Lean Thinking: Theory, Application and Dissemination

This book was written and compiled by the University of Huddersfield to share the learnings and experiences of seven years of Knowledge Transfer Partnership (KTP) and Economic and Social Research Council (ESRC) funded projects with the National Health Service (NHS). The focus of these projects was the implementation of Lean thinking and optimising strategic decision making processes. Each of these projects led to major local improvements and this book explains how they were achieved and compiles the lessons learnt. The book is split into three chapters; Lean Thinking Theory, Lean Thinking Applied and Lean Thinking Dissemination

Tanzania Review of Exemptions and Waivers

The work which is presented in this report reflects a need identified by the Ministry of Health to improve the functionality of the exemptions and waivers systems which had been introduced to reduce the financial burden on groups of the population who need access to health care and who either cannot afford to contribute to the costs or who have an illness or disease which threatens the public good and for which no direct charges should be imposed. The exemptions and waivers systems, while potentially very effective in principle, were deemed not to be working well in practice. A significant body of work already exists on the health sector in Tanzania, with plenty of references to the exemptions and waivers systems. The task of the team undertaking this study was not to replicate the work of previous studies but rather to find ways to make some of the recommendations happen. The ‘how to’ element was seen as the most crucial aspect of the work, and the aspect which presented the greatest challenge. The results from all the available documentation were used, and were augmented by field visits to a number of regions and districts in the north and south of the country, where proposals for reinforcement of the waivers and exemptions systems could be tested with practitioners and users of the health sector. The strategy proposed in the document is divided into a long term strategy and an interim strategy. The long terms strategy is to have the whole population of Tanzania covered by one or another insurance scheme, from a selection of current and proposed schemes: the National Health Insurance Fund scheme for civil servants, the Social Security Fund health benefits scheme for formal sector employees, the proposed social insurance scheme for informal sector workers, the CHF or a scheme to cover those who are not eligible or cannot afford to participate in any of the others. The interim strategy identifies ways and means of strengthening the systems to ensure more equitable access to health services for those who are entitled to exemptions and waivers, with recommendations about how those systems can be refined to target those who most need them. Successful examples from the field are used to show the way forward. The interim strategy includes refinement of the exemptions system; expansion and consolidation of the Community Health Fund (CHF); development of TIKA, the urban equivalent of the CHF; the development of an ID card scheme for those who cannot afford to pay or to participate in any of the schemes; and the strengthening of the institutions which provide health care and which plan and monitor the services provided. The ID card scheme, being new to the stable of proposals for strengthening the exemptions and waivers systems, is fully elucidated from the rationale, through the principles behind it, to the identification process for those eligible, the issuing of the card, the roles of each of the institutions at leach level of the administrative structure, the financing of the scheme and the advocacy required to endure that it works the way it is intended by providing for those most in need. Inevitably, the proposals cannot be implemented in a vacuum and where there are risks involved, either general or specific, these have been identified

Logistics Information and Knowledge Management Issues in Humanitarian Aid Organizations

In this paper, we assess the need for logistics information and knowledge management in humanitarian aid organizations. To do so, we combine literature sources with an extensive case study that we conducted at Médecins sans Frontières–Holland, which is following a trajectory to improve logistics information management within the organization. We observed that logistics information and logistics knowledge management has not yet matured. We indicate how, by making use of knowledge management strategies such as ‘personalization’ and ‘codification’, this can be improved.Humanitarian aid organizations;Knowledge management;Logistics information

Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study

Publisher version: http://www.bmj.com/content/340/bmj.c3111.full?sid=fcb22308-64fe-4070-9067-15a172b3aea

