In the last 10 years, the process of health care reform in several national health care programs has witnessed an increased need for complex and innovative approaches at the organizational, clinical and policy decision-making levels [1]. A closer look at many of these reform processes however, shows that little information is available on the specific role medical education plays (or can play) in aiding reform, and achieving high quality health care services [2]. There are reports in the literature that reflect a weak alignment between the roles of doctors and the health care needs in their communities. Also about how medical training programs are finding it difficult to deliver competent doctors, who are trained to effectively participate in modern patient and population-centered health care systems [3,4]. These developments apparently suggest that in order to achieve successful health care reform within a community, a favorable environment for change is necessary. Such an environment would need to be able to facilitate the development of relevant (and specific) competencies of health care professionals, needed to be able to function effectively within a modern health care system [1,4,5].
At present, several small scale and/or resource-limited communities are facing challenging times in achieving sustainable health care programs in their countries, due to limited financial resources. This is further complicated by the shortage of qualified health care professionals required to provide essential health care services within these communities. Extensive literature studies have shown that due to the high impact of local circumstances, no single strategy exists that can guarantee a successful approach and implementation of effective health care systems [6,7]. However, we are of the opinion, that contrary to the current views in the literature, implementation of a continuous learning organizational environment could serve as an important basis for effective health care reform in resource-limited settings. Especially when these are combined with clear descriptions of the organizational context for defining inherent and potential health care challenges within the community [4,8]. In order to illustrate this viewpoint, a description of a resource-limited environment currently facing challenges of health care reform is provided and how the incorporation of a structured educational framework formed an effective basis for implementing new health care strategies within the community.
Context
Curaçao is a Dutch Caribbean island with an estimated population of 150.563 inhabitants [9]. It is characterized demographically by a relatively high aging population, a high prevalence of chronic diseases (e.g. diabetes, obesity, hypertension), and poor financial and human resources to enable the reform of its health care system that is currently being driven by cost-containment. Furthermore, the delivery of health care on the island is portrayed by a fragmented, unsynchronized and inefficiently functioning primary, secondary and tertiary health care system.
In terms of economic health, the average gross household income in Curacao in 2011 was 5.331 NAF (3013 USD) with a median yearly income of 3.500 guilders (1980 USD). The Modal household income was between 1.001 – 2.000 NAF (565–1130 USD) per month with about 17% of the household population belonging to this income category and another 13% below 1.000 NAF (565 USD) a month [10]. In 2012, the per capita GDP for the Netherlands Antilles was estimated by the United Nations as 18.360 USD with the per capita GDP of the World, USA and Western Europe estimated as 10.269, 51.163 USD and 43.313 USD respectively [11]. The Per capita GDP is a measure of the total output of a country and is a useful indicator for comparing the relative economic performance of one country to another, with a rise in per capita GDP signaling a growth in the economy and the country’s productivity. In 2006, the perinatal mortality rate in Curacao was slightly lower than the average within the Caribbean region (23.5 vs. 31/1000). However, this figure was notably higher than those found in countries in North America and Western Europe (7 and 13/1000 respectively) [12]. According to the WHO, the health status of a country can be evaluated based on the perinatal mortality rate, as this tends to reflect the standard of a country’s obstetric and pediatric health care [12]. Finally between 2012 and 2013, there was a decline in the infant mortality rate in Curacao from 11.3/1000 to 7.7/1000 live births [13].
With its historic lack of clear governmental policy regarding health care organization and planning, the assurance of optimal patient care and a sustainable health care system in Curacao, has been subjected to continuous threat. The associated increase in health care consumption, poor formal patient representation and increasing expenditure on the delivery of health services, have also been of little help in this area [14]. Based on the above points, the situation in Curacao fits the description of a country (island) with limited resources and a poorly developed health care system. Consequently, this has implications for the prioritization and distribution of available resources as well as, for the successful implementation of (new) educational and health care initiatives.
In 2009 the health care council of the island initiated a new health care movement, advocating the development and implementation of a new and value-based approach that would reform the island’s health care delivery system. As a result, it became imperative to identify appropriate strategies and essential local conditions that would be needed to achieve the successful implementation of a new value-based health care system [15]. The outcome of this investigative process, as evidenced by the official reports by the national health care council, identified a key role for the St. Elisabeth Hospital as a (model) platform for implementing the new health care reform initiative [16–18].
The St. Elisabeth Hospital (SEHOS) is the sole general hospital of Curaçao and with its 536 beds, is the largest health care institution within the Dutch Caribbean area. In addition to the SEHOS, there are 2 smaller surgical clinics (40 & 45 beds respectively), 1 psychiatric hospital (200 beds), a 146 bed rehabilitation hospital, 2 nursing homes and a maternity clinic that serve the inhabitants of the island [19]. As of December 2012, a total of 284 medical professionals were reported to be practicing on the island. One hundred and forty were registered as medical specialists, 110 general practitioners, 294 allied health care professionals (e.g. physiotherapists), 6 registered midwives and 54 dental professionals [20].
