A safer place for patients: learning to improve patient safety

1 Every day over one million people are treated successfully by National Health Service (NHS) acute, ambulance and mental health trusts. However, healthcare relies on a range of complex interactions of people, skills, technologies and drugs, and sometimes things do go wrong. For most countries, patient safety is now the key issue in healthcare quality and risk management. The Department of Health (the Department) estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed, a rate similar to other developed countries. Around 50 per cent of these patient safety incidentsa could have been avoided, if only lessons from previous incidents had been learned. 2 There are numerous stakeholders with a role in keeping patients safe in the NHS, many of whom require trusts to report details of patient safety incidents and near misses to them (Figure 2). However, a number of previous National Audit Office reports have highlighted concerns that the NHS has limited information on the extent and impact of clinical and non-clinical incidents and trusts need to learn from these incidents and share good practice across the NHS more effectively (Appendix 1). 3 In 2000, the Chief Medical Officer’s report An organisation with a memory 1 , identified that the key barriers to reducing the number of patient safety incidents were an organisational culture that inhibited reporting and the lack of a cohesive national system for identifying and sharing lessons learnt. 4 In response, the Department published Building a safer NHS for patients3 detailing plans and a timetable for promoting patient safety. The goal was to encourage improvements in reporting and learning through the development of a new mandatory national reporting scheme for patient safety incidents and near misses. Central to the plan was establishing the National Patient Safety Agency to improve patient safety by reducing the risk of harm through error. The National Patient Safety Agency was expected to: collect and analyse information; assimilate other safety-related information from a variety of existing reporting systems; learn lessons and produce solutions. 5 We therefore examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. Key parts of our approach were a census of 267 NHS acute, ambulance and mental health trusts in Autumn 2004, followed by a re-survey in August 2005 and an omnibus survey of patients (Appendix 2). We also reviewed practices in other industries (Appendix 3) and international healthcare systems (Appendix 4), and the National Patient Safety Agency’s progress in developing its National Reporting and Learning System (Appendix 5) and other related activities (Appendix 6). 6 An organisation with a memory1 was an important milestone in the NHS’s patient safety agenda and marked the drive to improve reporting and learning. At the local level the vast majority of trusts have developed a predominantly open and fair reporting culture but with pockets of blame and scope to improve their strategies for sharing good practice. Indeed in our re-survey we found that local performance had continued to improve with more trusts reporting having an open and fair reporting culture, more trusts with open reporting systems and improvements in perceptions of the levels of under-reporting. At the national level, progress on developing the national reporting system for learning has been slower than set out in the Department’s strategy of 2001 3 and there is a need to improve evaluation and sharing of lessons and solutions by all organisations with a stake in patient safety. There is also no clear system for monitoring that lessons are learned at the local level. Specifically: a The safety culture within trusts is improving, driven largely by the Department’s clinical governance initiative 4 and the development of more effective risk management systems in response to incentives under initiatives such as the NHS Litigation Authority’s Clinical Negligence Scheme for Trusts (Appendix 7). However, trusts are still predominantly reactive in their response to patient safety issues and parts of some organisations still operate a blame culture. b All trusts have established effective reporting systems at the local level, although under-reporting remains a problem within some groups of staff, types of incidents and near misses. The National Patient Safety Agency did not develop and roll out the National Reporting and Learning System by December 2002 as originally envisaged. All trusts were linked to the system by 31 December 2004. By August 2005, at least 35 trusts still had not submitted any data to the National Reporting and Learning System. c Most trusts pointed to specific improvements derived from lessons learnt from their local incident reporting systems, but these are still not widely promulgated, either within or between trusts. The National Patient Safety Agency has provided only limited feedback to trusts of evidence-based solutions or actions derived from the national reporting system. It published its first feedback report from the Patient Safety Observatory in July 2005

Syntyvien alaryhmädynamiikkojen johtaminen merkittävissä päätöksentekotapahtumissa tietotekniikka-alan kasvuyrityksissä

