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In addition, LTs uncovered significant training needs e. We also felt that because few of the LTs had corresponding PSIs this actually showed the unique value of simulation over patient safety reporting and are treating this as a positive finding. In addition, incident reporting and in situ simulation provide different vistas on safety. Other studies have highlighted the need for different approaches to build a comprehensive picture of safety because of the complementary yet different information provided by each approach Some repeat simulation scenarios enabled development and testing of protocols and a shared perspective ordinarily unavailable.

For example, the dual location CBL simulations enabled a unique observation of simulated error at the interface of care between PICU and blood transfusion. This perspective resulted in an interdepartmental collaborative approach to patient safety, facilitated learning, and supported the rationale for system improvement. Likewise trust wide introduction of an intubation box reduced the time to intubate in all areas. Subsequently, excessive time to prepare for intubation has not recurred as an LT in simulated events.

However, as never reported as a PSI, system improvement impact cannot be assessed, although it is obvious that reduction in time to intubate improves patient care in a high-risk environment. Although most PSIs reported medication errors, emergency drug dose calculations never featured as a PSI possibly because of one of the LT service improvements emergency drug charts. The traditional definition of safety safety 1 is the absence of harm However, safety is not just non-events but a proactive sensitivity to the possibility of failure This deeper understanding of work-as-done enables anticipation of events and team and system flexibility and resilience In situ simulation can encompass both safety perspectives.

To the best of our knowledge, this is the first study to review LT detection over time, providing a rich reflection of work-as-done. Measuring LTs from simulation could be developed similarly by other trusts as a proxy safety metric, in conjunction with traditional retrospective PSI reporting, as complementary approaches to safety. There were several limitations to this study. However, voluntary reporting of adverse incidents captures only a minority of incidents and is subject to significant bias The possibility of bias and missing CBL events was recognized prompting review of the blood transfusion audit.

PSI limitations could have been overcome by triangulating them with other records of patient safety events such as patient complaint records, risk management databases, and safety walk-rounds. Retrospective categorization was another source of potential bias. There is no standard nomenclature for error analysis on PICUs although frameworks for incident analysis could have been adapted Other simulation studies have used failure modes effects analysis FMEA coupled to simulation training to prioritize predicted risk to enable solution development in stratified order In contrast, we addressed LTs as detected, according to the perceived patient risk because some FMEA critiques highlight the lack of evidence base and the resource heavy methodology involved Iterative testing of system improvement efficacy was not performed which might have prevented later emergence of LTs as PSIs 2—3 years later.

Follow-up interviews checking solution success might have enabled system improvement efficacy to be assessed Finally, participant psychological safety could have been threatened by reporting education and training LTs. Reassuringly, anonymous participant feedback never reported a negative impact on learning.

To the best of our knowledge, this is the first study comparing LTs identified during in situ simulation to existing safety reporting systems and evaluate subsequent service improvements. The unique strengths of in situ simulation were highlighted.

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First, the identification of potential threats to patient safety particularly for training and knowledge gaps undetected elsewhere. Second, in situ simulation offered a real-time unbiased multi-professional approach to patient safety. This cannot be achieved by one safety model but the best way to measure their individual or combined impact is unclear. More work is required to integrate the strengths of in situ simulation into traditional models of patient care and safety and robustly measure its efficacy.

This would enable in situ simulation to be harnessed by existing health-care systems and accepted as a valuable safety improvement modality. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Chief Medical Officer. Google Scholar. Does training with human patient simulation translate to improved patient safety outcome? Curr Opin Anesthesiol — High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training.

BMJ Qual Saf 22 6 — Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand 53 2 — Non-technical skills in the intensive care unit. Br J Anaesth 96 5 —9. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med — Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents. Association between implementation of a medical team training program and surgical mortality. JAMA — Pronovost P, Freischlag J. Improving teamwork to reduce surgical mortality.

JAMA 15 —2. Reason J. The contribution of latent human failures to the breakdown of complex systems. A method for measuring system safety and latent errors associated with pediatric procedural sedation.

