Table 1 Results of review of medical literature and jurisdictional papers on frameworks for organizing service delivery systems
Author(s), Year | Title | Country | Service focus | Proposed framework | Aim | Description |
|---|---|---|---|---|---|---|
1. Medical literature | ||||||
American Academy of Pediatrics Committee on Fetus And Newborn [10], 2012 | Levels of neonatal care | USA | Neonatal services | Levels of neonatal care | To review the current status of the designation of levels of newborn care definitions in the United States, which were delineated in a 2004 policy statement by the American Academy of Pediatrics [11]. | • Updates the previous classification to: basic care (Level I), specialty care (Level II), and subspecialty intensive care (Level III, Level IV). • Each level reflects the minimal capabilities, functional criteria, and provider type required. |
Falster et al. [12], 2012 | Development of a maternity hospital classification for use in perinatal research | Australia | Maternity services | Maternity hospital classification | To develop a maternity hospital classification, using stable and easily available criteria that would have wide application in maternity services research and allow comparison across state, national and international jurisdictions. | • Uses four dimensions of service level for categorization: neonatal care capability, geography, annual average number of births, and hospital status (public or private). • Classifies maternity hospitals by 13 obstetric groups, which were then collapsed into a set of six groups for analysis (tertiary hospital, hospital with continuous positive airways pressure, all other urban hospitals, large regional hospitals (delivery volume ≥ 1000), all other regional hospitals (< 1000), and private hospitals). |
Frankel et al. [13], 2019 | Criteria for critical care of infants and children: PICU admission, discharge, and triage practice statement and levels of care guidance | USA | Pediatric services | Levels of care for PICU | To update the American Academy of Pediatrics and Society of Critical Care Medicine’s 2004 Guidelines and levels of care for PICU. | • Distinguishes between three levels of care: quaternary or specialized PICU care (provides regional care and serves large population or has a large catchment area), tertiary PICU care (provides advanced care for many medical and surgical illnesses in infants and children), and community PICU care (provides a broad range of services and resources that may differ based on institution, hospital size, and referral base). • Addresses important specifications for each PICU level of care, including team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. |
Grzybowski et al. [14], 2009 | Planning the optimal level of local maternity service for small rural communities: a systems study in British Columbia | Canada | Maternity services | Population isolation model | To develop and apply a population isolation model to define the appropriate level of maternity service for rural communities in British Columbia, Canada. | • Models rural healthcare service based on community population size, social vulnerability, and degree of isolation or access to maternity services (determining the rural birth index score). • Applies the rural birth index score to six community maternity service levels: no local intrapartum service, local intrapartum service without operative delivery, local GP surgical service, mixed model of specialists and GP surgeons, specialist only models. |
Kilpatrick et al. [15], 2019 | Obstetric care consensus #9: levels of maternal care | USA | Maternity services | Levels of maternal care | To reaffirm the need for levels of maternal care, as initially presented in the 2015 Obstetric Care Consensus [16]. To reaffirm that the goal of levels of maternal care is to reduce maternal morbidity and mortality. To clarify definitions and revise criteria by applying experience from jurisdictions that are actively implementing levels of maternal care. | • Establishes a classification system with levels of maternal care that pertain to: basic care (Level I), specialty care (Level II), subspecialty care (Level III), and regional perinatal health care centers (Level IV), to standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care. • Provides definitions, capabilities, and health care providers for each of the four levels of maternal care and for birth centers. |
Marshall et al. [17], 2016 | What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine | Canada and others | Critical care services | - | To develop a globally applicable answer to the question “What is an ICU?” | • Describes three ICU levels: Level 1 ICU is capable of providing oxygen, non-invasive monitoring, and more intensive nursing care than on a ward; Level 2 ICU can provide invasive monitoring and basic life support for a short period; Level 3 ICU provides a full spectrum of monitoring and life support technologies, serves as a regional resource for the care of critically ill patients, and may play an active role in developing the specialty of intensive care through research and education. |
