case study of health systems

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Systems Thinking for Public Health: A Case Study Using U.S. Public Education

ABSTRACT | The initial response to the COVID-19 pandemic in the United States largely focused on addressing the immediate health consequences from the emergent pathogen. This initial focus often ignored the related impacts from the pandemic and from mitigation measures, including how existing social determinants of health compounded physical, social, and economic impacts on individuals who have historically been marginalized. The consequences of decisions around closing and reopening primary and secondary (K–12 in the United States) public schools exemplify the complex impacts of pandemic mitigation measures. Ongoing COVID-19 mitigation and recovery efforts have gradually begun addressing indirect consequences, but these efforts were slow to be identified and adopted through much of the acute phase of the pandemic, mirroring the decades-long neglect of contributors to the overall health and well-being of populations that have been made to be vulnerable.

A systems approach for decision-making and problem solving holistically considers the effects of complex interacting factors. Taking a systems approach at the start of the next health emergency could encourage response strategies that consider various competing public health needs throughout different sectors of society, account for existing disparities, and preempt undesirable consequences before and during response implementation. There is a need to understand how a systems approach can be better integrated into decision-making to improve future responses to public health emergencies. A wide range of stakeholders should contribute expertise to these models, and these partnerships should be formed in advance of a public health emergency.

Introduction

In September 2021 the National Academies of Sciences, Engineering, and Medicine hosted a workshop titled “Towards a Post-Pandemic World: Lessons from COVID-19 for Now and the Future.” (NASEM, 2022) In this article, select workshop participants further explore the application of systems thinking in evaluating COVID-19 mitigation measures.

Systems Thinking in Public Health

A systems science approach to outbreak response planning is a useful tool for broadening strategic thinking to consider critical factors driving the short- and long-term consequences of crisis response measures, including how such decisions will impact health disparities (Bradley et al., 2020). A conceptual framework, systems thinking accounts for the relationship between individual factors within a scenario as well as their contributions to the whole, and can facilitate the synthesis of response plans that match the scale and complexity of the problem at hand (Trochim et al., 2006).

Specifically for public health, a systems approach “applies scientific insights to understand the elements that influence health outcomes; models the relationships between those elements; and alters design, processes or policies based on the resultant knowledge” (Kaplan et al., 2013). Complex and interconnected risk factors collectively influenced health outcomes in the COVID-19 pandemic. Response to an evolving public health emergency requires a systems approach that can weigh disparate needs and account for systemic inequities to quickly generate solutions while remaining adaptable as new data emerges.

In this article, we use the issue of K–12 public school closures in the United States to illustrate the need for systems approaches in public health situations. Mapping tools, such as causal loop diagrams, can show the complexity of interconnected factors and their use should be prioritized to guide evidence-based decisions in complex and evolving circumstances. This article argues for the adoption of a systems science approach to outbreak decision-making that:

• addresses the inherent complexity of societal impacts during public health emergencies,
• accounts for social determinants of health, and
• includes perspectives from a wide range of stakeholders

COVID-19 Decision-Making and Unintended Consequences

At the start of the COVID-19 pandemic, policy decisions and responses were enacted quickly to contain the spread of disease. However, the public health implications of COVID-19 extend beyond the disease itself, as the pandemic exacerbated disparities in health outcomes closely correlated with social determinants of health and structural inequalities (Karmakar et al., 2021; Liao and De Maio 2021; Webb Hooper et al., 2020). While strong infection control measures, such as lockdowns and school closures, were considered essential when COVID-19 was an emergent disease, these responses resulted in unintended consequences that were not prioritized in the early decision-making process (Turcotte-Tremblay et al., 2021).

This trade-off may have been necessary at the time, given the rapid disease spread and lack of data about the disease to guide initial decisions. However, as the potential for containment or eradication of COVID-19 dimmed, decision-makers were slow to update mitigation measures based on evolving knowledge and accounting for the broader population health needs. The COVID-19 response stemmed largely from concern about acute infections, reflecting a mindset that was more focused on medical response than broader public health impacts.

Biological factors (e.g., age or comorbidities such as hypertension, diabetes, lung disease, or immunodeficiencies) and social determinants of health (e.g., disparities stemming from marginalized socioeconomic status, lack of access to housing and transportation, race and ethnicity, and language and literacy barriers) interact to affect health and well-being (WHO, 2023; Gao et al., 2021). While awareness of biological risk factors for severe illness grew rapidly and mitigation measures were enacted to protect individuals at risk, consideration for social risk factors in COVID response plans were not equally prioritized (Laylavi, 2021).

For example, while the federal government heavily invested in the development of vaccines and anti-viral treatments early in the pandemic (Lalani et al., 2023), expanded unemployment support to address pandemic-related job losses and educational support for students during school closures were deprioritized and debated at length in government. This inaction slowed critical support for populations disproportionately impacted by pandemic spread-related closures.

The neglect of programs that would create a social safety net for the populations most marginalized is not specific to the pandemic, but is an exacerbation of systematic neglect over decades (Mody et al., 2022; Dorn et al., 2020; Saenz and Sparks, 2020). Even when educational support programs were rolled out, they were implemented inconsistently and did not specifically consider the additional needs of populations that have been made to be vulnerable and that were more likely to be disproportionately impacted by school closures and loss of income due to pandemic restrictions (Wright, 2021).

Officials did not give significant attention to the secondary impacts of the COVID-19 pandemic as the pandemic progressed. While these social disparities existed before the onset of COVID-19, decisions made in response to the pandemic widened many of these gaps.

There have been earlier calls to apply a systems approach to improve public health outcomes, and many examples exist to illustrate the strength of a systems approach in successfully addressing complex public health challenges (Kaplan et al., 2013; Honoré et al., 2011). The example of public school closures demonstrates how the social impacts of mitigation measures widened existing disparities. The example also highlights the need for holistic, systems-based approaches in addressing future public health crises.

Public School Closures and Remote Learning: A Case for Applying Systems Thinking to Improve Health Outcomes during Future Disease Outbreaks

The issue of school closures during the pandemic serves as a case study for how factors affecting health were not holistically considered during decision-making. School closures can exacerbate social and health disparities, with long-lasting consequences (NASEM, 2020). Many students rely on school systems for adequate nutrition, safety, supervision, and socioemotional and cognitive development (Van Lancker and Parolin, 2020). In addition, substantial evidence shows that remote learning is an inadequate and unequitable substitute for in-person learning and does not completely mitigate learning losses during school closures (Agostinelli et al., 2022; Engzell et al., 2021; Bettinger and Loeb, 2017).

Furthermore, school closures may have a greater impact on students in underserved communities. Systemically disadvantaged students (e.g., those who are experiencing poverty or are from racial or ethnic minority communities) are less likely to have access to the technology or broadband internet that is necessary for remote learning. They are less likely to have parents who are able to work from home and supervise them and often encounter other barriers to achieving learning goals (Smith and Reeves, 2020). Students with special educational needs have had disproportionate learning losses and have limited access to other supportive resources otherwise provided through schools while schools are closed (Hurwitz et al., 2021; Nelson and Murakami, 2020).

Importantly, education access and achievement are associated with improved health outcomes, and the above-mentioned educational disparities may translate to worsened health disparities among the different communities (Dorn et al., 2021; Zajacova and Lawrence, 2018).

The decision-making surrounding school closures is complex (Allen, 2021; World Bank Group Education, 2020). While decision makers now know that K–12 public school children have reduced physical risk to severe disease outcomes from COVID-19 compared to adults, school closures were implemented early in the pandemic, when this risk was unknown and there was limited time for decision-making. Students experienced related impacts from pandemic mitigation measures, and some have suffered mentally, emotionally, and developmentally as a direct result of school closures specifically (Viner et al., 2022; Engzell et al., 2021).

However, decisions about school closures and transitions to remote learning at the start of the COVID-19 pandemic generally focused on physical health risk factors (e.g., preventing transmission and mortality) rather than holistic evaluations of children’s multifaceted developmental needs (e.g., socialization in cognitive and emotional development; Viner et al., 2022). Factors such as public fear and parental pressure may have also affected decisions both to close and reopen schools. Many under-resourced schools may have also had limited ability to facilitate a safe return to in-person learning. The many factors affecting school closure decisions further demonstrates the overall need for a systematic, context-specific model for decision-making in future emergencies.

Widespread school closures lasted well into 2021, despite early and repeated warnings about the potential costs to student well-being (Allen, 2021; Kaffenberger, 2021; Balingit and Meckler, 2020) and evidence that with adequate interventions, in-person schooling could be made safe (Alonso et al., 2022; Rotevatn et al., 2022; Head et al., 2021).

Furthermore, school closures were experienced unequally. A nationwide study by Parolin and Lee (2021) found a correlation between school closures in fall 2021 and the racial and ethnic composition of the student body, with nearly 70 percent in-person attendance in schools with a high majority of White students and more than 70 percent closure among schools with large proportions of non-White students. This difference was observed across the United States and within local metro areas.

For example, in Los Angeles County, schools with the highest proportion of racial and ethnic minority students stayed closed at higher rates and for longer durations than schools with the highest proportion of White students (see Figure 1 ). Many factors could have contributed to this observation, including governance, demographic distribution in urban and suburban areas, differences in resource availability in public schools (including school health services), and differences in transmission rates due to population density.

A separate study by Grossmann et al. (2021) also suggested that other outside factors, such as political pressure and strength of teachers unions, may have had significant influence over school closure decisions. A diversity of factors impact student well-being; thus, a systems approach would support informed decision-making in school closure policies.

Multiple factors must also be accounted for in remediation plans, not just initial decision-making, in response to a public health crisis. In July 2021, the Center on Reinventing Public Education (CRPE, 2022) evaluated published plans from 100 major US school districts on spending the more than $43 billion allocated from the Elementary and Secondary School Emergency Relief Fund. While most districts included learning loss and social, emotional, and mental health as key target areas for remediation, only about 30 percent of schools accounted for special needs, equity, and community engagement in their remediation plans (see Figure 2 ). This data revealed that many school districts have attempted to address pandemic-related health outcomes, but these efforts can be further improved with a more holistic approach to decision-making regarding public education and student health.

Students’ well-being and long-term health outcomes are not the only considerations in deciding when best to resume in-person learning. Plans for safe and sustainable resumption of in-person learning also need to consider the needs and concerns of other stakeholders, such as parents, school staff (including nurses and health human resources), and public officials. For example, federal school reopening strategies included practices to safeguard the well-being of educators and other school staff (Department of Education, 2021). Other concerns include the need for data to understand and mitigate transmission dynamics within classrooms and in the local community, especially with the emergence of new viral variants (Honein et al., 2021). These complexities further underline the need for a holistic decision-making strategy that accounts for different needs and dynamics as information unfolds during a public health emergency such as the COVID-19 pandemic.

Using Systems Thinking to Redefine Strategies for Public Health Preparedness

Implementing a systems approach to public health planning requires tools, trained experts, and collaboration with stakeholders. Causal loop diagrams (CLDs) are analytical tools used to map a complex set of factors and forces in a system. They can be used to analyze interplay between factors or develop response strategies. CLDs are gaining attention in public health spheres and can be developed for various purposes, including for influencing policy and practice and for system dynamics modeling (Baugh Littlejohns et al., 2021).

Several CLDs have been developed to demonstrate the variety and interconnectedness of issues related to COVID-19, including mitigation measures. In a series of workshops, Sahin et al. (2020) gathered a group of subject matter experts in various fields (e.g., public health, social science, systems thinking) to develop a CLD that maps the unintended impacts of COVID-19 mitigation measures on socioeconomic systems (see Figure 3 ). One of the loops shows that social distancing will likely decrease virus transmission but also has negative, lasting mental health consequences (loop B3). Sahin et al. (2020) note there is a “a high risk of catastrophic social order demise” if enacted policies do not account for impacts on society.

Tools such as CLDs can facilitate understanding of varying factors within a public health system, a view that is needed to enact holistic solutions. This model captures the severity of social consequences, which were largely overlooked throughout the pandemic.

To further demonstrate their potential, we have created an example CLD that highlights components that could inform a more complex CLD addressing public education issues for children (see Figure 4 ). This illustrative CLD integrates several of the factors that have been discussed in this article (e.g., children’s physical health, mental and emotional health, family stressors). While not developed with the intent of immediate application, this example CLD could be modified and used for decision-making.

An analysis of COVID-19 CLDs by Strelkovskii and Rovenskaya (2021) concluded that these tools can “draw the attention of policy makers to areas where unintended and unwanted effects may be anticipated”; they identified CLDs as useful tools for highlighting the diverse impacts of the pandemic. Their analysis also found that, while there have been numerous calls to apply systems thinking approaches to the impacts of COVID-19, there are few examples of practical applications. The authors highlighted that there have been relatively few examples of CLDs developed for COVID-19, and these have been developed for purposes other than influencing decision-making.

As with many aspects of the COVID-19 pandemic, there is an opportunity to develop tools, such as CLDs, that are more actionable and policy related. The means of developing the CLD are also critical to its use. Such development should include an interdisciplinary group of experts to capture the multiple layers of a complex system. Stakeholder and community participation in developing CLDs represent a step toward developing tools that are more comprehensive and that may be more actionable from a policy standpoint (Baugh Littlejohns et al., 2021). Collaborative groups that include experts, community members, and policy makers can be better poised to develop a dynamic model that can be useful in depicting complex social, physical, and economic relationships. These nuanced models could serve as critical tools for weighing the impacts of mitigation measures in a public health emergency, and developing system models in advance will facilitate immediate action at the onset of an emergency. While providing substantial benefits, developing CLDs also presents challenges. Because systems are inherently complex, it is difficult to capture all relevant factors in a diagram while maintaining the detail that is needed to be useful. Also, translating a CLD into action can be challenging, as evidenced by the lack of actionable CLDs that address the impacts of the COVID-19 pandemic. Despite these challenges, CLDs remain a useful tool for providing a decision-making framework in complex situations with interconnected factors.

The U.S. response strategy to the COVID-19 pandemic suffered from a lack of a holistic and systems-oriented approach to decision-making. This paper outlines the complexities that should have been considered in making the shift to fully remote learning inK–12 schools during COVID-19. There is a need to integrate diverse perspectives from interdisciplinary experts, stakeholders, and community members in developing models that influence decision-making. In the example of school closures, educators, parents, school health leaders, and community leaders are relevant stakeholders for public health decisions that affect health outcomes in schools.

Systems approaches facilitate more comprehensive assessments to inform decision-making, and CLDs are a valuable tool that can be used for response planning. Time is of the essence in a public health emergency, especially when there is minimal information about an emerging threat. Systems models can be built to respond to an emerging threat and developed as information is gained.

We assert that using CLDs as part of a systems approach can improve the transparency, inclusiveness, and credibility of the decision-making process during future public health emergencies. Systems thinking, and tools such as CLDs, should be prioritized in future public health emergencies.

Despite the widely acknowledged usefulness of CLDs, there are few examples of CLDs that were applied during the COVID-19 pandemic to influence decision-making. Partnerships between public health experts and decision-makers should be developed in advance of public health emergencies, so they will be poised to respond immediately. Further, perspectives from the economic and social sectors should also be sought, to understand the complex impact of emergencies, including the impacts of mitigation measures. Increased stakeholder engagement can result in tools that are more actionable and effective.

A commitment to incorporate systems thinking will require broadening the preparedness planning approach for public health decision-making, emphasizing the inclusion of physical and related impacts, and securing buy-in from decision-makers (Zięba, 2021; Klement, 2020). This type of thinking would also require training, so the public health workforce can learn to design and implement these methods.

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• Viner, R., S. Russell, R. Saulle, H. Croker, C. Stansfield, J. Packer, D. Nicholls, A.-L. Goddings, C. Bonell, L. Hudson, S. Hope, J. Ward, N. Schwalbe, A. Morgan, and S. Minozzi. 2022. School closures during social lockdown and mental health, health behaviors, and well-being among children and adolescents during the first COVID-19 wave: A systematic review. JAMA Pediatrics 176(4):400–409. https://doi.org/10.1001/jamapediatrics.2021.5840.
• Walsh, S., A. Chowdhury, V. Braithwaite, S. Russell, J. M. Birch, J. L. Ward, C. Waddington, C. Brayne, C. Bonell, R. M. Viner, and O. T. Mytton. 2021. Do school closures and school reopenings affect community transmission of COVID-19? A systematic review of observational studies. BMJ Open 11(8):e053371. https://doi.org/10.1136/bmjopen-2021-053371.
• Webb Hooper, M., A. M. Nápoles, and E. J. Pérez-Stable. 2020. COVID-19 and racial/ethnic disparities. JAMA 323(24):2466–2467. https://doi.org/10.1001/jama.2020.8598.
• WHO (World Health Organization). 2023. Social determinants of health . Available at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 (accessed October 13, 2023).
• World Bank Group Education. 2020. The COVID-19 pandemic: Shocks to education and policy responses. Washington, DC: World Bank. https://openknowledge.worldbank.org/bitstream/handle/10986/33696/148198.pdf (accessed October 17, 2023)
• Wright, A. 2021. “It’s patchwork”: Rural teachers struggle to connect in pandemic. Stateline , March 3. Available at: https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2021/03/03/its-patchwork-rural-teachers-struggle-to-connect-in-pandemic (accessed October 17, 2023).
• Zajacova, A., and E. M. Lawrence. 2018. The relationship between education and health: Reducing disparities through a contextual approach. Annual Review of Public Health 39(1):273–289. https://doi.org/10.1146/annurev-publhealth-031816-044628.
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https://doi.org/10.31478/202311a

Suggested Citation

Ashby, E., C. Minicucci, J. Liao, D. Buonsenso, S. González- Dambrauskas, R. Obregón, M. Zahn, W. Hallman, and C. John. 2023. Systems thinking for public health: A case study using U.S. public education. NAM Perspectives . Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/202311a .

Author Information

Elizabeth Ashby, MS, is Associate Program Officer, National Academies of Sciences, Engineering, and Medicine. Charlie Minicucci, BS, is Research Associate, National Academies of Sciences, Engineering, and Medicine.  Julie Liao, PhD, is Program Officer, National Academies of Sciences, Engineering, and Medicine. Danilo Buonsenso, MD, PhD, is Pediatric Infectious Disease Physician, Department of Woman & Child Health & Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS. Sebastián González-Dambrauskas, MD, is Founder and Chair, LARed: Red Colaborativa Pediátrica de Latinoamérica and Adjunct Professor, Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños, Universidad de la República. Rafael Obregón, PhD, is Country Representative, Paraguay, UNICEF. Matt Zahn, MD, is Pediatric Infectious Disease Physician, Children’s Hospital of Orange County. William Hallman, PhD, is Professor and Chair, Department of Human Ecology, School of Environmental and Biological Sciences, Rutgers University. Chandy John, MD, MS, is Professor of Pediatrics, Indiana University School of Medicine.

Acknowledgments

Charlie Minicucci and Elizabeth Ashby contributed equally to this work.

This manuscript benefited from the thoughtful input of Jessica G. Burke , University of Pittsburgh; Erin D. Maughan , George Mason University; and Carol Walsh , National Association of School Nurses.

Conflict-of-Interest Disclosures

Danilo Buonsenso reports funding from Pfizer outside the submitted work.

Correspondence

Questions or comments about this paper should be directed to Charlie Minicucci at [email protected].

The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

Health Case Studies

(29 reviews)

Glynda Rees, British Columbia Institute of Technology

Rob Kruger, British Columbia Institute of Technology

Janet Morrison, British Columbia Institute of Technology

Copyright Year: 2017

Publisher: BCcampus

Language: English

Formats Available

Conditions of use.

Learn more about reviews.

Reviewed by Jessica Sellars, Medical assistant office instructor, Blue Mountain Community College on 10/11/23

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and... read more

Comprehensiveness rating: 5 see less

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and plan. There is an appendix to refer to as well if you are needing to find something specific quickly. I have been looking for something like this to help my students have a base to do their project on. This is the most comprehensive version I have found on the subject.

Content Accuracy rating: 5

This is a book compiled of medical case studies. It is very accurate and can be used to learn from great care and mistakes.

Relevance/Longevity rating: 5

This material is very relevant in this context. It also has plenty of individual case studies to utilize in many ways in all sorts of medical courses. This is a very useful textbook and it will continue to be useful for a very long time as you can still learn from each study even if medicine changes through out the years.

Clarity rating: 5

The author put a lot of thought into the ease of accessibility and reading level of the target audience. There is even a "how to use this resource" section which could be extremely useful to students.

Consistency rating: 5

The text follows a very consistent format throughout the book.

Modularity rating: 5

Each case study is individual broken up and in a group of similar case studies. This makes it extremely easy to utilize.

Organization/Structure/Flow rating: 5

The book is very organized and the appendix is through. It flows seamlessly through each case study.

Interface rating: 5

I had no issues navigating this book, It was clearly labeled and very easy to move around in.

Grammatical Errors rating: 5

I did not catch any grammar errors as I was going through the book

Cultural Relevance rating: 5

This is a challenging question for any medical textbook. It is very culturally relevant to those in medical or medical office degrees.

I have been looking for something like this for years. I am so happy to have finally found it.

Reviewed by Cindy Sun, Assistant Professor, Marshall University on 1/7/23

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and... read more

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and students. For faculty, the introduction section titled ‘How to use this resource’ and individual notes to educators before each case study contain application tips. An appendix overview lists key elements as issues / concepts, scenario context, and healthcare roles for each case study. For students, learning objectives are presented at the beginning of each case study to provide a framework of expectations.

The content is presented accurately and realistic.

The case studies read similar to ‘A Day In the Life of…’ with detailed intraprofessional communications similar to what would be overheard in patient care areas. The authors present not only the view of the patient care nurse, but also weave interprofessional vantage points through each case study by including patient interaction with individual professionals such as radiology, physician, etc.

In addition to objective assessment findings, the authors integrate standard orders for each diagnosis including medications, treatments, and tests allowing the student to incorporate pathophysiology components to their assessments.

Each case study is arranged in the same framework for consistency and ease of use.

This compilation of eight healthcare case studies focusing on new onset and exacerbation of prevalent diagnoses, such as heart failure, deep vein thrombosis, cancer, and chronic obstructive pulmonary disease advancing to pneumonia.

Each case study has a photo of the ‘patient’. Simple as this may seem, it gives an immediate mental image for the student to focus.

Interface rating: 4

As noted by previous reviewers, most of the links do not connect active web pages. This may be due to the multiple options for accessing this resource (pdf download, pdf electronic, web view, etc.).

Grammatical Errors rating: 4

A minor weakness that faculty will probably need to address prior to use is regarding specific term usages differences between Commonwealth countries and United States, such as lung sound descriptors as ‘quiet’ in place of ‘diminished’ and ‘puffers’ in place of ‘inhalers’.

The authors have provided a multicultural, multigenerational approach in selection of patient characteristics representing a snapshot of today’s patient population. Additionally, one case study focusing on heart failure is about a middle-aged adult, contrasting to the average aged patient the students would normally see during clinical rotations. This option provides opportunities for students to expand their knowledge on risk factors extending beyond age.

This resource is applicable to nursing students learning to care for patients with the specific disease processes presented in each case study or for the leadership students focusing on intraprofessional communication. Educators can assign as a supplement to clinical experiences or as an in-class application of knowledge.

Reviewed by Stephanie Sideras, Assistant Professor, University of Portland on 8/15/22

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five... read more

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five overarching learning objectives pulled from the Institute of Medicine core competencies will clearly resonate with any faculty familiar with Quality and Safety Education for Nurses curriculum.

The presentation of symptoms, treatments and management of the health alterations was accurate. Dialogue between the the interprofessional team was realistic. At times the formatting of lab results was confusing as they reflected reference ranges specific to the Canadian healthcare system but these occurrences were minimal and could be easily adapted.

The focus for learning from these case studies was communication - patient centered communication and interprofessional team communication. Specific details, such as drug dosing, was minimized, which increases longevity and allows for easy individualization of the case data.

While some vocabulary was specific to the Canadian healthcare system, overall the narrative was extremely engaging and easy to follow. Subjective case data from patient or provider were formatted in italics and identified as 'thoughts'. Objective and behavioral case data were smoothly integrated into the narrative.

The consistency of formatting across the eight cases was remarkable. Specific learning objectives are identified for each case and these remain consistent across the range of cases, varying only in the focus for the goals for each different health alterations. Each case begins with presentation of essential patient background and the progress across the trajectory of illness as the patient moves from location to location encountering different healthcare professionals. Many of the characters (the triage nurse in the Emergency Department, the phlebotomist) are consistent across the case situations. These consistencies facilitate both application of a variety of teaching methods and student engagement with the situated learning approach.

Case data is presented by location and begins with the patient's first encounter with the healthcare system. This allows for an examination of how specific trajectories of illness are manifested and how care management needs to be prioritized at different stages. This approach supports discussions of care transitions and the complexity of the associated interprofessional communication.

The text is well organized. The case that has two levels of complexity is clearly identified

The internal links between the table of contents and case specific locations work consistently. In the EPUB and the Digital PDF the external hyperlinks are inconsistently valid.

The grammatical errors were minimal and did not detract from readability

Cultural diversity is present across the cases in factors including race, ethnicity, socioeconomic status, family dynamics and sexual orientation.

The level of detail included in these cases supports a teaching approach to address all three spectrums of learning - knowledge, skills and attitudes - necessary for the development of competent practice. I also appreciate the inclusion of specific assessment instruments that would facilitate a discussion of evidence based practice. I will enjoy using these case to promote clinical reasoning discussions of data that is noticed and interpreted with the resulting prioritizes that are set followed by reflections that result from learner choices.

Reviewed by Chris Roman, Associate Professor, Butler University on 5/19/22

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various... read more

Comprehensiveness rating: 4 see less

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various learning strategies to be employed to leverage the cases for deeper student learning and application.

The narrative form of the cases is less subject to issues of accuracy than a more content-based book would be. That said, the cases are realistic and reasonable, avoiding being too mundane or too extreme.

These cases are narrative and do not include many specific mentions of drugs, dosages, or other aspects of clinical care that may grow/evolve as guidelines change. For this reason, the cases should be “evergreen” and can be modified to suit different types of learners.

Clarity rating: 4

The text is written in very accessible language and avoids heavy use of technical language. Depending on the level of learner, this might even be too simplistic and omit some details that would be needed for physicians, pharmacists, and others to make nuanced care decisions.

The format is very consistent with clear labeling at transition points.

The authors point out in the introductory materials that this text is designed to be used in a modular fashion. Further, they have built in opportunities to customize each cases, such as giving dates of birth at “19xx” to allow for adjustments based on instructional objectives, etc.

The organization is very easy to follow.

I did not identify any issues in navigating the text.

The text contains no grammatical errors, though the language is a little stiff/unrealistic in some cases.

Cases involve patients and members of the care team that are of varying ages, genders, and racial/ethnic backgrounds

Reviewed by Trina Larery, Assistant Professor, Pittsburg State University on 4/5/22

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand... read more

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand and apply to the classroom. The E-reader format included hyperlinks that bring the students to subsequent clinical studies.

Content Accuracy rating: 4

The treatments were explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse. The case studies were accurate in explanation. The DVT case study incorrectly identifies the location of the clot in the popliteal artery instead of in the vein.

The content is relevant to a variety of different types of health care providers and due to the general nature of the cases, will remain relevant over time. Updates should be made annually to the hyperlinks and to assure current standard of practice is still being met.

Clear, simple and easy to read.

Consistent with healthcare terminology and framework throughout all eight case studies.

The text is modular. Cases can be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point providing great flexibility. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

The book is well organized, presenting in a logical clear fashion. The appendix allows the student to move about the case study without difficulty.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change based on current guidelines. A few hyperlinks had "page not found".

