Evaluating the impact of service delivery initiatives on patients’ waiting times in diagnostic radiology: a mixed methods study

This thesis describes the impact of service delivery initiatives (SDIs) on patients’ waiting times within radiology departments. A systematic review of the literature (71 studies included) found the following broad type of SIDs: extended scope practice, quality management, productivity-enhancing technologies, outsourcing, pay-for-performance and multiple interventions. Ninety-six percent of the studies used either the pre- and post-intervention without control or the post-intervention only designs; but these designs are fundamentally weak and prone to bias. Furthermore, this thesis also described a case-study for the evaluation of the impact on patients’ waiting times of a 320-slice computed tomography (CT) scanner, speech recognition reporting and extended-working-hours within the Birmingham Heartlands Hospital (Heart of England NHS Foundation Trust), Birmingham. The evaluation combined the interrupted time series (ITS) design and qualitative interviews with healthcare professionals in a mixed methods approach. The mixed methods approach leverages the strengths of the quantitative and qualitative methods, so that the triangulation of the findings of one research method might be strengthened when supported by the findings of the other research method. The thesis used a distinctive implementation of ITS segmented regression which accounts for the changing trends of patients waiting times – an approach referred to as ITS ‘segmented spline’ regression

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

BackgroundHospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.AimsTo investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.MethodsThe project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.FindingsPatients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.ConclusionsThis research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula

Case study of strategic development process in the Umhlanga Dental Practice (UDP)

Thesis (MBA)-University of Natal, 2003.The dissertation evolved out a need to determine the strategic way forward for the Umhlanga Dental Practice (UDP). The practice has been experiencing major and minor changes in its internal and external environments. The general strategic approach has been to merely adapt to these changes but with a distinct lack of formal, planned sustainable initiatives.The First chapter of the dissertation highlights the necessary theory that will be applied to the specific situation surrounding the practice. Includes the various approaches to strategic analysis of the external and internal environments of the organisation. Thus a theoretical framework is illustrated that may be applicable to determining the various situations of any organisation. Chapter Two presents the application of the theoretical framework to illustrate the specific conditions that the practice finds itself in. Chapter Three identifies all the necessary analysis and evaluation of the strategic options available to the practice and aids in determining the strategic way forward. The present and future resources required to implement the chosen strategies are also analysed. Thus providing the basis for the next chapter. The last chapter focuses on Implementation of the various strategic options available to the practice. Implementation is encouraged in incremental stages and with a definite time line that enables the key resources within the practice to be adapted to the new strategies. Control of the organisation and monitoring of the strategies is an essential part of any strategic implementation and is discussed as the last part of Chapter Five. The dissertation thus addresses an actual problem that is relevant and applicable to an existing practice

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background: Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown. Aims: To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners. Methods: The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources. Findings: Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity. Conclusions: This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions. Funding: The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown. Aims To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners. Methods The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources. Findings Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity. Conclusions This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions

The application of process mining to care pathway analysis in the NHS

Background: Prostate cancer is the most common cancer in men in the UK and the sixth-fastest increasing cancer in males. Within England survival rates are improving, however, these are comparatively poorer than other countries. Currently, information available on outcomes of care is scant and there is an urgent need for techniques to improve healthcare systems and processes. Aims: To provide prostate cancer pathway analysis, by applying concepts of process mining and visualisation and comparing the performance metrics against the standard pathway laid out by national guidelines. Methods: A systematic review was conducted to see how process mining has been used in healthcare. Appropriate datasets for prostate cancer were identified within Imperial College Healthcare NHS Trust London. A process model was constructed by linking and transforming cohort data from six distinct database sources. The cohort dataset was filtered to include patients who had a PSA from 2010-2015, and validated by comparing the medical patient records against a Case-note audit. Process mining techniques were applied to the data to analyse performance and conformance of the prostate cancer pathway metrics to national guideline metrics. These techniques were evaluated with stakeholders to ascertain its impact on user experience. Results: Case note audit revealed 90% match against patients found in medical records. Application of process mining techniques showed massive heterogeneity as compared to the homogenous path laid out by national guidelines. This also gave insight into bottlenecks and deviations in the pathway. Evaluation with stakeholders showed that the visualisation and technology was well accepted, high quality and recommended to be used in healthcare decision making. Conclusion: Process mining is a promising technique used to give insight into complex and flexible healthcare processes. It can map the patient journey at a local level and audit it against explicit standards of good clinical practice, which will enable us to intervene at the individual and system level to improve care.Open Acces

Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model

Background We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design. Objective(s), study design, settings and participants Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions. Results A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality. Limitations Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly. Conclusions We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people. Future work Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs. Study registrations This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information

Assuming Data Integrity and Empirical Evidence to The Contrary

Background: Not all respondents to surveys apply their minds or understand the posed questions, and as such provide answers which lack coherence, and this threatens the integrity of the research. Casual inspection and limited research of the 10-item Big Five Inventory (BFI-10), included in the dataset of the World Values Survey (WVS), suggested that random responses may be common. Objective: To specify the percentage of cases in the BRI-10 which include incoherent or contradictory responses and to test the extent to which the removal of these cases will improve the quality of the dataset. Method: The WVS data on the BFI-10, measuring the Big Five Personality (B5P), in South Africa (N=3 531), was used. Incoherent or contradictory responses were removed. Then the cases from the cleaned-up dataset were analysed for their theoretical validity. Results: Only 1 612 (45.7%) cases were identified as not including incoherent or contradictory responses. The cleaned-up data did not mirror the B5P- structure, as was envisaged. The test for common method bias was negative. Conclusion: In most cases the responses were incoherent. Cleaning up the data did not improve the psychometric properties of the BFI-10. This raises concerns about the quality of the WVS data, the BFI-10, and the universality of B5P-theory. Given these results, it would be unwise to use the BFI-10 in South Africa. Researchers are alerted to do a proper assessment of the psychometric properties of instruments before they use it, particularly in a cross-cultural setting

Leading Towards Voice and Innovation: The Role of Psychological Contract

Background: Empirical evidence generally suggests that psychological contract breach (PCB) leads to negative outcomes. However, some literature argues that, occasionally, PCB leads to positive outcomes. Aim: To empirically determine when these positive outcomes occur, focusing on the role of psychological contract (PC) and leadership style (LS), and outcomes such as employ voice (EV) and innovative work behaviour (IWB). Method: A cross-sectional survey design was adopted, using reputable questionnaires on PC, PCB, EV, IWB, and leadership styles. Correlation analyses were used to test direct links within the model, while regression analyses were used to test for the moderation effects. Results: Data with acceptable psychometric properties were collected from 11 organisations (N=620). The results revealed that PCB does not lead to substantial changes in IWB. PCB correlated positively with prohibitive EV, but did not influence promotive EV, which was a significant driver of IWB. Leadership styles were weak predictors of EV and IWB, and LS only partially moderated the PCB-EV relationship. Conclusion: PCB did not lead to positive outcomes. Neither did LS influencing the relationships between PCB and EV or IWB. Further, LS only partially influenced the relationships between variables, and not in a manner which positively influence IWB