Techniques for improving client relations in family planning programs

Demand for children and demand for contraceptives are not independent of the system of supply. And client transactions are the major means for lowering costs. Family planning workers, providers of services and mass media campaigns, are the harbingers of new ideas and new delivery systems that could modify the demand for fertility regulation and patterns of contraceptive use. The authors describe four broad techniques for improving client relations, emphasizing their potential as entry points into program development (systematic change). These techniques are presented as a sampling of experience that can be brought to bear on dysfunctional client relations. Among examples described: Patient flow analysis (PFA). A self-administered time-and-motion diagnosis that allows computerized documentation of patient flow and personnel use in health service clinics. Using relatively unobtrusive data collection, PFA seeks to get a representative snapshot of a program and its dysfunctions, replicating a typical clinic session. Data are later diagnosed and remedies proposed for bottlenecks and inefficiencies. Training and visit (T&V). A managerial approach for dealing with geographically scattered outreach programs. The four main principles of T&V: focus on a few key tasks, frequent in-service training and supervision, regularity and predictability, and face-to-face communication. The T&V model focuses on what workers should be doing with their time in the field to meet client needs. A goal of T&V: to enable all clients to name their worker and the day of the week s/he visits, and identify a few themes from their most recent encounter. Activity planning. The antithesis of T&V, activity planning calls for abandoning rigid time-place-movement schedules and specific messages and replacing them with a fluid work schedule adapted to local conditions. Workers must be well-trained in collecting data, listening and building rapport, and communicating with conviction. The quality of the worker-client relationship is all-important. A weakness is that if the workers have no objective they lose control of the exchange with clients. Training and worker empowerment. Training by itself is not enough for systematic change - training for what? But training can serve as an entry point into organizational development when it is rooted in methodologies that help to develop the participant's technical and interpersonal skills and ability to innovate. But training must be accompanied by changes in the system of supply that supports and facilitates innovation and quality of care. Techniques to improve client relations can address either the client-provider interface directly or the system of underlying determinants. It is important to ask basic questions: Is the idea to fix a single worker-client dysfunction or is it to provide a continuous program for modification and growth? Who will be affected by the change? Whoor what will be responsible for initiating and overseeing the course of action? What are the short- and long-run goals of intervention?Health Monitoring&Evaluation,ICT Policy and Strategies,Adolescent Health,Poverty Monitoring&Analysis,Geographical Information Systems

Chronic disease care in primary health care facilities in rural South African settings

