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Junior doctors' views on clinical audit - has anything changed? A postal questionnaire survey of junior doctors' views was conducted in a large acute hospital in the south-east of England, amongst 146 junior medical staff recorded as being employed by the Trust across 21 specialities. It profiled their level of participation in audit and the quality of current audit programmes within their specialities and assessed their knowledge and understanding of clinical governance. Our findings suggest: a high level of involvement in activities labelled audit, but that these activities did not necessarily conform to robust audit methodologies; that junior doctors' professional attitudes towards clinical audit are influenced by negative experience of undertaking audit within their specialities; and that there was a variety of understanding about the principles and meaning of clinical governance. It concluded that the conditions for coherent strategy aimed at promoting effective audit programmes which could support the use of clinical audit as a tool for continuous professional development are not yet in place across the Trust.
Keywords: Doctors, Audit, Attitudes, Governance, Risk, Evidence
Comparing patients' experience of mental health services in England: a five-Trust survey The implementation of the Care Programme Approach (CPA) in English mental health services has been slow to proceed despite general support, both in England and in other countries, of its principles of good practice. This study set out to evaluate the implementation of the CPA directly from patients' experience using the "Your Treatment and Care" assessment tool. The results of a survey of 503 patients across five NHS Trusts in England showed that many patients did not have a copy of their care plan and had not been involved in the care planning procedure. Many reported shortcomings in their experience of their key worker and their psychiatrist. However, there was substantial variation in experience across services. "Your Treatment and Care" showed good internal reliability, was acceptable to users, and appeared to be able to access actual experiences better than a traditional "satisfaction" item. It appears to be very useful as a benchmarking tool and is now being used in services across the UK, the USA and Australia.
Keywords: Quality, Feedback, Mental health, United Kingdom
Quality improvement in the healthcare industry: some evidence from Singapore Presents an exploratory field research on all hospitals in Singapore, highlighting the different routes hospitals have adopted in pursuing their corporate quality journey for the new millennium. In general, both continuous improvement and innovation-based approaches have generated cost and time savings and helped to streamline work processes. However, the initial survey results show that innovation-based programs require a longer time frame for implementation, are more prone to resistance to change and suffer from program failure. Also, large hospitals and public hospitals are more inclined to implement innovation based approaches while medium-sized hospitals tend to use continuous improvement as a medium for quality improvement.
Keywords: Continuous improvement, Total quality management, BPR, Hospitals, Singapore
Re-engineering pharmaceutical care: towards a patient-focused care approach As healthcare reform takes shape, many challenges face hospital pharmacists. An opportunity exists to combine the principles of patient-focused care and pharmaceutical care to redesign the role of pharmacy. To achieve this objective, pharmacy departments should adopt business concepts such as process re-engineering. Process re-engineering is a change management tool which aims to produce dramatic improvement in performance measures by re-designing the process. The goal of restructuring is to increase the amount of time pharmacists spend providing pharmaceutical care to patients. The pharmaceutical care concept is a method of delivering pharmaceutical care services that match individual patient needs with the services provided. This article describes many hospital pharmacy department transitions to a patient focused care environment by adopting the patient focused care concept and the process re-engineering to improve the quality of patient care through systems improvement.
Keywords: Pharmaceuticals, Process re-engineering, Organizational change, Hospitals
Patient participation requires a change of attitude in health care A partnership is founded on equality and mutual respect. In health care there is no balance of power between the patient and the health-care professional. To be able to create healthy partnerships we can aim for a balance by focusing on the interpersonal relationship between partners. To understand the system and be able to change it we have to see it from the patient's point of view. This implies a change of attitude in health care. Each of us have to select, plan and execute our own behavioural changes. We also have to create a system based on the premises of the consumers. Establishing a patient/relative panel is an example of creating an arena for building partnerships with patients. By combining professional knowledge with systematic input from experienced consumers the hospital organization can get access to valuable knowledge and insight to improve the care for the patients.
