation
paper: Instrument choice in global democracies. Ottawa: Policy
Research Initiative.
References
Adams, D. (2001). Conclusions: Proposals for advancing federalism,
democracy and governance of the Canadian health care system. In
Duane Adams (Ed.), Federalism, democracy and health policy in
Canada. Montreal and Kingston: McGill-Queen's University Press.
Baker, G.R., & Norton, P. (2001). Patient safety and healthcare
error in the Canadian health care system. Report to Health
Canada.
http://www.hc-sc.gc.ca/english/pdf/care/report_f.pdf
Canadian Council on Health Services Accreditation. (October 2001). Submission
to the Commission on the Future of Health Care in Canada.
ftp://ftp.cchsa.ca/pub/download/downloads/Final_Romanow_Submission.PDF
Committee on Quality of Health Care in America (2001). Crossing
the quality chasm: A new health system for the 21st century.
Institute of Medicine. Washington, DC: National Academy Press.http://books.nap.edu/books/0309072808/html/index.html
Department of Health, United Kingdom. (2000). An organization
with a memory: Report of an expert group on learning from adverse
events in the NHS chaired by the Chief Medical Officer.
http://www.doh.gov.uk/pdfs/org.pdf
Eliadis, F. Pearl. (2002). Foundation paper: Instrument choice
in global democracies. Ottawa: Policy Research Initiative.
http://policyresearch.gc.ca/page.asp?pagenm=law-droit_instruments_foundation
Forest, P.-G., Gagnon, D., Abelson, J., Turgeon, J., & Lamarche,
P. (1999). Issues in the governance of integrated health systems.
Canadian Health Services Research Foundation. Ottawa: Library Series.
Kohn, L., Corrigan, J., & Donaldson, M. (Eds.). (1999). To
err is human: Building a safer health system. Institute of
Medicine. Washington, DC: National Academy Press. http://books.nap.edu/books/0309068371/html/index.html
Morris, J.J. (1996). Law for Canadian health care administrators.
Toronto: Butterworths.
National Steering Committee on Patient Safety. (2002). Building
a safer system: A national integrated strategy for improving
patient safety in Canadian health care.
http://rcpsc.medical.org/english/publications/
National Health Committee: New Zealand. (May 2002). Safe systems
supporting safe care: Final report on health care quality improvements
in New Zealand.
http://www.nhc.govt.nz/publications/SafeSystemsSupportingSafeCare.pdf
Plumptre, T., & Graham, J. (2000). Governance in the new
millenium: Challenges for Canada. Ottawa: Institute on Governance.
http://www.iog.ca/publications/governance.pdf
Wilson, R.M., Runciman, W.B., Gibberd, R.W., Harrison, B.T., Newby,
L., & Hamilton, J.D. (1995). The quality in Australian health
care study. Medical Journal of Australia, 163(9), 458-471.
Wilson, R.M., Harrison, B.T., Gibberd, R.W., & Hamilton, J.D.
(1999). An analysis of the causes of adverse events from the quality
in Australian health care study. Medical Journal of Australia,
170(9), 411-415.
World Health Organization. (2002). Quality of care: patient
safety. Report by the Secretariat, Fifty-fifth World Health
Assembly: Provisional agenda item, 13.9:A55/13. http://www.who.int/gb/EB_WHA/PDF/WHA55/ea5513.pdf
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