Startups have been a growing subject both in the academia and industrial world in the past years. More and more focus has been given to them, not least in terms of venture capital funding. The hype can be argued, but startups are, nevertheless, gaining a foothold both in employing talent and having an economic impact. Compared to large and established corporations, startups operate on an immensely faster and iterative cycle. Globally distributed teams are, today, the de facto modus operandi for large corporations to stay competitive in the globalizing markets. Similarly, startups also need to operate on a global level but have to do so much earlier in their lifecycle. Existing research has studied the effect and conflicts of globally distributed teams, and how they relate to subgroups. However, there is a gap in the literature on how the unique context of startups adopts to such circumstances. This thesis is focusing on studying what effects globally distributed teams, or in this case, the opening of the first offices abroad, have on fast-growing software startups and, in particular, what impact does the emerging subgroup dynamics have on key decision-making processes. The study relates its theory to social identity theory (Tajfel & Turner 1979). In addition, theory on entrepreneurship research and globally distributed teams is used. The study was conducted as a qualitative research, and it was based on three case studies. The case companies were selected based on their fit to the defined scope. The selected companies were all software companies that had raised venture capital and had recently established offices abroad from their home country. Two employees or founders per company were interviewed by a theme interview for the data gathering. The data analysis of the empirical research provided various different sets of generalized statements and direct quotes that were used in the findings. The chosen method was used because the respondents were agreed to be kept anonymous throughout the research. After conducting the analysis, the findings were discussed at a more general level to develop a framework for knowledge sharing and proposal on underlying subgroup dynamics. The findings propose that emerging subgroups do not have such a strong identity within employees or founders as compared to the startup company as a whole or to the team they are assigned to work in. However, when in significant decision-making events, there does arise interactions and behaviors within individuals that have attributes to social identity groups.Startupit, eli aikaisen vaiheen kasvuyritykset, ovat viime aikoina kasvattaneet kiinnostusta niin tieteellisen tutkimuksen kuin teollisuuden puolella. Kasvuryityksiin kiinnitetään yhä enemmän huomiota, ei vähiten riskisijoitusrahan muodossa. Tätä niin kutsuttua hypeä voidaan luonnehtia ja argumentoida monin tavoin. Voidaan myös sanoa varmaksi, että kasvuyritykset ovat merkittäviä sekä työpaikkojen luomisen että talouskasvun kannalta. Suuriin ja vakiintuneisiin yrityksiin verrattuna kasvuyritykset toimivat huomattavasti nopeammin ja iteratiivisemmin. Globaalit hajautetut tiimit ovat isoille yrityksille nykyään vakiintunut tapa toimia globaaleilla markkinoilla säilyttääkseen kilpailukykynsä. Myös kasvuyritysten on toimittava kansainvälisesti, mutta niiden on tehtävä tämä huomattavasti aikaisemmassa vaiheessa elinkaartaan. Nykyinen tutkimuskirjallisuus on tutkinut hajautettujen tiimien vaikutuksia ja niiden synnyttämiä konflikteja sekä sitä, kuinka ne vaikuttavat alaryhmien muodostumiseen. Kirjallisuudesta löytyy kuitenkin puutteita siitä, kuinka kasvuyritysten ainutlaatuinen konteksti vaikuttaa näihin tilanteisiin. Tämä diplomityö keskittyy tutkimaan mitä vaikutuksia globaaleilla hajautetuilla tiimeillä tai tässä tapauksessa ensimmäisten toimistojen avaamisella oman kotimaan ulkopuolelle on tietotekniikka-alan kasvuyritykselle. Erityisesti tutkitaan, miten alaryhmien dynamiikka (subgroup dynamics) vaikuttaa tärkeissä päätöksentekoprosesseissa. Tutkimus pohjautuu sosiaalisen identiteetin teorialle (social identity theory, Tajfel & Turner 1979), jonka lisäksi teoriaosuudessa käsitellään yrittäjyyttä sekä hajautettuja tiimejä. Tutkimusaineisto kerättiin laadullisilla teemahaastatteluilla ja se pohjautui kolmeen tapaustutkimukseen. Kohdeyritykset valittiin tutkimuksessa määriteltyjen kriteerien mukaisesti. Yritykset olivat tietotekniikka-alan kasvuyrityksiä, jotka olivat keränneet riskisijoitusrahaa ja avanneet viime aikoina toimistoja kotimaansa ulkopuolelle. Kustakin kohdeyrityksestä haastateltiin kahta työntekijää tai yrityksen perustajaa. Empiirisen osuuden data-analyysi tuotti useita eri joukkoja yleistettyjä toteamuksia sekä suoria lainauksia, joita käytettiin tuloksissa. Näin meneteltiin, koska vastaajat haluttiin pitää anonyymeinä. Tulokset esiteltiin yleisemmällä tasolla ja luotiin viitekehys tiedon jakamiselle ja ehdotelma piilevien alaryhmien dynamiikoille. Tulosten mukaan alaryhmiin ei identifioiduta yhtä voimakkaasti kuin itse yritykseen tai ryhmään, johon henkilö on määrätty työskentelemään. On kuitenkin huomattava, että tärkeiden päätöksentekoprosessien aikana henkilöillä on vuorovaikutusta, joka osoittaa identifioitumista sosiaalisiin alaryhmiin