Few grammatical errors were noted in text.

The case studies include people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. There are roughly 25 broken online links or "pages not found", care needs to be taken to update at least annually and assure links are valid and utilizing the most up to date information.

Reviewed by Benjamin Silverberg, Associate Professor/Clinician, West Virginia University on 3/24/22

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what... read more

Comprehensiveness rating: 3 see less

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what is going on where, especially since each case is largely conversation-based. Since this presents 8 cases (really 7 with one being expanded upon), there are many medical topics (and venues) that are not included. It's impossible to include every kind of situation, but I'd love to see inclusion of sexual health, renal pathology, substance abuse, etc.

Though there are differences in how care can be delivered based on personal style, changing guidelines, available supplies, etc, the medical accuracy seems to be high. I did not detect bias or industry influence.

Relevance/Longevity rating: 4

Medications are generally listed as generics, with at least current dosing recommendations. The text gives a picture of what care looks like currently, but will be a little challenging to update based on new guidelines (ie, it can be hard to find the exact page in which a medication is dosed/prescribed). Even if the text were to be a little out of date, an instructor can use that to point out what has changed (and why).

Clear text, usually with definitions of medical slang or higher-tier vocabulary. Minimal jargon and there are instances where the "characters" are sorting out the meaning as well, making it accessible for new learners, too.

Overall, the style is consistent between cases - largely broken up into scenes and driven by conversation rather than descriptions of what is happening.

There are 8 (well, again, 7) cases which can be reviewed in any order. Case #2 builds upon #1, which is intentional and a good idea, though personally I would have preferred one case to have different possible outcomes or even a recurrence of illness. Each scene within a case is reasonably short.

Organization/Structure/Flow rating: 4

These cases are modular and don't really build on concepts throughout. As previously stated, case #2 builds upon #1, but beyond that, there is no progression. (To be sure, the authors suggest using case #1 for newer learners and #2 for more advanced ones.) The text would benefit from thematic grouping, a longer introduction and debriefing for each case (there are learning objectives but no real context in medical education nor questions to reflect on what was just read), and progressively-increasing difficulty in medical complexity, ethics, etc.

I used the PDF version and had no interface issues. There are minimal photographs and charts. Some words are marked in blue but those did not seem to be hyperlinked anywhere.

No noticeable errors in grammar, spelling, or formatting were noted.

I appreciate that some diversity of age and ethnicity were offered, but this could be improved. There were Canadian Indian and First Nations patients, for example, as well as other characters with implied diversity, but there didn't seem to be any mention of gender diverse or non-heterosexual people, or disabilities. The cases tried to paint family scenes (the first patient's dog was fairly prominently mentioned) to humanize them. Including more cases would allow for more opportunities to include sex/gender minorities, (hidden) disabilities, etc.

The text (originally from 2017) could use an update. It could be used in conjunction with other Open Texts, as a compliment to other coursework, or purely by itself. The focus is meant to be on improving communication, but there are only 3 short pages at the beginning of the text considering those issues (which are really just learning objectives). In addition to adding more cases and further diversity, I personally would love to see more discussion before and after the case to guide readers (and/or instructors). I also wonder if some of the ambiguity could be improved by suggesting possible health outcomes - this kind of counterfactual comparison isn't possible in real life and could be really interesting in a text. Addition of comprehension/discussion questions would also be worthwhile.

Reviewed by Danielle Peterson, Assistant Professor, University of Saint Francis on 12/31/21

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare... read more

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare workers in acute hospital settings. The cases are primarily set in the inpatient hospital setting, so the bulk of the clinical information is basic emergency care and inpatient protocol: vitals, breathing, medication management, etc. The text provides a table of contents at opening of the text and a handy appendix at the conclusion of the text that outlines each case’s issue(s), scenario, and healthcare roles. No index or glossary present.

Although easy to update, it should be noted that the cases are taking place in a Canadian healthcare system. Terms may be unfamiliar to some students including “province,” “operating theatre,” “physio/physiotherapy,” and “porter.” Units of measurement used include Celsius and meters. Also, the issue of managed care, health insurance coverage, and length of stay is missing for American students. These are primary issues that dictate much of the healthcare system in the US and a primary job function of social workers, nurse case managers, and medical professionals in general. However, instructors that wish to add this to the case studies could do so easily.

The focus of this text is on healthcare communication which makes it less likely to become obsolete. Much of the clinical information is stable healthcare practice that has been standard of care for quite some time. Nevertheless, given the nature of text, updates would be easy to make. Hyperlinks should be updated to the most relevant and trustworthy sources and checked frequently for effectiveness.

The spacing that was used to note change of speaker made for ease of reading. Although unembellished and plain, I expect students to find this format easy to digest and interesting, especially since the script is appropriately balanced with ‘human’ qualities like the current TV shows and songs, the use of humor, and nonverbal cues.

A welcome characteristic of this text is its consistency. Each case is presented in a similar fashion and the roles of the healthcare team are ‘played’ by the same character in each of the scenarios. This allows students to see how healthcare providers prioritize cases and juggle the needs of multiple patients at once. Across scenarios, there was inconsistency in when clinical terms were hyperlinked.

The text is easily divisible into smaller reading sections. However, since the nature of the text is script-narrative format, if significant reorganization occurs, one will need to make sure that the communication of the script still makes sense.

The text is straightforward and presented in a consistent fashion: learning objectives, case history, a script of what happened before the patient enters the healthcare setting, and a script of what happens once the patient arrives at the healthcare setting. The authors use the term, “ideal interactions,” and I would agree that these cases are in large part, ‘best case scenarios.’ Due to this, the case studies are well organized, clear, logical, and predictable. However, depending on the level of student, instructors may want to introduce complications that are typical in the hospital setting.

The interface is pleasing and straightforward. With exception to the case summary and learning objectives, the cases are in narrative, script format. Each case study supplies a photo of the ‘patient’ and one of the case studies includes a link to a 3-minute video that introduces the reader to the patient/case. One of the highlights of this text is the use of hyperlinks to various clinical practices (ABG, vital signs, transfer of patient). Unfortunately, a majority of the links are broken. However, since this is an open text, instructors can update the links to their preference.

Although not free from grammatical errors, those that were noticed were minimal and did not detract from reading.

Cultural Relevance rating: 4

Cultural diversity is visible throughout the patients used in the case studies and includes factors such as age, race, socioeconomic status, family dynamics, and sexual orientation. A moderate level of diversity is noted in the healthcare team with some stereotypes: social workers being female, doctors primarily male.

As a social work instructor, I was grateful to find a text that incorporates this important healthcare role. I would have liked to have seen more content related to advance directives, mediating decision making between the patient and care team, emotional and practical support related to initial diagnosis and discharge planning, and provision of support to colleagues, all typical roles of a medical social worker. I also found it interesting that even though social work was included in multiple scenarios, the role was only introduced on the learning objectives page for the oncology case.

Reviewed by Crystal Wynn, Associate Professor, Virginia State University on 7/21/21

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied... read more

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied health care team members are represented within the case study. Key terms appear throughout the case study textbook and readers are able to click on a hyperlink which directs them to the definition and an explanation of the key term.

Content is accurate, error-free and unbiased.

The content is up-to-date, but not in a way that will quickly make the text obsolete within a short period of time. The text is written and/or arranged in such a way that necessary updates will be relatively easy and straightforward to implement.

The text is written in lucid, accessible prose, and provides adequate context for any jargon/technical terminology used

The text is internally consistent in terms of terminology and framework.

The text is easily and readily divisible into smaller reading sections that can be assigned at different points within the course. Each case can be divided into a chronic disease state unit, which will allow the reader to focus on one section at a time.

Organization/Structure/Flow rating: 3

The topics in the text are presented in a logical manner. Each case provides an excessive amount of language that provides a description of the case. The cases in this text reads more like a novel versus a clinical textbook. The learning objectives listed within each case should be in the form of questions or activities that could be provided as resources for instructors and teachers.

Interface rating: 3

There are several hyperlinks embedded within the textbook that are not functional.

The text contains no grammatical errors.

Cultural Relevance rating: 3

The text is not culturally insensitive or offensive in any way. More examples of cultural inclusiveness is needed throughout the textbook. The cases should be indicative of individuals from a variety of races and ethnicities.

Reviewed by Rebecca Hillary, Biology Instructor, Portland Community College on 6/15/21

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health... read more

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health care program. I read the textbook in E-reader format and this includes hyperlinks that bring the students to subsequent clinical study if the book is being used in a clinical classroom. This book is significantly more comprehensive in its approach from other case studies I have read because it provides a bird’s eye view of the many clinicians, technicians, and hospital staff working with one patient. The book also provides real time measurements for patients that change as they travel throughout the hospital until time of discharge.

Each case gave an accurate sense of the chaos that would be present in an emergency situation and show how the conditions affect the practitioners as well as the patients. The reader gets an accurate big picture--a feel for each practitioner’s point of view as well as the point of view of the patient and the patient’s family as the clock ticks down and the patients are subjected to a number of procedures. The clinical information contained in this textbook is all in hyperlinks containing references to clinical skills open text sources or medical websites. I did find one broken link on an external medical resource.

The diseases presented are relevant and will remain so. Some of the links are directly related to the Canadian Medical system so they may not be applicable to those living in other regions. Clinical links may change over time but the text itself will remain relevant.

Each case study clearly presents clinical data as is it recorded in real time.

Each case study provides the point of view of several practitioners and the patient over several days. While each of the case studies covers different pathology they all follow this same format, several points of view and data points, over a number of days.

The case studies are divided by days and this was easy to navigate as a reader. It would be easy to assign one case study per body system in an Anatomy and Physiology course, or to divide them up into small segments for small in class teaching moments.

The topics are presented in an organized way showing clinical data over time and each case presents a large number of view points. For example, in the first case study, the patient is experiencing difficulty breathing. We follow her through several days from her entrance to the emergency room. We meet her X Ray Technicians, Doctor, Nurses, Medical Assistant, Porter, Physiotherapist, Respiratory therapist, and the Lab Technicians running her tests during her stay. Each practitioner paints the overall clinical picture to the reader.

I found the text easy to navigate. There were not any figures included in the text, only clinical data organized in charts. The figures were all accessible via hyperlink. Some figures within the textbook illustrating patient scans could have been helpful but I did not have trouble navigating the links to visualize the scans.

I did not see any grammatical errors in the text.

The patients in the text are a variety of ages and have a variety of family arrangements but there is not much diversity among the patients. Our seven patients in the eight case studies are mostly white and all cis gendered.

Some of the case studies, for example the heart failure study, show clinical data before and after drug treatments so the students can get a feel for mechanism in physiological action. I also liked that the case studies included diet and lifestyle advice for the patients rather than solely emphasizing these pharmacological interventions. Overall, I enjoyed reading through these case studies and I plan to utilize them in my Anatomy and Physiology courses.

Reviewed by Richard Tarpey, Assistant Professor, Middle Tennessee State University on 5/11/21

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate... read more

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate for entry-level health care students. The book includes important health problems, but I would like to see coverage of at least one more chronic/lifestyle issue such as diabetes. The book covers adult issues only.

Content is accurate without bias

The content of the book is relevant and up-to-date. It addresses conditions that are prevalent in today's population among adults. There are no pediatric cases, but this does not significantly detract from the usefulness of the text. The format of the book lends to easy updating of data or information.

The book is written with clarity and is easy to read. The writing style is accessible and technical terminology is explained with links to more information.

Consistency is present. Lack of consistency is typically a problem with case study texts, but this book is consistent with presentation, format, and terminology throughout each of the eight cases.

The book has high modularity. Each of the case studies can be used independently from the others providing flexibility. Additionally, each case study can be partitioned for specific learning objectives based on the learning objectives of the course or module.

The book is well organized, presenting students conceptually with differing patient flow patterns through a hospital. The patient information provided at the beginning of each case is a wonderful mechanism for providing personal context for the students as they consider the issues. Many case studies focus on the problem and the organization without students getting a patient's perspective. The patient perspective is well represented in these cases.

The navigation through the cases is good. There are some terminology and procedure hyperlinks within the cases that do not work when accessed. This is troubling if you intend to use the text for entry-level health care students since many of these links are critical for a full understanding of the case.

There are some non-US variants of spelling and a few grammatical errors, but these do not detract from the content of the messages of each case.

The book is inclusive of differing backgrounds and perspectives. No insensitive or offensive references were found.

I like this text for its application flexibility. The book is useful for non-clinical healthcare management students to introduce various healthcare-related concepts and terminology. The content is also helpful for the identification of healthcare administration managerial issues for students to consider. The book has many applications.

Reviewed by Paula Baldwin, Associate Professor/Communication Studies, Western Oregon University on 5/10/21

The different case studies fall on a range, from crisis care to chronic illness care. read more

The different case studies fall on a range, from crisis care to chronic illness care.

The contents seems to be written as they occurred to represent the most complete picture of each medical event's occurence.

These case studies are from the Canadian medical system, but that does not interfere with it's applicability.

It is written for a medical audience, so the terminology is mostly formal and technical.

Some cases are shorter than others and some go in more depth, but it is not problematic.

The eight separate case studies is the perfect size for a class in the quarter system. You could combine this with other texts, videos or learning modalities, or use it alone.

As this is a case studies book, there is not a need for a logical progression in presentation of topics.

No problems in terms of interface.

I have not seen any grammatical errors.

I did not see anything that was culturally insensitive.

I used this in a Health Communication class and it has been extraordinarily successful. My studies are analyzing the messaging for the good, the bad, and the questionable. The case studies are widely varied and it gives the class insights into hospital experiences, both front and back stage, that they would not normally be able to examine. I believe that because it is based real-life medical incidents, my students are finding the material highly engaging.

Reviewed by Marlena Isaac, Instructor, Aiken Technical College on 4/23/21

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with... read more

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with a situation in clinical they are not surprised and now how to move through it effectively.

The case studies provided accurate information that relates to the named disease.

It is relevant to health care studies and the development of critical thinking.

Cases are straightforward with great clinical information.

Clinical information is provided concisely.

Appropriate for clinical case study.

Presented to facilitate information gathering.

Takes a while to navigate in the browser.

Cultural Relevance rating: 1

Text lacks adequate representation of minorities.

Reviewed by Kim Garcia, Lecturer III, University of Texas Rio Grande Valley on 11/16/20

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at... read more

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at different levels of clinical knowledge. The human element of both patient and health care provider is well captured. The cases are presented with a focus on interprofessional interaction and collaboration, more so than teaching medical content.

Content is accurate and un-biased. No errors noted. Most diagnostic and treatment information is general so it will remain relevant over time. The content of these cases is more appropriate for teaching interprofessional collaboration and less so for teaching the medical care for each diagnosis.

The content is relevant to a variety of different types of health care providers (nurses, radiologic technicians, medical laboratory personnel, etc) and due to the general nature of the cases, will remain relevant over time.

Easy to read. Clear headings are provided for sections of each case study and these section headings clearly tell when time has passed or setting has changed. Enough description is provided to help set the scene for each part of the case. Much of the text is written in the form of dialogue involving patient, family and health care providers, making it easy to adapt for role play. Medical jargon is limited and links for medical terms are provided to other resources that expound on medical terms used.

The text is consistent in structure of each case. Learning objectives are provided. Cases generally start with the patient at home and move with the patient through admission, testing and treatment, using a variety of healthcare services and encountering a variety of personnel.

The text is modular. Cases could be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

Each case follows a patient in a logical, chronologic fashion. A clear table of contents and appendix are provided which allows the user to quickly locate desired content. It would be helpful if the items in the table of contents and appendix were linked to the corresponding section of the text.

The hyperlinks to content outside this book work, however using the back arrow on your browser returns you to the front page of the book instead of to the point at which you left the text. I would prefer it if the hyperlinks opened in a new window or tab so closing that window or tab would leave you back where you left the text.

No grammatical errors were noted.

The text is culturally inclusive and appropriate. Characters, both patients and care givers are of a variety of races, ethnicities, ages and backgrounds.

I enjoyed reading the cases and reviewing this text. I can think of several ways in which I will use this content.

Reviewed by Raihan Khan, Instructor/Assistant Professor, James Madison University on 11/3/20

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients. read more

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients.

The health information contained in the textbook is mostly accurate.

I think the book is written focusing on the current culture and health issues faced by the patients. To keep the book relevant in the future, the contexts especially the culture/lifestyle/health care modalities, etc. would need to be updated regularly.

The language is pretty simple, clear, and easy to read.

There is no complaint about consistency. One of the main issues of writing a book, consistency was well managed by the authors.

The book is easy to explore based on how easy the setup is. Students can browse to the specific section that they want to read without much hassle of finding the correct information.

The organization is simple but effective. The authors organized the book based on what can happen in a patient's life and what possible scenarios students should learn about the disease. From that perspective, the book does a good job.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change that is beyond the author's control. It's frustrating for the reader when the external link shows no information.

The book is free of any major language and grammatical errors.

The book might do a little better in cultural competency. e.g. Last name Singh is mainly for Sikh people. In the text Harj and Priya Singh are Muslim. the authors can consult colleagues who are more familiar with those cultures and revise some cultural aspects of the cases mentioned in the book.

The book is a nice addition to the open textbook world. Hope to see more health issues covered by the book.

Reviewed by Ryan Sheryl, Assistant Professor, California State University, Dominguez Hills on 7/16/20

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality... read more

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality improvement, and informatics. While the case studies do not cover all medical conditions or bodily systems, the book is thorough in conveying details of various patients and medical team members in a hospital environment. Rather than an index or glossary at the end of the text, it contains links to outside websites for more information on medical tests and terms referenced in the cases.

The content provided is reflective of best practices in patient care, interdisciplinary collaboration, and communication at the time of publication. It is specifically accurate for the context of hospitals in Canada. The links provided throughout the text have the potential to supplement with up-to-date descriptions and definitions, however, many of them are broken (see notes in Interface section).

The content of the case studies reflects the increasingly complex landscape of healthcare, including a variety of conditions, ages, and personal situations of the clients and care providers. The text will require frequent updating due to the rapidly changing landscape of society and best practices in client care. For example, a future version may include inclusive practices with transgender clients, or address ways medical racism implicitly impacts client care (see notes in Cultural Relevance section).

The text is written clearly and presents thorough, realistic details about working and being treated in an acute hospital context.

The text is very straightforward. It is consistent in its structure and flow. It uses consistent terminology and follows a structured framework throughout.

Being a series of 8 separate case studies, this text is easily and readily divisible into smaller sections. The text was designed to be taken apart and used piece by piece in order to serve various learning contexts. The parts of each case study can also be used independently of each other to facilitate problem solving.

The topics in the case studies are presented clearly. The structure of each of the case studies proceeds in a similar fashion. All of the cases are set within the same hospital so the hospital personnel and service providers reappear across the cases, giving a textured portrayal of the experiences of the various service providers. The cases can be used individually, or one service provider can be studied across the various studies.

The text is very straightforward, without complex charts or images that could become distorted. Many of the embedded links are broken and require updating. The links that do work are a very useful way to define and expand upon medical terms used in the case studies.

Grammatical errors are minimal and do not distract from the flow of the text. In one instance the last name Singh is spelled Sing, and one patient named Fred in the text is referred to as Frank in the appendix.

The cases all show examples of health care personnel providing compassionate, client-centered care, and there is no overt discrimination portrayed. Two of the clients are in same-sex marriages and these are shown positively. It is notable, however, that the two cases presenting people of color contain more negative characteristics than the other six cases portraying Caucasian people. The people of color are the only two examples of clients who smoke regularly. In addition, the Indian client drinks and is overweight, while the First Nations client is the only one in the text to have a terminal diagnosis. The Indian client is identified as being Punjabi and attending a mosque, although there are only 2% Muslims in the Punjab province of India. Also, the last name Singh generally indicates a person who is a Hindu or Sikh, not Muslim.

Reviewed by Monica LeJeune, RN Instructor, LSUE on 4/24/20

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process. read more

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process.

Accurately presents health scenarios with real life assessment techniques and patient outcomes.

Relevant to nursing practice.

Clearly written and easily understood.

Consistent with healthcare terminology and framework

Has a good reading flow.

Topics presented in logical fashion

Easy to read.

No grammatical errors noted.

Text is not culturally insensitive or offensive.

Good book to have to teach nursing students.

Reviewed by april jarrell, associate professor, J. Sargeant Reynolds Community College on 1/7/20

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process. read more

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process.

The content is accurate and evidence based. There is no bias noted

The content in the text is relevant, up to date for nursing students. It will be easy to update content as needed because the framework allows for addition to the content.

The text is clear and easy to understand.

Framework and terminology is consistent throughout the text; the case study is a continual and takes the student on a journey with the patient. Great for learning!

The case studies can be easily divided into smaller sections to allow for discussions, and weekly studies.

The text and content progress in a logical, clear fashion allowing for progression of learning.

No interface issues noted with this text.

No grammatical errors noted in the text.

No racial or culture insensitivity were noted in the text.

I would recommend this text be used in nursing schools. The use of case studies are helpful for students to learn and practice the nursing process.

Reviewed by Lisa Underwood, Practical Nursing Instructor, NTCC on 12/3/19

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own... read more

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own set of learning objectives that can be tweaked to fit several allied health courses. Although the case studies are designed around the Canadian Healthcare System, they are quite easily adaptable to fit most any modern, developed healthcare system.

Content Accuracy rating: 3

Overall, the text is quite accurate. There is one significant error that needs to be addressed. It is located in the DVT case study. In the study, a popliteal artery clot is mislabeled as a DVT. DVTs are located in veins, not in arteries. That said, the case study on the whole is quite good. This case study could be used as a learning tool in the classroom for discussion purposes or as a way to test student understanding of DVTs, on example might be, "Can they spot the error?"

At this time, all of the case studies within the text are current. Healthcare is an ever evolving field that rests on the best evidence based practice. Keeping that in mind, educators can easily adapt the studies as the newest evidence emerges and changes practice in healthcare.

All of the case studies are well written and easy to understand. The text includes several hyperlinks and it also highlights certain medical terminology to prompt readers as a way to enhance their learning experience.

Across the text, the language, style, and format of the case studies are completely consistent.

The text is divided into eight separate case studies. Each case study may be used independently of the others. All case studies are further broken down as the focus patient passes through each aspect of their healthcare system. The text's modularity makes it possible to use a case study as individual work, group projects, class discussions, homework or in a simulation lab.

The case studies and the diagnoses that they cover are presented in such a way that educators and allied health students can easily follow and comprehend.

The book in itself is free of any image distortion and it prints nicely. The text is offered in a variety of digital formats. As noted in the above reviews, some of the hyperlinks have navigational issues. When the reader attempts to access them, a "page not found" message is received.

There were minimal grammatical errors. Some of which may be traced back to the differences in our spelling.

The text is culturally relevant in that it includes patients from many different backgrounds and ethnicities. This allows educators and students to explore cultural relevance and sensitivity needs across all areas in healthcare. I do not believe that the text was in any way insensitive or offensive to the reader.

By using the case studies, it may be possible to have an open dialogue about the differences noted in healthcare systems. Students will have the ability to compare and contrast the Canadian healthcare system with their own. I also firmly believe that by using these case studies, students can improve their critical thinking skills. These case studies help them to "put it all together".

Reviewed by Melanie McGrath, Associate Professor, TRAILS on 11/29/19

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case. read more

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case.

I saw no areas of inaccuracy

As in all healthcare texts, treatments and/or tests will change frequently. However, everything is currently up-to-date thus it should be a good reference for several years.

Each case is written so that any level of healthcare student would understand. Hyperlinks in the text is also very helpful.

All of the cases are written in a similar fashion.

Although not structured as a typical text, each case is easily assigned as a stand-alone.

Each case is organized clearly in an appropriate manner.

I did not see any issues.

I did not see any grammatical errors

The text seemed appropriately inclusive. There are no pediatric cases and no cases of intellectually-impaired patients, but those types of cases introduce more advanced problem-solving which perhaps exceed the scope of the text. May be a good addition to the text.

I found this text to be an excellent resource for healthcare students in a variety of fields. It would be best utilized in inter professional courses to help guide discussion.

Reviewed by Lynne Umbarger, Clinical Assistant Professor, Occupational Therapy, Emory and Henry College on 11/26/19

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational... read more

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational purposes. The material was easily understood by the students but challenging enough for classroom discussion. There are no mentions in the book about occupational therapy, but it is easy enough to add a couple words and make inclusion simple.

Very nice lab values are provided in the case study, making it more realistic for students.

These case studies focus on commonly encountered diagnoses for allied health and nursing students. They are comprehensive, realistic, and easily understood. The only difference is that the hospital in one case allows the patient's dog to visit in the room (highly unusual in US hospitals).

The material is easily understood by allied health students. The cases have links to additional learning materials for concepts that may be less familiar or should be explored further in a particular health field.

The language used in the book is consistent between cases. The framework is the same with each case which makes it easier to locate areas that would be of interest to a particular allied health profession.

The case studies are comprehensive but well-organized. They are short enough to be useful for class discussion or a full-blown assignment. The students seem to understand the material and have not expressed that any concepts or details were missing.

Each case is set up like the other cases. There are learning objectives at the beginning of each case to facilitate using the case, and it is easy enough to pull out material to develop useful activities and assignments.

There is a quick chart in the Appendix to allow the reader to determine the professions involved in each case as well as the pertinent settings and diagnoses for each case study. The contents are easy to access even while reading the book.

As a person who attends carefully to grammar, I found no errors in all of the material I read in this book.

There are a greater number of people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book. With each case, I could easily picture the person in the case. This book appears to be Canadian and more inclusive than most American books.

I was able to use this book the first time I accessed it to develop a classroom activity for first-year occupational therapy students and a more comprehensive activity for second-year students. I really appreciate the links to a multitude of terminology and medical lab values/issues for each case. I will keep using this book.

Reviewed by Cindy Krentz, Assistant Professor, Metropolitan State University of Denver on 6/15/19

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some... read more

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some understanding of the patient's background. I think it could benefit from having a glossary. I liked how the authors included the vital signs in an easily readable bar. I would have liked to see the labs also highlighted like this. I also felt that it would have been good written in a 'what would you do next?' type of case study.

The book is very accurate in language, what tests would be prudent to run and in the day in the life of the hospital in all cases. One inaccuracy is that the authors called a popliteal artery clot a DVT. The rest of the DVT case study was great, though, but the one mistake should be changed.

The book is up to date for now, but as tests become obsolete and new equipment is routinely used, the book ( like any other health textbook) will need to be updated. It would be easy to change, however. All that would have to happen is that the authors go in and change out the test to whatever newer, evidence-based test is being utilized.

The text is written clearly and easy to understand from a student's perspective. There is not too much technical jargon, and it is pretty universal when used- for example DVT for Deep Vein Thrombosis.

The book is consistent in language and how it is broken down into case studies. The same format is used for highlighting vital signs throughout the different case studies. It's great that the reader does not have to read the book in a linear fashion. Each case study can be read without needing to read the others.

The text is broken down into eight case studies, and within the case studies is broken down into days. It is consistent and shows how the patient can pass through the different hospital departments (from the ER to the unit, to surgery, to home) in a realistic manner. The instructor could use one or more of the case studies as (s)he sees fit.

The topics are eight different case studies- and are presented very clearly and organized well. Each one is broken down into how the patient goes through the system. The text is easy to follow and logical.

The interface has some problems with the highlighted blue links. Some of them did not work and I got a 'page not found' message. That can be frustrating for the reader. I'm wondering if a glossary could be utilized (instead of the links) to explain what some of these links are supposed to explain.