Keywords: Partnering, Attitudes, Co-operation, Customers, Organizational change, Norway
The patient care development programme: organisational development through user and staff involvement A number of approaches have been developed in recent years to try effectively to engage service users in the process of planning and delivering health-care services. The consumerist methodology for the strategy described in this paper was designed to maximise staff involvement in capturing user views, in order to develop services at a district general hospital. This strategy - the Patient Care Development Programme (PCDP) - provides a framework for both staff and patient involvement in shaping and influencing the development of health-care services. Uses the findings from applying the strategy to modify care packages, roles, skills, layouts, protocols and procedures, in response to both the "shortfalls" and the service strengths that the patient's view uncovers. Discusses the results of an evaluation of the programme which has been replicated in another part of the UK. The PCDP now forms part of a clinical governance framework and is being used to develop multi-agency integrated care pathways.
Keywords: Qualitative techniques, Employee involvement, Organizational development, User studies
Quality in finance of health care: the unaddressed imperative As the health-care industry undergoes major change, a method of "accounting for quality" has become a key factor in health services delivery and fiscal accountability. This article examines several aspects of health care that inhibit the development of common methods of defining and accounting for quality. Key issues and characteristics of the health-care market are addressed and the article provides a synthesis of these obstacles to the process of deriving common measures and standards of quality that may be utilized by the health-care industry for financial decisions.
Keywords: Quality, Health care, Finance, Accountability, Stakeholders, Efficiency
System negligence is at the root of medical error This article compares the ways in which we think about errors and poor quality in health care to the approach taken by other industries. It proposes a more scientific study of accidents and "near misses" in health care and a systems perspective to understand errors as the logical outcome of a chain of events. The present focus on individuals as the source of quality needs to be balanced with an understanding of the role of systems in preventing error and ensuring high quality.
Keywords: Medical professions, Quality systems
Managing the development of partnerships in Health Action Zones Within Britain the Blair Government has committed itself to a modernisation process within the public sector. This process involves rethinking how to organise services internally and how to integrate services across government. Policy makers are talking about "joined-up" government, innovation and partnerships. In the UK there are now a plethora of partnerships and initiatives. The Health Action Zones (HAZ) were one of the first of such initiatives and as such present fertile ground for analysis of the modernisation process. This paper draws on the experience of those engaged in the HAZ partnerships and also on research conducted by the author on "conditions for partnership". It appears that the conditions in the UK are not conducive for partnerships when national frameworks are focused on monitoring rather than on development, and when the measurement of partnership success is short term. Although the partnership and modernisation policy encourages innovation, the development of partnerships is hampered by internal blame cultures, poor change management and a development gap in thinking among policy makers.
Keywords: Public sector, Partnering, Stakeholders, Policy, Health care, United Kingdom
Are different models of care pathways being developed? Care pathways are becoming increasingly popular within UK healthcare organisations yet very little is known about the tool. Using the results from a survey of healthcare organisations, which are members of the National Pathways Association (NPA), the author suggests that different models of care pathways are being implemented. Four models or different types of care pathways are identified, with different features in each model. The models can be used prospectively by organisations to decide which particular features they may want to include. Alternatively, the models can be used as an assessment tool to identify the type of pathway being developed. This assessment can form the basis for any future evaluations of the effectiveness of the pathways which are developed.
Keywords: Health care, Model, Survey
Culturally sensitive mental health services through quality improvement An urban mental health service undertook a quality improvement programme to involve staff in the identification and resolution of cross-cultural issues. The programme involved clinical file audits, staff survey and workshops, and a focus group for consumers and their carers. It was found that non-English speaking patients received a different spectrum of services from English speaking patients. Non-English speaking patients were found to receive more pharmacological treatments and less cognitive behavioural therapy. In seeking to address these issues and improve their service delivery to all patients, the mental health service is now in the process of developing cross-cultural training; revising policies and procedures; and engaging bilingual mental health counsellors in a revision of their roles, particularly to increase their availability to staff as cultural consultants.