A THESIS Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 2016Background: South Africa has a dual high burden of HIV and non-communicable diseases (NCDs). In a response to the dual burden of these chronic diseases, the National Department of Health (NDoH) introduced a pilot of the Integrated Chronic Disease Management (ICDM) model in June 2011 in selected Primary Health Care (PHC) facilities, one of the first of such efforts by an African Ministry of Health. The main aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs in order to improve the quality of chronic disease care and health outcomes of adult chronic disease patients. Since the initiation of the ICDM model, little is known about the quality of chronic care resulting in the effectiveness of the model in improving health outcomes of chronic disease patients. Objectives: To describe the chronic disease profile and predictors of healthcare utilisation (HCU) in a rural population in a South African municipality; and assess quality of care and effectiveness of the ICDM model in improving health outcomes of chronic disease patients receiving treatment in PHC facilities. Methods: An NDoH pilot study was conducted in selected health facilities in the Bushbuckridge municipality, Mpumalanga province, northeast South Africa, where a part of the population has been continuously monitored by the Agincourt Health and Socio-Demographic Surveillance System (HDSS) since 1992. Two main studies were conducted to address the two research objectives. The first study was a situation analysis to describe the chronic disease profile and predictors of healthcare utilisation in the population monitored by the Agincourt HDSS. The second study evaluated quality of care in the ICDM model as implemented and assessed effectiveness of the model in improving health outcomes of patients receiving treatment in PHC facilities. This second study had three components: (1) a qualitative and (2) a quantitative evaluation of the quality of care in the ICDM model; and a (3) quantitative assessment of effectiveness of the ICDM model in improving patients‘ health outcomes. The two main studies have been categorised into three broad thematic areas: chronic disease profile and predictors of healthcare utilisation; quality of care in the ICDM model; and changes in patients‘ health outcomes attributable to the ICDM model. In the first study, a cross-sectional survey to measure healthcare utilisation was targeted at 7,870 adults 50 years and over permanently residing in the area monitored by the Agincourt HDSS in 2010, the year before the ICDM model was introduced. Secondary data on healthcare utilisation (dependent variable), socio-demographic variables drawn from the HDSS, receipt of social grants and type of medical aid (independent variables) were analysed. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. The quantitative component of the second study was a cross-sectional survey conducted in 2013 in the seven PHC facilities implementing the ICDM model in the Agincourt sub-district (henceforth referred to as the ICDM pilot facilities) to better understand the quality of care in the ICDM model. Avedis Donabedian‘s theory of the relationships between structure, process, and outcome (SPO) constructs was used to evaluate quality of care in the ICDM model exploring unidirectional, mediation, and reciprocal pathways. Four hundred and thirty-five (435) proportionately sampled patients ≥ 18 years and the seven operational managers of the PHC facilities responded to an adapted satisfaction questionnaire with measures reflecting structure (e.g. equipment), process (e.g. examination) and outcome (e.g. waiting time) constructs. Seventeen dimensions of care in the ICDM model were evaluated from the perspectives of patients and providers. Eight of these 17 dimensions of care are the priority areas of the HIV treatment programme used as leverage for improving quality of care in the ICDM model: supply of critical medicines, hospital referral, defaulter tracing, prepacking of medicines, clinic appointments, reducing patient waiting time, and coherence of integrated chronic disease care (a one-stop clinic meeting most of patients‘ needs). A structural equation model was fit to operationalise Donabedian‘s theory using patient‘s satisfaction scores. The qualitative component of the second study was a case study of the seven ICDM pilot facilities conducted in 2013 to gain in-depth perspectives of healthcare providers and users regarding quality of care in the ICDM model. Of the 435 patients receiving treatment in the pilot facilities, 56 were purposively selected for focus group discussions. An in-depth interview was conducted with the seven operational managers within the pilot facilities and the health manager of the Bushbuckridge municipality. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and emerging themes. In addition to the emerging themes, codes generated in the qualitative analysis were underpinned by Avedis Donabedian‘s SPO theoretical framework. A controlled interrupted time-series study was conducted for the 435 patients who participated in the cross-sectional study in the ICDM pilot facilities and 443 patients proportionately recruited from five PHC facilities not implementing the ICDM model (Comparison PHC facilities in the surrounding area outside the Agincourt HDSS) from 2011-2013. Health outcome data for each patient were retrieved from facility records at 30-time points (months) during the study period. We performed autoregressive moving average (ARMA) statistical modelling to account for autocorrelation inherent in the time-series data. The effect of the ICDM model on the control of BP (350 cells/mm3) was assessed by controlled segmented linear regression analysis. Results: Seventy-five percent (75%) of the 7,870 eligible adults 50+ responded to the health care utilization survey in the first study. All 5,795 responders reported health problems, of whom 96% used healthcare, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% e.g. HIV and TB) and injuries (3%). Chronic communicable (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable (OR=2.85, 95% CI: 1.96, 4.14) diseases were the main predictors of healthcare utilisation. Out of the 17 dimensions of care assessed in the quantitative component of the quality of care study, operational managers reported dissatisfaction with patient waiting time while patients reported dissatisfaction with the appointment system, defaulter-tracing of patients and waiting time. The mediation pathway fitted perfectly with the data (coefficient of determination=1.00). The structural equation modeling showed that structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Patients‘ perception of availability of equipment, supply of critical medicines and accessibility of care (structure construct) had a direct influence on the ability of nurses to attend to their needs, be professional and friendly (process construct). Patients also perceived that these process dimensions directly influenced coherence of care provided, competence of the nurses and patients‘ confidence in the nurses (outcome construct). These structure-related dimensions of care directly influenced outcome-related dimensions of care without the mediating effect of process factors. In the qualitative study, manager and patient narratives showed inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). Patients reported anti-hypertension drug stock-outs; sub-optimal defaulter-tracing; rigid clinic appointments; HIV-related stigma in the community resulting from defaulter-tracing activities; and government nurses‘ involvement in commercial activities in the consulting rooms during office hours. Managers reported simultaneous treatment of chronic diseases by traditional healers in the community and thought there was reduced HIV stigma because HIV and NCD patients attended the same clinic. In the controlled-interrupted time series study the ARMA model showed that the pilot facilities had a 5.7% (coef=0.057; 95% CI: 0.056,0.058; P<0.001) and 1.0% (coef=0.010; 95% CI: 0.003,0.016; P=0.002) greater likelihood than the comparison facilities to control patients‘ CD4 counts and BP, respectively. In the segmented analysis, the decreasing probabilities of controlling CD4 counts and BP observed in the pilot facilities before the implementation of the ICDM model were respectively reduced by 0.23% (coef = -0.0023; 95% CI: -0.0026,-0.0021; P<0.001) and 1.5% (Coef= -0.015; 95% CI: -0.016,-0.014; P<0.001). Conclusions: HIV and NCDs were the main health problems and predictors of HCU in the population. This suggests that public healthcare services for chronic diseases are a priority among older people in this rural setting. There was poor quality of care reported in five of the eight priority areas used as leverage for the control of NCDs (referral, defaulter tracing, prepacking of medicines, clinic appointments and waiting time); hence, the need to strengthen services in these areas. Application of the ICDM model appeared effective in reducing the decreasing trend in controlling patients‘ CD4 counts and blood pressure. Suboptimal BP control observed in this study may have been due to poor quality of care in the identified priority areas of the ICDM model and unintended consequences of the ICDM model such as work overload, staff shortage, malfunctioning BP machines, anti-hypertension drug stock-outs, and HIV-related stigma in the community. Hence, the HIV programme should be more extensively leveraged to improve the quality of hypertension treatment in order to achieve optimal BP control in the nationwide implementation of the ICDM model in PHC facilities in South Africa and, potentially, other LMICs.MT201

Community Involvement in TB Research

While communities at risk have been both drivers and partners in HIV research, their important role in TB research is yet to be fully realized. Involvement of communities in tuberculosis care and prevention is currently on the international agenda. This creates opportunities and indicates the urgency to also engage communities in TB research