I found two or three typos, I don't think they were grammatical errors. In one case I think the Canadian spelling and the United States spelling of the word are just different.

This is a very culturally competent book. In today's world, however, one more type of background that would merit delving into is the trans-gender, GLBTQI person. I was glad that there were no stereotypes.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. Since we are becoming more interprofessional, I liked that we saw what the phlebotomist and other ancillary personnel (mostly different technicians) did. I think that it could become even more interdisciplinary so colleges and universities could have more interprofessional education- courses or simulations- with the addition of the nurse using social work, nutrition, or other professional health care majors.

Reviewed by Catherine J. Grott, Interim Director, Health Administration Program, TRAILS on 5/5/19

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this. read more

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this.

The book is accurate, however it has numerous broken online links.

Relevance/Longevity rating: 3

The content is very relevant, but some links are out-dated. For example, WHO Guidelines for Safe Surgery 2009 (p. 186) should be updated.

The book is written in clear and concise language. The side stories about the healthcare workers make the text interesting.

The book is consistent in terms of terminology and framework. Some terms that are emphasized in one case study are not emphasized (with online links) in the other case studies. All of the case studies should have the same words linked to online definitions.

Modularity rating: 3

The book can easily be parsed out if necessary. However, the way the case studies have been written, it's evident that different authors contributed singularly to each case study.

The organization and flow are good.

Interface rating: 1

There are numerous broken online links and "pages not found."

The grammar and punctuation are correct. There are two errors detected: p. 120 a space between the word "heart" and the comma; also a period is needed after Dr (p. 113).

I'm not quite sure that the social worker (p. 119) should comment that the patient and partner are "very normal people."

There are roughly 25 broken online links or "pages not found." The BC & Canadian Guidelines (p. 198) could also include a link to US guidelines to make the text more universal . The basilar crackles (p. 166) is very good. Text could be used compare US and Canadian healthcare. Text could be enhanced to teach "soft skills" and interdepartmental communication skills in healthcare.

Reviewed by Lindsey Henry, Practical Nursing Instructor, Fletcher on 5/1/19

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning... read more

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning objectives, which were effectively met in the readings.

As a seasoned nurse, I believe that the content regarding pathophysiology and treatments used in the case studies were accurate. I really appreciated how many of the treatments were also explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse.

The case studies are up to date and correlate with the current time period. They are easily understood.

I really loved how several important medical terms, including specific treatments were highlighted to alert the reader. Many interventions performed were also explained further, which is great to enhance learning for the nursing student or novice nurse. Also, with each scenario, a background and history of the patient is depicted, as well as the perspectives of the patient, patients family member, and the primary nurse. This really helps to give the reader a full picture of the day in the life of a nurse or a patient, and also better facilitates the learning process of the reader.

These case studies are consistent. They begin with report, the patient background or updates on subsequent days, and follow the patients all the way through discharge. Once again, I really appreciate how this book describes most if not all aspects of patient care on a day to day basis.

Each case study is separated into days. While they can be divided to be assigned at different points within the course, they also build on each other. They show trends in vital signs, what happens when a patient deteriorates, what happens when they get better and go home. Showing the entire process from ER admit to discharge is really helpful to enhance the students learning experience.

The topics are all presented very similarly and very clearly. The way that the scenarios are explained could even be understood by a non-nursing student as well. The case studies are very clear and very thorough.

The book is very easy to navigate, prints well on paper, and is not distorted or confusing.

I did not see any grammatical errors.

Each case study involves a different type of patient. These differences include race, gender, sexual orientation and medical backgrounds. I do not feel the text was offensive to the reader.

I teach practical nursing students and after reading this book, I am looking forward to implementing it in my classroom. Great read for nursing students!

Reviewed by Leah Jolly, Instructor, Clinical Coordinator, Oregon Institute of Technology on 4/10/19

Good variety of cases and pathologies covered. read more

Good variety of cases and pathologies covered.

Content Accuracy rating: 2

Some examples and scenarios are not completely accurate. For example in the DVT case, the sonographer found thrombus in the "popliteal artery", which according to the book indicated presence of DVT. However in DVT, thrombus is located in the vein, not the artery. The patient would also have much different symptoms if located in the artery. Perhaps some of these inaccuracies are just typos, but in real-life situations this simple mistake can make a world of difference in the patient's course of treatment and outcomes.

Good examples of interprofessional collaboration. If only it worked this way on an every day basis!

Clear and easy to read for those with knowledge of medical terminology.

Good consistency overall.

Broken up well.

Topics are clear and logical.

Would be nice to simply click through to the next page, rather than going through the table of contents each time.

Minor typos/grammatical errors.

No offensive or insensitive materials observed.

Reviewed by Alex Sargsyan, Doctor of Nursing Practice/Assistant Professor , East Tennessee State University on 10/8/18

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study. read more

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study.

Overall the book is accurately depicting the clinical environment. There are numerous references to external sites. While most of them are correct, some of them are not working. For example Homan’s test link is not working "404 error"

Book is relevant in its current version and can be used in undergraduate and graduate classes. That said, the longevity of the book may be limited because of the character of the clinical education. Clinical guidelines change constantly and it may require a major update of the content.

Cases are written very clearly and have realistic description of an inpatient setting.

The book is easy to read and consistent in the language in all eight cases.

The cases are very well written. Each case is subdivided into logical segments. The segments reflect different setting where the patient is being seen. There is a flow and transition between the settings.

Book has eight distinct cases. This is a great format for a book that presents distinct clinical issues. This will allow the students to have immersive experiences and gain better understanding of the healthcare environment.

Book is offered in many different formats. Besides the issues with the links mentioned above, overall navigation of the book content is very smooth.

Book is very well written and has no grammatical errors.

Book is culturally relevant. Patients in the case studies come different cultures and represent diverse ethnicities.

Reviewed by Justin Berry, Physical Therapist Assistant Program Director, Northland Community and Technical College, East Grand Forks, MN on 8/2/18

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles,... read more

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles, interprofessional roles, when to initiate communication with other healthcare practitioners due to a change in patient status, and treatment ideas. Some additional patient information, such as lab values, would have been beneficial to include.

Case study information is accurate and unbiased.

Content is up to date. The case studies are written in a way so that they will not be obsolete soon, even with changes in healthcare.

The case studies are well written, and can be utilized for a variety of classroom assignments, discussions, and projects. Some additional lab value information for each patient would have been a nice addition.

The case studies are consistently organized to make it easy for the reader to determine the framework.

The text is broken up into eight different case studies for various patient diagnoses. This design makes it highly modular, and would be easy to assign at different points of a course.

The flow of the topics are presented consistently in a logical manner. Each case study follows a patient chronologically, making it easy to determine changes in patient status and treatment options.

The text is free of interface issues, with no distortion of images or charts.

The text is not culturally insensitive or offensive in any way. Patients are represented from a variety of races, ethnicities, and backgrounds

This book would be a good addition for many different health programs.

Reviewed by Ann Bell-Pfeifer, Instructor/Program Director, Minnesota State Community and Technical College on 5/21/18

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical... read more

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical laboratory technologists, medical radiology technologists, and respiratory therapists and their roles in caring for patients. Most of the overview is accurate. One suggestion is to provide an embedded radiologist interpretation of the exams which are performed which lead to the patients diagnosis.

Overall the book is accurate. Would like to see updates related to the addition of direct radiography technology which is commonly used in the hospital setting.

Many aspects of medicine will remain constant. The case studies seem fairly accurate and may be relevant for up to 3 years. Since technology changes so quickly in medicine, the CT and x-ray components may need minor updates within a few years.

The book clarity is excellent.

The case stories are consistent with each scenario. It is easy to follow the structure and learn from the content.

The book is quite modular. It is easy to break it up into cases and utilize them individually and sequentially.

The cases are listed by disease process and follow a logical flow through each condition. They are easy to follow as they have the same format from the beginning to the end of each case.

The interface seems seamless. Hyperlinks are inserted which provide descriptions and references to medical procedures and in depth definitions.

The book is free of most grammatical errors. There is a place where a few words do not fit the sentence structure and could be a typo.

The book included all types of relationships and ethnic backgrounds. One type which could be added is a transgender patient.

I think the book was quite useful for a variety of health care professionals. The authors did an excellent job of integrating patient cases which could be applied to the health care setting. The stories seemed real and relevant. This book could be used to teach health care professionals about integrated care within the emergency department.

Reviewed by Shelley Wolfe, Assistant Professor, Winona State University on 5/21/18

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should... read more

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should be noted that the authors include a statement that conveys that this text is not like traditional textbooks and is not meant to be read in a linear fashion. This allows the educator more flexibility to use the text as a supplement to enhance learning opportunities.

The content of the text appears accurate and unbiased. The “five overarching learning objectives” provide a clear aim of the text and the educator is able to glean how these objectives are captured into each of the case studies. While written for the Canadian healthcare system, this text is easily adaptable to the American healthcare system.

Overall, the content is up-to-date and the case studies provide a variety of uses that promote longevity of the text. However, not all of the blue font links (if using the digital PDF version) were still in working order. I encountered links that led to error pages or outdated “page not found” websites. While the links can be helpful, continued maintenance of these links could prove time-consuming.

I found the text easy to read and understand. I enjoyed that the viewpoints of all the different roles (patient, nurse, lab personnel, etc.) were articulated well and allowed the reader to connect and gain appreciation of the entire healthcare team. Medical jargon was noted to be appropriate for the intended audience of this text.

The terminology and organization of this text is consistent.

The text is divided into 8 case studies that follow a similar organizational structure. The case studies can further be divided to focus on individual learning objectives. For example, the case studies could be looked at as a whole for discussing communication or could be broken down into segments to focus on disease risk factors.

The case studies in this text follow a similar organizational structure and are consistent in their presentation. The flow of individual case studies is excellent and sets the reader on a clear path. As noted previously, this text is not meant to be read in a linear fashion.

This text is available in many different forms. I chose to review the text in the digital PDF version in order to use the embedded links. I did not encounter significant interface issues and did not find any images or features that would distract or confuse a reader.

No significant grammatical errors were noted.

The case studies in this text included patients and healthcare workers from a variety of backgrounds. Educators and students will benefit from expanding the case studies to include discussions and other learning opportunities to help develop culturally-sensitive healthcare providers.

I found the case studies to be very detailed, yet written in a way in which they could be used in various manners. The authors note a variety of ways in which the case studies could be employed with students; however, I feel the authors could also include that the case studies could be used as a basis for simulated clinical experiences. The case studies in this text would be an excellent tool for developing interprofessional communication and collaboration skills in a variety healthcare students.

Reviewed by Darline Foltz, Assistant Professor, University of Cincinnati - Clermont College on 3/27/18

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks... read more

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks Clinical Procedures for Safer Patient Care and Anatomy and Physiology: OpenStax" as noted by the authors.

The book appears to be accurate. Although one of the learning outcomes is as follows: "Demonstrate an understanding of the Canadian healthcare delivery system.", I did not find anything that is ONLY specific to the Canadian healthcare delivery system other than some of the terminology, i.e. "porter" instead of "transporter" and a few french words. I found this to make the book more interesting for students rather than deter from it. These are patient case studies that are relevant in any country.

The content is up-to-date. Changes in medical science may occur, i.e. a different test, to treat a diagnosis that is included in one or more of the case studies, however, it would be easy and straightforward to implement these changes.

This book is written in lucid, accessible prose. The technical/medical terminology that is used is appropriate for medical and allied health professionals. Something that would improve this text would to provide a glossary of terms for the terms in blue font.

This book is consistent with current medical terminology

This text is easily divided into each of the 6 case studies. The case studies can be used singly according to the body system being addressed or studied.

Because this text is a collection of case studies, flow doesn't pertain, however the organization and structure of the case studies are excellent as they are clear and easy to read.

There are no distractions in this text that would distract or confuse the reader.

I did not identify any grammatical errors.

This text is not culturally insensitive or offensive in any way and uses patients and healthcare workers that are of a variety of races, ethnicities and backgrounds.

I believe that this text would not only be useful to students enrolled in healthcare professions involved in direct patient care but would also be useful to students in supporting healthcare disciplines such as health information technology and management, medical billing and coding, etc.

Table of Contents

• Introduction

Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)

• Learning Objectives
• Patient: Erin Johns
• Emergency Room

Case Study #2: Pneumonia

• Day 0: Emergency Room
• Day 1: Emergency Room
• Day 1: Medical Ward
• Day 2: Medical Ward
• Day 3: Medical Ward
• Day 4: Medical Ward

Case Study #3: Unstable Angina (UA)

• Patient: Harj Singh

Case Study #4: Heart Failure (HF)

• Patient: Meryl Smith
• In the Supermarket
• Day 0: Medical Ward

Case Study #5: Motor Vehicle Collision (MVC)

• Patient: Aaron Knoll
• Crash Scene
• Operating Room
• Post Anaesthesia Care Unit (PACU)
• Surgical Ward

Case Study #6: Sepsis

• Patient: George Thomas
• Sleepy Hollow Care Facility

Case Study #7: Colon Cancer

• Patient: Fred Johnson
• Two Months Ago
• Pre-Surgery Admission

Case Study #8: Deep Vein Thrombosis (DVT)

• Patient: Jamie Douglas

Appendix: Overview About the Authors

Ancillary Material

About the book.

Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.

The case studies can be used online in a learning management system, in a classroom discussion, in a printed course pack or as part of a textbook created by the instructor. This flexibility is intentional and allows the educator to choose how best to convey the concepts presented in each case to the learner.

Because these case studies were primarily developed for an electronic healthcare system, they are based predominantly in an acute healthcare setting. Educators can augment each case study to include primary healthcare settings, outpatient clinics, assisted living environments, and other contexts as relevant.

About the Contributors

Glynda Rees teaches at the British Columbia Institute of Technology (BCIT) in Vancouver, British Columbia. She completed her MSN at the University of British Columbia with a focus on education and health informatics, and her BSN at the University of Cape Town in South Africa. Glynda has many years of national and international clinical experience in critical care units in South Africa, the UK, and the USA. Her teaching background has focused on clinical education, problem-based learning, clinical techniques, and pharmacology.

Glynda‘s interests include the integration of health informatics in undergraduate education, open accessible education, and the impact of educational technologies on nursing students’ clinical judgment and decision making at the point of care to improve patient safety and quality of care.

Faculty member in the critical care nursing program at the British Columbia Institute of Technology (BCIT) since 2003, Rob has been a critical care nurse for over 25 years with 17 years practicing in a quaternary care intensive care unit. Rob is an experienced educator and supports student learning in the classroom, online, and in clinical areas. Rob’s Master of Education from Simon Fraser University is in educational technology and learning design. He is passionate about using technology to support learning for both faculty and students.

Part of Rob’s faculty position is dedicated to providing high fidelity simulation support for BCIT’s nursing specialties program along with championing innovative teaching and best practices for educational technology. He has championed the use of digital publishing and was the tech lead for Critical Care Nursing’s iPad Project which resulted in over 40 multi-touch interactive textbooks being created using Apple and other technologies.

Rob has successfully completed a number of specialist certifications in computer and network technologies. In 2015, he was awarded Apple Distinguished Educator for his innovation and passionate use of technology to support learning. In the past five years, he has presented and published abstracts on virtual simulation, high fidelity simulation, creating engaging classroom environments, and what the future holds for healthcare and education.

Janet Morrison is the Program Head of Occupational Health Nursing at the British Columbia Institute of Technology (BCIT) in Burnaby, British Columbia. She completed a PhD at Simon Fraser University, Faculty of Communication, Art and Technology, with a focus on health information technology. Her dissertation examined the effects of telehealth implementation in an occupational health nursing service. She has an MA in Adult Education from St. Francis Xavier University and an MA in Library and Information Studies from the University of British Columbia.

Janet’s research interests concern the intended and unintended impacts of health information technologies on healthcare students, faculty, and the healthcare workforce.

She is currently working with BCIT colleagues to study how an educational clinical information system can foster healthcare students’ perceptions of interprofessional roles.

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Welcome To Open Case Studies

Connecting you with real-world public health data.

The Open Case Studies project showcases the possibilities of what can be achieved when working with real-world data.

Housed in a freely accessible GitHub repository, the project’s self-contained and experiential guides demonstrate the data analysis process and the use of various data science methods, tools, and software in the context of messy, real-world data.

These case studies will empower current and future data scientists to leverage real-world data to solve leading public health challenges.

Who Are Open Case Studies For?

Your experiential guide to the power of data analysis.

The Open Case Studies project provides insights about gathering and working with data for students, instructors, and those with experience in data science or statistical methods at nonprofit organizations and public sector agencies.

Each case study in the project focuses on an important public health topic and introduces methods to provide users with the skills and knowledge for greater legibility, reproducibility, rigor, and flexibility in their own data analyses.

Case Study Bank Overview

Real data on ten public health challenges in the U.S.

The following in-depth case studies use real data and focus on five areas of public health that are particularly pressing in the United States.

Vaping Behaviors in American Youth

This case study explores the trends of tobacco product usage among American youths surveyed in the National Youth Tobacco Survey (NYTS) from 2015-2019. It demonstrates how to use survey data and code books and provides an introduction to writing functions to wrangle similar but slightly different data repetitively. The case study introduces packages for using survey weighting and survey design to perform an analysis to compare vaping product usage among different groups, and covers how to use a logistic regression to compare groups for a variable that is binary (such as true or false — in this case it was using vaping products or not). This case study also covers how to make visualizations of multiple groups over time with confidence interval error bars.

Opioids in the United States

This case study examines the number of opioid pills (specifically oxycodone and hydrocodone, as they are the top two misused opioids) shipped to pharmacies and practitioners at the county-level around the United States from 2006 to 2014 using data from the Drug Enforcement Administration (DEA). This case study demonstrates how to get data from a source called an application programming interface (API). It explores why and how to normalize data, as well as why and how to potentially stratify or redefine groups. It also shows how to compare two independent groups when the data is not normally distributed using a test called the Wilcoxon rank sum test (also called the Mann Whitney U test) and how to add confidence intervals to plots (using a method called bootstrapping).

Disparities in Youth Disconnection

This case study focuses on rates of youth (people between 16-24) disconnection (those who are neither working nor in school) among different racial, ethnic and gender subgroups to identify subgroups that may be particularly vulnerable. It demonstrates that deeper inspection of subgroups yields some differences that are not otherwise discernable, how to import data from a PDF using screenshots of sections of the PDF, and how to use the Mann-Kendall trend test to test for the presence of a consistent direction in the relationship of disconnection rates with time. This case study also shows how to make a visualization that stylistically matches that of an existing report, how to add images to plots, and how to create effective bar plots for multiple comparisons across several groups.

Mental Health of American Youth

This case study investigates how the rate of self-reported symptoms of major depressive episodes (MDE) has changed over time among American youth (age 12-17) from 2004-2018. It describes the impact of self-reporting bias in surveys, how to get data directly from a website, as well as how to compare changes in the frequency of a variable between two groups using a chi-squared test to determine if two variables are independent (in this case if the sex of the students influenced the frequency of reported MDE symptoms in 2004 and 2018). This case study also demonstrates how to create direct labels on visualizations with many groups across time, as well as how to create an animated gif.

Exploring CO2 Emissions Across Time

This case study investigates how CO2 emissions have changed since the 1700s and how the level of emissions has compared for different countries around the world. It explores how yearly average temperature and the number of natural disasters in the United States has changed over time and provides an introduction for examining if two sets of data are correlated with one another. This case study also goes into great detail about how to make what are called heatmaps and other plots to visualize multiple groups over time. This includes adding labels directly to lines on plots with multiple lines.

Predicting Annual Air Pollution

This case study uses machine learning methods to predict annual air pollution levels spatially within the United States based on data about population density, urbanization, road density, as well as satellite pollution data and chemical modeling data among other predictors. Machine learning methods are used to predict air pollution levels when traditional monitoring systems are not available in a particular area or when there is not enough spatial granularity with current monitoring systems. The case study also demonstrates how to visualize data using maps.

Exploring Global Patterns of Obesity Across Rural and Urban Regions

This case study compares average Body Mass Index measurements for males and females from rural and urban regions from over 200 countries around the world, with a particular emphasis on the United States. It provides a thorough introduction to wrangling data from a PDF, how to compare two paired groups using the t test and the nonparametric Wilcoxon signed-rank test using R programming, and how to make visualizations of group comparisons that emphasize a particular subset of the data.

Exploring Global Patterns of Dietary Behaviors Associated with Health Risk

This case study investigates the consumption of dietary factors associated with health risk among males and females from over 200 countries around the world, with a particular emphasis on the United States. It demonstrates how to wrangle data from a PDF; how to combine data from two different sources; how to compare two paired groups and multiple paired groups using t-tests, ANOVA, and linear regression; and how to create visualizations of several groups and how to combine plots together with very different scales.

Influence of Multicollinearity on Measured Impact of Right-To-Carry Gun Laws

This case study focuses on two well-known studies that evaluated the influence of right-to-carry gun laws on violent crime rates. It demonstrates a phenomenon called multicollinearity, where explanatory variables that can predict one another can lead to aberrant and unstable findings; how to make visualizations with labels, such as arrows or equations; and how to combine multiple plots together.

School Shootings in the United States

This case study illustrates ways to communicate trends in a dataset about the number and characteristics of school shooting events for students in grades K-12 in the United States since 1970. It demonstrates how to create a dashboard, which is a website that shows patterns in a dataset in a concise manner; how to import data from a Google Sheets document; how to create interactive tables and maps; and how to properly calculate percentages for data when there are missing values.

Which Case Study Is Right For Me?

Connecting with the public health data you need.

The Open Case Studies project approaches data in many different ways. The guide below will help connect you with a case study:

Data science projects often start with a question. Here, you may look for case studies that explore a question that is similar to one you are interested in investigating with your data.

How does something change over time?

Investigating how a variable has changed over time can help identify consistent trends.

How do survey responses compare for different groups over time?

Survey data requires special care and attention to the survey design.

How do groups compare?

Public health researchers are often interested to know if one group is more vulnerable than another or if two or more groups are actually different from one another.

How do groups compare over time?

Comparing several groups over time can provide insight into if the change over time is different for different groups.

How do paired groups compare?

Paired groups are those that are not independent in some way. Perhaps you want to know how data from the same person over time compares with that of another person over time, or perhaps you are interested in how something changed in a city before and after an intervention, or perhaps you want to compare groups using data that has structure where there is coupling or matching of data values across samples.

Are certain groups or possibly subgroups more vulnerable?

Understand how to compare subpopulations at a deeper level.

How does something compare across regions?

Often it is useful to investigate if data differs by region, as many environmental, cultural, and political differences can influence public health outcomes.

How can I predict outcomes for new data?

Learn how the data might look next year or for locations that you don’t have data about.

Does this influence my data?

Analyze how a variable influences another variable.

Are these two variables related to one another?

Understand how two variables are related and how strongly they are related to one another.

How can I display this data for others to find and interpret and use easily?

Make it easy for others to find your data, see the major trends in your data, or search for specific values in your data.

Data can come from many different sources, from the more obvious like an excel file to the less obvious like an image or a website. These case studies demonstrate how to use data from a variety of possible sources.

Using data from a PDF or just parts of a PDF can be challenging. You could type the data into a new excel file, but this can result in mistakes and it is difficult to reproduce.

Data are often in CSV files and it is typically easy to import data and work with data in this form. However, sometimes it can be difficult if, for example, the first few lines are structured differently or if you have unusual missing value indicators.

If you find data on a website that doesn’t allow you to download in a convenient way, you can actually directly import the data into R programming language.

This is one of the most common data forms, and it is typically easy to import data and work with data in this form. However, sometimes it can be challenging, especially if you have many files.

You can extract text from image files. This can be useful if, for example, you want to only use certain parts of a PDF.

It is possible to find the data that you need to use from an application programming interface (API).

Google Sheet

You can download data from a Google Sheet, copy and paste it into Excel, or directly import the data into R programming language.

Survey data/Code books

Working with survey data requires special care and attention, and you can do this directly with R programming language.

Multiple files

If you find that you need to import data from multiple files, there is a more efficient way to do so without importing each one by one.

Data wrangling is the process of organizing your data in a more useful format. These case studies explore how to clean, rearrange, reshape, modify, filter, combine, or join your data.

Extracting data from a PDF

Extracting and organizing data from a PDF will make it easier to use.

Geocoding data

The process of assigning relevant latitude and longitude coordinates to data values is called geocoding. This can be helpful (although not always necessary) to create a map of your data.

Recoding data

If you have data values that are confusing and could be changed to something better, or if you want to convert your data to true or false, you might want to consider recoding these values.

Methods of joining data

Sometimes, you obtain data from multiple sources that need to be combined together.

Filtering data

Perhaps you need to filter your data for only specific values for given variables. In other words, you might want to filter census employment data to only values for females who are also Black and live in Connecticut.

Modifying data (normalizing, transforming, scaling etc.)

Sometimes it is difficult to know when or how to normalize data.

Working with text

You can work with, remove, replace, or change words, phrases, letters, numbers, or punctuation marks in your data.

Reshaping data

Sometimes it is useful to shape your data so that you have many columns (for example, when performing certain analyses), however it can be useful at other times (for example, when creating plots) to collapse multiple columns into fewer columns with more rows.

Repetitive process

Sometimes you need to wrangle multiple datasets from different sources in a similar manner.

A picture is worth a thousand words, particularly when it comes to interpreting data. These case studies demonstrate how to make effective visualizations in various contexts. The first ten represent basic visualizations while 11-22 are more advanced.

A table that is easy to interpret

Adding colors or simple graphics can make tables easier to interpret.

Scatter plot

Scatter plots can be a strong option for evaluating the relationship between variables, and especially for evaluating changes in a variable over time.

Line plots are often useful for evaluating changes over time.

Bar plots are a good choice if you want to compare data to a threshold.

Box plots are particularly useful for comparing groups with many data values. They provide information about the spread of the data.

Pie chart/waffle plot

Pie charts or waffle plots can be a strong option when comparing relative percentages.

It can be difficult to visualize multiple groups at simultaneously. In these situations, heat maps can be a great option.

Correlation plots

If you have many variables and need to know if they are correlated to one another, there are methods to efficiently check this.

Visualize missing data

It can be helpful to quickly identify how much of your data is missing (has NA values).

Create a map of your data

Often the best way to interpret regional differences in data is to make a map.

• Advanced Visualizations

Matching a style

If you are working with collaborators, you can make your visualizations match the style of their figures.

Faceted plots allow you to quickly create multiple plots at once

It can be difficult to visualize multiple groups at the same time, so faceted plots are a great option in this situation.

Adding labels directly to plots with many different groups

If you compare many groups over time, for example, it can be difficult to see which line corresponds to which group. Adding labels directly to these lines can be very helpful and negates the need for an overcomplicated legend.

Emphasize a particular group

Sometimes you will have several different groups and you want to highlight a specific group.

Adding annotations to plots

Adding labels, such as thresholds, arrows, or equations, can make it easier for people to interpret your plot.

Add error bars to your plot

Adding error bars can help convey information about the confidence of the estimates in your plots.

Combine multiple plots together

Sometimes it is useful to put a variety of plots together and add text to explain what the plot shows.

Create an interactive plot when you have too many groups to label

If you compare a very large number of groups, it can be difficult to tell what is happening. Often it can help to make the plot interactive so that the user can hover over points or lines to see what they indicate.

Create an interactive map of your data

Sometimes it is easiest to see regional differences by interacting with and exploring an interactive map.

Create an interactive table of your data

Sometimes you might want to be able to search through your data or allow others to easily do so.

Add images to your figures

Including images to a plot, such as a logo, can be a helpful addition.

