Modeling a healthcare system as a queueing network:The case of a Belgian hospital.

The performance of health care systems in terms of patient flow times and utilization of critical resources can be assessed through queueing and simulation models. We model the orthopaedic department of the Middelheim hospital (Antwerpen, Belgium) focusing on the impact of outages (preemptive and nonpreemptive outages) on the effective utilization of resources and on the flowtime of patients. Several queueing network solution procedures are developed such as the decomposition and Brownian motion approaches. Simulation is used as a validation tool. We present new approaches to model outages. The model offers a valuable tool to study the trade-off between the capacity structure, sources of variability and patient flow times.Belgium; Brownian motion; Capacity management; Decomposition; Health care; Healthcare; Impact; Model; Models; Performance; Performance measurement; Queueing; Queueing theory; Simulation; Stochastic processes; Structure; Studies; Systems; Time; Tool; Validation; Variability;

ForgetMeNot: Active Reminder Entry Support for Adults with Acquired Brain Injury

Smartphone reminding apps can compensate for memory impairment after acquired brain injury (ABI). In the absence of a caregiver, users must enter reminders themselves if the apps are going to help them. Poor memory and apathy associated with ABI can result in failure to initiate such configuration behaviour and the benefits of reminder apps are lost. ForgetMeNot takes a novel approach to address this problem by periodically encouraging the user to enter reminders with unsolicited prompts (UPs). An in situ case study investigated the experience of using a reminding app for people with ABI and tested UPs as a potential solution to initiating reminder entry. Three people with severe ABI living in a post-acute rehabilitation hospital used the app in their everyday lives for four weeks to collect real usage data. Field observations illustrated how difficulties with motivation, insight into memory difficulties and anxiety impact reminder app use in a rehabilitation setting. Results showed that when 6 UPs were presented throughout the day, reminder-setting increased, showing UPs are an important addition to reminder applications for people with ABI. This study demonstrates that barriers to technology use can be resolved in practice when software is developed with an understanding of the issues experienced by the user group

A Quality Improvement Initiative to Improve Access and Patient Flow in a Non-Emergency Walk-in Care Clinic

Background: A community-based non-emergency walk-in clinic in Southern New Hampshire experienced high volume and inefficient workflows during the pandemic, causing delays in care, long visit times, and low net promoter scores. Purpose: Institute an evidence-based approach to improve work efficiency through innovative models of care. Methods: A literature review on best practices for workflow redesign guided the project. The project instituted an on-demand telemedicine service and a clinic fast-track workflow. A mixed methods approach analyzed pre /post cycle times, net promoter scores, and themes from staff interviews. Pre/post cycle times analyzed 12,767 completed appointments. Results: There was a statistically significant improvement in cycle times, with a P-value of \u3c .0001. Door-to-door time decreased by 26%, waiting room time decreased by 56%, net promoter scores improved by 12.5%, and there was a 30.5% improvement in the percentage of appointments ≤ 60 minutes. 6.4% of patients were booked for telemedicine visits to offload clinic volume. Themes from the semi-structured interviews revealed supportive themes around improved workflow and communication and disruptive themes around nurse visits for telemedicine testing, EHR scheduling, and feelings of burnout. Conclusions: There was improved clinic efficiency and ability to meet volume demands. The interventions contributed to these improvements. Additional studies that evaluate project effectiveness over time to account for seasonal variability, patient acuity across multiple sites, and the impact of workflow changes on staff burnout are indicated

Supporting Mothers with Mental Illness: Postpartum Mental Health Service Linkage as a Matter of Public Health and Child Welfare Policy