Anesth Analg — Failure modes and effects analysis based on in situ simulations: a methodology to improve understanding of risks and failures. In situ simulation to assess workplace attitudes and effectiveness in a new facility. Simul Healthc 8 6 —8. Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies. Qual Saf Health Care 19 Suppl 3 :i53—6. Portable advanced medical simulation for new emergency department testing and orientation. Acad Emerg Med —5. Developing learning organisations in the new NHS. BMJ — Can incident reporting improve patient safety?

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Healthcare practitioners views of the effectiveness of incident reporting. Int J Qual Health Care 25 2 — Closing the loop: follow-up and feedback in a patient safety programme. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care — Frey B, Schwappach D. Critical incident monitoring in paediatric and adult critical care: from reporting to improved outcomes? Curr Opin Crit Care 16 6 — Impact of an embedded simulation team training programme in a paediatric intensive care unit: a prospective, single-centre, longitudinal study.

Intensive Care Med 38 1 — Reliability of team-based self-monitoring in critical events: a pilot study. BMC Emerg Med Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin —7. Berwick D. London: Department of Health Using in situ simulation to identify and resolve threats to patient safety: case study involving a labor and delivery ward. J Patient Saf 5 3 —7. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf — Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.

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The elephant of patient safety: what you see depends on how you look. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 21 10 —8. PubMed Abstract Google Scholar. Reiman T, Pietikainen E. However, several studies have shown that the decisions to introduce these user fees exemption policies in Africa were often electorally motivated, sudden, prompted by external pressures, and consequently very chaotic in their implementation Meessen et al.

This was still the case at the end of , such as in Gabon, where the President suddenly announced exemption from payment for deliveries without anything having been prepared on the ground. These policies are obviously essential, because asking patients to pay at the point of care is known to be one of the biggest barriers to access to care Robert et al. Yet contrary to international recommendations and discourse Robert and Ridde, , many countries in Africa continue to impose user fees for certain services or categories of people, thereby hindering the achievement of universal health coverage UHC and Sustainable Development Goal 3.

For example, in some African countries, the practice persists of detaining patients in hospitals because they cannot pay for their care Yates, Brookes and Whitaker, , and there has been a return to some forms of user fees for HIV patients, which was denounced at the UHC Forum in Tokyo in December MSF, Thus, the right to access healthcare is still far from being respected in many countries, and there is a persistent gap between decisions and their actual implementation.

The role of preconceived ideas with respect to this policy instrument is also certainly not negligible Ridde, Queuille and Ndour, Unlike some countries that rushed into such decisions, with the result that their policies were not as effective as intended Meessen et al. The process took almost 10 years, from the time of first discussions and pilot projects to the moment of deciding to eliminate user fees for children under five and pregnant women.

The objective of this article is to describe and analyse this story using a reflexive approach. In this commentary article, we analyse this process based on our participation as a long-standing researcher VR and a technical advisor and decision-maker PY involved in this policy process. Reflexivity is essential for professional development, especially for public health researchers Tremblay and Parent, In this article, we adopt a posteriori a reflexive posture on action, which in this case is the process that led to the decision to abolish user fees.

The following paragraphs briefly present the careers of the two authors of this article, as well as our place and involvement in the policy studied, so that the reader may better understand our stance with respect to this analysis. While not social scientists per se , we follow the development of knowledge on public policies and the science of using science and draw upon their concepts and theories in this reflexive analysis. While we support user fees exemption policies based on the state of the art on their effectiveness, we have also published on or participated in projects that have shown their ineffectiveness and implementation challenges or errors.

Thus, we believe the analysis presented in this article is relatively distanced in this respect and neutral in terms of our reflexivity on the role of evidence. VR is a public health researcher based in Canada — , Burkina Faso —, and France since Prior to his academic career, he was in charge of projects for public health NGOs in Africa. This involved a large number of international and national researchers, research assistants, and students.

PY was the chief medical officer of Tougan health district from to , where another NGO Tdh tested an intervention for healthcare user fees exemption Blanchet, Zonon and Aggagliate, He was involved in the design and implementation of the exemption in this district from to Subsequently, he carried out the feasibility study, designed the national strategy, and drafted the advocacy document on this national policy. At the same time, he supported NGOs as a consultant in advocating for this instrument. Since , he has been the national coordinator for implementation of the national exemption policy.