Matthey et al. [18], 2010 | Facilities for the treatment of adults with haematological malignancies – ‘Levels of Care’: BCSH Haemato-Oncology Task Force 2009 | United Kingdom | Oncology services | Levels of care (BCSH Haemato-Oncology Task Force) | To provide an updated guideline for use both by providers of this clinical care and by those who commission it. | • Propose three levels of care with Level 2 being subdivided into Levels 2a and 2b. • Levels of care reflect the facilities and resources required to treat patients with haematological malignancies. |
Queensland Government [19], 2016 | The clinical services capability framework | Australia | Different clinical services | Clinical services capability framework | References the jurisdictional paper [20], which objective is: to guide a coordinated and integrated approach to health service planning and delivery in Queensland. | • Categorizes clinical services into six levels. Each level builds on the previous level, with Level 1 managing the least complex patients to Level 6 managing the highest level of patient complexity. • Informs health service planning and delivery by providing a set of minimum patient safety criteria by each clinical service area’s capability level. |
Saigal et al. [21], 2017 | Mapping the characteristics of critical care facilities: assessment, distribution, and level of critical care facilities from Central India | India | Critical care services | - | To classify Intensive Care Units (ICUs) according to the level of care in the state of Madhya Pradesh. | • Provides a consensus scoring grid to define three levels of care of ICUs. • Assigns ten parameters to the scoring grid including number of ICU beds, nurse to patient ratio, invasive ventilator to bed ratio, doctor’s qualification, monitoring devices, imaging, laboratory, procedures conducted, protocols, teaching and training. |
Vandenberg et al. [22], 2009 | A framework for the organization and delivery of systemic treatment | Canada | Oncology services | Regional model of care for systemic treatment | To provide safe, evidence-based systemic cancer treatment while maximizing the efficient use of resources and implementing the principle of patient-centred care provided as close to home as possible. | • Comprises four levels of care determined by a regional systemic treatment program and three integrated structures (integrated cancer programs, affiliate institutions, and satellite institutions). • Level of complexity and availability of service differentiate one level from another. |
2. Jurisdictional papers | ||||||
American Association of Community Psychiatrists [23], 2009 | Level of care utilization system for psychiatric and addiction services (LOCUS): adult version 2010 | USA | Mental health and addiction services | Level of care utilization system for psychiatric and addiction services | To describe a continuum of service arrays which vary according to the amount and scope of resources available at each “level” of care.a | • Defines six levels of care in the service continuum: recovery maintenance and health management, low intensity community based services, high intensity community based services, medically monitored non-residential services, medically monitored residential services, and medically managed residential services. • Each level is described in terms of four variables: care environment, clinical services, support services and crisis resolution and prevention services. |
American College of Surgeons [24], 2015 | Optimal resources for children’s surgical care v.1. | USA | Pediatric surgical services | Children’s surgical center levels | To define optimal resources for children’s surgical care. | • Classifies three tiers of children’s surgical centers: basic, advanced, comprehensive. • Identifies criteria that are judged essential for each level of children’s surgical center designation. • Considers medical and access needs of the pediatric population. |
American College of Surgeons [25], 2014 | Resources for optimal care of the injured patient | USA | Trauma services | Levels of trauma centers | To set appropriate standards for the optimal care of the trauma patient, ensure the right infrastructure and people, ensure high quality data for performance improvement and verify that quality outcomes are present.a | • Defines four levels of trauma care facilities: Level I (regional resource trauma center that is a tertiary care facility), Level II (expected to provide initial definitive trauma care, regardless of the severity of injury), Level III (serves communities that do not have immediate access to a Level I or II institution), Level IV (provides advanced trauma life support before patient transfer in remote areas where no higher level of care is available). |
Australian Government [26], 2012 | National maternity services capability framework | Australia | Maternity services | National maternity services capability framework | To support the provision of safe maternity services in as many localities as possible across Australia in both the public and private sectors. | • Defines six levels of maternity care by describing the minimum service capability requirements for both public and private maternity services across all rural, regional and metropolitan settings. • Identifies four key elements to meet the objectives of service safety, quality, planning and coordination: complexity of care, workforce, clinical support services, and service networks and integration. |