Proceeding: 3rd Java International Nursing Conference 2015 “Harmony of Caring and Healing Inquiry for Holistic Nursing Practice; Enhancing Quality of Care”, Semarang, 20-21 August 2015

This is the proceeding of the 3rd Java International Nursing Conference 2015 organized by School of Nursing, Faculty of Medicine, Diponegoro University, in collaboration with STIKES Kendal. The conference was held on 20-21 August 2015 in Semarang, Indonesia. The conference aims to enable educators, students, practitioners and researchers from nursing, medicine, midwifery and other health sciences to disseminate and discuss evidence of nursing education, research, and practices to improve the quality of care. This conference also provides participants opportunities to develop their professional networks, learn from other colleagues and meet leading personalities in nursing and health sciences. The 3rd JINC 2015 was comprised of keynote lectures and concurrent submitted oral presentations and poster sessions. The following themes have been chosen to be the focus of the conference: (a) Multicenter Science: Physiology, Biology, Chemistry, etc. in Holistic Nursing Practice, (b) Complementary Therapy in Nursing and Complementary, Alternative Medicine: Alternative Medicine (Herbal Medicine), Complementary Therapy (Cupping, Acupuncture, Yoga, Aromatherapy, Music Therapy, etc.), (c) Application of Inter-professional Collaboration and Education: Education Development in Holistic Nursing, Competencies of Holistic Nursing, Learning Methods and Assessments, and (d) Application of Holistic Nursing: Leadership & Management, Entrepreneurship in Holistic Nursing, Application of Holistic Nursing in Clinical and Community Settings

Occasional Groups in Crowdsourcing Platforms

Contributors to online crowdsourcing systems generally work independently on pieces of the product but in some cases, task interdependencies may require collaboration to develop a final product. These collaborations though take a distinctive form because of the nature of crowdsourced work. Collaboration may be implicit instead of explicit. Individuals engaged in a group conversation may not stay with the group for long, i.e., the group is an ``occasional group.\u27\u27 Occasional group interactions are often not well supported by systems, as they are not designed for team work. This dissertation examines the characteristics and work of occasional groups in the Gravity Spy citizen science project. Occasional groups in this system form to reach agreement about the description of novel categories of data that volunteers identify in the system. The author first employed virtual ethnography over six months to investigate volunteers\u27 interactions and to identify features of the occasional groups in this setting. Most groups were transient, interacting only for a short time to develop one product, but a few worked together repeatedly.To describe the overall process of finding new categories brings individuals to work together, the author interviewed nine active volunteers about their work practices. Volunteers individually or collectively use tools such as hashtags, collections and a search tool to identify examples of a new category and to agree on a name and description. Finally, the author investigated the details of the processes of developing proposals for four new categories over three years. She employed virtual and trace ethnography to collect messages from several discussion threads and boards to identify the analytical moves made by occasional group members in developing a new category. Volunteers would speculate on a new pattern and its causes, discuss how different categories are related and split or merge descriptions. They employed techniques such as detailed descriptions of data to create common ground, @-mention of other volunteers to increase the visibility of their work to each other and use of the category proposal as a vehicle to coordinate their actions. Findings contribute to the group literature by recognizing that groups with no formal formation and work processes are capable of doing work that would not otherwise be possible. The results advance our understanding of group categorization literature by showing how the analytical moves are different when group members work occasionally. The thesis also provides some suggestions for better support of occasional groups in crowdsourcing platforms