In October , he was appointed the Technical Secretary in charge of Universal Health Coverage at the Ministry of Health, coordinating the national healthcare user fees exemption policy. The data for this analysis come from our notes and reflections compiled over the course of our involvement in this policy since , as well as from observation sometimes participant of all the events we present below. We used all available literature, whether scientific or grey, to support our analysis. Writing this article was also a process of support for our reflection.

First, we agreed on the content of the article within the three dimensions of the chosen conceptual framework see below. Writing the discussion allowed us to associate reflection with concepts more widely used in political science. We presented the preliminary results of our reflections at two international conferences in Senegal and Japan in It is often recommended that policy change analysis should cover a long time frame of at least 10 years Sabatier and Weible, , and we have done this in our analysis.

In this article we use the approach proposed by Hassenteufel because it is more conducive to our descriptive and reflexive approach. Other agenda-setting frameworks call for an empirical-analytical approach that goes beyond the intent of our article and will need to be mobilised later. Obviously, this triple dynamic occurred within a specific context, which we will first present. The health system is thus hampered by inadequate resources and is strongly dependent on healthcare user fees, which have remained the primary source of health financing.

Health policy is focused on primary health care, which is the basis of the health system. Human, material, and technical medical resources are insufficient in both quantity and quality and often poorly distributed. The North, North Central, and Sahel regions concentrate scarce human resources to meet basic reproductive health needs precisely where the first pilot user fees exemption projects began in Burkina Faso does not have functional health insurance, so healthcare user fees are the mechanism promoted by health policy to help finance the health sector.

However, numerous studies have shown this leads to very low use of care Ridde et al. While some forms of user fees exemption had long existed for certain diseases tuberculosis, HIV, malnutrition , an initial ambitious subsidy policy was launched in for deliveries and newborns under seven days of age; this was not, however, an exemption i. Financed entirely by the State, it has been relatively well implemented and has proved very effective, including for the poorest Ridde et al. Nevertheless, financial barriers remain high for women and children.

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In early , a report hypothesised that, despite the abundant data produced on health financing in Burkina Faso, little knowledge seemed to have been mobilised by decision-makers Ridde, Zerbo, et al. The two worlds did not seem to have influenced each other much. However, the story has since changed, as we will see in this article.

Their aim was to support NGOs wishing to organise pilot projects to implement user fees exemption for health services, one of the major determinants in the fight against malnutrition. They have been of varying magnitude and duration, but some have been sustained for more than eight years. On one hand, while scientific evidence has shown the challenges of implementing the exemption, it has also revealed its capacity to reduce catastrophic health expenditure, improve the use of health centres, and redress inequities Ridde et al.

On the other hand, these NGOs also produced tacit knowledge that they built on as their projects progressed and shared with Ministry of Health technicians and decision-makers at the central, regional, and local levels. This knowledge was related to topics such as: processes for monitoring and verifying the exemption; flat-rate reimbursement methods; contents of the services package; computerised medical records; monitoring tools; approaches for targeting the indigent; etc.

As a result, several good practice guides have been written by these NGOs in collaboration with health system actors. The NGOs organised numerous meetings to discuss and present results at the level of the Ministry of Health. For example, in , the results were presented at the annual meeting of all district medical officers and regional health directors from across the country. Some NGOs had provided upstream support to the presenters, who were the chief medical officers of the districts where the pilot projects were being implemented.

The first results of the pilot experiments were brought to the attention of the participants especially researchers and international NGOs through presentations and posters. At the end of , donors organised a special advocacy meeting for technical and financial partners TFP on scaling up the user fees exemption for children under five and pregnant women.

The Ministry of Health received this plea favourably and embarked on a process of studying the feasibility of free healthcare at the national level. This main objective of this study, conducted in , was to estimate the costs of eliminating user fees at the national scale and to identify the conditions for success.

An international consultant from the London School of Hygiene and Tropical Medicine, paid by Tdh, was made available to the Ministry of Health team to conduct this study. The report from that study was submitted to decision-makers in the Ministry of Health the central directors in December The main recommendation that emerged from this feasibility study feedback meeting was that a national strategy document be drafted for the implementation of free care for children under five and pregnant women.