Government of South Australia [27], 2016 | Clinical services capability framework: fundamentals of the framework | Australia | Different clinical services | Clinical services capability framework | To guide a coordinated and integrated approach to health service planning and delivery in South Australia.a | • Categorizes clinical services into six service levels with Level 1 managing the least complex patients and Level 6 managing the highest level of patient complexity. Outlines indicative service requirements, workforce requirements and support services for health services to deliver safe and appropriately supported clinical service delivery. |
Government of Western Australia [28], 2015 | WA health clinical services framework 2014–2020 | Australia | Different clinical services | WA health clinical services framework | To describe medium and long-term horizons and strategic parameters that can be used by individual health services, hospitals, and non-hospital service providers to inform and guide their individual clinical service/s plans. | • Provides a blueprint for the whole health system in planning services, workforce, infrastructure, technology and budgeting. • Gives an overview of the minimum requirements and capabilities necessary to deliver safe and quality services at a particular level in the range one through six (form least to most complex). |
National Health Service [29], 2016 | Paediatric critical care standards for London: level 1 and 2 | United Kingdom | Pediatric critical care services | Paediatric critical care levels | For NHS Trusts: to determine whether current paediatric critical care services meet appropriate standards. For commissioners: to guide their decisions about service provision and quality assurance. | • Distinguishes between three pediatric critical care units: Level 1 (basic critical care), Level 2 (intermediate critical care in a district general hospital or tertiary hospital setting), and Level 3 (advanced critical care). • Provides the pediatric critical care Level 1 and 2 standards. |
New Zealand Ministry of Health and District Health Boards [30], 2014 | The NZ role delineation model: overview and instructions for use | New Zealand | Different clinical services | New Zealand role delineation model | To differentiate complexity between services within, and across District Health Boards providers. | • Creates specialty service capability levels that can be used to describe and understand patient services across the region. • The six levels of complexity usually extends from community based services through to the most complex setting. |
NSW Government [31], 2018 | NSW health guide to the role delineation of clinical services | Australia | Different clinical services | Role delineation | To provide a consistent language across NSW for describing clinical services. | • Describes the minimum support services, workforce and other requirements for clinical services to be delivered safely. • Clinical services are categorised into six service levels with Level 1 managing the least complex patients and Level 6 managing the highest level of patient complexity. |
Provincial Council for Maternal and Child Health [32], 2018 | Paediatric levels of care | Canada | Pediatric services | Paediatric levels of care | To ensure that quality services are provided to paediatric patients and their families as close to home as possible, in other words, care provided in the right place at the right time by the right providers. | • Describes three components: (i) three levels of inpatient care; (ii) classification of paediatric medical and surgical patients by acuity/complexity and procedural complexity; (iii) paediatric requirements related to physician/nursing skills and education needs; organizational/continuous quality improvement requirements; allied health human resource requirements; and diagnostic imaging, procedures, treatments, and equipment. |
Provincial Council for Maternal and Child Health [33], 2013 | Standardized maternal and newborn levels of care definitions | Canada | Maternity and neonatal services | Levels of maternal-newborn care | None stated | • Describes maternal and newborn services for Levels Ia and Ib (small hospital), Levels IIa, IIb and IIc (large community hospital), and Level III (tertiary hospital). • Highlights that maternal and newborn levels should be aligned (i.e. the levels are the same within each organization). |
Tasmanian Government [34], 2018 | Tasmanian role delineation framework and clinical services profile | Australia | Different clinical services | Tasmanian role delineation framework | To describe the minimum support services, safety standards, skills and competencies, networking arrangements, and other service requirements necessary to provide a service at a specific level to ensure safe and appropriately supported clinical service delivery. | • Categorizes core clinical services (e.g. medical imaging, or anaesthetics) and clinical support services into six levels of service provision. • The service levels are cumulative and build on each previous level’s capability requirement. |
Victorian Government [35], 2017 | Statewide design, service and infrastructure plan for Victoria’s health system: 2017–2037 | Australia | Different clinical services | System role delineation framework | None stated | • Different capability frameworks, such as the capability framework for Victorian maternity and newborn services [36], specify the minimum requirements each health service must meet to provide safe, high-quality services to patients of varying complexity. |