Create an interactive dashboard/website for your data

Dashboards can quickly convey major trends in a dataset, and they can also allow users to interact with the data to choose what aspects about the data they wish to explore.

To better understand data, it is helpful to use statistical tests. These case studies demonstrate a variety of statistical tests and concepts.

Are two groups different?

Correlation

Are two variables related to one another?

Are multiple groups different?

Linear regression

Would you like to compare groups?

Chi-squared test of independence

Do the frequencies of two groups suggest that they are independent?

Mann-Kendall Trend test

Is there a consistent change over time?

Machine learning

Would you like to predict data?

Calculate percentages with missing data?

Would you like to calculate percentages, but you are missing some data?

About The Project

Learn about the team behind the Open Case Studies project.

As part of the larger Open Case Studies project (OCS) at opencasestudies.org , these case studies were developed for and funded by the Bloomberg American Health Initiative. The OCS project is made up of a team of researchers at the Johns Hopkins Bloomberg School of Public Health (JHSPH).

Let us know how the Open Case Studies project has enhanced your educational curriculum or ability to tackle tough data-rich research projects.

JHSPH Faculty Contributors

Jessica Fanzo, PhD

Brendan Saloner, PhD

Megan Latshaw, PhD, MHS

Renee M. Johnson, PhD, MPH

Daniel Webster, ScD, MPH

Elizabeth Stuart, PhD

Bloomberg American Health Initiative

Joshua M. Sharfstein, MD – Director, Bloomberg American Health Initiative

Michelle Spencer, MS – Associate Director, Bloomberg American Health Initiative

Paulani Mui, MPH – Special Projects Officer, Bloomberg American Health Initiative

Other Contributors

Aboozar Hadavand, PhD, MA, MS, Minerva University

Roger Peng, PhD, MS, Johns Hopkins Bloomberg School of Public Health

Kirsten Koehler, PhD, MS, Johns Hopkins Bloomberg School of Public Health

Alex McCourt, PhD, JD, MPH, Johns Hopkins Bloomberg School of Public Health

Ashkan Afshin, MD, ScD, MPH, MSc, University of Washington and Institute for Health Metrics and Evaluation (IHME)

Erin Mullany, BA, Institute for Health Metrics and Evaluation (IHME)

External Review Panel

Leslie Myint, PhD, Macalester College

Shannon E. Ellis, PhD, University of California – San Diego

Christina Knudson, PhD, University of St. Thomas

Michael Love, PhD, University of North Carolina

Nicholas Horton, ScD, Amherst College

Mine Çetinkaya-Rundel, PhD, University of Edinburgh, Duke University, RStudio

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• Review Article
• Published: 17 May 2021

Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries

• Victoria Haldane   ORCID: orcid.org/0000-0002-8674-4099 1   na1 ,
• Chuan De Foo   ORCID: orcid.org/0000-0001-7254-4881 2   na1 ,
• Salma M. Abdalla 3 , 4   na1 ,
• Anne-Sophie Jung 5   na1 ,
• Melisa Tan 2 ,
• Shishi Wu 2 ,
• Alvin Chua 2 ,
• Monica Verma 2 ,
• Pami Shrestha 2 ,
• Sudhvir Singh 4 , 6 ,
• Tristana Perez 5 ,
• See Mieng Tan 2 ,
• Michael Bartos 4 , 7 ,
• Shunsuke Mabuchi 4 ,
• Mathias Bonk 4 , 8 ,
• Christine McNab 4 ,
• George K. Werner 4 ,
• Raj Panjabi 4 ,
• Anders Nordström 4 &
• Helena Legido-Quigley 2 , 4 , 5  

Nature Medicine volume  27 ,  pages 964–980 ( 2021 ) Cite this article

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• Infectious diseases
• Public health

Health systems resilience is key to learning lessons from country responses to crises such as coronavirus disease 2019 (COVID-19). In this perspective, we review COVID-19 responses in 28 countries using a new health systems resilience framework. Through a combination of literature review, national government submissions and interviews with experts, we conducted a comparative analysis of national responses. We report on domains addressing governance and financing, health workforce, medical products and technologies, public health functions, health service delivery and community engagement to prevent and mitigate the spread of COVID-19. We then synthesize four salient elements that underlie highly effective national responses and offer recommendations toward strengthening health systems resilience globally.

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COVID-19 has caused an unprecedented global crisis, including millions of lives lost, public health systems in shock and economic and social disruption, disproportionately affecting the most vulnerable. As of April 2021, there are over 140 million confirmed cases and over three million COVID-19 deaths globally 1 . While vaccination has commenced in numerous countries, new outbreaks and variants continue to emerge. At the same time, the global distribution of vaccines is marred by challenges of equity on top of logistical complications. Millions more are therefore still at risk of dying, facing significant morbidity or losing their livelihoods given the uncertain economic outlook.

The pandemic has challenged local, national, regional and global capacities to prepare and respond. The various national strategies taken to control viral transmission are widely debated 2 , 3 . However, the relative success of these strategies depends largely on how an existing health system is organized, governed and financed across all levels in a coordinated manner 4 . The pandemic has exposed the limitations of many health systems, including some that have been previously classified as high performing and resilient 5 . A comprehensive analysis of the resilience of health systems during the pandemic can therefore pinpoint important lessons and help strengthen countries’ preparedness, response and approach to future health challenges.

While resilience is a core concept in disaster risk reduction, its application to health systems is relatively new. It has been defined broadly as institutions’ and health actors’ capacities to prepare for, recover from and absorb shocks, while maintaining core functions and serving the ongoing and acute care needs of their communities 6 , 7 . During a crisis, a resilient health system is able to effectively adapt in response to dynamic situations and reduce vulnerability across and beyond the system. Experience from previous epidemics, such as Ebola, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome, emphasized the links between resilience and thwarting new outbreak transmission 8 .

Health systems resilience literature stresses that efforts should focus not only on absorbing unforeseen shocks precipitated by emerging health needs, but also on ensuring continuity in health improvement, sustaining gains in systems functioning and fostering people centeredness, while delivering high-quality care 9 , 10 . As COVID-19 has overwhelmed health systems worldwide, debates around resilience have become more urgent, and there is a need to better understand the elements of national responses through a resilience lens 11 , 12 . Thus, in this perspective, we use an expanded health systems resilience framework centered on community engagement to examine 28 national responses to COVID-19. This analysis provides insights into the policies countries implemented and how these were implemented to tackle the pandemic.

Conceptual framework

Our conceptual framework (Fig. 1 ) is grounded in the World Health Organization’s (WHO) health systems framework 13 . We develop the framework elements by adding public health functions, including testing, contact tracing, disease surveillance and non-pharmaceutical public health interventions, which often operate separately from health service delivery. Yet, they are critical both to pandemic responses and to ongoing population health. Similarly, health information systems are vital functions for both public health and health systems as, ideally, they should be integrated to capture data at individual, health system and population levels.

The scheme illustrates the components of the resilient health systems framework we developed based on the WHO’s health systems building blocks framework. The five elements of resilient health systems are centered around community engagement as core to all elements of health systems resilience.

We centered our analysis on community engagement as core to all elements of health systems resilience (see Box 1 for more information on the analytical approach). To serve communities in a more equitable manner and promote healthy societies, resilience must be developed with these communities and according to their needs. There can be no health systems resilience without community engagement across domains 14 . We also acknowledge the critical role of coordination with non-health sectors as essential to providing necessary supports to address the social determinants of health. Underpinning these elements are health equity and outcomes. Resilient health systems should aim to generate positive physical and mental health outcomes for all, including vulnerable and marginalized groups. In many countries, COVID-19 mortality rates have been disproportionately higher among older populations, minority ethnic groups, socioeconomically deprived populations and low-wage and migrant workers, emphasizing the interconnectedness between equity and health outcomes 15 .

Box 1 Analytical approach

The analysis presented in this review is based on a purposive selection of countries including positive and negative outliers in relation to reported COVID-19 deaths per capita among highly populous countries, as well as a selection of countries in the middle ground from different regions and with widely varying health systems and economic status. Figure 2 provides an overview of countries in our review. Countries were selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. Given the dynamic and continuously changing situation, the ranking of positive and negative outliers in terms of death per capita may have changed during the pandemic. The analysis is thus limited to this specific time period.

Five complementary methods were adopted to analyze national responses to COVID-19:

Literature review: using standardized methods, we identified peer-reviewed papers and public reports that examined national and subnational policy responses and extracted data for each country on five dimensions comprising 62 items. The dimensions and items were identified through a review of 14 existent frameworks.

Semi-structured interviews and national government submissions : to supplement the literature review, we asked the selected countries and country experts a set of questions related to the measures implemented to contain COVID-19 in their respective countries. A total of 45 interviews and written submissions were provided. Semi-structured interviews with COVID-19 national experts at the policy, operational and academic levels were recorded and transcribed in full. All interviews were coded through an inductive approach and thematic analysis, using QSR NVivo 12 software, drawing on techniques of the constant comparison method.

In-depth case studies of 6 countries to validate the data from the 28 countries.

Expert validation of country-specific data with country experts. Experts in countries were provided with the specific data for each of their respective countries to validate the data.

Expert validation through roundtable discussions with country experts. A total of 35 national and international experts in COVID-19 policies participated in two roundtable discussions.

COVID-19 responses in 28 countries

Using our framework, we organized our results beginning with domains often viewed as external to health, which are nevertheless central determinants of health systems resilience—governance, finance, collaboration across sectors and community engagement—before exploring domains more closely associated with traditional views of health and health systems—health service delivery, health workforce, medical products and technologies and public health functions. We offer illustrative examples of selected countries for each domain in Tables 1 – 6 . We analyzed 28 countries based on a purposive selection, including positive and negative outliers in relation to reported COVID-19 deaths per capita among highly populous countries, as well as a selection of countries in the middle ground (as of 6 November 2020). Figure 2 provides an overview of countries in our review.

The map presents an overview of countries selected according to the recorded number of deaths attributed to COVID-19 per 100,000 inhabitants on 6 November 2020. Countries are listed according to region and in alphabetical order.

Governance, finance and collaboration across sectors

COVID-19 has made policymakers and the wider public acutely aware of the relationship between health systems, domestic economies and governance. Government decisions determine healthcare infrastructures, regulations and guidelines, defining access to medication and treatment, the provision of health coverage and the financing of these. Government responses to COVID-19, in the immediate term, have meant the difference between lockdown or business as usual, and have eroded or increased public trust. In the longer term, they have shaped national choices regarding private healthcare or universal health coverage (UHC) and strengthened or impoverished social safety nets that underpin health and well-being.

Overall, COVID-19 responses saw health policy moving beyond the remit of Ministries of Health and in doing so, draw on expertise from other ministries, particularly during the early response. Countries took whole-of-government approaches to strengthen health systems in response to COVID-19, particularly those with experience of other health-related disasters, such as Ebola. These decisions were, in most countries, made by translating evidence-based research into policies that preserve health system capacity, while protecting both public health and livelihoods. As such, most countries established temporary COVID-19 advisory groups to inform government decisions. However, in the majority of countries, the views represented on these committees were largely biomedical. More information on national responses from a governance and leadership perspective is available (V.H., A.-S.J., R. Neill, S.W. and M. Jamieson, unpublished data).

The COVID-19 response requires testing, treatment and vaccines to be financed with either a portion or all of these costs coming from public funds, and depends on healthcare infrastructures, workforce and supplies to provide much-needed surge capacity within health systems. Additionally, fiscal support measures, including relief packages aiming at helping businesses stay viable, protect jobs or provide financial aid to low-income households and the unemployed have been taken by many countries. These policies support people to adhere to public health guidance, with the aim of preventing infections, in turn mitigating the strain on the health system resulting from the need to deliver high-intensity COVID-19 care. To further enhance the reach of health services, many countries reviewed took specific actions to mitigate potential financial and physical barriers to care, such as covering part or all of the costs of COVID-19 care, and funding the establishment of testing and treatment centers in communities 16 . Importantly, the outcomes resulting from financial expenditures on health and well-being are only as good as the structures that support them. Thus, they require governance expertise across levels, sectors and domains and depend on a system’s ability to reach (vulnerable) populations.

Community engagement

Deep engagement with local communities is central to resilient health systems as a way to inform service delivery, decision-making and governance and to meet the needs of communities before, during and after crises. Community engagement strategies, such as building partnerships with local leaders and working alongside community members to tailor messages and campaigns are crucial during public health emergencies 17 . The range of non-pharmaceutical public health interventions employed in response to COVID-19, such as mask wearing and social distancing, rely on shared values and a sense of social responsibility within communities to break chains of viral transmission 18 .

Several countries reviewed engaged networks of community health workers (CHWs) to encourage active community participation in COVID-19 responses. Their roles range from creating awareness through door-to-door visits, supporting contact tracing efforts, maintaining essential health services, providing necessary medication to patients without COVID-19, surveillance or monitoring adherence to quarantine measures and assessing mental well-being 19 . They are also key to identifying and referring patients who face barriers to accessing healthcare services. For example, Thailand deployed over 1 million CHWs to disseminate and amplify messages widely in communities. Singapore deployed volunteers to educate seniors and help distribute daily necessities. Liberia further empowered community leaders by providing orientation on COVID-19 epidemiology to support containment efforts. However, many of these efforts depended on volunteers.

During early response efforts, a few countries conducted surveys to understand public sentiment regarding evolving measures. Japan conducted a survey in April 2020 to understand compliance with social distancing measures, using the results to inform response strategies. Governments also started multilingual hotlines to ensure comprehensive access to COVID-19 information. Other countries used social media platforms to engage communities. For example, the #TakeResponsibility campaign in Nigeria called on citizens to join forces and be proactive in taking greater individual and collective responsibility in controlling the spread of COVID-19 20 .

Health service delivery

Health systems globally have employed three common approaches to rapidly scale up health system infrastructure, namely by constructing new treatment facilities, converting public venues and reconfiguring existing medical facilities to provide care for patients with COVID-19. Thus, some of the health systems reviewed invested significant resources into rapidly creating dedicated field facilities. For example, in early 2020, China established two specialty field hospitals in under 2 weeks 21 . Where field hospitals were set up to house patients with COVID-19, countries often drew on their armed forces and military field hospital models, or adapted existing large public facilities. However, most health systems relied on a less resource-intensive approach that modified traditional healthcare facilities into dedicated COVID-19 care centers 22 . Other health systems relied on home care for patients with mild to moderate COVID-19, with facilities available if patients were unable to safely self-isolate within their homes. Additionally, the majority of reviewed countries canceled elective surgeries in an effort to ensure system capacity for COVID-19 care.

In many health systems, primary-care providers are the frontline of the health system providing continuous, coordinated and people-centered care. Primary care is an important point of COVID-19 triage, as well as the point at which most routine and acute care services are provided within communities 23 . In many of the countries reviewed, primary-care providers rapidly adopted and scaled up digital technology or telehealth services to provide ongoing and acute care while also triaging and referring persons with symptoms of COVID-19 to onward care 24 . Additionally, some countries complemented digital technology with proactive deployment of existing and new community health resources 25 . Community-based approaches developed with deep knowledge of local contexts are crucial to pandemic response and health systems resilience, particularly given the disproportionate impact of the pandemic on vulnerable groups 15 , 26 . While outside the reach of the health system in many countries, there have been extensive outbreaks in long-term care homes with devastating impacts on the health and well-being of high-risk older adults, long-term care patients and their families 27 . In response, most countries reviewed prioritized long-term care facilities and older adults for testing, surveillance and vaccine distribution, although often not until there had been high rates of mortality in these settings.

Health workforce

Resilient health systems manage crises by having an adequate, trained and willing workforce. Yet, in many countries, COVID-19 has spread quickly among health workers as they have been the most exposed to the virus, with data indicating that they have been disproportionately affected by the pandemic 28 . Health workforce challenges during COVID-19 include low staffing levels (particularly among nurses) and uneven geographical distribution, shortages of adequate personal protective equipment (PPE), limited testing capacity, insufficient training, social discrimination and attacks and poor mental health 29 .

As cases surged globally, most reviewed countries reallocated healthcare professionals, including primary-care workers, to emergency care wards, intensive care units (ICUs) and diagnosis and surveillance activities. Several recruitment strategies were implemented to increase the healthcare workforce. Retired, student or nonpracticing medical and paramedical professionals were asked to volunteer for healthcare tasks. For example, medical and nursing students were recruited and allowed to perform supervised work in different COVID-19 response capacities in countries such as Germany, Russia, Spain, the United Kingdom and Vietnam. Given these new roles or expanded job scopes, there was an immediate need for rapid and high-quality pandemic-related training of frontline healthcare workers, which was accomplished through virtual training courses in many countries.

Further measures were taken by countries to maintain, protect and support their healthcare workers in light of the physical and psychological strain of the pandemic. In some countries (for example, Japan, Mozambique, Singapore and South Korea), healthcare professionals were supported by measures such as organization of shifts to avoid extended hours without rest, leaves from duty for mental and physical recovery, accommodation near their workplaces to protect their families, and childcare. Additionally, most countries reported giving some form of financial support to their health workers, such as monetary incentives, bonuses, insurance, tax benefits, overtime pay, meal allowances, classification of their infections as an occupational disease or injury and declaring cause of death as work related. Several countries reported making psychological support available for health workers, such as counseling or trauma support, to maintain well-being and morale. Frontline staff and their families were especially vulnerable and were targeted for psychological interventions. Moreover, some countries launched social media campaigns that encourage people to show their pride, admiration and gratitude for healthcare workers to promote solidarity.

Medical products and technologies

High-quality prevention, diagnosis and management of COVID-19 require the ongoing development, production and sustained distribution of mass quantities of medical products and technologies. However, overreliance on a few countries for production, competition among countries and supply chain disruptions have caused global supply shortages. Some countries reviewed had national or regional stockpiles of PPE, including masks, gloves, face shields and gowns, which were used as a buffer while awaiting imported supplies or scale up of domestic production. Singapore, for example, drew from experience responding to SARS and preserved a national stockpile of medical products for up to 6 months 30 . To replenish stockpiles in Japan, medical product manufacturers were urged to boost production output, resulting in the tripling of production volume as factories operated 24 h a day 31 .

Governments also worked beyond the typical health sectors and developed guidelines and specifications for non-health sectors to supplement the existing medical product manufacturing lines. In India, automotive manufacturers were repurposed to produce low-cost ventilators and PPE 32 . Beyond industry, communities in some countries mobilized to bolster medical product supplies. Several countries had also relied on purchasing consortia, like the UN COVID-19 Supply Chain System and Africa Medical Supplies Platform, donations from development partners or grants and loans from other countries and international financial entities (that is, The World Bank and Asian Development Bank) to secure medical supplies 33 , 34 , 35 , 36 , 37 . Vaccine procurement is also an essential part of the medical supply chain, and countries have either made advance-purchase agreements or participated in the COVAX facility to ensure prompt access to the vaccine for their populations, although concerns remain about equitable access to vaccines in short supply.

In response to increased demand driven by widespread community transmission, countries enacted laws to prevent hoarding and exploitative pricing, as well as policies prohibiting export of medical supplies, while relaxing import licensing requirements and tariffs 38 . Within health facilities, measures including rational-use guidelines, per WHO recommendations, and postponement of nonemergency medical procedures helped stretch existing medical inventories 39 . Although supply chains began to stabilize during 2020, many points of care globally faced uncertain stocks and reports of counterfeit medical essentials highlighting the need for secure supply pipelines. Platforms that assist in monitoring logistics networks are integral in ensuring a steady and rapid flow of medical products and technologies, promoting transparency and ensuring better management of supply chains.

Public health functions

Public health interventions embedded within communities, such as testing, contact tracing, quarantine or self-isolation, and surveillance are crucial functions to break chains of transmission 40 . However, in many health systems, public health and health service delivery systems are siloed: their coordination is limited or ineffective, and they have separate referral processes and reporting systems, all of which serve to undermine health systems resilience 41 . Testing and contact tracing are a case in point that clearly illustrates why public health and health systems must act together in a coordinated manner.

Diagnostic tests to identify whether a person is, or has been, infected are foundational to infectious disease responses to pinpoint locations of spread, and provide care and treatment if it exists. Testing strategies are broadly classified as passive or proactive. Many of the countries reviewed relied on passive testing strategies, where symptomatic individuals self-present to a healthcare facility for testing after meeting certain criteria. However, some countries adopted proactive testing strategies characterized by programs tailored to the unique needs of specific populations as an important tool toward breaking chains of transmission and offering a clearer epidemiological picture 42 , 43 . Additionally, many countries rapidly decentralized testing capacity by strengthening or developing new laboratory networks.

Proactive testing must be accompanied by comprehensive contact tracing in partnership with communities. Contact tracing is the systematic process of following up with individuals who may have been exposed to COVID-19 44 . It can be characterized as either forward, aiming to find ‘downstream’ individuals who have been in contact with a person with COVID-19, or backwards, aiming to find an ‘upstream’ source of infection 45 . While most countries reviewed conducted forward contact tracing, Japan conducted backwards contact tracing measures aimed at identifying and ‘busting’ clusters by working with individuals to trace 14 d before symptom onset 46 . Contact tracing, particularly backwards tracing, is labor and time intensive and may be stigmatizing if not done with community engagement and consideration of at-risk and vulnerable groups 47 . The majority of countries reviewed introduced digital contact tracing tools. Even when fully operational, they may not be accessible, acceptable or feasible for use among those with limited access to, or concerns in using, adequate technology such as migrants, refugees or those experiencing homelessness, among others 48 .

Once cases and contacts are identified, self-isolation and quarantine measures are crucial to prevent onwards transmission and identify emergent cases. All countries reported on quarantine and isolation protocols. While necessary to outbreak management, unless done in coordination with communities, quarantine measures can have negative impacts on mental health and well-being, become a source of stigma and be deployed at the significant cost of human rights 49 . Some countries have implemented policies to provide social and economic assistance to those who must self-isolate or quarantine. Social supports range from services that ensure food and necessities during quarantine to dedicated quarantine or isolation facilities (for example, converted hotels, public facilities or purpose-built quarantine hospitals). Such self-isolation supports are recognized as integral to mitigating transmission, particularly among younger people and those working in high-exposure occupations, living in overcrowded housing or without a home 50 . However, to avoid negative unintended consequences, such facilities must be operationalized with a human rights focus 51 .

These efforts are enhanced by surveillance, including testing in areas or settings with outbreaks, to rapidly limit community circulation 52 . Given the high transmissibility of severe acute respiratory syndrome coronavirus 2, surveillance needs to be geographically comprehensive to provide accurate depictions of disease burden and epidemiology to prevent and mitigate community transmission 53 , 54 , 55 . As recommended by WHO guidelines, nearly all countries have adapted existing surveillance system infrastructure to collect information on COVID-19 cases 55 . However, surveillance based on case reporting may underestimate the epidemiological characteristics of COVID-19, given that stigma or other barriers may limit healthcare seeking, particularly in vulnerable populations 56 , 57 . Therefore, New Zealand, Sweden and the United States have additionally deployed syndromic surveillance, which monitors cases that meet the clinical definition of COVID-19 without confirmation by testing. By implementing active surveillance approaches, countries have expanded surveillance coverage from healthcare settings into communities, such as through primary care, thereby strengthening epidemiological surveillance among vulnerable populations.

Timely sharing of case-based data between public health and healthcare sectors is key to early detection of outbreaks, identification of changes in epidemiological trends and planning of health services 58 . This was facilitated by the use of innovative digital technology. For example, the China CDC launched a web-based infectious disease reporting system that allows real-time reporting of confirmed and suspected COVID-19 cases by healthcare providers 59 , 60 . Similar real-time surveillance and information systems are also used in Fiji, India, Japan and Vietnam.

Assessing health systems resilience is vital in helping policymakers plan for sustainable recovery and strengthen systems to better prepare and respond to current and future crises. Using an adapted and improved resilience framework, our review highlights many parallels in the measures implemented by countries in response to COVID-19. The similarities across countries with divergent health outcomes makes clear that there is no one silver bullet toward a resilient health system. Nevertheless, there are a number of characteristics of well-performing countries across the resilience determinants that stand out. These are summarized as four elements of resilience that are featured in highly effective country responses. These elements draw on the concept that resilient health systems are systems that: (1) activate comprehensive responses, which are responses that consider and address health and well-being as intertwined with social and economic considerations; (2) adapt capacity within and beyond the health system to meet the needs of communities; (3) preserve functions and resources within and beyond the health system to maintain pandemic-related and non-related routine and acute care; and (4) reduce vulnerability to catastrophic losses in communities, both in terms of health and well-being, as well as individual or household finances; all while continually learning, monitoring and adjusting in light of emerging evidence or the evolving epidemiological situation (Fig. 3 ).

The framework presented expands upon and applies the determinants of health systems resilience framework to identify four resilience elements characteristic of highly effective country responses to COVID-19.

High-performing countries

High-performing countries activated comprehensive responses across the determinants’ domains, including through whole-of-government approaches and the creation of multi-ministry task forces, to ensure adequate translation of evidence into policy and practices that preserve health system capacity, while protecting public health and livelihoods. Specific measures taken include training health workers, bolstering public health functions (including offering designated isolation facilities, either for all or for those unable to safely self-isolate at home) and preparing for new technologies and medicines through purchase agreements, while also engaging communities through routine communications on the epidemiological situation and emergent policies.

These countries also learned from emerging evidence and adapted the capacity of their health system in response to the evolving epidemiological situation. This was achieved by increasing capacity in hospitals, through construction of makeshift hospitals or repurposing of existing health facilities or civic spaces. The health workforce in high-performing countries was expanded through reallocation and recruitment and supported through financial and social supports.

These countries took action to preserve health system functions and resources through purchasing consortia and rational-use guidelines to maximize available material resources such as PPE, as well as investing in domestic research, development and production of medical supplies, test kits and vaccines. Additionally, these countries protected health and well-being more broadly by ensuring health system functioning for non-COVID-19-related health services. High-performing countries supported primary care and CHWs to conduct COVID-19 screening, assessment and/or referral, while providing ongoing routine and acute care in communities.

High-performing countries also sought to reduce vulnerability across the resilience determinants by providing financial relief and social supports to complement proactive and robust testing and contact tracing in partnership with communities to ensure public health measures and safety net supports reached all groups.

Building resilient health systems

While some countries have demonstrated elements of resilience, as we highlight above, progress is limited in developing resilient health systems overall. Our review highlights six areas requiring urgent action to build resilient health systems globally.

First, COVID-19 responses provide a clear illustration of the importance of governance supported by scientific evidence and leadership willing to learn and adjust course for successful health systems that protect health and well-being. Enhancing resilience to future disease outbreaks requires longer-term work to create high-quality healthcare systems and build community trust. Our review emphasizes that governments are well advised to address COVID-19, and any future disease outbreak, through a whole-of-government approach that incorporates all sectors, engages relevant actors across all levels, including community and local authorities, and is based on strong and clear coordination that extends beyond early-stage emergency management 61 . Crucial to health systems resilience is that governance must consider the intersections of gender, racialization and human rights, and their impact on health and well-being before, during and after crises 62 , 63 , 64 . Urging governments to adopt such an approach, which COVID-19 has made clear is essential, is not a new proposal. Yet, our review highlights a lack of uniform appreciation or adoption of such an approach by countries.

Second, health systems need appropriate financing, not only to prepare for new pandemics, but also to ensure that at all times, all people have access to the health services they need, when and where they need them, without financial hardship, regardless of ability to pay 65 . This is the foundation of UHC. While many countries have provided subsidized COVID-19 testing and treatment, more must be done to ensure people are not pushed into poverty due to out-of-pocket spending on health. Investing in UHC not only protects people from health threats but also mitigates the social and economic burdens that have characterized COVID-19. Countries will have to revisit the thresholds of health expenditure that they are willing to invest to build resilient health systems, promote population health and protect communities against financial risk.