A team of key actors service providers, NGOs, central level of the Ministry of Health, international donors met in a workshop in the city of Koudougou from March 12 to 15, The strategy content and an advocacy document to influence decision-makers to adopt the content were developed during this workshop. The two documents were presented at the Ministry of Health cabinet meeting in August and then officially transmitted to the TFPs by WHO letter of October 7, for their opinion. In December , by correspondence, the TFPs were in favour of implementing the user fees exemption.

They stressed the wish that this be done at the national level from the outset, building on the experience gained by NGOs and placing the financing of this strategy within the overall framework of a national health financing strategy for UHC. Burkina Faso was eligible. However, in May , the Ministry of Health informed AFD that it wished to await the results of internal discussions and evaluations of its national strategy of subsidising deliveries before launching a feasibility study on I3S financing.

AFD responded five months later, taking note of this position but announcing that it would not finance this feasibility study. Thus, the financial support earmarked for Burkina Faso was redirected towards other Sahelian countries. Then there was a slowdown. For four years an NGO HELP financed the presence of a knowledge broker to support researchers in making their work relevant and especially in implementing knowledge transfer strategies Dagenais et al. Research on this process has shown that the actors involved NGOs, Ministry, researchers, etc.

This obviously was not easy, as NGOs often have their own agendas and sometimes seek to put themselves ahead of others. To our knowledge, this was the first time AI researchers committed themselves in the health field, which is not their usual area of expertise. They collaborated extensively with the NGO coalition on the ground, as well as with researchers to use evidence to support their report Amnesty International, This report gave rise not only to many international advocacy activities, but also was especially helpful to the local AI office and other NGOs.

The various NGOs also engaged extensively with international, national, and regional media. The strategy deployed was wide-ranging so as not to rely on a single medium, because decision-makers in the capital are more likely to read paper newspapers, while the general public is more influenced by TV in the city and radio in rural areas. On at least three occasions, actors involved in user fees exemption including PY, VR, and the broker took part in the RFI health programme, which is widely listened to in Burkina Faso, Africa, and France. The politicisation phase was largely led by this coalition of NGOs at both the European and national levels.

This was not easy, because it was also necessary to convince their colleagues in the development aid offices different from those in the humanitarian aid office , who were quite resistant towards this policy instrument Howlett, , i. In a letter sent at the beginning of , she congratulated the NGOs on this work of subsidising healthcare user fees, which had made it possible to advance beyond the declaration of principle issued by the ECHO Directorate-General in ECHO, in this respect and to open the whole Commission to this instrument.

In her statement, she even quoted the study, not yet published Johri et al. The use by a senior decision-maker of research results not yet published in a scientific journal also demonstrates the relevance of producing policy briefs before scientific publications so that the results can be quickly put to use by decision-makers Dagenais and Ridde, In addition, the NGO coalition, accompanied by PY and the knowledge broker, went to Brussels in September to meet with decision-makers to advocate for ECHO funding, because the funding for the user fees exemption remained under debate and its sustainability was not ensured.

A great many advocacy activities based on evidence sometimes using policy briefs were carried out to politicise the issue at the national level. AI also organised a caravan in to travel to rural areas and to draw the attention of regional authorities and decision-makers to this policy instrument. In , HELP produced a capitalisation report on its experience after two years Ridde and Queuille, , which it handed over to the First Lady in , as it was not possible to meet with the President directly.

Tdh also submitted its activity report on free care that year. The President responded with a letter of congratulations and encouragement for their commitment to the poorest.

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That same year, a Harmonisation for Health in Africa community of practice organised a major conference on user fees exemption policies in Africa Footnote 1 , where more than researchers, experts, and stakeholders debated these issues. During this conference, Canadian researchers Footnote 2 provided training in knowledge transfer practices and policy brief writing. Then a major event changed the course of history. On October 30, , when the National Assembly was due to debate the universal health insurance AMU policy, the President, a man who had been in power for 27 years, decided to change the agenda and asked parliamentarians to vote on an amendment to the Constitution that would allow him to stand again in the next presidential election.