Through our work in youth advocacy as, respectively, legal and public health professionals, we are all too aware of the high levels of health care fragmentation experienced during pregnancy and postpartum by poor, young mothers of color. Meredith Matone’s research highlights the heightened risk of fragmentation for girls with histories of child welfare involvement. For example, she found that 66.7% of young mothers who had resided in out-of-home placements and who had taken antipsychotic medication prior to becoming pregnant failed to fill prescriptions for antipsychotics in their first postpartum year. Put another way, two-thirds of these vulnerable young mothers—a far higher proportion than young mothers without histories of child welfare involvement—were not getting the treatment that they needed to care for themselves and their children. The very real consequences of this phenomenon can be seen in the experiences of Jesse Krohn’s clients, several of whom have their stories told here. Treatment discontinuity, particularly during the transition to parenthood, places mothers at risk for poor health outcomes and maladaptive parenting approaches; threatens the health and safety of infants; and triggers child welfare involvement. This article explores the negative consequences and root causes of treatment discontinuity, as well as particularized population vulnerabilities for treatment discontinuity including, as noted, involvement with child welfare. It will also provide public health and child welfare policy solutions for reducing treatment discontinuity and improving mental and physical health outcomes for new mothers and infants. The population of mothers at highest risk for postpartum treatment gaps is not small: more than 40% of Medicaid-financed births to young women aged 15 to 24 occurred in mothers who had a childhood relationship to the child welfare system. It is unacceptable to be aware of the pervasiveness of this problem, particularly among intersectionally vulnerable women, and not deploy a targeted and evidence-based preventative and remedial response

Innovation and Adaptation: The Primary Digital Initiatives of Morocco in Education, Teleworking, and E-Administration for Enhanced Management of the Covid-19 Crisis

The Covid-19 pandemic constituted an unprecedented disruption to the Moroccan economy and society, forcing public authorities to accelerate the digital transition in order to ensure the continuity of essential services and productive activities. Although digital tools have proven to be opportune in addressing health challenges, they have also revealed the extent of the digital divide with the exclusion of rural populations from online platforms. Teleworking has demonstrated its operational efficiency but raises managerial challenges such as remote management of employees. The crisis has disrupted traditional management patterns, requiring in-depth reflection on the evolution of digital-based management methods. Regarding the education sector, the assessment of ICT equipment in schools predicted the inability to deploy distance learning accessible to all in an equitable manner. This partial digitalization has hindered the objective of pedagogical continuity. In summary, while digital technologies have enabled the continuation of activities, this crisis reveals the need to accelerate digital transformation in Morocco to bridge the digital divide and adapt managerial practices to the new challenges of teleworking.  The Covid-19 pandemic constituted an unprecedented disruption to the Moroccan economy and society, forcing public authorities to accelerate the digital transition in order to ensure the continuity of essential services and productive activities. Although digital tools have proven to be opportune in addressing health challenges, they have also revealed the extent of the digital divide with the exclusion of rural populations from online platforms. Teleworking has demonstrated its operational efficiency but raises managerial challenges such as remote management of employees. The crisis has disrupted traditional management patterns, requiring in-depth reflection on the evolution of digital-based management methods. Regarding the education sector, the assessment of ICT equipment in schools predicted the inability to deploy distance learning accessible to all in an equitable manner. This partial digitalization has hindered the objective of pedagogical continuity. In summary, while digital technologies have enabled the continuation of activities, this crisis reveals the need to accelerate digital transformation in Morocco to bridge the digital divide and adapt managerial practices to the new challenges of teleworking. &nbsp

Appointment planning and scheduling in primary care

The Affordable Care Act (ACA) puts greater emphasis on disease prevention and better quality of care; as a result, primary care is becoming a vital component in the health care system. However, long waits for the next available appointments and delays in doctors offices combined with no-shows and late cancellations have resulted in low efficiency and high costs. This dissertation develops an innovative stochastic model for patient planning and scheduling in order to reduce patients’ waiting time and optimize primary care providers’ utility. In order to facilitate access to patients who request a same-day appointment, a new appointment system is presented in which a proportion of capacity is reserved for urgent patients while the rest of the capacity is allocated to routine patients in advance. After the examination of the impact of no-shows on scheduling, a practical double-booking strategy is proposed to mitigate negative impacts of the no-show. Furthermore, proposed model demonstrates the specific circumstances under which each type of scheduling should be adopted by providers to reach higher utilization. Moreover, this dissertation extends the single physician’s model to a joint panel scheduling and investigates the efficiency of such systems on the urgent patients’ accessibility, the physicians’ utilization, and the patients’ waiting time. Incorporating the newsvendor approach and stochastic optimization, these models are robust and practical for planning and scheduling in primary care settings. All the analytical results are supported with numerical examples in order to provide better managerial insights for primary care providers