Curriculum renewal for interprofessional education in health

In this preface we comment on four matters that we think bode well for the future of interprofessional education in Australia. First, there is a growing articulation, nationally and globally, as to the importance of interprofessional education and its contribution to the development of interprofessional and collaborative health practices. These practices are increasingly recognised as central to delivering effective, efficient, safe and sustainable health services. Second, there is a rapidly growing interest and institutional engagement with interprofessional education as part of pre-registration health professional education. This has changed substantially in recent years. Whilst beyond the scope of our current studies, the need for similar developments in continuing professional development (CPD) for health professionals was a consistent topic in our stakeholder consultations. Third, we observe what might be termed a threshold effect occurring in the area of interprofessional education. Projects that address matters relating to IPE are now far more numerous, visible and discussed in terms of their aggregate outcomes. The impact of this momentum is visible across the higher education sector. Finally, we believe that effective collaboration is a critical mediating process through which the rich resources of disciplinary knowledge and capability are joined to add value to existing health service provision. We trust the conceptual and practical contributions and resources presented and discussed in this report contribute to these developments.Office of Learning and Teaching Australi

Developing and Facilitating Temporary Team Mental Models Through an Information-Sharing Recommender System

It is well understood that teams are essential and common in many aspects of life, both work and leisure. Due to the importance of teams, much research attention has focused on how to improve team processes and outcomes. Of particular interest are the cognitive aspects of teamwork including team mental models (TMMs). Among many other benefits, TMMs involve team members forming a compatible understanding of the task and team in order to more efficiently make decisions. This understanding is sometimes classified using four TMM domains: equipment (e.g., operating procedures), task (e.g., strategies), team interactions (e.g., interdependencies) and teammates (e.g., tendencies). Of particular interest to this dissertation is accelerating the development of teammate TMMs which include members understanding the knowledge, skills, attitudes, preferences, and tendencies of their teammates. An accurate teammate TMM allows teams to predict and account for the needs and behaviors of their teammates. Although much research has highlighted how the development of the four TMM domains can be supported, promoting the development of teammate TMMs is particularly challenging for a specific type of team: temporary teams. Temporary teams, in contrast to ongoing teams, involve unknown teammates, novel tasks, short task times (alternatively limited interactions), and members disbanding after completing their task. These teams are increasingly used by organizations as they can be agilely formed with individual members selected to accomplish a specific task. Such teams are commonly used in contexts such as film production, the military, emergency response, and software development, just to name a few. Importantly, although these teams benefit greatly from teammate TMMs due to the efficiencies gained in decision making while working under limited deadlines, the literature is severely limited in understanding how to support temporary teams in this way. As prior research has suggested, an opportunity to accelerate teammate TMM development on temporary teams is through the use of technology to selectively share teammate information to support these TMMs. However, this solution poses numerous privacy concerns. This dissertation uses four studies to create a foundational and thorough understanding of how recommender system technology can be used to promote teammate TMMs through information sharing while limiting privacy concerns. Study 1 takes a highly exploratory approach to set a foundation for future dissertation studies. This study investigates what information is perceived to be helpful for promoting teammate TMMs on actual temporary teams. Qualitative data suggests that sharing teammate information related to skills/preferences, conflict management styles, and work ethic/reliability is perceived as beneficial to supporting teammate TMMs. Also, this data provides a foundational understanding for what should be involved in information-sharing recommendations for promoting teammate TMMs. Quantitative results indicate that conflict management data is perceived as more helpful and appropriate to share than personality data. Study 2 investigates the presentation of these recommendations through the factors of anonymity and explanations. Although explanations did not improve trust or satisfaction in the system, providing recommendations associated with a specific teammate name significantly improved several team measures associated with TMMs for actual temporary teams compared to teams who received anonymous recommendations. This study also sheds light on what temporary team members perceive as the benefits to sharing this information and what they perceive as concerns to their privacy. Study 3 investigates how the group/team context and individual differences can influence disclosure behavior when using an information-sharing recommender system. Findings suggest that members of teams who are fully assessed as a team are more willing to unconditionally disclose personal information than members who are assessed as an individual or members who are mixed assessed as an individual and a team. The results also show how different individual differences and different information types are associated with disclosure behavior. Finally, Study 4 investigates how the occurrence and content of explanations can influence disclosure behavior and system perceptions of an information-sharing recommender system. Data from this study highlights how benefit explanations provided during disclosure can increase disclosure and explanations provided during recommendations can influence perceptions of trust competence. Meanwhile, benefit-related explanations can decrease privacy concerns. The aforementioned studies fill numerous research gaps relating to teamwork literature (i.e., TMMs and temporary teams) and recommender system research. In addition to contributions to these fields, this dissertation results in design recommendations that inform both the design of group recommender systems and the novel technology conceptualized through this dissertation, information-sharing recommender systems