Keywords: Mental health, Quality improvement, Organizational change, Ethnic groups, Australia
Is the practice of psychological therapists evidence-based? An interview-based survey of evidence-based practice (EBP) and the research, continuing professional development (CPD) and audit activity that support it was conducted in the North East of England amongst a representative sample of NHS clinical psychologists and counsellors (n = 30). It profiled their participation in EBP activities over the past year and their intentions for the next year. The findings suggest that the sample had used guidelines and protocols on 56 per cent of occasions, had on average drawn on research, CPD and audit approximately half of the time, but had been only minimally influenced by research, CPD or audit. It is concluded that EBP has occurred in all defined areas and that the conditions for an increased degree of EBP are promising.
Keywords: Audit, Psychology, Quality assurance, Continuing development
Measuring the inappropriate utilization of accident and emergency services? Accident and Emergency (A&E) departments are increasingly popular venues for primary care, causing a serious threat to healthcare quality. This paper reports the development of a comprehensive research method for identifying primary care patients attending A&E. Patients were randomly selected from the four A&E departments across different time periods and different regions in Hong Kong. The definition of GP cases was based on a retrospective record review conducted by a panel of emergency physicians using the standard laid down by the Hong Kong College of Family Physicians. The patients sampled were similar in sex and age distribution to A&E attendees for the whole territory. The level of GP cases was found to be 57 per cent, with a significantly higher proportion of patients in the younger age group. The high level of use reflects the lack of a well co-ordinated development of primary care services and interfacing with secondary care.
Keywords: Hospitals, Health care, General practice, Hong Kong
Q methodology, risk training and quality management The results of a Q methodological study of professional understandings of the notion of risk in mental health services within the UK are discussed in relation to the relevance for staff training and quality assurance. The study attempted to access the diversity of understandings of risk issues amongst a multi-professional group of staff (n = 60) attending inter-agency risk training workshops in 1998. Q methodology is presented as both an appropriate means for such inquiry and as a novel experiential technique for training purposes. A tentative argument is advanced that the qualitative accounts generated by Q research could assist in systematic reviews of quality, complementing the singularly quantitative approaches typically represented in the audit process.
Keywords: Risk, Mental health, Training, Quality assurance, Quality management, United Kingdom
Monitoring health-care processes: a framework for performance indicators Until recently, it was uncommon to ask professionals to give objective evidence to non-professionals regarding the quality of their work. Nowadays, however, professionals, their health-care processes and their health-care organisations have to face assessments concerning organisation, control and content of the work. Meanwhile, health-care organisations generate improvement programmes to mutually match activities of individual professionals and to redesign health-care processes within or between health-care organisations. In all these situations information is required on the current and sometimes the improved stage of the health-care process. Often performance indicators are mentioned to generate this information. In this paper we present a framework of performance indicators and related measuring instruments to monitor and evaluate health-care processes. It is based on a literature scan and on empirical research in two general hospitals and one mental hospital. The literature scan was guided by the three case studies and in the case studies the framework was tested.
Keywords: Performance indicators, Health care, Process management, Measurement
Developing a competency framework to support training in evidence-based healthcare This paper focuses on the practice of evidence-based healthcare by doctors, nurses, midwives and the professions allied to medicine in four NHS Trusts in and around London. This qualitative study, based on interviews and self-efficiency ratings uncovered the extent of evidence based practice between different groups and between acute and community Trusts, the perceived obstacles to the adoption and implementation of EBHC, and throws light on the knowledge, skills and attitudes required for such practice. Five clusters of competencies were identified - personal attributes, interpersonal, self-management, information management and technical knowledge skills - and these form the basis of a competency framework of measurable criteria to assess proficiency as well as staff training needs which it is hoped will enable NHS Trusts to devise strategies to meet the requirements and challenges of clinical governance from April 1999.
