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Humans care about things. The truth of this claim is obvious, yet scholars who have evaluated student interventions and outcomes in higher education have largely neglected how student values might inform their experience with those interventions and outcomes. This chapter will rely on a philosophical conceptualization of a particular type of value known as “caring” to explore what students value as they weigh various collegiate decisions. Elaborating on findings from a qualitative study of 143 college students from eight American universities, I will summarize previous findings related to what students cared about, how those cares were structured, and what the cares and structures meant for students' pathways through college. The categorical and theoretical patterns I share demonstrate how students approached values in ways that have not typically been considered by scholars or institutional administrators. After summarizing my previous findings, I offer a conceptual argument for a “dialectical” approach that considers the mutually formative interaction between student and institutional values. The practical result of naming and understanding the dialectic realities of values in higher education is the opportunity for institutions to use their relatively greater agency to help individual students pursue what is worth pursuing without reducing the agency of those students. Thus, the dialectic places necessary boundary lines on both the institution and the student while also clarifying the opportunity to help students develop moral expertise and navigate their collegiate pathways successfully.

Purpose – This chapter argues that health care is best conceptualized as a complex adaptive system. Sustainable health care depends on harnessing the complexity of the system by building aligned purpose, flexible pathways to connect people, knowledge and resources, and the capacity for self-organization.

Design/methodology/approach – The case study of the Southern California Region of Kaiser Permanente is based on three years of interviews and archival data collection examining the system's transformational change that began in 2004 and has been aimed at building a sustainable health care system with the guiding principles of value and prevention. The case focuses primarily on the medical care delivery system designed by the Southern California Permanente Medical Group, the capabilities that have been built into the system to continually improve the quality of care and the outcomes of the system, and the results that have been achieved.

Findings – During the period from 2004 to 2011, the region improved significantly in slowing cost acceleration by significantly improving medical care. The implementation of an electronic medical records system and its integration with other clinical information technology systems have enabled: (1) truly integrated, well defined, and easily navigated care delivery systems that are based on evidence; (2) upstream focus on prevention, disease control, patient education, and population health; and (3) management accountability and organizational improvement systems based on transparency of data and feedback. Physician leadership and partnering with the region's administrative and hospital leadership have been critical change enablers.

Originality/value – Embracing the complexity of the system has led to the crafting of pathways and linkages that enable patients to move through the system to flexibly and efficiently connect to the knowledge and resources required to optimize their health. This requires continual self-organization based on well-defined roles and connections. Previous health care improvement approaches have stressed initiatives and organizational changes that may further fragment the health care system.

Improvements in neonatal and paediatric care mean that many children with complex care needs (CCNs) now survive into adulthood. This cohort of children places great challenges on health and social care delivery in the community: they require dynamic and responsive health and social care over a long period of time; they require organisational and delivery coordination functions; and health issues such as minor illnesses, normally presented to primary care, must be addressed in the context of the complex health issues. Their clinical presentation may challenge local care management. The project explored the interface between primary care and specialised health services and found that it is not easily navigated by children with CCNs and their families across the European Union and the European Economic Area countries. We described the referral-discharge interface, the management of a child with CCNs at the acute–community interface, social care, nursing preparedness for practice and the experiences of the child and family in all Models of Child Health Appraised countries. We investigated data integration and the presence of validated standards of care, including governance and co-creation of care. A separate enquiry was conducted into how care is accessed for children with enduring mental health disorders. This included the level of parental involvement and the presence of multidisciplinary teams in their care. For all children with CCNs, we found wide variation in access to, and governance of, care. Effective communication between the child, family and health services remains challenging, often with fragmentation of care delivery across the health and social care sector and limited service availability.

The Canadian healthcare system is recognized as one of the best health systems in the world. However, recent social and economic conditions have placed significant pressure on system administrators to demonstrate value-for-money for the investments made with an increased scrutiny on service delivery and cost structures. Challenges in providing more efficient healthcare often resonate two key constraints: the shortage of overall funding and barriers to accessing appropriate service providers in a timely fashion. The most common solution is simply to increase service provider manpower and invest further financial resources.