Software development performance in remote student teams in international computer science collaboration

Approximately two-thirds of software projects are late because project teams encounter challenges that threaten their success. In addition, many projects are developed using remote collaboration, due to pressure of time, distribution of expertise, and organisational constraints. In parallel, technology has developed that allows effective remote collaboration.The purpose of this research was to investigate what characterises high performance in software development in remote student teams. The data was drawn from the Runestone Project, which involved Swedish and American computer science students in international collaboration on a substantial software development project. Runestone gave students the opportunity to use different technologies for collaboration across time and distance, as well the chance to develop problem-solving experience with different cultures in a team-based environment.This research tracked the progress and changes in the entire electronic communication for 8 student teams identified as the 4 highest- and lowest- 4 performers in the 2000 presentation of Runestone. A set of categories was developed to characterise over 31,000 lines of communication, focusing on the amount and nature of communication for each team, and on decision-making patterns throughout the software development process. The research also looked at students' use of available communication technology.Results indicate that both communication and the process and timing of specific actions are crucial to a team's success. Teams communicated differently, with high performing groups communicating less. High performing teams were more organised in the way they conducted their meetings and work. The management of the software development process as a whole was crucial, as was leadership style. An effective use of the software development process can also mean that key decisions are made during the times in the software process where they will be most effective. This research has implications for remote collaboration in both education and industry

Situation awareness approach to context-aware case-based decision support.

Context-aware case-based decision support systems (CACBDSS) use the context of users as one of the features for similarity assessment to provide solutions to problems. The combination of a context-aware case-based reasoning (CBR) with general domain knowledge has been shown to improve similarity assessment, solving domain specific problems and problems of uncertain knowledge. Whilst these CBR approaches in context awareness address problems of incomplete data and domain specific problems, future problems that are situation-dependent cannot be anticipated due to lack of data by the CACBDSS to make predictions. Future problems can be predicted through situation awareness (SA), a psychological concept of knowing what is happening around you in order to know the future. The work conducted in this thesis explores the incorporation of SA to CACBDSS. It develops a framework to decouple the interface and underlying data model using an iterative research and design methodology. Two new approaches of using situation awareness to enhance CACBDSS are presented: (1) situation awareness as a problem identification component of CACBDSS (2) situation awareness for both problem identification and solving in CACBDSS. The first approach comprises of two distinct parts; SA, and CBR parts. The SA part understands the problem by using rules to interpret cues from the environment and users. The CBR part uses the knowledge from the SA part to provide solutions. The second approach is a fusion of the two technologies into a single case-based situation awareness (CBSA) model for situation awareness based on experience rather than rule, and problem solving predictions. The CBSA system perceives the users context and the environment and uses them to understand the current situation by retrieving similar past situations. The futures of new situations are predicted through knowledge of the history of similar past situations. Implementation of the two approaches in flow assurance control domain to predict the formation of hydrate shows improvements in both similarity assessment and problem solving predictions compared to CACBDSS without SA. Specifically, the second approach provides an improved decision support in scenarios where there are experienced situations. In the absence of experienced situations, the second approach offers more reliable solutions because of its rule-based capability. The adaptation of the user interface of the approaches to the current situation and the presentation of a reusable sequence of tasks in the situation reduces memory loads on operators. The integrated research-design methodology used in realising these approaches links theory and practice, thinking and doing, achieving practical as well as research objectives. The action research with practitioners provided the understanding of the domain activities, the social settings, resources, and goals of users. The user-centered design process ensures an understanding of the users. The agile development model ensures an iterative work, enables faster development of a functional prototype, which are more easily communicated and tested, thus giving better input for the next iteration