Keywords: Competences, Doctors, Evidence, Health care, Nurses, Self-efficiency, Training needs
Improving organisational culture through innovative development programmes Recognising that changing culture is the most important role of a leader, the authors provide a diagnostic description of the culture within the nursing directorate of a National Health Service Trust. When the characteristics of the prevailing culture are compared with those associated with one that is ideal, many gaps are identified. In an attempt to address and overcome these gaps, the leaders within the organisation worked with the staff of the nursing directorate and in turn identified that learning and development was a priority if improvements were to be attained. Consequently two innovative development programmes were designed and the necessary steps taken to effect their implementation. The details of the programmes are provided along with the benefits and drawbacks attributed to this particular initiative.
Keywords: Corporate culture, Development, Learning, Nurses, Organizational change
Quality of diagnostic services for cancer: a comparison of open access and conventional outpatient clinics Objective and study design: to assess quality of a quick and early diagnosis route (QED) by determining effectiveness and cost- effectiveness of five clinics compared with three conventional outpatient clinics. Prospective economic evaluation. Six-month cohort of all referrals (November 1996-April 1997). Subjects: all referrals for suspected cancers of: upper gastro-intestinal tract; urinary tract, prostate and testis; skin. Effectiveness: median days saved between GP referral and date of: diagnostic appointment; consultant decision; intervention. Results: GP referral to diagnostic appointment: QED was effective (median days) for all clinics. Diagnostic appointment to consultant decision: QED was effective for testicular and haematuria clinics. Consultant decision to intervention: QED was effective for haematuria, testicular and melanoma clinics. Cost-effectiveness: extra (incremental) NHS cost per patient diagnosed. Results: Less than £5 per day saved between GP referral and diagnostic appointment for: endoscopy; haematuria; prostate; testicular; melanoma. Less than £3 per day saved between GP referral and consultant decision for: testicular; haematuria. Less than £3 per day saved between GP referral and intervention for: endoscopy; haematuria; testicular; melanoma. Conclusion: A "quick and early" diagnostic route provides a higher quality service through improved effectiveness and cost-effectiveness compared to conventional outpatients.
Keywords: Cost-effectiveness, Effectiveness, Health care, Service quality, Tests
Improving performance through self-assessment Wakefield and Pontefract Community Health NHS Trust uses the European Business Excellence Model self-assessment for continuous improvement. An outline of the key aspects of the model, an approach to TQM, is presented. This article sets out the context that led to the adoption of the model in the Trust and describes the approach that has been taken to completing self-assessments. Use of the model to secure continuous improvement is reviewed against Bhopal and Thomson's Audit Cycle and consideration is given to lessons learned. The article concludes with a discussion on applicability of the model to health care organisations. It is concluded that, after an initial learning curve, the model has facilitated integration of a range of quality initiatives, and progress with continuous improvement. Critical to this was the linking of self-assessment to business planning and performance management systems.
Keywords: Kaizen, NHS, Performance management, Self assessment, Strategic planning, TQM
Survival during and after hospitalization: a medical record linkage In Sweden, hospital stays, deaths, sick- listings and censuses have long been stored on electronic media. The purpose of the study was to apply post-hospital survival measures to hospitals having differing degrees of specialization by linking existing data in censuses and in-patient registers. In-patient records totaling 3.6 million were collected. They were linked to the 1985 and 1990 censuses regarding patients' background data, and the national insurance register. Results found that the survival was longer and the return to work quicker when hospitals were well staffed, had competent personnel and many specialties. In general, small hospitals were worse off in all aspects. Concludes that small hospitals should be given better support.
Keywords: Hospitals, Measurement, Multivariate analysis, Outcomes, Statistics
As always we have only skimmed the surface of relevant articles this week and only those that are particularly relevant for Asia-Pacific managers. Many other articles are available as well including those focusing on other countries and international perspectives.
Health Care Management (1) Jan 2000 |
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