An Exploration of the Role of Substance Misuse Nurses in Scotland

Executive Summary Background With the increase of drug misuse over the past two decades, the role of the Substance Misuse Nurse has increased dramatically. Research on the role of nurses working in this field is minimal and there is little known about what they do, what they think about their clients and their role, and how they approach treatment. A pilot study on substance misuse nurses in Grampian indicated that nurses may be key gatekeepers to specialist services and some nurses appeared to have an important role in clinical decision making. However, clinical decision making and other key aspects of nurse practice may vary across services in different geographical areas. This research was designed to gain a better understanding of the role of the substance misuse nurse in Scotland. Aims and Objectives The aim of this research was to describe and analyse the role of substance misuse nurses working with drug misusers in Scotland. The objectives were: • to identify the population of specialist nurses working directly in the management of illicit drug users in Scotland and gain baseline data on their demography, caseload, services provided and level of interaction with other health professionals; • to compare their attitudes to drug misusers with those of other health professionals; • to explore their beliefs about the effectiveness of different treatment options; • to examine their role in the initial client assessment and subsequent management; • to describe their interaction with the client; • to explore their relationship with other professionals. Methods Mixed quantitative and qualitative methods were used. The population of Substance Misuse Nurses and midwives working specifically with drug misusers across Scotland were identified and posted a comprehensive questionnaire. The questionnaire covered issues including qualifications, training, attitudes and beliefs about treatment and aspects of practice such as caseloads, services provided and relationships with other health and social professionals. Face-to-face interviews were conducted with a sub-sample of nurses including a range of gender, experience, and NHS areas. Interviews covered nurses’ assessment and decision making regarding treatment and relationships with other professionals. Observations of specialist nurse and client consultations allowed for some insight into the general structure of the consultation, the setting where the consultation took place and the roles of nurse and client in assessment and treatment planning. Characteristics of SMS nurses and services • A scoping exercise indentified 272 nurses. Of these 244 were sent a questionnaire (the remainder having left or being on sick leave). Of these, 79% responded. • Seventy percent (70%) were Grade G or above indicating a senior level workforce. • Most nurses were employed in substance misuse services (48%) or, similarly, drug and alcohol services (30%). • Formal training (university certificate/diploma) in substance misuse had been undertaken by 40% of nurses, induction training (i.e. at the start of employment) by 62% of nurses. • The median caseload was 38 clients. • The majority of consultations took place in clinical consultation rooms but this was not observed to influence the consultation. • Nurses reported that the average length of a consultation was 38 minutes. All of the observed consultations were scheduled for 30 minutes but half over-ran. Motivation, attitudes and beliefs • The challenging nature of working with drug misusers was a positive motivating factor for nurses working in this field. • Seventy-seven percent (77%) of nurses considered working with drug misusers to be rewarding, although 79% also considered that this population were not easy to deal with. Opinion was split about whether drug misusers could be manipulative in consultations. Initial assessment of clients • Waiting times for assessment were generally an issue of concern to nurses. • A detailed assessment was almost always conducted at the first consultation. • An SMR24 was almost always completed at the first consultation. • Interviews and observation of nurse-client consultations found that the approach to assessment seemed consistent across geographical areas. • Assessment included: brief physical examination, urine sampling, detailed exploration of drug use, exploration of physical problems, discussion of social and family support, housing and employment status and history of involvement in the criminal justice system. • Consultations were often brought to a close by discussing treatment expectations. • Initial assessment could take place over more than one appointment and several appointments could be required before a treatment plan was implemented. Making treatment decisions • Clients were actively encouraged to participate in treatment decisions. • Although 84% of nurses reported they were expected to follow a treatment protocol only 44% said they always did (for any treatment). • Eighty-six percent (86%) of nurses had seen the National Clinical Guidelines (DoH, 1999), and those who were interviewed felt that these provided a good framework for treatment, although they were perhaps lacking in detail. • Nurses reported that they often consulted widely with other