Third, while country capacities varied, the pandemic has demonstrated a need to invest in improving both the quantity and quality of health workers to better prepare for and respond to future pandemics. Our review highlights that resilient health systems are those that not only invest in pandemic-related planning and training of health workers, but also ensure their physical, mental and economic protection in the workplace and beyond. Emphasis should also be placed on community mobilization where adequately trained and supported CHWs are equipped to play substantial roles in outbreak response and community engagement, much as they have played a crucial role in tuberculosis and HIV/AIDS response efforts globally for decades 66 .

Fourth, in terms of access to medicines and products, the pandemic has made visible, yet again, the clearly identified and thoroughly debated challenges to global supply chains for medicines and products. These challenges range from limited manufacturing capacities to financing to equity in access. The early experience of COVAX, with some high-income countries bypassing the initiative, has demonstrated the glaring limitations in the current system.

Fifth, health service delivery, including non-COVID-19-related health services, has been directly threatened, and often compromised, at all levels by the demands of the pandemic, even in traditionally high-performing health systems. Our review emphasizes that bolstering system capacity requires strong and well-funded primary care, with a skilled and protected workforce, to ensure that high-quality care is delivered in communities, with strengthened linkages to public health systems. Similarly, the long-term care sector, and care for older adults, must be prioritized and better integrated into health service delivery and public health functions. This must be underpinned by a renewed commitment to UHC to ensure high-quality care for all.

Finally, public health functions, such as testing and contact tracing, that are delivered in coordination with the health service system, are cornerstones for successful COVID-19 responses. These approaches often depend on innovative digital technologies, which bear their own challenges, including the potential to exacerbate inequalities and be the vehicle for human rights violations 67 , 68 , 69 , 70 . As such, future investments in these technologies requires a more holistic approach—one that engages communities, particularly the most vulnerable—that takes into account the potential risks and considers how health systems can minimize harms from their use 71 .

Importantly, our analysis of country responses points toward foundational debates on how we understand and think about resilient health systems. Health system resilience as a concept must expand beyond technical and biomedical knowledge and actions, to engage with the broader social, economic and political factors in society. Such comprehensive understanding of resilience requires a systems approach and should be guided by equity concerns, which include concerns for gender, human rights and racialization in health and healthcare 12 , 72 . Further, resilience cannot be achieved solely through unidirectional and top-down approaches by governments and other entities. Resilience requires community engagement as much as regulations and hospital capacity. Community engagement and its interlinkage with community resilience is fundamental to managing not only health threats but also other threats, such as climate and environmental change 73 . Importantly, health systems resilience requires countries worldwide to be open to exchange of knowledge and expertise from regions such as Asia and Africa, which have effectively mobilized CHWs and communities to extend the reach, capacity and quality of their health systems.

Our findings and recommendations are not new, and there have been prior incremental moves to expand what constitutes, influences and governs health and healthcare. COVID-19 demands dynamic systemic transformation. The pandemic has fundamentally challenged health systems and the communities they serve globally. The effect of a major shock represented by the pandemic is to manifest the points where the system is weakest, and to demonstrate the interdependencies of a range of health, social and economic structures. While the evidence of system failures has come at a huge cost in human and monetary terms, it has also pointed to what needs to change. With over 3 million global deaths and pervasive social and economic costs, the pandemic must serve as a call for transformation and investment toward resilience and people centeredness, beginning with health systems. COVID-19 provides a renewed prospect for solidarity, both within and between countries. It also serves as a reminder that health is more than healthcare and that a whole-of-government approach to health and well-being is needed to create healthy populations able to collectively prevent and respond to crises, leaving no one behind.

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Acknowledgements

Data for this review were collected under the auspices of the Independent Panel for Pandemic Preparedness and Response. The analysis of this paper is separate from the Independent Panel’s Final Report and has been facilitated by the Independent Panel Secretariat. The Secretariat of the Independent Panel for Pandemic Preparedness and Response is independent and impartial. The views expressed in this work are solely that of the authors and do not represent the views of the Independent Panel for Pandemic Preparedness and Response.

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These authors contributed equally: Victoria Haldane, Chuan De Foo, Salma M. Abdalla, Anne-Sophie Jung.

Authors and Affiliations

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Victoria Haldane

Saw Swee Hock School of Public Health, Singapore, Singapore

Chuan De Foo, Melisa Tan, Shishi Wu, Alvin Chua, Monica Verma, Pami Shrestha, See Mieng Tan & Helena Legido-Quigley

School of Public Health, Boston University, Boston, MA, USA

Salma M. Abdalla

The Independent Panel for Pandemic Preparedness and Response Secretariat, Geneva, Switzerland

Salma M. Abdalla, Sudhvir Singh, Michael Bartos, Shunsuke Mabuchi, Mathias Bonk, Christine McNab, George K. Werner, Raj Panjabi, Anders Nordström & Helena Legido-Quigley

London School of Hygiene and Tropical Medicine, London, UK

Anne-Sophie Jung, Tristana Perez & Helena Legido-Quigley

Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

Sudhvir Singh

School of Sociology, Australian National University, Canberra, New South Wales, Australia

Michael Bartos

Berlin Institute of Global Health, Berlin, Germany

Mathias Bonk

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V.H., C.D.F., S.A., A.-S.J. and H.L.-Q. conceived and designed this Review. V.H., C.D.F., S.A., A.-S.J., M.M.J.T., S.W., A.C., M.V., P.S., S.M.T. and H.L.-Q. collected the data. V.H., C.D.F., S.A., A.-S.J., M.M.J.T., S.W., S.S. and H.L.-Q. analyzed the data and drafted the manuscript with input from all authors. All authors contributed to revision of the manuscript.

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Haldane, V., De Foo, C., Abdalla, S.M. et al. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nat Med 27 , 964–980 (2021). https://doi.org/10.1038/s41591-021-01381-y

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Hospital management and challenges during COVID-19 outbreaks: lessons from a level 1 hospital in the southeast of Iran-case study

• Open access
• Published: 20 August 2024
• Volume 3 , article number  65 , ( 2024 )

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• Saeid Esmaeilian 1 ,
• Elham Mohajeri 1 ,
• Meisam Hoseinyazdi 2 ,
• Mohammad Ghorbani 1 ,
• Elham Rahmanipour 1 &
• Kamran Sarmast 1  

The COVID-19 pandemic has presented unparalleled challenges to hospitals globally, particularly those in resource-limited settings. This case study elucidates the experiences and lessons from managing a 40-bed public hospital in Rask, Iran, during the pandemic .

Data were gathered through focus group discussions with the management team and key informants, supplemented by document analysis. Thematic analysis was employed to discern key themes and subthemes related to the challenges encountered and solutions implemented by the hospital .

The study underscores the necessity of a dynamic management team, effective external stakeholder communication, staff involvement in decision-making, and establishing connections with pre-hospital care units. It also emphasizes the need for adaptable protocols, comprehensive staff training, and infrastructure enhancements. Despite these strategies, the hospital grappled with unresolved issues such as inadequate disaster planning, ethical dilemmas, and poor inter-hospital coordination .

This case study offers insights into managing a small hospital in a resource-limited setting during a health crisis, highlighting the importance of effective leadership, staff support, infrastructural flexibility, and community engagement. The lessons gleaned can guide the development of context-specific strategies to bolster the resilience and preparedness of similar hospitals. Further research is warranted to assess the long-term impacts of the pandemic on these hospitals and to explore the perspectives of frontline staff, patients, and families for a more comprehensive understanding of effective hospital management during health disasters .

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• Medical Ethics
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Avoid common mistakes on your manuscript.

1 Introduction

The COVID-19 pandemic presented governments worldwide with a multitude of challenges. These included addressing issues in public hospitals such as technical and allocation inefficiencies, low productivity, lack of accountability to patients, and instances of waste, fraud, and corruption [ 1 , 2 ]. In many developing countries, healthcare managers primarily focus on referral and educational hospitals [ 3 , 4 ]. Despite the service capacity and quality in these referral hospitals, they were unable to function effectively during the COVID-19 outbreaks due to an overload of hospital admissions [ 5 , 6 ]. The only viable strategy to alleviate this pressure and control disease spread during such outbreaks and crises is through healthcare systems and local hospitals [ 1 , 7 , 8 ].

In this case study, we present our experiences managing a small hospital, detailing the challenges we faced, the local solutions we implemented, and the lessons we learned over two years from September 2020 to September 2022. We posit that small hospitals serving high populations with limited facilities encountered unique experiences and opportunities that larger, better-equipped hospitals did not. The aim of this case study is to share these experiences and lessons learned during the pandemic from a 40-bed public hospital in southeast Iran, a region characterized by significant poverty and poor health indicators.

2.1 Study design

This qualitative solitary case study was conducted to gain an in-depth understanding of a 40-bed public hospital’s experiences in managing the COVID-19 crisis in southeast Iran. The case study approach was chosen as it allows for a detailed exploration of a complex phenomenon within its real-life context, enabling researchers to identify key factors, processes, and relationships that contribute to the hospital’s response to the pandemic.

2.2 Setting

The study was conducted at a public hospital located in the “Sarbaz” Mountains, adjacent to the “Sarbaz” River, in southeast Iran. The hospital serves a population of approximately 200,000 people, primarily from the rural areas of Sarbaz and Rask regions. The area also has a considerable number of migrants from Pakistan and Afghanistan, particularly near Pishin City, a major city close to the Pakistan border. Due to the historical culture of Baluchistan, residents of Rask frequently travel between Iran and Pakistan, making this area a critical point for infection transmission.

2.3 Healthcare system and infrastructure

The hospital operates under a public-governmental healthcare system supervised by the “Iranshahr University of Medical Sciences”. There are no other public or non-governmental organization (NGO) centers in the area. The nearest hospitals are in “Iranshahr,” “Chabahar,” and “Nikshahr,” which are approximately two to three hours away by car. The roads are in poor condition, and there is no public transportation available between these cities. The hospital has two outdated ambulances, with only one being operational, and a helipad is required.

2.4 Hospital capacity and resources

Prior to the COVID-19 outbreaks, the hospital had forty active beds, including a 3-bed coronary care unit (CCU), a labor ward, two general surgery rooms, a thalassemia ward, a dialysis ward, and a general ward. The hospital was equipped with an old analog X-ray machine but lacked a computed tomography (CT) scan and a picture archiving and communication system (PACS). It had an oxygen concentrator machine with a capacity of 120 L, four ventilators, and thirty-five oxygen cylinders, each with a capacity of forty liters. The nearest center for recharging oxygen cylinders is in “Konarak” Port, which is 3 h away.

2.5 Staffing

The hospital staff consisted of 210 individuals, 127 of whom worked in the medical department. Only twelve were trained nurses, while the remaining medical personnel were nurse-aids (Behyar). There was no security guard. Two to four general physicians worked in the emergency ward and examined all outpatients and inpatients. Additionally, there were twelve clinical specialists, each of whom stayed at the site for only two weeks, including two internists, two obstetricians and gynecologists, two anesthetists, two radiologists, two pediatricians, one surgeon, and one psychiatrist.

2.6 COVID-19 crisis and conditions

The hospital faced three distinct COVID-19 crises that severely impacted its operations and management. The first positive COVID-19 polymerase chain reaction (PCR) test was reported on March 20, 2020, in the area. The first crisis, caused by the Wuhan variant, occurred from mid-February 2021 to the end of April 2021. The second crisis, attributed to the Delta variant, took place from June to September 2021. The third crisis, caused by the Omicron variant, occurred from March 2022 to May 2022. Each crisis and inter-crisis period presented unique challenges for the hospital in terms of patient care, resource management, and infection control.

2.7 Participants

Purposeful sampling was used to select sixteen members of the hospital management team who were actively involved in hospital administration during the COVID-19 pandemic. The participants were divided into two focus groups to facilitate in-depth discussions on the challenges faced and the solutions implemented by the hospital.

The first focus group consisted of 12 participants: the chairperson (overseeing overall hospital affairs), the chief operating officer (managing non-medical staff and assessments), the chief nursing officer (managing medical staff and assessments), the medical director (representing doctors and responsible for decision-making), and eight head nurses (in charge of active hospital wards or nursing supervision). This focus group composition allowed for a comprehensive representation of the hospital's management structure and diverse perspectives on the crisis.

The second focus group included four key decision-makers: the chairperson, the chief operating officer, the chief nursing officer, and the medical director. This smaller group enabled a more focused discussion on the strategic aspects of crisis management and the development of solutions.

2.8 Data collection

The data for this case study was collected through focus group discussions and document and artifact analysis.

2.8.1 Focus group discussions

Two semi-structured focus group discussions were conducted to explore the challenges and solutions of managing the hospital during the COVID-19 pandemic. The first focus group involved twelve participants, including the chairperson, chief operating officer (COO), chief nursing officer (CNO), medical director, and eight head nurses. This focus group participated in three 90 min sessions to identify the key challenges faced by the hospital. The second focus group consisted of four participants: the chairperson, COO, CNO, and medical director. This group took part in two 120 min sessions to discuss the solutions implemented by the hospital.

A semi-structured interview guide was developed based on the research objectives and existing literature on hospital management during health crises. The guide included open-ended questions that encouraged participants to share their experiences, perspectives, and insights. The focus group discussions were audio-recorded with the participants' consent and later transcribed verbatim. The researchers reviewed the transcripts for accuracy and clarity.

2.9 Document and artifact analysis

In addition to focus group discussions, the researchers analyzed various official and unofficial documents and artifacts relevant to the case study. Official documents included reports from the hospital and the health ministry, such as statistics on COVID-19 cases and hospital capacity, policy changes in response to the pandemic, and feedback from staff and patients. Unofficial documents consisted of local media and social media reports, including news articles, blogs, and posts that reflected public perceptions and opinions of the hospital. The researchers also reviewed minutes from hospital meetings and committees, such as the infection control committee, quality improvement committee, and crisis management committee.

2.10 Data analysis

Thematic analysis, as described by Braun and Clarke (2006), was employed to identify, and categorize the main themes and subthemes from the collected data. The six-step process involved: familiarization with the data: the researchers read and re-read the transcripts and documents to become immersed in the data. Generating initial codes: they identified and labeled relevant features of the data. Searching for themes: the codes were collated into potential themes. Reviewing themes: the researchers checked the themes’ fit and coherence with the data. Defining and naming themes: the scope and meaning of each theme were refined. Producing the report: the most salient themes and subthemes were selected and illustrated with quotes and examples.

NVivo 12 software was used to organize and manage the codes and themes. The researchers triangulated the data by comparing the findings across focus group transcripts, official documents, unofficial documents, and artifacts to enhance the credibility and validity of the results. They also looked for convergent and divergent patterns among the data sources to provide a more nuanced understanding of the case.

2.11 Trustworthiness

Several strategies were employed to ensure the trustworthiness of the research process and findings: member checking: the researchers shared the preliminary themes with the participants for verification and feedback. Peer debriefing: the data and findings were discussed with research experts who offered guidance and examined alternative interpretations. Triangulation: the findings were compared across different data sources to enhance credibility and validity. Rich description: detailed descriptions of the context, methods, and findings were provided to allow for transferability assessment. Audit trail: records of the research process were kept enabling scrutiny of the methods and findings.

2.12 Ethical considerations

The study received ethical approval from the local institutional review board (Iranshahr University of Sciences and the local health and treatment network of the Rask region [shabake-Behdasht-va-Darman-Rask]). All participants provided informed consent and were assured of data confidentiality and anonymity. For unofficial documents and artifacts, the researchers obtained the necessary permissions and ensured that the use of these sources adhered to ethical standards and guidelines.

3.1 Challenges

Following the provision of adequate facilities and plans for controlling any surge by the task force from the health ministry, the hospital also faced a significant increase in emergency admissions from locals due to the growing fear of COVID-19 symptoms. Prior to the onset of COVID-19, the emergency department (ED) ward had about 900 to 1000 visits per month. After the start of COVID-19 outbreaks in Qom (the first city where confirmed COVID-19 patients were reported in Iran), this number increased to about three thousand monthly visits in March 2020, and it reached seven thousand monthly visits in July 2021. The key challenges that emerged from the study are summarized in “Supplementary Table”. These challenges fell into six themes: (1) deficits in supply and logistics, (2) spatial constraints, (3) staffing strains, (4) difficulties in training, (5) complexities in management, and (6) internal hospital issues. The solutions focused on infrastructure upgrades, training programs, staff support, communication with stakeholders, and localized protocols.

Deficits in supply and logistics

The hospital faced shortages in personal protective equipment, ventilators, pharmaceuticals, oxygen cylinders, infrastructure, and advanced equipment. As the COO described: “We didn’t have even basic medical supplies like gloves and masks when the pandemic started. Our oxygen supplies were extremely limited for the number of respiratory patients we received.” “We had no reserve of laboratory equipment, and laboratory kits were entirely scarce.” (Medical Director).

“The hospital’s 120 L capacity concentrator machine was insufficient for its needs, and its oxygen cylinders were inadequate due to the time-consuming recharging process.” (COO).

3.1.1 Infrastructure vulnerability

The study site is in one of the regions of Iran with inadequate facilities, which has experienced several droughts and low voltage problems due to overloading on the network or small conductors, especially in the summers. Therefore, the resources for the water and sewage system, as well as the fuel reservation for electric generators, were extremely limited. Due to fuel smuggling in the region, the government restricted the amount of fuel that could be reserved at the site. To provide electricity when the electric network was offline, sufficient fuel reserves were needed. Moreover, the hospital’s uninterruptible power supply (UPS) system was out of service. The hospital’s heating, ventilation, and air conditioning (HVAC) system needed to be updated and required proper maintenance and safety services. Additionally, communication and information technology (IT) systems needed to be improved. For most of the weekdays, there was no internet connection at the site.

3.1.2 Shortages of advanced medical equipment

The hospital lacked more advanced medical equipment for respiratory support, except for four ventilators and twelve vital sign monitors. Additionally, it had one blood gas analyzer that was out of service and one biochemistry spectrophotometer. The rest of the hospital laboratory was entirely non-functional.

3.1.3 Drug shortages

Throughout the COVID-19 outbreak, the hospital faced a shortage of saline, corticosteroids, and some specific COVID-19 drugs such as remdesivir and tocilizumab, due to the increasing demand across the country. Drug manufacturers preferred to distribute these drugs to more prominent or more important hospitals.

3.1.4 Shortages in oxygen supplies

The hospital faced a high demand for oxygen resources for COVID-19 patients, as oxygen therapy played a crucial role in their management and prognosis. The hospital’s 120 L capacity concentrator machine was insufficient for its needs, and its oxygen cylinders were inadequate due to the time-consuming recharging process. Moreover, the hospital always needed some reserved cylinders for operation rooms and the ED. Additionally, any instability in the electric network caused the machine to shut down for more than an hour. The hospital could not provide home oxygen, and there was no private center for home oxygen needs.

3.1.5 Shortages of routine hospital needs

The hospital lacked room furniture and standard hoteling equipment to increase bed capacity or open new wards. It also had no reserve of laboratory equipment, and laboratory kits were entirely scarce.

3.1.6 Personal protection equipment

At the onset of COVID-19, the hospital had no personal protective equipment (PPE). Every patient and staff member had to provide their own PPE.

3.1.7 Ineffective diagnosis tools

The hospital had an outdated analog X-ray machine, and no computed tomography (CT) scan or polymerase chain reaction (PCR) set was available. The doctors had no diagnostic tools, except for one ultrasound machine for pregnant patients.

3.1.8 Unstandardized or warned-out equipment.

Most of the existing equipment was worn out, such as beds, chairs, and pads.

3.1.9 Low-quality or low-standard equipment

All new equipment, such as PPE, diagnostic kits, or even detergent materials, had low quality or standard conditions and needed to be more effective.

3.1.10 Delay in the arrival of equipment

3.1.11 low access to engineering services.

Most of the engineering services for maintenance or installation of new equipment arrived with a significant delay compared to other cities due to the long distance and the fear of low security in the Baluchistan area.

3.1.12 Transferring patients

Due to the high demand for oxygen on the road and outdated ambulances, transferring most patients to other high-facility hospitals or higher referral levels was impossible. Moreover, all the hospitals during the crisis were completely over capacity and could not accept any patients (even respiratory or non-respiratory patients) from the study site. Therefore, referring patients was almost zero during the COVID-19 crisis.

Spatial constraints

The hospital confronted significant challenges in expanding its shared space due to various constraints, such as a lack of authorization for new constructions, limited financial resources, and a shortage of standard construction materials and qualified engineers and workers. As noted by several head nurses, “we don’t have standard resting rooms during shifts and proper housing after each shift”. Another challenge was providing accommodation for staff, particularly non-native physicians, and health workers, as locals were unwilling to rent homes to them due to fear of COVID-19.

Staffing strains

The high patient volumes and expanded services strained the staff, who faced challenges such as high nurse-to-patient and physician-to-patient ratios, personal stressors, burnout, and overwork. As one staff member described, “We were overwhelmed with the workload. Our staff hadn’t been trained to handle an ICU or this patient volume.” “I had to work in compact shifts and have fewer off days. This also increased my attendance duration.” (ED Head Nurse) “Despite being vaccinated, most of our health workers were infected by COVID-19 and had to stay in home quarantine.” (Medical Director).

3.2 Some of the problems they encountered included

3.2.1 high nurse-to-patient and physician-to-patient ratios.

Prior to the COVID-19 outbreaks, the nurse-to-patient ratio in the ED ward was approximately one to three or four, and each physician dealt with about 20 to 30 patients in each eight-hour shift. During the COVID-19 crisis, the nurse-to-patient ratio increased to one per 19 or 20, and each general physician dealt with about 80 to 100 patients in about eight-hour shifts. In the general ward, the nurse-to-patient ratio increased to one per 10 or 12 patients in every shift.

3.2.2 Personnel’s stressors

Our staff experienced various stressors that affected their performance, such as obligations to their family and the risk of transmitting the virus to their home or family members. Furthermore, most personnel had to deal with their family’s financial or health problems. Some of the staff lost family members during COVID-19.

3.2.3 Burnout and overwork

Staff worked for extended periods in a high-stress environment with high turnover wards, overheating, and limited access to food, water, or even a bathroom. Additionally, low motivation due to low payment and unclear employment status led to decreased efficiency among the health workers.

3.2.4 Shift work and attendance duration

As we increased the number of active beds and busy wards without increasing our staff, all health workers had to work in compact shifts and have fewer off days. This also increased their attendance duration in the local area. Moreover, our general physicians and some specialists spent more time in the hospital despite being non-native. For example, one of our GPs and our second radiologist stayed for the entire duration of the crisis in the hospital to reduce patient overload pressure.

3.2.5 Staff protection and resilience support

Our ED staff, ICU staff, and COVID-19 staff were on the front line of COVID-19 exposure and were exposed more than standard to COVID-19 patients. Their protection and vaccination were always our concerns because every staff member had a valuable role in controlling the COVID-19 crisis. It was also important for the staff to know that we cared about their protection. This challenge persisted until the end of our service in the Rask region.

3.2.6 Oversimplification of protocols

After receiving the first dose of vaccination, most of the patients, visitors, and staff relaxed their adherence to safety protocols due to fatigue from restrictions.

3.2.7 Post-COVID-19 recovery periods

Despite being vaccinated, most of our health workers were infected by COVID-19 and had to stay in home quarantine for about five to 10 days. This condition completely disrupted the shift schedule and increased pressure on health staff.

Training difficulties

The provision of consistent information, practical protocols, and adequate training time posed significant challenges. As one head nurse explained, “We desperately needed training, but the information we received kept changing. There was no time to properly train people.” “We also had to train our current staff to establish ICUs or new care units because we did not have permission to hire new staff.” (CNO), “Most of our health workers were nurse aides (Behyar & Komak-behyar) who required more experience and training.” (Head Nurse). We also had to train our current staff to establish ICUs or new care units because we did not have permission to hire unfamiliar staff.

Management complexities

Challenges were faced in disaster planning, ethical issues, hospital coordination, managing visitors, and data reliability. As the medical director stated, “We had no clear ethical framework for COVID-19 patients. These issues included who should be treated, new and unknown drug side effects, pregnant COVID-19 patients.” “We faced multiple ethical issues during every COVID-19 crisis, and we had no clear ethical framework for COVID-19 patients.” (Chairperson), “We needed access to realistic pandemic data to make proper decisions in the early periods.” (COO). Some of the challenges were:

3.2.8 Lack of disaster planning

Most policymakers were surprised and unprepared for any disaster and pandemic conditions at the beginning of the COVID-19 outbreak in many countries. This lack of preparedness was evident in small hospitals. Most existing disaster plans were unrealistic and outdated. This situation caused problems for our hospital, which needed a practical disaster plan. Moreover, most of the previous strategic plans were designed for local diseases with low demand for medical services.

3.2.9 Ethical issues

We faced multiple ethical issues during every COVID-19 crisis, and we had no clear ethical framework for COVID-19 patients. These issues included who should be treated, new and unknown drug side effects, pregnant COVID-19 patients, allocation of expensive drugs, distribution of ICU and ward beds, prioritization of limited equipment, fugitive COVID-19 patients, cardiopulmonary resuscitation (CPR) of COVID-19 patients, bad news delivery, and conflict between our hospital’s ethical framework and the local public’s expectations and beliefs.

3.2.10 Links with pre-hospital care and inter-hospital coordination

The only way to decrease hospital healthcare demand and control any disease crisis was by linking with pre-hospital care. They had a significant role in prevention, tracking of new patients, vaccination of the general population, and treating mild symptom patients in rural care houses. However, there were substantial gaps and disconnection between our hospital and the pre-hospital care system (Behdasht). Moreover, there was no relation and grading among our hospital, which provided no cooperation at patient admission and supported the hospital’s deficits.

3.2.11 Disconnection with local non-health managers

To implement our solutions and manage patients, we needed to establish connections with local non-health managers to facilitate the provision of many hospital infrastructures and urban facilities, such as electricity and water. We also require these influential managers as external supporters.

3.2.12 Lack of financial resources and insurance uncooperating

Like other parts of the world, we needed more financial resources, in addition to dealing with our country’s universal inflation and economic challenges. Our hospital received insufficient financial resources from our center and the affiliated university due to its location in a region considered a low priority by policymakers. We understood that other hospitals were overcrowded and required more attention from policymakers and related authorities in the affiliated university. However, our region consistently requires more recognition from them. Furthermore, we had to obtain our financial outcomes from insurance systems to provide for our routine needs. However, there were many disorganizations and unusual bureaucracy between our hospital and the insurance system. For example, one of the public insurance organizations categorized us as having the wrong capacity with the wrong affiliated university.

3.2.13 Visitors’ organization

One of our significant problems was controlling the unnecessary influx of visitors due to the supportive culture in this area. Most families and patients tried to visit their patients in the hospital and ICU to provide them with as much hope and help as they could. This was not only for non-COVID-19 patients but even for severe COVID-19 cases. Our hospital required security guards for this situation. This condition posed a significant problem in controlling the infection cycle and preventing new COVID-19 cases. Moreover, we could not use local police or armed forces for financial and non-financial reasons.

3.2.14 Unreliable pandemic data

In the early periods of COVID-19 outbreaks, we needed access to realistic data to make proper decisions. This unclear data led us to make restricted or unrealistic decisions.

3.2.15 External influencers’ unfamiliarity with our hospital

Due to our location, most of the external influencers and non-governmental organizations (NGOs) had no data or perspective about our hospital and no trustful relations or tendencies to support us.