The SEHOS provides services in all major clinical specialties, and also offers adult, pediatric, and neonatal intensive care. The hospital, as an educational setting, is affiliated to a number of tertiary medical institutions in the Netherlands and provides accredited residency and pre-residency training for Dutch medical students of the University Medical Center Groningen (UMCG) [21,22].
Prior to the health council’s project in 2009, the new (G2010) curriculum of the UMCG was implemented in SEHOS as a novel competency-based training program for medical residents and students. A specific educational strategy was developed and used to implement the curriculum as well as evaluate and monitor its impact on the quality of the professional training [22]. As a result, in evaluating the suitability of the SEHOS as a model platform for the health care reform initiative, a systematic analysis of the hospital’s characteristics was performed using a medical education quality assurance project. This project focused on assuring the delivery of competency based training to health professionals in Curacao. In other words, ensuring that professionals have been appraised and found capable of providing the clinical duties they had been assigned to perform [23]. The focus of the analysis was to clearly describe the educational characteristics of the affiliate teaching hospital and while making use of this environment, achieve a new professional culture i.e. competent and patient centered care, among health care providers of the island.
This was necessary for guaranteeing the quality of both medical education and of health care delivery on the island. The main objectives of this process were first, to identify the different perspectives and organizational requirements required to build a health care environment that was conducive for change and second, to create an environment that would facilitate the smooth migration of existent services into an effective and sustainable value based health care system. The ultimate goal was to have physicians as health care professionals be leaders in the process. Hence, this report demonstrates as a proof of concept, the development and successful introduction of a new health care delivery framework using inputs from the local health care environment and guided by the recommendations for competency based training, derived from the revised Dutch postgraduate medical curriculum [24] Similar to the CanMeds competency framework, seven professional competencies considered essential for practicing physicians were identified and outlined for implementation in the national postgraduate training programs [25].
Methods
The strategy that we applied in developing and implementing this framework involved the systematic application and synthesis of the existing knowledge of change in health care, the application of expert opinions and the use of methods of qualitative research to obtain information from different stakeholders (triangulation). The approach we used included:
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1.
Formulating the standards of the quality of health care based on review of national health care council reports, existent literature, consultation with experts and national health care council by a content expert,
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Formulating a proposal for the reform of the health care environment and services (by selected members of the health care council and the content expert) based on the desired local health care objectives in combination with relevant evidence in the literature. This proposal was designed with a clearly defined aim, framework and process for implementation,
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3.
Seeking the input, approval and support of important stakeholders (i.e. the national health care council, health care providers e.g. physicians and nurses and funders of care i.e. health care insurers) for the proposal (Figure 1).
Formulating the standards for the quality of health care
The project was conducted between the period of September 2010 and April 2011. A content expert drafted a recommendation document defining the requirements for achieving a proper environment for achieving value based medical care in Curaçao. The content expert was a physician manager and educationalist, with a first hand experience of the health care delivery system of the island having trained and practiced in Curaçao. In the first stage of preparation, use was made of relevant reference documents, literature on organizational and health care development as well as the personal professional experience [5,24,26]. Between September and December of 2010, a draft describing the context/environment was developed highlighting the framework for competency-based training for trainee physicians and the continued professional development of practicing health care professionals. The aims and objectives were defined and important stakeholders for consultation during the process were identified.
Formulating the reform proposal
A comprehensive pathway for implementing and evaluating the various stages of the proposed recommendations was designed including a timeline for achieving the different steps involved in the process. The second stage of the process involved a qualitative analysis of the proposed standards and pathway aimed at addressing local requirements and testing the feasibility, acceptability and comprehensiveness of the recommendations among the stakeholders and supplementing any omissions found. For this purpose, twelve separate interviews were conducted in December 2010 with the Chief executive officer (CEO) of SEHOS and the CEO’s of 2 small surgical clinics (primarily short stay surgery e.g. ophthalmology and Ear Nose and throat) on the island (all physicians), the clinical directors of 3 specialty departments and the director of the department of epidemiology and biostatics in the St. Elisabeth Hospital, representatives of the two biggest health care insurers, the inspector general of the island’s health care inspectorate, a representative of the association of family physicians and with a delegate of the island’s health care council. The health care council of Curaçao comprised of representatives from the providers, consumers and funder organizations present on the island. Prior to each interview, the stakeholders received a copy of the draft proposal for critical evaluation and requested to provide written feedback on the feasibility, acceptability and comprehensiveness of the content in the proposal. All of the stakeholders provided written feedback on the proposal and also elaborated and clarified their responses in the face-to-face interview that followed. Between January and April 2011, all interviews (60 minutes duration) were conducted and the comments received were transcribed, analyzed and synthesized into the initial proposal (See Table 1). The comments were categorized as relating to a) Professional standards, b) Distribution of responsibilities, c) Accountability, or d) quality assurance and improvement.
Seeking approval and support of important stakeholders for the proposal
The last phase of the project involved seeking approval and acceptance of the final drafted proposal. Using the inputs we received from the participating stakeholders, a revised proposal was sent back to each of them for evaluation and approval. This resulted in a more inclusive recommendation that contained inputs from all of the stakeholders and a definite reference document [23].