health professionals but, most frequently, with the client, before making a treatment decision. • A third of nurses reported writing prescriptions for a doctor to sign. • Seventy percent (70%) of respondents felt nurses should be able write prescriptions but only if they were experienced nurses with appropriate training. Comparing beliefs of nurses with those of GPs and pharmacists Nurses were asked some questions which had been asked of GPs and pharmacists in previous national surveys conducted in 2000. This allowed for comparisons to be made: • When making treatment decisions nurses were less influenced than GPs by the attitude and behaviour of drug misusers. • When making treatment decisions nurses were more influenced than GPs by societal factors such as reducing the transmission of infectious disease. • Nurses were less likely than GPs to favour detoxification as a treatment approach, although 83% of nurses agreed that a community based detoxification programme was an effective tool for the treatment of drug misuse. • Nurses were more confident than GPs about their ability to successfully manage polydrug users. • Nurses and GPs were split in their beliefs about the effectiveness of dihydrocodeine. • Nurses believed more strongly than pharmacists that maintenance prescribing could stop the use of illicit drugs. • Fewer nurses than pharmacists believed that controlled drug dispensing should take place in central clinics rather than community pharmacies. Multidisciplinary working • Over half of nurses considered their relationship with pharmacists, GPs, health visitors/community nurses, hospital doctors and social workers to be good. • Opportunities to discuss services with local policy makers were considered insufficient. • Relationships with GPs seemed positive because nurses felt GPs valued their specialist knowledge. • Nurses had frequent contact with pharmacists and respected the difficulties of a pharmacist’s work. • Relationships with social services were variable. Some nurses felt undervalued by their social work colleagues, or felt there was a lack of joint planning for individual client care. • Nurses were clear about what circumstances should lead to a break in confidentiality between services and of how to go about this. • Integrated drug services were seen as potentially beneficial but there were specific concerns about the implications for clients of sharing information with other agencies and practical concerns about the size of joint assessment tools. Health and Safety at work • Sixty-four percent (64%) of nurses reported that they had been physically or verbally abused by clients, and half of those who had been subject to abuse felt current safety provision in their service was insufficient. Nurses in most areas said that the safety of staff was considered to be a high service priority, but there was evidence from interviews this was still lacking in some areas. • Greater use of personal alarms and alarms in consultation rooms, use of mobile phones, and specialised training were suggested as ways of improving safety. • Nurses said that the majority of their consultations take place in clinics/consultation rooms rather than clients’ homes. • The feeling was commonly expressed among interviewees that their work could be stressful, and this was seen as due to paperwork, excessive caseloads and working in isolation. Discussion of Findings This study provides baseline information which can be used to inform individual nurses, services, policy makers and researchers. Some individual nurses reading this report might find an element that is simply describing what they already know. This is inevitable but it is hoped individual nurses will still find interest in the views and practice of others within their profession. The value of this report is that it has quantified these findings on a national basis, providing robust data for workforce planning and needs assessment. It has not been possible to compare findings, and thus the practice of substance misuse nurses in Scotland, with other areas or countries because there is no comparable published work. It is also not possible to give guidelines or examples of ‘good practice’ as this would have involved data collection from clients and other professionals which was outwith this study’s remit. This study has found a reassuring consistence of practice across Scotland. Although many substance misuse nurses work in some degree of isolation there is an apparently high level of discussion and consultation with other service colleagues which provides support. The role of the nurse in the initial assessment and treatment plan is critical. Nevertheless, decisions regarding treatment plans were made largely between nurses and clients, with nurses making use of service protocols/guidelines. Some might question whether a nurse is the most appropriate person to undertake these tasks. Ability to conduct physical examination, some knowledge of pharmacology, mental health and psychology as well as an ability to explore the wider social context is required. On reflection a nurse, with mental health qualifications seems to have the most appropriate skills for this. There is a willingness by nurses to take on the role of prescribing albeit in a limited capacity, and only by very experienced nurses