3.2.16 Remuneration and recognition

The health ministry promised many facilities and recognition for all the health workers. However, there were problems in the allocation and distribution of these benefits among health workers. This caused a lot of protests and distrust among the staff, while we had no authority over this recognition. Moreover, a significant delay in remuneration from the health ministry added more pressure on the health workers.

3.2.17 Organizational instability

The central supervised university management team changed about four times over 30 months. These changes resulted in multiple changes in the policies. Most of the trained and experienced high-ranked managers were replaced, and most of the procedures had to be changed. Also, there was a significant gap and delay between ongoing developing programs between every shift, making it disorderly and chaotic in the region. For example, the development of a new part of our laboratory and emergency units faced a six to nine-month delay due to bureaucratic reasons.

Internal hospital issues

The hospital had to address numerous internal issues, such as managing non-COVID patients, infection control, unnecessary admissions, respiratory triage, and patient safety. As the chairperson noted, "One of our significant problems was controlling the unnecessary influx of visitors due to the supportive culture in this area." "Despite the high demand for oxygen on the road and outdated ambulances, transferring most patients to other hospitals was impossible." (Medical Director), "One of our significant problems was controlling the unnecessary influx of visitors due to the supportive culture in this area." (Head Nurse).

3.3 Decision-making process

The management team, consisting of the Chairperson, COO, CNO, and Medical Director, met every night or every two nights during the COVID-19 crisis periods and every two weeks during the inter-crisis periods. They evaluated the situation, conducted stakeholder analysis, and identified latest problems. All challenges and problems were approached using a local algorithm (Fig.  1 ), which involved prioritizing issues based on their solvability or importance and seeking solutions through internal resources, the affiliated university, or external influencers.

Hospital Problem-Solving Algorithm: this algorithm begins by prioritizing issues based on solvability or importance. Our team refines solutions through reevaluation, feedback, and data from peer hospitals. Unresolved problems are escalated to the affiliated university and, if necessary, external influencers such as local legislators, council members, deans, governors, NGOs, bloggers, and journalists. Despite these efforts, some challenges remain due to their need for fundamental, long-term solutions

3.4 Consequences of local solutions

The hospital implemented various strategies to address the challenges, including infrastructure upgrades, increased bed capacity, establishment of an ICU, staff training and support, localized protocols, and engagement with external stakeholders. “Supplementary Table” provides a summary of the key challenges and solutions. Despite these efforts, some challenges remained unresolved, such as the lack of disaster planning, ethical issues, and poor coordination with other hospitals.

We sought to engage the affiliated university and external influencers to provide infrastructure and increase capacity. We repaired and renewed most of the essential infrastructure. We relocated the clerical units out of the main building into restored unused rooms and mobile containers in the hospital’s yard. The indoor space was gradually repaired and redesigned. Ultimately, our active beds reached a total of ninety-five. Without significant construction, our wards underwent several changes, including a four-bed CCU, a five-bed labor ward with eight postpartum beds, a six to eight-capacity modern ICU, and a four to six-capacity neonatal ward. Our imaging unit was equipped with digital radiology X-ray, a 16-slice CT scan with dual injectors, and an effective domestic PACS. The oxygen unit was equipped with two concentrator machines (120 L + 600 L), 20 non-portable ventilators, two portable ventilators, and 79 oxygen cylinders, each with a 40 L capacity. The laboratory was equipped with a new blood gas and electrolyte machine. All blood bank and laboratory electronic devices were repaired and serviced. Through real-time planning and estimation of our drug and equipment needs, we supplied most of our medical needs with university support, and external influencers provided our income and remaining needs. Despite the high demand conditions and limitations of drugs and equipment, we were one of the prepared hospitals in the inter-crisis and crisis periods. Computerizing and updating the Health Information System (HIS) and Laboratory Information System (LIS), as well as continuous observation by the management team, led to control of our drug and equipment storage. Unessential needs and non-standard purchased items were returned. Our staff numbers remained the same (input and output staff approximately remained equal), except in the crisis periods when we could use some temporary nurse aides (89-days personnel). We designed our personnel chart, though most of the charts still needed to be filled in. We had no security guard until the end. The number of doctors also remained the same. Despite this staff limitation, we could train our medical and non-medical staff as we established a new ICU and increased bed capacity. Our external influencers in the town prepared proper houses for staff accommodation. We tried to reduce most staff stressors, and our psychologist played a prominent role through face-to-face communication and evaluating the persons. All staff had access to precise data and were engaged in many decisions. Staff had enough rest time and tried to change every team unit except head nurses. This made all staff ready and prepared for serving in any department. We provided early vaccination for our staff except for pregnant staff. After involving public opinion and pressure from external influencers, especially the legislators, the health ministry ordered to make all COVID-19 patients in “Sistan va Baluchistan” province free of admission costs. So, our staff were satisfied with their admission costs.

In addition to COVID-19, we encountered the G6PD crisis, influenza, and traumatic patients during this period, necessitating the management and screening of COVID-19 patients. Furthermore, the rate of labor admission increased for distinct reasons, presenting additional challenges that we had to overcome. We redesigned and localized national protocols, discovering that managing low-symptom COVID-19 patients at home and conducting daily visits significantly decreased the “bed turnover ratio” and “average length of stay”. We ought to involve more management teams in decision-making about inpatient admissions to reduce unnecessary patient admissions. In cases of disagreements between specialists, the management team endeavored to resolve them immediately, thereby increasing patient satisfaction and reducing discontent.

We also established an ethical council, comprising management teams, related doctors, the head of the pre-hospital care system, and a trusted ordinary native staff. This council aimed to resolve moral dilemmas. When necessary, we consulted influential local members such as the dean or the city’s governors. We strived to maintain an unwritten ethical framework that combined the national ethical framework and traditional local preferences. All activities, challenges, needs, and demands were reported both orally and in writing. Weekly hospital needs were sent directly to the high-level authority in the affiliated university, and when necessary, we reported to trusted external influencers. We held special meetings and daily reports with local pre-hospital care managers and local council members to foster relationships and involvement in hospital affairs. This increased our authority to solve some problems and use them as external supporters. Pre-hospital care units played an essential role in resolving most challenges and controlling every COVID-19 crisis.

3.5 Lessons learned

The initial step towards establishing a dynamic and efficient hospital in smaller cities involves “selecting an effective management team.” The influence of the COO, CNO, and Medical Director can resolve most challenges.

Having a sufficiently trained hospital workforce is the most critical factor in managing crises and outbreaks.

Active planning and localization of national protocols to create flexible plans and protocols enhance hospital efficacy.

Limitations of financial and human resources are realities in small hospitals.

Continuous communication and data sharing with pre-hospital units are essential in any crisis.

Trustful relationships and continuous communication with external influencers can resolve deficits in financial and non-financial resources.

Continuous personnel training should be considered in every management period.

Engagement of the management team along with doctors can prevent many mismanagements.

Access to transparent and trustworthy data by health workers during crises and outbreaks can enhance their functions and cooperation.

Special attention to staff and provision of financial and emotional support increase efficacy during crises and outbreaks.

In the inter-crisis periods, the health ministry should rigorously enforce small hospital accreditation to improve infrastructural hospital problems.

Having effective small hospitals and pre-hospital systems significantly reduces overload pressures on referral hospitals.

Some challenges and problems are never resolved; they persist from one management period to another.

4 Discussion

This qualitative single-case study explored how a small, resource-constrained public hospital in southeast Iran managed the challenges and implemented solutions during the COVID-19 pandemic. The findings revealed that the hospital encountered various difficulties related to supply chain and logistical operations, staffing, spatial constraints, training, and overall management. These challenges were consistent with those reported by other hospitals in Iran [ 3 , 4 , 9 ]and globally [ 1 , 2 , 10 , 11 ] during the pandemic, highlighting the unprecedented pressure that COVID-19 exerted on healthcare systems worldwide.

The study emphasized the crucial role of the hospital management team in leading the pandemic response, making timely decisions, adapting national guidelines, and collaborating with external stakeholders. This finding aligns with previous research that underscored the importance of strong leadership during health emergencies and the COVID-19 pandemic [ 1 , 7 , 9 , 12 , 13 ]. The hospital management team demonstrated agility, problem-solving abilities, and the capacity to make context-specific decisions, which were essential in mobilizing resources, supporting staff, and ensuring quality of care despite immense challenges [ 13 , 14 ].

The study also highlighted the hospital's focus on staff training, support, and engagement to address shortages and burnout. Despite constraints, the hospital provided early vaccination, facilitated recovery, implemented safety measures, and fostered open communication to support its overburdened staff. These findings are consistent with research that emphasizes the need for hospitals to prioritize staff well-being through interventions [ 2 , 8 , 15 , 16 , 17 , 18 , 19 ]such as vaccines, flexible schedules, transparent communication, and other support measures to retain and motivate the workforce during the pandemic [ 2 , 8 , 12 , 20 , 21 , 22 ].

Furthermore, the study found that upgrading hospital infrastructure, expanding bed capacity, and establishing an ICU helped mitigate spatial constraints and accommodate surges in admissions. This aligns with research on hospitals in other resource-limited settings [ 1 , 12 , 23 , 24 , 25 ], which also emphasized the need for infrastructural adaptability in pandemic response [ 19 , 20 ].

The hospital implemented various strategies to overcome the identified difficulties, such as prompt decision-making, adaptation of national protocols, engagement with external stakeholders, staff training and support, infrastructure upgrades, and establishment of an ICU. These strategies were consistent with previous research that emphasized the importance of leadership [ 12 ], staff well-being [ 2 , 8 , 16 ], and infrastructural adaptability in pandemic response [ 1 , 7 , 8 , 12 , 14 , 26 ].

The findings of this study have important implications for small, public hospitals in low-resource settings seeking to enhance their pandemic preparedness and response. The study underscores the need for effective supply chain management, staff training and support systems, flexible infrastructure, and robust leadership, which require planning and mobilization well before outbreaks occur. Additionally, the study suggests that small rural hospitals should develop context-specific protocols, decentralized decision-making, ethical frameworks, and community linkages based on their limited resources and vulnerability to health crises. These measures can help tailor their response to local needs and conditions while leveraging available resources and support from the external environment [ 1 , 7 , 8 ].

4.1 Limitations

This study has several limitations that should be acknowledged. First, the sole case study design focusing on a small hospital in southeast Iran limits the generalizability of the findings to other hospitals in different regions or countries. Future research could conduct comparative case studies to examine the similarities and differences in hospitals’ responses to the pandemic. Second, the reliance on qualitative data collected from the management team may introduce bias and exclude the perspectives of frontline staff, patients, and families. Future research could include these voices to provide a more holistic understanding of the hospital’s response. Third, the study does not provide a quantitative assessment of the impact of the local solutions on various aspects of the hospital’s functioning and performance. Future research could use quantitative methods to evaluate the effectiveness and efficiency of the implemented solutions. Fourth, the study does not explore the long-term effects of the COVID-19 crisis on the hospital and its staff or the potential implications of future pandemics. Future research could follow up with the hospital over a longer period to examine the long-term consequences and lessons learned. Finally, the study does not consider the role and influence of external factors, such as socio-economic context, government policies, ethical issues, technological innovations, community engagement, and international cooperation, in addressing the challenges faced by the hospital. Future research could examine the interaction and integration of internal and external factors and their impact on the hospital's resilience and sustainability.

5 Conclusion

This case study explored the challenges and solutions of managing a small hospital in southeast Iran during the COVID-19 pandemic. The findings revealed the importance of having well-equipped and trained staff, an efficient management team, and robust infrastructure to cope with the health crisis. The study also emphasized the need for localizing protocols, communicating with pre-hospital care units, and engaging external stakeholders to overcome resource limitations. Despite facing numerous difficulties, the hospital successfully implemented various strategies, such as upgrading facilities, expanding bed capacity, establishing an ICU, providing staff training and support, and adapting protocols to the local context. These strategies, along with the resilience and dedication of the hospital staff, were instrumental in managing the crisis. The study offers valuable insights for small hospitals in similar settings, but more research is required to examine the long-term impacts of the pandemic on the hospital and its staff, as well as the perspectives of patients and their families, to provide a more comprehensive understanding of the hospital's response to the crisis.

Data availability

The data that support the findings of this study are not publicly accessible due to commercial constraints. However, the data can be obtained from the corresponding authors upon reasonable request and with the permission of “Iranshahr University of Medical Sciences”.

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Saeid Esmaeilian, Elham Mohajeri, Mohammad Ghorbani, Elham Rahmanipour & Kamran Sarmast

Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA

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S.E.: conceptualization (lead); methodology (lead); investigation (lead); writing—original draft (lead); writing—review and editing (equal); visualization (equal); supervision (equal). E.M. &M.H: conceptualization (supporting); methodology (supporting); investigation (supporting); writing—original draft (equal); writing—review and editing (equal); visualization (equal); supervision (equal). M.G.: data curation (lead); formal analysis (lead); validation (lead); writing—original draft (equal); writing—review and editing (equal). E.R.: funding acquisition (lead); project administration (lead); writing—original draft (equal); writing—review and editing (equal). K.S.: software (lead); resources (lead); writing—original draft (equal); writing—review and editing (equal).

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The first and Third authors were the chairperson and medical director of Rask Hospital. They served their “Compulsory medical service programme” between September 2020 and September 2022. At the time of writing this article, they are not in charge anymore in that Hospital or other part of the health ministry. They received no funds for this project. All other authors do not have any competing interest to declare.

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Esmaeilian, S., Mohajeri, E., Hoseinyazdi, M. et al. Hospital management and challenges during COVID-19 outbreaks: lessons from a level 1 hospital in the southeast of Iran-case study. Discov Health Systems 3 , 65 (2024). https://doi.org/10.1007/s44250-024-00137-y

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Embedding health literacy into health systems: a case study of a regional health service

Affiliations.

• 1 Clinical Governance Unit, Illawarra Shoalhaven Local Health District, Level 1, 66-71 King Street, Warrawong, NSW 2052, Australia.
• 2 National Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, Innovation Campus, University of Wollongong, Squires Way, North Wollongong, NSW, 2500, Australia. Email.
• PMID: 27788351
• DOI: 10.1071/AH16109

Objective The aim of the present study was to describe how one regional health service the Illawarra Shoalhaven Local Health District embedded health literacy principles into health systems over a 3-year period. Methods Using a case study approach, this article describes the development of key programs and the manner in which clinical incidents were used to create a health environment that allows consumers the right to equitably access quality health services and to participate in their own health care. Results The key outcomes demonstrating successful embedding of health literacy into health systems in this regional health service include the creation of a governance structure and web-based platform for developing and testing plain English consumer health information, a clearly defined process to engage with consumers, development of the health literacy ambassador training program and integrating health literacy into clinical quality improvement processes via a formal program with consumers to guide processes such as improvements to access and navigation around hospital sites. Conclusions The Illawarra Shoalhaven Local Health District has developed an evidence-based health literacy framework, guided by the core principles of universal precaution and organisational responsibility. Health literacy was also viewed as both an outcome and a process. The approach taken by the Illawarra Shoalhaven Local Health District to address poor health literacy in a coordinated way has been recognised by the Australian Commission on Safety and Quality in Health Care as an exemplar of a coordinated approach to embed health literacy into health systems. What is known about the topic? Poor health literacy is a significant national concern in Australia. The leadership, governance and consumer partnership culture of a health organisation can have considerable effects on an individual's ability to access, understand and apply the health-related information and services available to them. Currently, only 40% of consumers in Australia have the health literacy skills needed to understand everyday health information to effectively access and use health services. What does this paper add? Addressing health literacy in a coordinated way has the potential to increase safety and quality of care. This paper outlines the practical and sustainable actions the Illawarra Shoalhaven Local Health District took to partner with consumers to address health literacy and to improve the health experience and health outcomes of consumers. Embedding health literacy into public health services requires a coordinated whole-of-organisation approach; it requires the integration of leadership and governance, revision of consumer health information and revision of consumer and staff processes to effect change and support the delivery of health-literate healthcare services. What are the implications for practitioners? Embedding health literacy into health systems promotes equitable, safe and quality healthcare. Practitioners in a health-literate environment adopt consumer-centred communication and care strategies, provide information in a way that is easy to understand and follow and involve consumers and their families in decisions regarding and management of the consumer's care.

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A system for allowing patients and employers in the United States to compare health services on the basis of price would be inadequate. To make such a tool worthwhile, quality comparisons are also essential. This article offers three steps that would put the country on a path to create such a system: 1) incentivizing the adoption of patient-centered quality measures at the condition level, 2) identifying clinicians, such as surgeons, who meet a minimum volume threshold for common procedures, and 3) ensuring the accuracy of clinician directories.

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Has cross-level clinical coordination changed in the context of the pandemic? The case of the Catalan health system

• Daniela Campaz-Landazabal   ORCID: orcid.org/0000-0002-3211-960X 1 ,
• Ingrid Vargas   ORCID: orcid.org/0000-0002-1778-2411 1 ,
• Elvira Sánchez   ORCID: orcid.org/0000-0003-2549-322X 2 ,
• Francesc Cots   ORCID: orcid.org/0000-0003-0238-8902 3 ,
• Pere Plaja   ORCID: orcid.org/0000-0001-9488-8626 4 ,
• Joan Manuel Perez-Castejón   ORCID: orcid.org/0000-0003-2618-8040 5 ,
• Antonio Sánchez-Hidalgo 6 &
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BMC Health Services Research volume  24 , Article number:  959 ( 2024 ) Cite this article

Metrics details

The COVID-19 pandemic triggered numerous changes in health services organisation, whose effects on clinical coordination are unknown. The aim is to analyse changes in the experience and perception of cross-level clinical coordination and related factors of primary (PC) and secondary care (SC) doctors in the Catalan health system between 2017 and 2022.

Comparison of two cross-sectional studies based on online surveys by means of the self-administration of the COORDENA-CAT (2017) and COORDENA-TICs (2022) questionnaires to PC and SC doctors. Final sample n  = 3308 in 2017 and n  = 2277 in 2022. Outcome variables: experience of cross-level information and clinical management coordination and perception of cross-level clinical coordination in the healthcare area and related factors. Stratification variables: level of care and year. Adjusting variables: sex, years of experience, type of specialty, type of hospital, type of management of PC/SC. Descriptive bivariate and multivariate analysis using Poisson regressions models to detect changes between years in total and by levels of care.

Compared with 2017, while cross-level clinical information coordination remained relatively high, with a slight improvement, doctors of both care levels reported a worse experience of cross-level clinical management coordination, particularly of care consistency (repetition of test) and accessibility to PC and, of general perception, which was worse in SC doctors. There was also a worsening in organisational (institutional support, set objectives, time available for coordination), attitudinal (job satisfaction) and interactional factors (knowledge between doctors). The use of ICT-based coordination mechanisms such as shared electronic medical records and electronic consultations between PC and SC increased, while the participation in virtual joint clinical conferences was limited.

Conclusions

Results show a slight improvement in clinical information but also less expected setbacks in some dimensions of clinical management coordination and in the perception of clinical coordination, suggesting that the increased use of some ICT-based coordination mechanisms did not counteract the effect of the worsened organisational, interactional, and attitudinal factors during the pandemic. Strategies are needed to facilitate direct communication, to improve conditions for the effective use of mechanisms and policies to protect healthcare professionals and services in order to better cope with new crises.

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Introduction

Cross-level clinical coordination is a priority for health systems, particularly for national health systems (NHS) based on primary care (PC), such as the Catalan health system, as it contributes to care quality and efficiency [ 1 , 2 ]. Among others, it is highly relevant for the care of patients with chronic conditions or complex needs, who frequently transit across different levels of care over time [ 3 , 4 ]. It has been addressed in the last decades by a range of policies and organisational strategies to promote care coordination [ 5 , 6 , 7 ], which underwent a rapid transformation during the pandemic [ 8 , 9 ].

Clinical coordination is here defined [ 10 ] as the harmonious connection of the different health services needed to provide care to a patient throughout the care continuum to achieve a common objective without conflicts and it is analysed based on a comprehensive theoretical framework [ 11 , 12 ]. Two types are distinguished [ 12 ]: (a) clinical information coordination, that refers to the transfer and use of the patient clinical information between providers and (b) clinical management coordination, which involves healthcare provision in a sequential and complementary way and encompasses three dimensions: consistency of care, adequate patient follow-up and accessibility between levels. Clinical coordination is influenced, among others, by organisational factors, such as institutional support, the existing cross-level coordination mechanisms, time available to coordinate and integration of providers’ management [ 13 ] and interactional factors, such as knowledge between doctors or attitudinal factors, job satisfaction [ 13 ].

During the COVID-19 pandemic, several organisational changes were introduced in the health services, to reduce the risk of contagion while maintaining an appropriate response to the population healthcare needs [ 8 , 9 , 14 ], the effects of which on clinical coordination and its related factors is unknown. On the one hand, there was an acceleration in the introduction of information and communication technologies (ICT) based-coordination mechanisms [ 8 , 15 , 16 ], such as shared electronic medical records (EMR) or electronic consultations between PC and secondary care (SC) [ 8 , 16 ], which should have increased cross-level clinical information coordination by facilitating transfer of information between levels [ 2 ] and clinical management coordination by improving access to SC and adequacy of referrals [ 17 ]. On the other hand, the cancellation of non-urgent treatments, tests, or consultations [ 8 ], especially during the first waves of the pandemic, and the introduction of telephone triage [ 8 ] and the rapid adoption of telemedicine [ 9 , 18 ] opened new avenues of access to services that increased professionals workload, especially in PC [ 19 ], decreasing the time available to coordinate with the other level [ 8 ].

Despite its relevance, international evidence on cross-level clinical coordination during the pandemic is scarce. No methodological solid studies have been identified and the few reports mostly based on clinical records review of specific health services focused on evaluating one dimension of clinical coordination, accessibility between levels, reporting a global backlog in access especially to SC [ 20 , 21 ]. The analysis of changes in factors influencing coordination is even more limited, and mostly explored by surveys to SC doctors that analysed job satisfaction during the pandemic [ 22 , 23 ].

The Catalan NHS is part of the Spanish NHS, which is funded by taxes, of universal access and decentralised to the regions [ 24 ]. The provision of healthcare is organised into two care levels: PC, which acts as the gatekeeper and coordinator of the patient care throughout the care continuum, and SC that acts as a consultant to PC and is responsible for the management of more complex procedures [ 24 ]. in the Catalan NHS, patient care is the responsibility of a variety of providers: a large public entity, the Catalan Health Institute, and several public consortia, municipal foundations, and some private foundations (mostly non-profit but also some for-profit), which make up the Integrated Healthcare System for Public Use [ 25 ]. This diversity has originated differences in the type of management of PC and SC providers across the different healthcare areas (1) integrated: PC and SC providers are mostly managed by the same entity; (2) partially integrated: an entity manages SC and some PC centres, while the rest are managed by other entities, and (3) non-integrated: where PC and SC are managed by different entities [ 26 , 27 ]. This complexity makes cross-level coordination even more relevant. Before the pandemic, the Catalan NHS had implemented several strategies, such as promoting integrated management or the introduction of a variety of coordination mechanisms, such as case managers, liaison nurses or shared protocols between levels, including ICT-based mechanisms, such as shared EMRs and electronic consultations between professionals [ 28 ], with great differences in implementation between areas and services [ 29 ]. Analysis on the changes during the pandemic in Spain or Catalonia are limited to few studies on accessibility of specific SC services that reported an increase in waiting times [ 30 , 31 ] and a survey to PC doctors showing a low perception of clinical coordination between levels [ 32 ]. Regarding influencing factors, a study showed an increase in the use of electronic consultations [ 31 ] and a low satisfaction with the job was reported by a survey to SC doctors in training [ 33 ].

This study allowed us to explore whether there were any changes in cross-level clinical coordination and influencing factors in the Catalan health system during the pandemic and identify elements to guide strategies for improving it.

The aim of this study, which forms part of a wider research [ 34 ], is to analyse the changes in the experience, perception of cross-level clinical coordination of primary care (PC) and secondary care (SC) doctors and related factors in the Catalan health system between 2017 and 2022.

Study design and areas of study

A comparative analysis was conducted of two cross-sectional studies based on the online surveys by means of the self-administration of the COORDENA-CAT (2017) and COORDENA-TICs (2022) questionnaires by primary (PC) and secondary care (SC) doctors of the Catalan National Health System. In both years, the areas of study were defined based on the primary healthcare areas (PCC) and their referral hospitals (acute, and in 2017 also long-term care).

Study population and sample

The study population consisted of PC and SC doctors that had been working for at least one year in the organisation, and whose daily practice involved direct contact with patients, and with doctors of the other care level. Specialists in pathology, immunology, neurophysiology, radiology, pharmacy and clinical analysis and preventive medicine were excluded. In both surveys, the selection of the sample took place in two stages. In the first, 41 healthcare areas and its organisations belonging to the Catalan public health system were invited to participate (in 2022, starting by those that had already participated in 2017). In the second, those organisations that agreed to participate, sent an invitation with the questionnaire to all doctors who met the inclusion criteria. The final sample in 2017 was 3,308 doctors of 15,813 invited to participated (21% participation rate) and in 2022, a total of 2,277 doctors of 12,987 invited (17.5% participation rate). Of the 41 healthcare areas invited, in 2017, 32 areas participated both with primary care centres and hospitals, while in 2022, 22 areas did so.

Questionnaire

In 2017, the COORDENA questionnaire, which had been developed following the theoretical framework underlying this study [ 35 ] was adapted, pre-tested, piloted, and validated for the Catalan context [ 36 ]. It consists of three main sections: the first measures doctors’ experience of cross-level clinical information and clinical management coordination and perception of coordination within the healthcare area, by means of 12 items (described in detail in the variables of analysis section) and using a Likert scale and two open-ended questions on their reasons for that perception and suggestions for improvement. The second section measures the availability and use of cross-level clinical coordination mechanisms (shared electronic medical records (EMR), electronic consultations, telephone consultations, email consultations, joint clinical case conference, liaison nurses, shared protocols, and guidelines); and the third, individual, organisational and interactional factors that influence clinical coordination. In 2022, the questionnaire was slightly modified and renamed as COORDENA-TICs [ 34 ]. This new version keeps all main sections and all items of doctors’ experience of cross-level clinical information and clinical management coordination, perception of coordination and of factors related to clinical coordination. The adaptation relies in the coordination mechanisms section, that focuses on ICT-based coordination mechanisms but maintaining the items. Additional items related to the pandemic and some characteristics of use of some mechanisms were included but were not analysed in this study [Additional file 1 ].

Data collection

Data collection for the first survey took place between October and December in 2017 and for the second, between May and June of 2022 and October 2022 to April 2023. In both surveys, all PC and SC doctors who met the inclusion criteria of the organisations that agreed to participate, were invited to answer the questionnaire. To promote doctors’ participation, the involved organisations conducted informative sessions and displayed posters and posts in their institutional intranets. The invitation was sent to their corporate e-mail address, and included a link randomly generated that provided anonymous access to the questionnaire. The participants had the possibility of closing the incomplete questionnaire and retaking it on another occasion, and as many times as they wished, as long as it had not been sent.

Variables of analysis

The outcome variables were (a) experience of cross-level coordination of clinical information (information transfer and use; 3 items) and of clinical management (consistency of care, adequate follow-up, and accessibility; 11 items); (b) general perception of cross-level coordination in the area (1 item); (c) organisational, interactional, and attitudinal related factors (8 items); (d) use of ICT-based coordination mechanisms (shared EMR of the region (HC3/HES) and of the organisation and, electronic consultations through EMR, telephone consultations, email consultations and joint clinical session through videoconference (in 2022) (12 items). The explanatory variables were stratification variables : year and level of care and, adjustment variables : (a) sociodemographic: sex, type of speciality (clinical and surgical/clinical-surgical), (b) employment characteristics: years working as a doctor (c) type of hospital (local/regional, high-resolution, high-technology); and type of area according to the management of PC/SC (integrated, partially integrated, non-integrated).

