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Background Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. Objectives We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. Methods As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. Results Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). Conclusions We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

Summary Background HIV pre-exposure prophylaxis (PrEP) is highly effective in men who have sex with men (MSM) at the individual level, but data on population-level impact are lacking. We examined whether rapid, targeted, and high-coverage roll-out of PrEP in an MSM epidemic would reduce HIV incidence in the cohort prescribed PrEP and state-wide in Australia's most populous state, New South Wales. Methods The Expanded PrEP Implementation in Communities–New South Wales (EPIC-NSW) study is an implementation cohort study of daily co-formulated tenofovir disoproxil fumarate and emtricitabine as HIV PrEP. We recruited high-risk gay men in a New South Wales-wide network of 21 clinics. We report protocol-specified co-primary outcomes at 12 months after recruitment of the first 3700 participants: within-cohort HIV incidence; and change in population HIV diagnoses in New South Wales between the 12-month periods before and after PrEP roll-out. The study is registered with ClinicalTrials.gov , number NCT02870790 . Findings We recruited 3700 participants in the 8 months between March 1, 2016, and Oct 31, 2016. 3676 (99%) were men, 3534 (96%) identified as gay, and 149 (4%) as bisexual. Median age was 36 years (IQR 30–45 years). Overall, 3069 (83%) participants attended a visit at 12 months or later. Over 4100 person-years, two men became infected with HIV (incidence 0·048 per 100 person-years, 95% CI 0·012–0·195). Both had been non-adherent to PrEP. HIV diagnoses in MSM in New South Wales declined from 295 in the 12 months before PrEP roll-out to 221 in the 12 months after (relative risk reduction [RRR] 25·1%, 95% CI 10·5–37·4). There was a decline both in recent HIV infections (from 149 to 102, RRR 31·5%, 95% CI 11·3 to 47·3) and in other HIV diagnoses (from 146 to 119, RRR 18·5%, 95% CI −4·5 to 36·6). Interpretation PrEP implementation was associated with a rapid decline in HIV diagnoses in the state of New South Wales, which was greatest for recent infections. As part of a combination prevention approach, rapid, targeted, high-coverage PrEP implementation is effective to reduce new HIV infections at the population level. Funding New South Wales Ministry of Health, Gilead Sciences.

The use of arbitration in investor-state dispute settlement (ISDS) enables foreign investors to sue host states for alleged breaches of international investment law. But the practise has grown increasingly controversial over the past decade, with respondent states refusing to pay damages, or withdrawing from the system entirely. ISDS is founded on the principles of commercial arbitration that uphold contract law. When used to resolve disputes between foreign companies it is an exercise in private international law. Arbitration in ISDS, however, operates at the level of public international law, because foreign investors enjoy protection standards under treaties signed between their home state and the host state. ISDS thus operates as a form of judicial review, adjudicating on the lawfulness of actions taken by the host State’s Government, Parliament, or Court that may have violated the property rights of the investor. Its decisions can cost host states billions of dollars of taxpayer’s money, and directly impact on rights of citizens protected under International Human Rights Law (IHRL). Yet IHRL is construed as playing little to no role in ISDS arbitration. Thus, the question this paper seeks to answer is whether the continued use of arbitration in ISDS is justified, or not. To do that, ISDS will be put on ‘trial’, charged with being incompatible with public law and the obligations of international law as codified in IHRL. Chapter One presents the case for arbitration in ISDS, Chapter Two the case against, and Chapter 3 reaches a verdict. ISDS is at the frontline of adjudicating globalisation, of striking a balance between profit and people, business and human rights. If it is not justified in law, it can hardly be justified in policy.