with appropriate training. Currently, a minority of nurses reported writing prescriptions to be signed by doctors, which is possible for doctors with handwriting exemptions. This raises issues about clinical governance. In signing the prescription a GP is still taking responsibility even though s/he may know little about the patient’s current condition. An important strand of a substance misuse nurse’s practice is ongoing support or counselling for clients. This raises issues about models of counselling followed and nurses’ competencies in doing this. The nature or model of counselling used by nurses was not explicitly covered in this research and further exploration of counselling would be an area for future research. Relationships with other professionals, were generally reported to be good. Nurses generally believed GPs valued their role. Comparison of attitudes of substance misuse nurses with earlier surveys of pharmacists and GPs indicates they are more positive in general and about treatment outcomes in particular. Nurses viewed the challenging aspect of working with drug misusers more positively than pharmacists and GPs. Nurses were less positive about their ability to influence policy. Currently substance misuse nurses have little input at policy level. At a local level, through Drug and Alcohol Action Teams (DAATs) this could improve the feeling of ownership towards service developments related to the Joint Future agenda. Service managers are currently the key link between nurses and DAATs. Perhaps a service nurse with more client contact should also attend to provide client feedback. At a national level greater nursing input into policy could give this specialist group a greater feeling of professional cohesion as well as keeping policy makers informed. Concerns about health and safety at work need to be considered at a national professional level as well as locally. Whether these issues should be addressed through the involvement of an organisation such as the Association of Nurses in Substance Abuse (ANSA) or an appointed individual is for discussion. Recommendations • All substance misuse nurses should receive induction training prior to commencing their post. Greater time should be protected to allow participation in training. • There should be further exploration of what models of counselling, if any, are followed to assess whether current training is adequate. • Appointment scheduling may need review as there was evidence that consultation time was routinely underestimated. Frequency of missed appointments needs to be considered at the same time. • Staffing of substance misuse nurses should be expanded in order to reduce: excessive caseloads; lengthy waiting lists; insufficient cover for holidays, training and absences; and occupational stress. • Nurses could be involved in GP training to share their experience of managing difficult cases such as poly-drug users and widen GPs perspective of the social benefits of drug misuse treatment. • Nurses should be kept aware of developments on integrated care for drug misusers. This would allow them to understand the principles behind integrated care and be aware of how their service fits into the overall plan. • Extending the role of senior substance misuse nurses to include the prescribing of controlled drugs should be considered. • A clearer job title should be given to nurses working in substance misuse so that they may be easily identified and representable at both DAAT and Scottish Executive level, e.g. Specialist Nurse in Substance Misuse. • Efforts should be made to improve substance misuse nurses’ opportunities to influence policy. • All substance misuse nurses should be provided with appropriate on going training, procedures and practices to allow them to carry out their work safely

Identifying common problems in the acquisition and deployment of large-scale software projects in the US and UK healthcare systems

Public and private organizations are investing increasing amounts into the development of healthcare information technology. These applications are perceived to offer numerous benefits. Software systems can improve the exchange of information between healthcare facilities. They support standardised procedures that can help to increase consistency between different service providers. Electronic patient records ensure minimum standards across the trajectory of care when patients move between different specializations. Healthcare information systems also offer economic benefits through efficiency savings; for example by providing the data that helps to identify potential bottlenecks in the provision and administration of care. However, a number of high-profile failures reveal the problems that arise when staff must cope with the loss of these applications. In particular, teams have to retrieve paper based records that often lack the detail on electronic systems. Individuals who have only used electronic information systems face particular problems in learning how to apply paper-based fallbacks. The following pages compare two different failures of Healthcare Information Systems in the UK and North America. The intention is to ensure that future initiatives to extend the integration of electronic patient records will build on the ‘lessons learned’ from previous systems