A bivariate descriptive analysis stratified by level of care (primary and secondary care) and year was conducted to determine the distribution of the outcome and explanatory variables. To identify differences between years in total and within the subgroups, the Chi-square test was used. To analyse the changes in the degree of clinical coordination and related factors including use of ICT-based coordination mechanisms between the two years in the total sample and within the levels of care, Poisson regression models with robust variance were estimated, obtaining prevalence ratios (PR) and their 95% confidence intervals (CI 95%), adjusting for the explanatory variables: level of care, sex, years working as a doctor, type of specialty, and type of hospital, in the case of the aggregated analysis of the sample. And sex, years working as a doctor, type of specialty, and type of hospital for the subgroup analysis. Type of area according to the management of PC/SC was used to control for a possible cluster effect. Participants who answered don’t know/no answer were excluded. Bayesian and Akaike reporting criteria were used to assess the fitness of the models.

Missing values were low for the outcome variables related to the experience and perception of clinical coordination (0.66–7.26%) and those related to factors and use of coordination mechanisms varied from 2.23 to 17.35% and were at random [see Additional file 2 ]. Percentage of missing values for explanatory variables varied from 0 to 19.46% and were at random [see Additional file 2 ]. A full case analysis to manage missing values was adopted. To make the results more robust, sensitivity analyses were performed to evaluate two alternative scenarios (1) analysis of the data after doing multiple imputation of those variables with a percentage of missing values higher than 10% [see Additional file 2 ] and (2) analysis of the data including the participants who answered do not know/no answer to the questions [see Additional file 3 ]. In both cases, there were not significant differences with the results presented in this article. Finally, a content analysis was performed for the open-ended questions on reasons for the general perception of cross-level clinical coordination in the healthcare area and suggestions for improvement in 2022. The answers were coded and classified into categories. Frequencies were calculated and presented stratified by level of care. Statistical analyses were conducted using Stata v.15.

Characteristics of the sample

The sample composition was similar in both study years, with some differences. In 2022, most doctors still were women, but the proportion slightly decreased in PC (68.51% in 2017 to 66.50%) and increased in SC (51.76–53.62%) and in both levels most doctors still were between 41 and 55 years of age. Most doctors in both levels had clinical specialities, but the proportion of doctors with surgical (9.23% in 2017 to 14.85%) and medical/surgical (12.37% in 2017 to 23.31%) specialities considerably increased in SC and dropped almost to zero in PC [Table  1 ]. Regarding employment characteristics, one third of SC doctors still had 11–20 years’ work experience and 6 to 15 years working in the organisation (30.09% and 31.34% respectively), while in the case of PC, there was an increase of the doctors who had 21 to 30 years’ work experience (30.67% in 2017 to 38.79%) and 16 to 25 years working in the organisation (33.58% in 2017 to 37.22%). The proportion of doctors with a permanent contract increased in SC (88.10% in 2017 to 92.96%) and decreased in PC (96.31% in 2017 to 93.57%) and in both levels increased those with a full-time contract (PC: 92.71% in 2017 to 96.40%; SC: 91.44% in 2017 to 94.25%). Finally, regarding the type of area, the highest proportion of doctors worked in an area where the same entity manages SC and the majority of PC (44,04% in 2017 and 46,60% in 2022) and this proportion increased in SC (45.22% in 2017 to 50.45%). In terms of the type of hospital, the proportion of doctors working on an area with a high-technology hospital almost doubled (19.38 in 2017 to 38.21%) [Table  1 ].

Changes in doctor’s experience and perception of cross-level clinical coordination

Compared with 2017, the degree of cross-level coordination of clinical information (transfer and use) experienced by doctors was still high in 2022, with a slight increase of those reporting that the information they share is needed for the patient clinical management (PR:1.07, CI 95% 1.03–1.10), which was higher among PC doctors (PR:1.08, CI 95% 1.03–1.12) [Table  2 ].

Regarding cross-level coordination of clinical management, when compared with 2017, there were improvements in the relative high levels of experience but also setbacks in 2022. Regarding consistency of care, there was an increase in the relatively high proportion of doctors who reported agreeing with the treatments prescribed at the other care level (PR:1.02, CI95% 1.01–1.04), which was higher in PC doctors (PR:1.09, CI95% 1.06–1.12). However, there was a worsening in the already very low proportion of doctors who reported that joint patient management plans were established when needed (PR:0.90, CI95% 0.83–0.97) with no differences between levels, and an increase in the repetition of tests (PR:1.19, CI95% 1.06–1.32) [Table  2 ].

Concerning adequate follow-up between levels, when compared with 2017, the high proportion of doctors who considered that patients were adequately referred to SC decreased, and this decrease was higher in SC doctors (PR:0.96, CI95% 0.92–0.99). Likewise, the relatively high proportion of PC doctors who reported that SC doctors send patients to PC when appropriate decreased (PR:0.94, CI95% 0.91–0.97). Although there is still room for improvement, the proportion of PC doctors who reported receiving follow-up recommendations from SC doctors improved (PR:1.16, CI95% 1.09–1.24) and the proportion of doctors of both levels that reported that PC doctors consult with SC doctors doubts on the patient follow-up also increased (PR:1.10, CI95% 1.05–1.15) and this increase was higher among PC doctors [Table  2 ].

Regarding accessibility between levels, there was an increase in the already high proportion of doctors at both levels who reported long waiting times for patients to be seen after being returned to PC (PR: 1.52, CI95% 1.26–1.83), which was higher for SC doctors [Table  2 ].

Finally, the already low perception of cross-level clinical coordination in the healthcare are in 2017 has worsened by 2022 (PR: 0.78, CI95% 0.66–0.93) and more so among SC doctors (PR: 0.78, CI95% 0.69–0.88) [Table  2 ]. Reasons for considering the coordination to be low continued to be the limited direct communication between professionals and the insufficient availability of coordination mechanisms that promote cross-level communication [Fig.  1 ]. In the same line, main suggestions for improvement of cross-level clinical coordination included implementation of joint clinical case conferences and other mechanisms for direct communication between levels, as well as improving the existing coordination mechanisms [Fig.  2 ].

Reasons for a low perception of clinical coordination within the area, total and by level of care. Year 2022

Suggestions for improving coordination, total and by level of care. Year 2022

Changes in factors influencing cross-level clinical coordination, including use of ICT-based coordination mechanisms

Compared with 2017, there was a worsening of some organisational factors that influence cross-level clinical coordination, with an improvement in use of some ICT-based coordination mechanisms in 2022. On the one hand, there was a decrease in the already relatively low proportion of doctors reporting that their organisation’s management facilitated cross-level clinical coordination (PR: 0.78, CI95% 0.75–0.81) or set objectives aimed at cross-level clinical coordination (PR: 0.82, CI95% 0.78–0.87) and this decrease was higher among SC doctors [Table  3 ]. The proportion of those reporting to have enough time to dedicate to coordination, which was already low in 2017, decrease even more in 2022, especially among SC doctors (PR: 0.70, CI95% 0.61–0.81) [Table  3 ].

On the other hand, in 2022 there was an increase, among doctors from both levels of care who had access to [Additional file 4 ] and frequent use of some ICT-based coordination mechanisms such as, the shared EMR of the region (HC3/HES) (PR:1.21, CI95% 1.15–1.27) and the shared EMR of the organisations (PR:1.07, CI95% 1.04–1.11), that was already relatively high. This increase in use for both EMRs was higher among SC doctors, although they continue to be more used by PC doctors. There was also an increase in the relatively low proportion of doctors using electronic consultations between levels through EMR, especially by PC doctors (PR:1.48, CI95% 1.29–1.70) [Table  3 ]. Nonetheless, difficulties in the use of the mechanisms such as contradictory or disorganised information, technical problems, or lack of relevant information were reported [Additional file 5 ]. In addition, participation in joint clinical case conferences (PR: 0.89, CI95% 0.81–0.98) and use of email consultations (PR:0.66 CI95% 0.50–0.88) decreased, especially among PC doctors [Table  3 ].

As for interactional factors related to cross-level clinical coordination, when compared with 2017, the already low proportion of doctors that reported knowing doctors from the other level decreased (PR:0.56 CI95%. 0.43–0.72), especially among PC doctors. While factors such as trusting in the clinical skills of the other level’s doctors and perceiving that their own practice influences the other level’ remained high, with no differences between years or levels. Finally, doctors’ relatively high satisfaction with their job in their organisations fell significantly at both levels of care (PR: 0.91, CI95% 0.89–0.93) [Table  3 ].

Improving cross-level clinical coordination is essential for healthcare systems based on PC, given the increasingly complex health needs of the patients, which often require care by multiple professionals at different levels of care [ 3 , 4 ]. To address this challenge in recent years European healthcare systems have promoted the implementation of ICT-based coordination mechanisms as tools to improve communication and collaboration between professionals, as well as accessibility, quality, and efficiency [ 37 ]. Moreover, the disruption generated by the COVID-19 pandemic to the health services accelerated the introduction of those mechanisms, among other measures, but their impact on clinical coordination and quality of care is unknown and needs to be analysed to guide future strategies and to contribute to increase health systems resilience. This is the first study that comprehensively analyse changes in the experience and perception of clinical coordination of PC and SC doctors, and related factors, in a NHS following the pandemic, allowing the identification of areas for improvement.

Results show, with some differences between levels, that in 2022 the experience of cross-level coordination of clinical information remained relatively high, with slight improvement, while the experience of coordination of clinical management showed both improvements and setbacks related to cross-level care consistency and patient follow-up. Cross-level accessibility continued to be low and, particularly access to PC has worsened. Likewise, the already low perception of clinical coordination in the healthcare area worsened. There were also setbacks in the organisational factors related to coordination, although there was an improvement in the use of some ICT-based coordination mechanisms. In addition, interactional and attitudinal factors worsened.

Changes in the experience of clinical coordination highlights some resilience but also the need for improvement measures

Despite the relatively high experience of coordination of cross-level clinical information that remained in 2022, there was a worsening of some aspects related to consistency of care, such as tests repetition and contraindications and/or duplications of prescribed treatments, which should have improved with the increased use of the ICT-based coordination mechanisms (EMR, electronic consultations). This is probably related, on the one hand, to the difficulties reported such as, technical problems or outdated or contradictory information [ 38 ] and on the other hand, to the uneven implementation throughout the healthcare areas [ 39 , 40 ] due to the diversity of service provision that characterises the Catalan NHS [ 52 , 53 , 54 ], pointing out the difficulties of implementing shared ICT-based coordination mechanisms and the efforts to overcome them [ 15 , 25 , 28 ]. Therefore, it is necessary for the health authority to address the problems related to the interoperability and uneven implementation of EMRs and electronic consultations [ 41 , 42 ], promoting, in collaboration with the different stakeholders, the implementation of a single electronic health record throughout the territory, on which the rest of the ICT-based coordination mechanisms are based [ 43 , 44 ].

Regarding clinical management coordination, there was an improvement in the agreement on prescribed treatments, consultation of doubts by PC and recommendations made by SC that could be related to the increase in the use of electronic consultations through the EMR, whose main use is to request the clinical opinion of colleagues in their area of expertise [ 11 , 17 ]. However, it seems to be insufficient to improve the limited joint definition of individualized treatments plans, which fell even more in 2022. This could be explained by that shared management of patients with complex needs requires other types of direct synchronous feedback mechanisms (e.g., telephone consultations, joint clinical case conferences) [ 11 , 43 , 44 ]. The results of the study show precisely that the low mutual knowledge reported by doctors before the pandemic has been intensified, among others, because of the backlog in the use of mechanisms that allow direct contact such as joint clinical case conferences and the high staff turnover that healthcare organisations have faced during the pandemic [ 45 ], making interaction between professionals even more difficult.

The COVID-19 added pressure to healthcare professionals [ 8 , 19 ] by increasing work overload with subsequent mental stress and exhaustion, especially in PC [ 46 , 47 ], and may have contributed to the increase of inadequate referrals reported by PC and SC doctors. On the one hand, some studies have shown that it may be more difficult for mentally stressed and exhausted doctors to perform an adequate anamnesis [ 48 , 49 ] and thus make proper referrals and, on the other, the increased use of ICT-based mechanisms may have exacerbated the stress [ 50 , 51 ] and increased the unnecessary referrals to SC to release work overload [ 52 ]. Moreover, as some of the PC doctors reported that SC doctors refused referrals without explanation, the lack of proper feedback could lead to repeated unnecessary referrals. So, further research is needed to analyse more in-depth the factors related with this worsening, as well as, to promote strategies to improve the working environment of professionals, since it might have a negative impact on coordination and quality of care.

Finally, the results show an important decrease in the already limited accessibility between levels before the pandemic, with long waiting times to SC, and, particularly to PC. These results are in line with the available evidence [ 20 , 21 , 30 , 31 ] that analyse the consequences of the measures introduced during the pandemic (elective procedures postponed, resources redirected to COVID-19 care, shift to telemedicine, etc.) [ 8 , 20 , 37 , 53 ], that affected the functioning of health services already under pressure (and underfunded) due to the austerity measures introduced during the last financial crisis [ 16 ]. These results call into question the effectiveness of measures that were put in place to improve accessibility during the pandemic, such as the use of electronic consultations between levels [ 16 ]. In this regard, some studies have linked their use to increased barriers of access to SC, as SC doctors could refuse face-to-face referrals until additional tests were performed, among others [ 54 ]. It is also necessary to strengthen access to PC, among others, by promoting reorganisation plans in PC that includes mixed face-to-face/telematic consultations and optimisation of resources, so that it can properly act as the gatekeeper to the NHS and coordinator of patients care throughout the healthcare process [ 8 ].

Reduction in the poor perception of cross-level clinical coordination may be related to setbacks in organisational, interactional, and attitudinal factors during and after the pandemic

Despite maintenance or improvement in some aspects of the experience of clinical coordination between levels, there was a significant worsening in the perception of coordination in the healthcare area, already low before the pandemic, especially among SC doctors. This is congruent with a survey carried out with PC doctors of Catalonia during the first waves of the pandemic that showed a perception of lack of coordination, especially with emergency rooms and hospital outpatient care [ 32 ]. The results of the analysis of changes in factors related to coordination show that this drop may be related to: (1) the decrease in the use of synchronous coordination mechanisms such as joint clinical case conferences that facilitate direct communication, collaboration, and mutual knowledge [ 55 ]; (2) the decrease in institutional support to provide the appropriate conditions for coordination (time, common objectives, etc.); (3) the decrease in job satisfaction, also described in the literature [ 32 , 56 ], and in addition to the above-mentioned factors, to the general worsening of working conditions and the burnout to which they are subjected [ 56 , 57 ], especially in primary care [ 32 ]. The worsening of all these factors, which would have been exacerbated during the first waves of the pandemic, does not seem to have been reversed in the subsequent phases. Therefore, it is necessary to further analyse the causes of the high job dissatisfaction of professionals and organisational factors such as institutional support, to promote the implementation of strategies for their improvement.

Improving doctors’ mutual knowledge and existing coordination mechanisms: strategies proposed by doctors to improve cross-level coordination

Results on doctors’ suggestions to improve clinical coordination between levels referred to improving organisational and interactional factors and are consistent with previous results [ 58 ], highlighting the way forward and the relevance of involving professionals in the selection and design of interventions [ 59 ]. First, they suggested the implementation of mechanisms that promote direct communication and knowledge between professionals, essential factors to improve the experience and perception of coordination [ 60 , 61 ]. Although ICT-based coordination mechanisms (e.g., shared EMR or electronic consultations) have been introduced to address this issue [ 28 ], due to their potential for improving transfer of clinical information and communication between professionals [ 17 , 38 ], they need to be used in combination with others that allow verbal communication, feedback and standardisation of processes [ 40 , 55 , 58 , 62 ] -specifically joint clinical case conferences, direct synchronous communication channels (telephone) between PC and SC and shared protocols-, even though they are more time consuming, they allow to establish common clear pathways of diagnosis and treatment and collaboration [ 40 , 55 ]. Hence, the importance of facilitating an organisational environment that allows their proper use: time and an increase in needed resources [ 63 ].

Second, they suggested the improvement of the existing coordination mechanisms, in keeping with the evidence that difficulties -especially those affecting interoperability and safety- can discourage their use and limit the impact on clinical coordination [ 38 , 42 , 51 ]. Interventions for improving clinical coordination are often introduced but are not designed or evaluated in a participatory way [ 64 ], although the involvement of professionals in the process can be relevant to correct deficiencies or difficulties that may arise and generates greater acceptance, increasing its sustainability over time [ 65 ]. In short, results show the need for development of multicomponent strategies that include the participation of professionals in the identification of difficulties and design of mechanisms, since their involvement is key to adapt the strategies to the conditions and needs of each context to ensure that they can be properly implemented [ 59 ].

One of the potential limitations of this study is that there may have been a selection bias due to the self-administered nature of the questionnaire and the non-probabilistic sampling of the areas. Nevertheless, the characteristics of the sample were similar to the universe of doctors in the Catalan NHS [ 66 , 67 , 68 ] and the diversity of the health areas of the Catalan Health System was represented. Finally, a drop in participation in 2022, which may have been influenced by the critical time in which the survey was conducted, the beginning of the recovery after the increase in infections by the omicron variant of COVID-19 [ 69 ]. Nevertheless, the participation rate was within the expected range for an online survey [ 70 ].

The COVID-19 pandemic was a challenging milestone that put a great pressure on health systems. It led to the rapid adoption of strategies to ensure healthcare to the population such as ICT-based coordination mechanisms. However, its impact on clinical coordination is unknow. This study analysed the changes in the different dimensions of cross-level clinical coordination and related factors that occurred in the Catalan NHS after the pandemic. Its results help to identify areas of improvement and make recommendations that are also useful for others NHS.

Even though there was an increased use of coordination mechanisms such as shared EMRs or electronic consultations and an improvement in some elements of coordination of clinical information and of clinical management probably related to a greater use of these mechanisms, other aspects of coordination such as the adequacy of referrals and accessibility between care levels have worsened, contrary to expected. Therefore, further evaluation of the impact of ICT-based coordination mechanisms on care coordination, and the barriers and facilitators associated to its use, is needed. Likewise, particular attention must be paid to other issues that worsened and are associated to the low perception of general coordination seen such as institutional support for coordination, knowledge between doctors, and job satisfaction, as well as to the contextual elements that give rise to them and that have intensified following the pandemic, such as increased waiting lists, work overload, high staff turnover and worse working conditions.

In consequence, decision makers and managers would have to prioritise participatory strategies that facilitate direct communication and knowledge between professionals and to foster an organisational climate that facilitates its implementation and sustainability, as well as to address the difficulties detected in the existing ones. It is also necessary to encourage support and protection policies for healthcare professionals and services that improve the working environment, promote cross-level clinical coordination, and guarantee quality and efficient care for more resilient NHS.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

National Health System

Primary Care

Secondary Care

Electronic medical record

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Acknowledgements

We highly appreciate the contributions to the data collection of the members who, together with the authors of the paper, constitute the Healthcare Integration Evaluation Group (GAIA): Alex Escosa (Institut Català de la Salut), Marta Banqué (Consorci Sanitari de l’Anoia), Rami Qanneta (Gestió i Prestació de Serveis de Salut). We also thank Marcos Azuaga for the online programming of the questionnaires and Palmira Borràs, Verónica Espinel, Aida Oliver, Zahara Lucena (Consorci de Salut i Social de Catalunya) for their support.

This study analyses data that were collected as part of two research projects, “The coordination between levels of care and its relationship with the quality of care in different healthcare environments of the public health system (COORDENA-CAT project, 2017) (PI15/0021)” and “Impact of ICT-based coordination mechanisms on clinical coordination and care quality in the National Health System (COORDENA-TICs project, 2022) (PI20/00290)”, both partially funded by Carlos III Health Institute and the European Regional Development Fund. The funding body did not participate in the study design, data collection, analysis interpretation or in writing the manuscript.

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ML.V and I.V were responsible for the design and supervision of the study. D.C.L analysed and interpreted the data and wrote the first draft of the manuscript. ML.V, I.V, D.C.L, E.S, F.C, P.P, JM.P.C and A.S.H coordinated data collection, participated in its interpretation and were contributors in writing the manuscript. All authors reviewed and approved the final manuscript.

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The COORDENA-CAT study was carried out in accordance with the current legislation and EU and national conventions and declarations on ethics in research, in full conformance with principles of the Declaration of Helsinki (Fortaleza, Brazil, 2013) and was approved by the ethics committee of Parc de Salut Mar and Bellvitge hospital (code: (2016/6726/I) and the COORDENA-TICs study was approved by the ethics committee of Parc Salut Mar (code: 2020/9645), the research ethics committee of the Balearic Islands (code IB 4774/22) and the ethics committee for drug research of the Basque Country (code: PI2021151). All study participants read and gave their authorization by means of the informed consent prior to completing the survey and could withdraw at any time. The researchers did not have access to any of the participants’ personal data and anonymity was guaranteed by assigning a random code to each participant. The processing, communication, and transfer of personal data of all participating subjects complied with the provisions of the regulation (EU) 2016/679 of 27 April on the protection of personal data.

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Campaz-Landazabal, D., Vargas, I., Sánchez, E. et al. Has cross-level clinical coordination changed in the context of the pandemic? The case of the Catalan health system. BMC Health Serv Res 24 , 959 (2024). https://doi.org/10.1186/s12913-024-11445-7

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Published on 20.8.2024 in Vol 10 (2024)

Using Social Vulnerability Indices to Predict Priority Areas for Prevention of Sudden Unexpected Infant Death in Cook County, IL: Cross-Sectional Study

Authors of this article:

• Daniel P Riggins 1, 2 , MD, MPH ; 
• Huiyuan Zhang 1 , MS ; 
• William E Trick 1 , MD

1 Center for Health Equity & Innovation, Cook County Health, , 1950 W Polk St, Suite 5807, Chicago, IL, , United States

2 Program in Public Health, Feinberg School of Medicine, Northwestern University, , Chicago, IL, , United States

Corresponding Author:

Daniel P Riggins, MD, MPH

Background: The incidence of sudden unexpected infant death (SUID) in the United States has persisted at roughly the same level since the mid-2000s, despite intensive prevention efforts around safe sleep. Disparities in outcomes across racial and socioeconomic lines also persist. These disparities are reflected in the spatial distribution of cases across neighborhoods. Strategies for prevention should be targeted precisely in space and time to further reduce SUID and correct disparities.

Objective: We sought to aid neighborhood-level prevention efforts by characterizing communities where SUID occurred in Cook County, IL, from 2015 to 2019 and predicting where it would occur in 2021‐2025 using a semiautomated, reproducible workflow based on open-source software and data.

Methods: This cross-sectional retrospective study queried geocoded medical examiner data from 2015‐2019 to identify SUID cases in Cook County, IL, and aggregated them to “communities” as the unit of analysis. We compared demographic factors in communities affected by SUID versus those unaffected using Wilcoxon rank sum statistical testing. We used social vulnerability indicators from 2014 to train a negative binomial prediction model for SUID case counts in each given community for 2015‐2019. We applied indicators from 2020 to the trained model to make predictions for 2021‐2025.

Results: Validation of our query of medical examiner data produced 325 finalized cases with a sensitivity of 95% (95% CI 93%‐97%) and a specificity of 98% (95% CI 94%‐100%). Case counts at the community level ranged from a minimum of 0 to a maximum of 17. A map of SUID case counts showed clusters of communities in the south and west regions of the county. All communities with the highest case counts were located within Chicago city limits. Communities affected by SUID exhibited lower median proportions of non-Hispanic White residents at 17% versus 60% ( P <.001) and higher median proportions of non-Hispanic Black residents at 32% versus 3% ( P <.001). Our predictive model showed moderate accuracy when assessed on the training data (Nagelkerke R 2 =70.2% and RMSE=17.49). It predicted Austin (17 cases), Englewood (14 cases), Auburn Gresham (12 cases), Chicago Lawn (12 cases), and South Shore (11 cases) would have the largest case counts between 2021 and 2025.

Conclusions: Sharp racial and socioeconomic disparities in SUID incidence persisted within Cook County from 2015 to 2019. Our predictive model and maps identify precise regions within the county for local health departments to target for intervention. Other jurisdictions can adapt our coding workflows and data sources to predict which of their own communities will be most affected by SUID.

Introduction

Sudden unexpected infant death (SUID) exerts a severe burden on affected families and society at large. The National Institute of Child Health and Human Development (NICHD) defines SUID as “the death of an infant younger than 1 year of age that occurs suddenly and unexpectedly.” Sudden infant death syndrome (SIDS) is a specific type of SUID where a cause cannot be identified after a full medical investigation has been completed [ 1 ]. Other types of SUID where a cause can be identified include but are not limited to “suffocation, mechanical asphyxia, entrapment, infection, ingestions, metabolic diseases, or trauma” [ 2 ]. SIDS as a single subtype was ranked as the third leading cause of infant death in the United States in 2020 [ 3 ]. In terms of years of life lost (YLL), SIDS accounted for a higher burden of disease than congenital heart anomalies for infants younger than 1 year of age in the United States in 2019 (3600 YLL per 100,000 infants vs 3134) [ 4 ].

SUID trends in the US have changed dynamically over time. The respective rates of SUID and SIDS fell from 155 and 130 (cases per 100,000 live births) in 1990 to 90 and 52 in 2010 [ 5 ]. Epidemiologists attribute these drops in incidence to a series of programs started in the 1990s to target safe sleep practices. The programs included the release of specific guidelines by the American Academy of Pediatrics (AAP) and an educational campaign called “Safe to Sleep” [ 5 ]. The Safe to Sleep program continues to this day and centers on the idea of ABCs: a baby should sleep Alone on their Back in a separate Crib [ 6 ]. This is due to evidence that babies are at increased risk of (A) rebreathing their expired gases when lying in a prone or side-lying position and (B) falling victim to accidental suffocation when sharing a sleep surface with caregivers and bulky bed materials [ 2 ].

Despite the success of Safe to Sleep and associated programming, trends from the last decade suggest that novel approaches are needed to make further progress in the prevention of SUID. In 2020, the respective rates for SUID and SIDS remained relatively stagnant at 93 and 38 [ 5 ]. Such trends hold true in the local context of Illinois, the home state in which Cook County is located. The rate of SUID remained roughly even in Illinois at ~100 (cases per 100,000 live births) between 2000 and 2018. Furthermore, racial disparities were stark. In the Black infant population, rates were actually observed to increase from a nadir of ~200 in 2009 to ~300 in 2018 [ 7 ]. Reducing SIDS in a just, effective manner will require addressing these disparities.

There is active discussion in the scientific literature on how best to adjust prevention strategies. Some researchers argue there remains untapped potential in addressing external factors that are named by AAP guidelines but get less attention than the ABCs of safe sleep. For example, use of a pacifier, breastfeeding, and smoking and alcohol avoidance are all recommended protective practices against SUID that get relatively less attention in educational materials [ 8 ]. Pretorius and Rew [ 9 ] argue that targeting such factors would be particularly effective if implemented outside of the hospital in the clinic or community, where caregivers have greater time and mental capacity to internalize risk reduction strategies.

An example of such an approach in Chicago, IL, was demonstrated by Rasinski et al [ 10 ], when they targeted educational campaigns to Black communities estimated to be most at risk for SIDS. They found mixed results from their quasi-experimental design, where some risk behaviors like usage of an improper sleep surface were decreased but other behaviors like placement of extraneous materials in the sleep environment actually increased.