Study objective Online educational resources such as blogs are increasingly used for education by emergency medicine clinicians. The Social Media Index was developed to quantify their relative impact. The Medical Education Translational Resources: Indicators of Quality (METRIQ) study was conducted in part to determine the association between the Social Media Index score and quality as measured by gestalt and previously derived quality instruments. Methods Ten blogs were randomly selected from a list of emergency medicine and critical care Web sites. The 2 most recent clinically oriented blog posts published on these blogs were evaluated with gestalt, the Academic Life in Emergency Medicine Approved Instructional Resources (ALiEM AIR) score, and the METRIQ-8 score. Volunteer raters (including medical students, emergency medicine residents, and emergency medicine attending physicians) were identified with a multimodal recruitment methodology. The Social Media Index was calculated in February 2016, November 2016, April 2017, and December 2017. Pearson's correlations were calculated between the Social Media Index and the average rater gestalt, ALiEM AIR score, and METRIQ-8 score. Results A total of 309 of 330 raters completed all ratings (93.6%). The Social Media Index correlated moderately to strongly with the mean rater gestalt ratings (range 0.69 to 0.76) and moderately with the mean rater ALiEM AIR score (range 0.55 to 0.61) and METRIQ-8 score (range 0.53 to 0.57) during the month of the blog post's selection and for 2 years after. Conclusion The Social Media Index's correlation with multiple quality evaluation instruments over time supports the hypothesis that it is associated with overall Web site quality. It can play a role in guiding individuals to high-quality resources that can be reviewed with critical appraisal techniques.

This article provides a high-level overview on the creation of Local Health Integration Networks (LHINs) and illustrates the complexities involved in their implementation. To understand regional structures such as LHINs, one must understand the context in which design and execution takes place. The article ends with a commentary on how Ontario is performing post-LHINs and discusses next steps.

The Canadian taxpayer is an owner of the healthcare system and the owners have a right to be heard. This article encourages leaders both formal and informal to create cultures that promote ASKing questions to test assumptions held, LISTENing to hear the patient voice, and TALKing with patients and families to create new conversations and narratives. Looking at the label, “healthcare system” what’s your contribution to creating health, how will you dedicate yourself to caring about the healthcare consumer and care provider, and what will be your role in creating a new and improved system? An implied question at the foundation of the article is this: Is the difference between managing and leading a difference of empathy?

‘…the possibility of damages for those whose interests Urgenda represents, including current and future generations of Dutch nationals, is so great and concrete that given its duty of care, the state must make an adequate contribution, greater than its current contribution, to prevent hazardous climate change.’ Hague District Court, June 23rd, 2015. In light of the above landmark ruling - which found the Dutch government owed a duty of care to its citizens over action to mitigate climate change - critically evaluate the chances and possible outcomes of bringing a similar action in the English courts, with particular reference to locus standi under tort, public and international law.

Study objective Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r=0.92) and residents (r=0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment.

The lead paper, "Responsibility for Canada's Healthcare Quality Agenda: Interviews with Canadian Health Leaders," is a valuable contribution to the quality and safety improvement conversations taking place across the country. My commentary suggests a dramatic convergence of social, economic, demographic and technological forces has brought healthcare to a threshold of a perfect storm. To brace ourselves against this storm, I have suggested that we need to understand the system not as a structure but as relationships. I argue that alignment is not a concept that is particularly well understood - and we tend to focus almost exclusively on the component of structure.

"Twisting the Lion's Tail" is a valuable and timely contribution to the literature on the need to break down silo thinking and acting. If we stay within a narrow silo by suggesting that researchers generate knowledge, practitioners use the knowledge and then researchers evaluate the results, we will not get to the system thinking view articulated in the lead paper. The author hopes his observations presented in this commentary add to the conversation.

It is widely recognized that Ontario's Wait Time Strategy is a significant change management initiative. But has the province achieved the goal that it set out for itself in November 2004? This article answers this question, beginning with a brief overview of the major inputs or foundational building blocks of the strategy, followed by a detailed analysis of the major outputs or outcomes of the strategy to date.

Ontario's Wait Time Strategy--a significant change management initiative--is designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas by December 2006 (cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements, and MRI and CT scans). These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services beyond 2006. Change management initiatives are initially successful because of the significant time, attention and resources that are dedicated to the start-up effort. Many initiatives lose their momentum and impact and ultimately fail in the long run since it is difficult to sustain this level of intensity. The probability of success increases if a culture is developed to sustain the initiative into the future. A pivotal element for this sustained culture is accountability for achieving results. If Ontario is to reduce waits for quality healthcare services over the long term, it must shift from a paradigm where no one--or only a few--are accountable for achieving a particular set of results to one where a wide range of players is accountable for achieving a broad range of results. This includes explicit accountabilities of the public, healthcare providers (including physicians, other healthcare providers, professional associations and regulatory bodies), government and Local Health Integration Networks. Tools required to support these accountabilities include developing leaders, aligning incentives to reinforce what needs to be achieved, and developing information systems to provide the data needed to make decisions, and manage and improve performance.