In Ontario, Canada’s largest province, The Shoulder Centre (TSC) has introduced a transformative solution to address system constraints through the development of an innovative and comprehensive model of care which builds on (1) novel partnerships between community providers and the Centre’s clinical team, (2) A Patient-Centered Specialty Practice (PCSP) and (3) Leveraging technology solutions.

TSC’s model of care suggests that many challenges in healthcare are attributed to the inappropriate management of human capital and the under-development of social capital. As a solution, TSC has transformed the organizational structure of its health services by converting service providers into partners with shared accountabilities, resulting in economic value through human capital optimization and improved system efficiencies through the building of social capital. TSC’s performance results demonstrate measured system savings, increased patient and provider satisfaction, targeted knowledge growth and confirms that the healthcare system contains a greater than expected abundance of human and financial resources to provide access to appropriate and timely care without any further system investment.

This chapter provides a reflective synopsis of six cases focused on making healthcare sustainable. The nature and value of an ecosystem perspective is explored. The intent is to apply and generate organizational knowledge to understand and guide purposeful design and learning.

From five countries where healthcare is organized differently, these cases illuminate particular approaches to develop the capabilities for healthcare to deliver greater value to society. Each case is examined through the lens of an appropriate theoretical perspective. This chapter reports the themes that were common in the six case studies.

New approaches are changing the connections in the healthcare ecosystem, including the flows of: medical knowledge, clinical information, and resources. Common themes include: the importance of networks in the emerging healthcare ecosystem; the role of governance mechanisms and leadership to align the diverse ecosystem components; the engagement of dominant ecosystem actors; the need for adaptive change capabilities, and for multi-stakeholder research collaborations to generate actionable knowledge.

Taking an ecosystem perspective enables healthcare leaders to broaden their conceptualization of the changes that will be required to be sustainable in a changing society.

Almost every man, woman and child is affected by the healthcare system. Increasing the sustainability of healthcare is integral to increasing societal sustainability overall.

Viewing the ecosystem as the appropriate focus of purposeful change departs from a traditional approach that focuses on the effectiveness of each element.

Bundled payments for care are an efficient mechanism to align payer, provider, and patient incentives in the provision of health care services for an episode of care. In this chapter, we use agency theory to examine the evolution of bundled payment programs in private and public payer arrangements, and postulate future directions for bundled payment development as a key component in the provision and payment of health care services.

This chapter presents a framework for an action research based intervention to develop and transform sustainable healthcare in a regional context. The framework is illustrated by the case of the Regional Cancer Centre (RCC) West in western Sweden.

The framework draws upon and develops Pettigrew’s context–content–process model of strategic change and applies it to the unfolding narrative of the change effort. The empirical focus is the activities of a learning platform consisting of the RCC leadership, senior cancer physicians designated as process owners and an action research team. Data were collected from documents, observations of the learning platform, notes from meetings and interviews. Outcome data were obtained via the self-reporting of the physicians.

The learning platform established the capability for wide ranging development and quality improvement on the 23 cancer pathways as well as some support activities around principles of patient-centred care. A clear result is greater inter-organisational collaboration between care professionals as well as the introduction of new medicines, clinical methods, joint learning activities and new forms of measurement and monitoring of care practices. All of the improved measures are sustained.

Whilst there is no shortage of rhetoric on patient-centred care, the reality is that in complex healthcare systems solutions such as process-oriented approaches often fail. This case presents a model and an approach that eschews clear visions for change and instead places an emphasis on dialogue, participation, professional autonomy and collaborative communities as means for achieving the patient-centred ideal. The case also shows the value of seeing sustainable health systems as being grounded on practitioner–scholar collaboration that combines practical knowing with scientific knowledge.

This article explores the symbolic aspects of change agency on a learning platform designed to facilitate system-wide transformation in cancer care. A sensemaking–sensegiving perspective is adopted to analyze the construction of meaning in interaction between the leader of a regional cancer center, senior physicians, and an action research team in relation to patient-centered care. The analysis suggests that the physicians, as change agents, made sense of the vision from three quite distinct discourses in relation to the development effort. We argue that although meanings reconstructed in development initiatives may well be far from shared, this by no means implies that they are dysfunctional.