In response to such mixed results, Matoba and Collins [ 11 ] argue that to improve high infant mortality rates—and their racially disparate trends—public health practitioners must broaden their focus beyond individual behaviors to neighborhood factors like poverty, air quality, and crime. Indeed, within Chicago, Guest et al [ 12 ] demonstrated that geographic variation in infant mortality was significantly associated at the neighborhood level with racial segregation and unemployment.

To counteract these negative neighborhood influences and reduce the community incidence of SUID in a just manner, public health practitioners must precisely target their interventions in space and time. Without spatiotemporal precision, practitioners risk exacerbating inequity by bolstering communities already well resourced while neglecting the communities with the highest need [ 13 ].

In this study of Cook County, IL, we sought to enable a neighborhood-focused prevention approach by creating a semiautomated method to precisely describe where SUID occurred in the recent past (2015‐2019) and to predict where SUID would occur in the near future (2021‐2025) while pointing to social vulnerability indicators as explanatory variables. Previous analyses have not provided sufficient geospatial detail to name specific places within counties to target for highest priority [ 14 - 17 ], so we also sought to afford greater detail by using “communities” as our primary unit of analysis.

While these analytic efforts were specific to Cook County, we aimed for our methods to be as adaptable as possible to other jurisdictions by using open-source software and data whenever possible [ 18 , 19 ]. We intended for these tools to enable any interested jurisdiction to get assistance to communities most afflicted by SUID in a timely, targeted manner.

Study Design

We conducted a cross-sectional retrospective study on case counts of SUID in “communities” of Cook County, IL.

We used the concept of communities in order to increase the geographic catchment area for case counts (incidence in smaller census tracts was too low to make robust case count predictions) as well as to lend semantic meaning to the geographic unit of analysis, that is, being able to name each unit rather than using a numeric identifier.

Since census tracts and existing community boundaries do not exactly align, we designed a method for resolving differences. First, for each census tract, we calculated its centroid (the geographic center of an irregular shape). Second, we sent each census tract’s centroid to the OpenCage service [ 20 , 21 ], which uses open data to assign labels to geographic points (eg, the corresponding country, state, city, suburb, neighborhood, etc, for a given point). Third, we used a decision rule to resolve the collection of multiple labels for a given census tract into a single “community.” A community roughly corresponded to one of the 77 formally defined Chicago Community Areas (if within city limits) [ 22 ] or one of Suburban Cook County’s independent municipalities [ 23 ]. Finally, we performed a spatial join of all census tracts with the same community label (ie, combine all census tracts together by their shared borders into a common external border).

Although aggregating to “communities” lent the benefits listed above, it came at the cost of less precision for corresponding social vulnerability covariates, which were aggregated into community-level values by taking simple sums of their estimates at the census tract level without accounting for variations in their margins of error.

Primary Outcome

The primary outcome of interest was the SUID case count in each community. We translated the NICHD’s definition of SUID [ 1 ] into a structured query language (SQL) query of the Cook County Medical Examiner Office’s Archive ( Figure 1 ). Each case identified by the query was validated by team members from the SUID Case Registry for Cook County, who also shared cases that were missed by the query process. Each validated case was geocoded confidentially with latitude and longitude by using ArcGIS Pro geocoding tools behind Cook County’s firewall. Geocoded cases occurring in each community were aggregated into case counts.

Temporal Setting

The year of origin for each data variable was context-specific. SUID case counts were observed from 2015 to 2019. A descriptive comparison of census tracts with and without SUID present was performed on variables from contemporaneous years. We retrospectively trained a model predicting SUID case counts from 2015 to 2019 using predictor covariates from 2014. Using the trained model, we made prospective predictions for SUID case counts from 2021 to 2025 with covariates from 2020.

Coding Pipeline

We performed all steps in the data pipeline downstream from the SQL query in the R computing environment [ 24 ] using the “tidyverse” suite of packages [ 25 ] (The R Foundation). We used additional data cleaning convenience functions from the “janitor” and “RSocrata” packages [ 26 , 27 ]. The data pipeline was orchestrated using the “targets” package [ 28 ]. We generated data tables for publication using the “gt” package and its companion {gtsummary} [ 29 , 30 ]. We performed geospatial manipulation and mapping with the “sf,” “leaflet,” “tmap,” “opencage,” and “tigris” packages [ 31 - 34 ] along with their underlying computational infrastructure [ 35 - 41 ].

Statistical Analysis

Descriptive comparison.

We compared communities with and without observed cases of SUID using median values (and IQRs) of demographic variables. Median values were reported because most of the variables did not approximate normal distributions. Comparisons between communities with and without observed SUID were statistically conducted with the Wilcoxon rank sum test.

Predictive Modeling

We sourced all predictive covariates from US Census’ “American Community Survey” (ACS) and from the Agency for Toxic Substances and Disease Registry’s associated “Social Vulnerability Index” (SVI), which has 4 thematic domains: Socioeconomic (eg, estimate of people living below the poverty line), Household Composition and Disability (eg, estimate of single-parent households with children under 18), Minority Status and Language (eg, estimate of all non-White, non-Hispanic people), and Housing Type and Transportation (eg, estimate of households with more occupants than rooms) [ 42 , 43 ].

We modeled SUID case counts in each census tract using maximum likelihood estimation via the “MASS” R package [ 44 ]. We used the negative binomial family of generalized linear models instead of the Poisson family because overdispersion was detected [ 45 ]. A random forest model was considered as an alternative to negative binomial, but stakeholders expressed preference for a model where results could be explained by explicit predictor variables and their covariates.

The selection of model forms and predictors is described in detail in Multimedia Appendix 1 . Briefly, we started with the total population as an offset variable for use in the model. Next, to consider other predictor candidates, we calculated the Pearson correlation coefficients between the SUID case count and each underlying variable in the SVI [ 43 ]. One to two promising variables from each SVI thematic domain were assessed in the model using an additive step-wise strategy. The performance parameters assessed were Akaike information criteria and Bayesian information criteria, root mean squared error, and Nagelkerke R 2 using the “EasyStats” suite of R packages [ 46 ]. All predictor variables were log-transformed in the final model in order to reduce the influence of extreme values.

Ethical Considerations

To validate our query of the Cook County medical examiner’s database, infant mortality in the medical examiner data was shared with the county’s infant mortality review panel, who already had access to these data. As a population health study using publicly available data sources on decedents, this study was exempt from institutional review board review and informed consent processes. The analytic dataset was deidentified, and for publication, data were aggregated to protect affected families.

Data Availability

An export of the analytic dataset is available in Multimedia Appendix 2 or in an open web-based SQL database on DoltHub [ 19 ].

Case Identification

Our SQL query identified 333 prospective cases of SUID from the medical examiner archives. Reviewers from the SUID Case Registry of Cook County recommended adding 16 cases and removing 7 cases. Using all cases of death in children under 1 year of age as the denominator, our electronic query achieved a sensitivity of 326/342 (95%; 95% CI 93%‐97%) and a specificity of 102/109 (98%; 95% CI 94% to 100%). One case could not be used in subsequent spatial analyses because there was no associated address, which led to a final case count of 325.

Geospatial Aggregation

We spatially aggregated cases into counts within 199 communities; 49% of communities (97/199) observed at least one case of SUID from 2015 to 2019. Table 1 shows the full distribution of case counts.

Mapping SUID Case Counts

We generated an interactive map of SUID case counts ( Figure 2 ), which can be viewed online [ 47 ]. The map showed subjective clusters of cases on the West and South Sides of Chicago as well as the South Suburbs of Cook County. The top 10 communities with the largest case counts were all located within Chicago city limits: Austin (17 cases), Englewood (17 cases), West Englewood (14 cases), West Pullman (11 cases), Humboldt Park (10 cases), New City (10 cases), Roseland (10 cases), North Lawndale (9 cases), South Shore (9 cases), and the Near North Side (8 cases). The community outside of Chicago city limits with the largest case count was Chicago Heights (7 cases).

Comparing Communities Affected Versus Unaffected by SUID

Table 2 compares the demographics of communities observed with at least one case of SUID versus those without. There were statistically significant differences in age and sex composition, although the absolute differences were slight. In terms of race, communities with SUID present exhibited a lower composition of Asian residents at 2% versus 5% ( P <.001) and non-Hispanic White residents at 17% versus 60% ( P <.001; Figure 3 ). Conversely, communities with SUID present exhibited a higher composition of non-Hispanic Black residents at 32% versus 3% ( P <.001; Figure 4 ). There was no statistically significant difference in Hispanic composition. Variables algorithmically selected for use in the predictive model all showed statistically significant differences as well.

a Wilcoxon rank sum test.

Modeling SUID Case Counts

We fit a negative binomial regression model to predict SUID case counts for each community of Cook County based on total population, total people living below the poverty line, and total households with more occupants than rooms (“crowded” households; Table 3 ). The model was retrospectively trained on SUID case counts for 2015‐2019 with predictor variables from the 2014 SVI and ACS. Figure 5 depicts goodness of fit for the model on the training data, showing that it captured mid-range counts well, but underpredicted the number of communities with zero cases, overpredicted those with one case, and underpredicted those with counts over 6. Evaluation of the model’s predictive performance showed a Nagelkerke R 2 value of 70.2% and a root mean squared error of 17.49. See Multimedia Appendix 1 for further details on evaluation of performance.

The median difference between predicted and observed case counts in the training data was 0.24 (IQR −0.57 to 0.60). All 5 communities with the highest observed case counts (Austin, Englewood, Humboldt Park, West Englewood, and West Pullman) were also among the communities with the most significant individual underpredictions (ranging from 4.05 to 7.61 less than that observed). On the other end of the spectrum, the 5 communities with the most significant individual overpredictions were Chicago Lawn, Douglas, Grand Boulevard, Kenwood, and Rogers Park (ranging from 2.94 to 4.77 more than that observed; data available in Multimedia Appendix 2 ).

a Training data used outcome case counts from 2015 to 2019 and predictor variables from 2014.

b RR: risk ratio. Interpreted as the magnitude by which you would multiply the risk with a unit increase of 1 for each covariate.

Prospective Model Predictions

We applied predictor variables from the 2020 SVI and ACS to our trained model to predict case counts for 2021‐2025. Most of the top 10 communities predicted to have the highest case counts for 2021‐2025 were the same as those observed in the top 10 for 2015‐2019 except for Chicago Lawn, Auburn Gresham, and South Lawndale with predicted changes of +8, +5, and +3, respectively ( Table 4 ). Figure 6 depicts these communities in spatial relation to each other.

a Training data used outcome case counts from 2015 to 2019 and predictor variables from 2014. Forward predictions were made for the period from 2021 to 2025 using predictor variables from 2020.

b (Prediction from 2021 to 2025) − (Observation from 2015 to 2019).

c (Prediction from 2015 to 2019) − (Observation from 2015 to 2019).

d New to the top 10 (not in the top 10 for observed case counts from 2015 to 2019).

Principal Results

Our process for querying data from the Cook County Medical Examiner was able to identify cases of SUID from 2015 to 2019 with a high degree of fidelity to those identified by the county’s official registry. We aggregated these cases to the “community” level and found that those containing a case of SUID during the study period also had higher proportions of Black residents and lower proportions of Asian and White residents. We built a negative binomial regression model to predict SUID case counts and achieved moderate accuracy, especially within the mid-range of case counts. As an aide for deciding where to target preventive services, we mapped the communities most affected by SUID. Our results suggest that intervention programs should focus efforts on the north and west sides of Chicago and in the south suburbs of Cook County. The top 10 communities predicted to have the highest case counts were also in these general areas. Chicago Lawn was predicted to emerge with the largest predicted change of +8 cases.

Implications

We suggest our analytic outputs should be used in different ways based on their temporal context. Within the model training period of 2014‐2019, residuals between predictions and observations represent promising routes of inquiry for expanding understanding of community-level ecological factors correlating with SUID incidence. For example, public health practitioners might consider intensive qualitative inquiry in the communities most underpredicted (like Austin and Englewood) to identify new risk factors and in communities most overpredicted (like Douglas and Grand Boulevard) to identify new protective factors unaccounted for by the model. After the model training period in 2020‐2025, our prospective predictions represent opportunities to anticipate shifting dynamics in the communities most affected by SUID.

Regardless of the temporal context, all results from this study can be used to guide a targeted, local approach to SUID prevention. Turman and Swigonski [ 48 ] proposed a framework for such an approach. Both high-level goals of their framework hinged on identifying specific zip codes with the highest infant mortality rates in Central Indiana. The first goal focused on developing infrastructure in those zip codes to support healthy pregnancies and infants. For example, they increased the capacity of local early childhood education programs, which both provided childcare for mothers seeking employment and served as vehicles for education on safe sleep practices. The second goal focused on training women from those zip codes as grass roots maternal child health leaders. This framework is just as applicable to Cook County as it is to Central Indiana. Many of the key institutional partners like a local Fetal Infant Mortality Review Board are already in place and could use the maps and predictions from this study to identify targeted communities most at risk.

For a variety of reasons, more work must be done before designing interventions to apply within the framework above. First, because our model is designed for prediction rather than causal inference, differences in model covariates should not be interpreted as directly leading to differences in SUID incidence. Hence, we would caution against trying to act on these covariates in isolation. Second, the SVI on its own does not capture many population-level factors that would be directly relevant to modifiable, individual-level factors specific to SUID (eg, safe sleep practice, smoking, alcohol use, illicit drug use, and engagement in prenatal care) [ 49 ]. Additional work must be done to acquire data on these factors in our jurisdiction. Finally, one Cochrane synthesis of evidence suggests that a key source of data for health interventions is generated by direct conversation with local stakeholders in communities identified as most affected [ 50 ], which has yet to be performed. If local coalitions express preference for a menu of potential options, they might consider deploying targeted digital assessments of in-home sleep environments [ 51 ], smoking cessation campaigns, or educational programming in community-based organizations.

Comparison With Prior Work

Our findings are consistent with the broader body of research on sociodemographics related to infant mortality. Several other studies have also identified a correlation between infant mortality and community-level factors like alcohol or drug use, education, employment, immigration, insurance, involvement in child protective services, poverty, racism, and racial segregation [ 12 , 15 , 16 , 52 - 55 ]. Some studies have posited direct causal relationships between these factors and infant mortality, but the evidence is still equivocal. Both Hearst et al [ 55 ] and Johnson et al [ 54 ] used propensity score matching as a means of isolating such causal effects, the former for residential segregation on Black infant mortality and the latter for neighborhood poverty on American Indian infant mortality. Both were unable to detect an influence but emphasized that their inability to detect effects may have been due to limitations in the size of sampling pools to achieve adequate counterfactual comparisons. Our study does not attempt to identify causal effects and instead focuses on helping local health departments target precise regions of their jurisdictions for intervention.

Our study advances geospatial research on SUID in 3 major ways. First, we added finer detail to the available Chicago-based maps by using census tracts and “communities” as areal units, with the added benefit that these can be linked to census-derived demographics. Second, we added interactive capability to our maps for greater utility to practitioners wanting to explore the data first-hand. Third, to our knowledge, this is the first study to have made prospective predictions on the spatial incidence of SUID, helping to anticipate changing dynamics in regions of interest. In comparison, Briker et al [ 14 ] performed a different but complementary analysis of Cook County data, visualizing SUID incidence in 2015‐2016 by kernel density estimation (KDE). Relative to our method of displaying counts per “community” areal unit, KDE has the advantage of smoothing out random variation observed in the data to make clusters more apparent. With this method, the authors also found strong clusters of SUID on the West and South Sides of Chicago. The comparative disadvantages of KDE are that the visualized kernels do not have one-to-one matches with real-world administrative boundaries, and the units of intensity are less interpretable than counts. Also, because the map in Briker et al was not interactive, it was more difficult to ascertain specific high-risk communities. In another study, Drake et al [ 15 ] used KDE to visualize SUID incidence in Harris County, TX, and this approach had the same advantages and disadvantages as described above. Fee and Tarrell [ 16 ] used analogous techniques to those used in our study by visualizing incidence in administrative areal units of Douglas County, NE. These authors were also able to correlate incidence with other variables, although their variables were more relevant to individual-level risk (eg prenatal care and tobacco use) rather than the population-level approach used in our study. In an older seminal study, Grimson et al [ 17 ] focused on demonstrating statistical methods for identifying geospatial clusters. Their work is relevant to our study because the authors used SUID incidence as their example use-case, but our study was not focused on identifying statistically significant clusters and was more finely detailed on a smaller geographic scale.

Limitations

Our study has limitations. First, a Durbin-Watson test of our model for autocorrelated residuals rejected the null hypothesis, suggesting that observations were not independent from each other. This was at least partially due to the interconnected nature of census tracts in physical space. Indeed, a Moran I test also rejected the null hypothesis, suggesting the presence of spatial autocorrelation. Second, our model did not account for measurement error in our covariates, which are estimated by the ACS using subsamples of the population. Failure to account for the margins of error and for spatial autocorrelation risked introducing systematic bias into our model predictions [ 56 ]. This was likely compounded by aggregating estimates for census tracts into the “community” areal unit. Trade-offs for this approach are described in the Methods section.

One means of addressing these first two limitations would be to implement a hierarchical Bayesian model of spatial measurement error [ 57 ]. We attempted to do so using the “geostan” R package [ 58 ], but preliminary attempts yielded warnings from the software that sampling chains did not converge--significantly raising the risk of inaccurate parameter estimates. An additional limitation, which may have contributed to nonconvergence, was that we did not have access to estimates of the true denominator for the incidence of SUID (the count of live births in each areal unit during the study period). The model implemented in geostan requires an offset denominator variable, so we used population counts of children under 5 as a proxy, but this may have contributed to additional imprecision that hampered the sampling algorithm’s ability to converge.

A final limitation was that not enough time had passed to empirically assess our model’s prospective predictions. Decision makers at local health departments might be more confident in the model’s performance if they could see how it fared at predicting outside of the training dataset. We suggest mitigating this limitation by comparing prospective predictions with retrospective observations, both of which together make a more compelling argument for risk than either piece of information alone.

Conclusions

Like many public health jurisdictions throughout the United States, Cook County, IL, is mired in persistent rates of SUID tied to racial and socioeconomic disparities. Our semiautomated process for compiling, analyzing, and predicting cases may allow intervention programs to more quickly and effectively address such disparities with efforts targeted at communities most in need of prevention services.

Acknowledgments

This work was supported by a grant to Cook County Health from the US Department of Justice's Office for Victims of Crime: Reducing Child Fatalities and Recurring Child Injuries Caused by Crime Victimization (award #2019-V3-GX-K004). The authors thank Kyran Quinlan and his team at the SUID Case Registry for Cook County for reviewing cases identified by our querying method. The authors also thank Joseph Feinglass, Phil Fontanarosa, and Sijia Wei for early feedback on this manuscript.

Authors' Contributions

DPR contributed to conceptualization, primary analysis, original draft preparation, and review/editing. HZ contributed to data curation, analysis, and review/editing. WET contributed to conceptualization, supervision, and review/editing.

Conflicts of Interest

None declared.

Model selection and evaluation.

Data export.

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Abbreviations

Edited by Amaryllis Mavragani, Travis Sanchez; submitted 23.05.23; peer-reviewed by Carolyn Ahlers-Schmidt, Colin Rogerson, Godwin Osei-Poku; final revised version received 01.02.24; accepted 05.03.24; published 20.08.24.

© Daniel P Riggins, Huiyuan Zhang, William E Trick. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 20.8.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on https://publichealth.jmir.org , as well as this copyright and license information must be included.

The Importance of a Health and Safety Policy

Healthcare policy presents multiple barriers, from organizational challenges to inefficient policy design and restricted resources. Despite the obstacles that affect health policy development and the challenges of policy faced by the healthcare system, it’s essential to understand what healthcare policy is, why it’s important to your day-to-day functions, and how it actually works.

Healthcare policies provide operational guidance and help with standardizing care. Overall, they are the backbone of a well-functioning healthcare system. They ensure proper healthcare navigation as well as effective and equitable clinical care to patients.

Regardless of your role in the industry, understanding the relationship between healthcare professionals and policy can be beneficial.

Understanding Healthcare Policy

In simple terms, healthcare policies are the rules, regulations, and complete guidelines established to achieve specific healthcare goals. Healthcare policy as a whole consists of a variety of fundamental topics, such as health insurance and managed care. Policy also covers other sub-areas of the industry, such as mental, global, and public health, which are just three categories of health policy.

Understanding healthcare policy is only half of what healthcare professionals need to know — you also need to understand its purpose and how it works throughout society. Health policy serves as a framework for decision-making and actions across different focus areas, including patient care and pharmaceuticals.

On a broader scale, health policy is also designed to have significant positive impacts on things such as:

• Clinical care improvement
• Equitable access
• Disease prevention
• Range of private sector involvement
• Promotion of healthcare communication

Overall, health policy provides a direction for healthcare delivery and is meant to make healthcare safer for the public and professionals alike.

The Importance of Health and Safety Policy

Over 3 million annual deaths are caused by unsafe care. Healthcare policy affects workers and patients by preventing potential incidents of unsafe care delivery. This is possible by outlining specific regulations, standardizing care, and presenting methods for adhering to all regulations related to your role and specialty.

Consider the primary reasons why health and safety policies are crucial to your day-to-day functions.

Protecting Patient Health

Health and safety policies are designed to protect patients from preventable harm. These policies include guidelines on infection control and medication management, safe patient handling practices, and reporting processes. By adhering to these policies, healthcare providers can minimize the risk of hospital-acquired infections, medication errors, and other adverse events.

Ensuring Provider Safety

Healthcare workers face multiple hazards, from exposure to infectious diseases to the strenuous physical demands of delivering consistent patient care. Healthcare policies ensure continued safety by focusing on risk management and compliance and centering internal guidelines on critical aspects of care.

Compliance With Regulations

The importance of health policy spans into regulation adherence and directly affects what healthcare professionals can and can’t do throughout different processes, from patient care to administrative tasks. Overall, it helps healthcare facilities comply with local, state, and federal regulations.

Promoting a Culture of Safety

Healthcare policies make it more possible to meet regulatory requirements in industries considered to be high-risk. This type of standardization aims to improve communication, reduce errors, and improve overall staff performance. This affects your role as a healthcare provider or administrator, considering that policy provides ways to organize performance tracking and policy adherence.

Enhancing Patient Trust

The patients you work with and the care you provide them are the primary reasons healthcare policy exists. Consider that at least 37% of millennials don’t trust the healthcare providers they see. Healthcare policy is meant to decrease the percentage of distrust in health providers across all age groups.

Clear health and safety policies demonstrate a commitment to high standards of care, patient satisfaction, and more trust in the healthcare system.

Making Policy Adherence Less Complicated

Healthcare policy is designed to streamline operations, facilitate more effective communication, enhance training and development opportunities, and guide better clinical decision-making tactics. The importance of health and safety policy directly affects your day-to-day functions, whether you’re a provider, compliance professional, or administrator.

While health policy consists of various moving parts, a primary way to approach and monitor policy adherence is to use automated software options. Doing so eliminates the manual component of policy training management and simplifies the way staff receive updates.

To learn more about simplifying your healthcare and safety policy development and distribution, schedule a demo today .

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Fines for parents for taking children out of school: What you need to know

Every moment in school counts and days missed add up quickly. Evidence shows that pupils who have good  attendance  enjoy better wellbeing and school performance than those who don't.  

The school day is split into two sessions – one session counts as a morning or afternoon spent in school. There are only a few occasions where a child is allowed to miss  school , such as illness or where the school has given permission because of an exceptional circumstance.  

However, if your child misses school without a good reason, local councils and schools can intervene and you may be issued a fine.  

We’ve also introduced a national framework which will mean all councils have the same rules in place for when they need to consider a fine. We explain more on this below.  

It’s important to note that children with long-term medical or more serious mental health conditions, and those with  special educational needs and disabilities  may face additional barriers.  

For children who face complex barriers to attendance, schools should have sensitive conversations with children and families and work with them to put support in place for their individual needs.  

How much could I be fined if my child misses school?    

In the majority of cases, schools and local authorities will try and provide support to help you improve your child’s attendance first, but if this isn’t effective or the absence is for unauthorised term time holiday, parents may face paying a fine.  

It’s the responsibility of the local authority to decide when to issue fines to parents, meaning the process varies from council to council.  

However, under the national rules, all schools are required to consider a fine when a child has missed 10 or more sessions (5 days) for unauthorised reasons.  

From August 2024, the fine for school absences across the country will be  £80 if paid within 21 days , or  £160 if paid within 28 days . This rate is in line with inflation and is the first increase since 2012.  

In the case of repeated fines, if a parent receives a second fine for the same child within any three-year period, this will be charged at the higher rate of £160.  

Fines per parent will be capped to two fines within any three-year period. Once this limit has been reached, other action like a parenting order or prosecution will be considered.  

If you’re prosecuted and attend court because your child hasn’t been attending school, you could get a fine of up to £2,500.  

Money raised via fines is only used by the local authority to cover the costs of administering the system, and to fund attendance support. Any extra money is returned to the government.  

How can you be sure parent fines are fair?  

Fines are a last resort, and parents will be offered support to help improve their child’s attendance first. The vast majority of fines for unauthorised absence (89%) are issued for term time holidays.  

If your child is facing barriers to school attendance due to special education needs or disabilities (SEND), schools, local authorities and wider services are required to work together to provide the right support in the first place.  

What if my child needs to miss school?   

Your child must attend every day that the school is open, unless:  

• Your child is too ill to attend that day.  
• You have asked in advance and been given permission by the school for your child to be absent on that day due to exceptional circumstances.  
• Your child cannot attend school on that day because it is a day you are taking part in religious observance.  
• Your local authority is responsible for arranging your child’s transport to school and it is not available on that day or has not been provided yet.  
• You are a gypsy/traveller family with no fixed abode, and you are required to travel for work that day meaning your child cannot attend their usual school.  

What happens if my child misses school without a good reason?   

If your child is absent and you haven’t received advance permission from the headteacher to take your child out of school, the school and local council may take action.  

Before that, your child’s school and your local council are expected to support you to improve the child’s attendance before any measures are put in place .  

These measures can include:  

• Issue a fixed penalty notice, otherwise known as a ‘fine’  – your local council can give each parent a fine. If you do not pay the fine after 28 days you may be prosecuted for your child’s absence from school.  
• Seek an Education Supervision Order from the family court  – if the council thinks you need support getting your child to go to school but you’re not co-operating, they can apply to a court for an Education Supervision Order. A supervisor will be appointed to help you get your child into education. The local council can do this instead of, or as well as, prosecuting you.  
• Prosecute you  – this means you have to go to court. You could get a fine, a community order or a jail sentence up to three months. The court could also give you a Parenting Order.  

Why is attendance important?   

For most pupils, the best place to be during term-time is in school, surrounded by the support of their friends and teachers.  

This is important not just for your child’s learning, but also for their overall wellbeing, wider development and their mental health.  It’s not just children who fail to attend school who miss out, but  those around them too.    

We’re working with schools and local councils to improve attendance by supporting  them to reset the relationship between schools, families and the government to ensure children have the best start to life.  

You can read more about what we’re doing to help schools improve attendance on the Education Hub .  

You may also be interested in:

• What are 'ghost children' and why is attendance so important?
• Why is school attendance so important and what are the risks of missing a day?
• School attendance and absence

Tags: Fines for missing school , Fines for taking children out of school , missing school , parents fines for children missing school , School absence fines , school attendance , School fines for holidays , School fines UK , School holiday fines

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