In the end, neither the AMU nor the amendment was discussed. A transitional government was put in place. It was this government that voted in September to adopt a law on the AMU, in which the user fees exemption for indigents was included in article While the exemption did not yet apply to women and children, that decision, with the acceptance of this policy instrument, marked the beginning of a paradigm shift. However, the national user fees exemption strategy for children and women still had not been adopted. Thus, the NGO coalition got back on track and developed numerous advocacy activities aimed at candidates for the new and unprecedented presidential campaign.

All candidates were met and urged to take a public stand. The coalition of NGOs set up a committee to monitor presidential commitments in this area. The free healthcare policy was finally decreed on March 2, , at the Council of Ministers of the new government, just four months after the first free elections, but eight years after the first pilot projects organised by NGOs.

The then Minister of Health would have preferred a two-stage implementation, first to abolish fees for childbirth for women and then, six months later, extend it to children under five. But the President of the Republic wanted these to be implemented at the same time and within one month after the declaration by the Council of Ministers. Thus, in April all the health districts of the Centre, Hauts-Bassins, and Sahel regions launched the national policy.

Then in May it was applied in all regional and university hospitals.

Finally, as of June 1, , all other districts in the country organised exemptions from user fees. Figure 1 provides a summary of the chronology of significant events and key stakeholders. Chronology of significant events and key stakeholders. In the following discussion, we generalise our findings to the conceptual and theoretical levels to compare our analysis with the most relevant literature in the fields of public policy science and knowledge transfer.

We then offer some lessons learned for those wishing to engage in processes to influence decision-making using evidence. Finally, we present the methodological strengths and limitations of our analysis. The preponderant role of presidents in the decisions to launch free healthcare policies in Africa Ghana in , Uganda in , Zambia in , etc. However, in the context of Burkina Faso, while the new President called for implementation to start quickly, the process was not rushed. Thus it took eight years for the national policy to be decided after the first pilot projects, which, in the field of public policy change, is not so long in the end Sabatier and Weible, The policy instruments user fees were modified over the years—being first reduced, then abolished for part of the population—shaped in particular by political manoeuvres, the ideas of influential actors, and the context of development aid institutions and their multiple projects the role of the ECHO being central due to the scale of its funding.

The production of scientific evidence by legitimate actors that could be mobilised by knowledge brokers, NGOs, and advocacy activists was also instrumental. Individual political entrepreneurs also influenced the process, as did, for example among others! Our reflection leads us to believe international and national NGOs with their specific expertise , as well as their donors especially ECHO , have largely played this role of political entrepreneurs.

Independent research will be needed to better understand this. By , the national strategy is in place, almost entirely financed by the State The NGOs that launched the pilot projects in are now monitoring the effectiveness of the policy in with funding from the State itself. This separation of functions and the involvement of civil society in the governance and accountability process are two of the factors for successful implementation.

Obviously, this current implementation of the policy faces many challenges availability of drugs, delays in reimbursement, adjustment of amounts purchased, etc. Our aim in this article has been to focus solely on the history of decision-making, from our reflexive standpoint, and on the role of evidence in particular.

The considerable investments in not only generating knowledge but also mobilising it through knowledge brokering activities, storytelling techniques, and advocacy certainly contributed to this policy decision and the evolution of ideas Dagenais et al. Moreover, these investments were made over a very long period, mobilising not only recognised international and national scientists, but also civil society actors, to put this work into action. The legitimacy of those who produced and presented the research results was certainly a positive factor in the consideration of the evidence.

Patience, the accumulation of evidence, and the organisation of a broad coalition of actors were certainly success factors. We saw that sometimes obstacles were set up to prevent dissemination of the evidence in the media, and the NGOs had to accept that, for their advocacy to be effective, they needed to take into account the political issues.

Partnerships between researchers and NGOs can be advantageous Olivier, Hunt and Ridde, , and, as in Uganda and Ethiopia, the coordinated efforts of transnational actors is a success factor in influencing states Hickey et al. During the process described here, research on knowledge transfer activities was even conducted to improve the strategy and make it more effective Dagenais et al. The science of using science Langer et al. It was also essential to work with open-minded researchers and others who became open-minded , ready to invest themselves in this long-term adventure, agreeing to publish results first to national decision-makers in French and using lay vocabulary; see, for instance, the Nigerien case Dalglish et al.