Expert panels have been widely used in healthcare as a way of bringing knowledgeable people together to examine issues and identify solutions in well-defined areas. Various terms have been used to describe these groups of experts such as "consensus panels," "blue ribbon panels" and "expert committees or panels." Regardless of the term used, panels of healthcare experts have a history of providing invaluable advice to policy- and decision-makers.

Ontario's Wait Time Strategy was designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas-cancer surgery, cardiac revascularization procedures (cardiac surgery, percutaneous coronary intervention, diagnostic catheterization), cataract surgery, hip and knee total joint replacements and MRI and CT scans. These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services.

Public performance reporting is an increasingly common health policy tool to support accountability and quality improvement but there are few formal evaluations of this trend. In this review, we suggest that performance reporting may be an effective way to support improvements in performance when it is directed towards groups of providers rather than individuals and that there is enough evidence to support the use and further development of public performance reporting. However, the true impact of performance reporting depends on the policy context around reporting including clarity of strategy, incentives, and support for performance improvement.

Despite the prevailing opinion and consensus around how primary healthcare systems should be changed, there is very little agreement on how this should happen and a surprising paucity of research and evaluative evidence related to both system organization and mechanisms for change. The authors reflect on Ontario's experience with primary healthcare renewal and provide insight into lessons learned.

A hospital system is made up of interconnecting circles of complex activity; however, we are conditioned to see and think in straight lines. What we see depends on what we are prepared to see. This article asks the question: What do you see in terms of patient safety and quality of care?

How many days would you be comfortable waiting if you needed cancer surgery? What would you do if someone, not as medically urgent, was able to receive an MRI or CT scan before you? Would you want to know if you could wait less time for treatment at another location or with another clinician? These are some of the dilemmas facing patients and our health system when dealing with the issue of wait times. To address these pressing concerns, in the fall of 2004, Ontario launched its Wait Time Strategy. Two years later, Collins-Nakai et al. (2006) reported that Ontario had moved "from being a laggard to a leader" with respect to wait times. This article summarizes Ontario's work to date to improve access to care, including reviewing the need, action taken and the emerging results. Much can be learned and leveraged from the experiences described in this article and throughout this issue. They can serve as an important starting point for further discussion, improvement and action, for initiatives big and small, by all types of organizations and jurisdictions.

Ensuring that patients receive timely, high-quality healthcare is the highest priority of Ontario's hospitals, physicians and nurses. Given that the emergency department (ED) is often the "front door" to our healthcare system, developing approaches to improve access and flow in the ED is important - made more challenging by rising patient demand and acuity. Long-standing efforts to improve the ED system have outlined promising approaches and pushed access and flow up the priority list. Recently, in partnership with the Ministry of Health and Long-Term Care (MOHLTC), several Ontario hospitals participated in an intensive and sustained effort to improve access and flow, with promising results. Participants in these efforts described the initiatives as transformational, and the results have been promising and sustained. This article chronicles the efforts of three hospitals to enable other hospitals, physicians and nurses to learn from these experiences and gain confidence that a similar impact can be achieved in their facilities. Specifically, it discusses the following: The three pillars of sustainable transformation. Hospital case studies. St. Joseph's Health Centre (SJHC), Toronto. London Health Sciences Centre (LHSC) - University Hospital. University Health Network (UHN) - Toronto General and Toronto Western. Advice for other hospitals

As part of its Wait Time Strategy, the Ontario Ministry of Health and Long-Term Care provided significant amounts of money to perform more cases with the understanding that improving access by reducing wait times is not just a matter of increasing funding. Rather, fundamental system and practice change is required to sustain improvements in the long term.

In many ways SARS unmasked some painful truths about our existing system. Throughout the crisis we had to face head-on the unintended outcomes that flow from a healthcare delivery system designed as a series of unconnected silos.