Process mapping office activities of a small mechanical contractor for process improvement and enhancement of succession process

Includes bibliographical references

LAKOFF, Andrew (2005), Pharmaceutical Reason: Knowledge and Value in Global Psychiatry

LAKOFF, Andrew (2005), Pharmaceutical Reason:Knowledge and Value in Global Psychiatry. Cambridge:Cambridge University Press, 206 páginas

What does the ideal urgent and emergency care system look like? A qualitative study of service user perspectives

Background: Policies aimed at diverting care from EDs to alternative services have not been successful in reducing ED attendances and have contributed to confusion for service users when making care-seeking decisions. It is important that service users are at the heart of decision making to ensure new services meet the needs of those who will be accessing them. In this study, service users were encouraged to think freely about the desirable qualities of an ideal urgent and emergency care (UEC) system. Methods: From September to February 2019, an open inductive methodology was used to conduct focus groups with service users who had used UK UEC services within the previous year. Service users that had contact with NHS111, ambulance service, General Practice out-of-hours, minor injuries unit, walk-in centre or ED were purposively sampled and stratified into the following groups: (1) 18–45 years; (2)≥75 years; (3) adults with young children; (4) adults with long-term conditions. Focus groups were structured around experiences of accessing UEC services and perspectives of an ‘ideal’ UEC system. Results: 30 service users took part in the study, across four focus groups. The ideal UEC system centred around three themes: a simplified UEC system (easier to understand and a single-point of access); more ‘joined-up’ UEC services and better communication between health staff and patients. Conclusion: Desirable qualities of an ideal UEC system from a service user perspective related to simplifying access for example, through a single point of access system where health professionals decide the appropriate service required and improving continuity of care through better integration of UEC services. Service users value reassurance and communication from health professionals about care pathways and care choices, and this helps service users feel more in control of their healthcare journey

Can more appropriate support and services be provided for people who attend the emergency department frequently? National Health Service staff views

BACKGROUND: Interventions designed to help Emergency Department (ED) staff manage frequent attenders are labour-intensive and only benefit a small sample of frequent attenders. We aimed to use the in-depth knowledge of health professionals with experience of working with ED frequent attenders to understand the challenges of managing this group of patients and their opinions on providing more appropriate support. METHODS: Semi-structured interviews were conducted with medical and nursing ED staff, mental health liaison nurses and general practitioners (GPs). Interviews covered the following: definitions and experiences of treating frequent attenders and thoughts on alternative service provision. Vignettes of frequent attenders were used to elicit discussions on these topics. Thematic analysis of transcribed interviews was undertaken. RESULTS: Twelve health professionals were interviewed. Three groups of frequent attenders were identified: people with long-term physical conditions, mental health problems and health-related anxiety. Underlying reasons for attendance differed between the groups, highlighting the need for targeted interventions. Suggested interventions included improving self-management of long-term physical conditions; creating a 'go-to' place away from the ED for patients experiencing a mental health crisis; increasing the provision of mental health liaison services; and for patients with health-related anxiety, the role of the GP in the patients' care pathway was emphasised, as were the benefits of providing additional training for ED staff to help identify and support this group. CONCLUSION: Interventions to address frequent attendance should focus on redirection to and liaison with more appropriate services, located on the hospital site or in the community, tailored to each identified patient group

The impact of different liaison psychiatry models on the emergency department: A systematic review of the international evidence

Objective This review aimed to evaluate the current evidence for what impact different Liaison Psychiatry (LP) services are having on Emergency Departments (ED). Mental Health (MH) problems contribute to 12 million annual US ED attendances and 5% in the UK. Methods Databases were searched for articles describing LP services for adult MH patients attending EDs which reported ED care-related outcomes, published since 2000. Articles were screened and relevant articles quality assessed and narratively synthesized. Results 3653 articles were identified and 17 included in the review. Study designs were overall of poor-moderate quality, using retrospective before-and-after study designs. LP services were categorized into four models. Models with MH personnel integrated into the ED team or triage reduced patient waiting time to be seen, may reduce patients leaving without being seen and have high staff satisfaction. Co-located MH space or personnel reduced patient waiting times. Care agreements with existing psychiatry teams don't affect waiting times or ED length of stay. Transferring patients to external services reduces patients' time in the ED. There is insufficient evidence about patient satisfaction, costs, and onward care. Conclusions Waiting times are shortened by MH personnel integrated into the ED and are more satisfactory to staff than other LP models. The involvement of a psychiatrist in the LP team improves the care quality. All models may improve safety for patients but most evaluations are of poor quality and therefore there is still insufficient evidence to recommend one service model over another and further robust research is required

Improving outcomes for older people in the emergency department : a review of reviews

Background: There has been a recognised trend of increasing use of emergency and urgent care and emergency departments (EDs) by older people, which is marked by a substantial evidence base reporting interventions for this population and guidance from key organisations. Despite this, outcomes for this population remain suboptimal. A plethora of reviews in this area provides challenges for clinicians and commissioners in determining which interventions and models of care best meet people’s needs. The aim of this review was to identify effective ED interventions which have been reported for older people, and to provide a clear summary of the myriad reviews and numerous intervention types in this area. Methods: A review of reviews, reporting interventions for older people, either initiated or wholly delivered within the ED. Results: A total of 15 review articles describing 83 primary studies met our content and reporting standards criteria. The majority (n=13) were systematic reviews (four using meta-analysis.) Across the reviews, 26 different outcomes were reported with inconsistency. Follow-up duration varied within and across the reviews. Based on how authors had reported results, evidence clusters were developed: (1) staff-focused reviews, (2) discharge intervention reviews, (3) population-focused reviews and (4) intervention component reviews. Conclusions: The evidence base describing interventions is weak due to inconsistent reporting, differing emphasis placed on the key characteristics of primary studies (staff, location and outcome) by review authors and varying quality of reviews. No individual interventions have been found to be more promising, but interventions initiated in the ED and continued into other settings have tended to result in more favourable patient and health service outcomes. Despite many interventions reported within the reviews being holistic and patient focused, outcomes measured were largely service focused. PROSPERO registration number: PROSPERO CRD42018111461

8 Different approaches needed to manage ED demand among different age-groups

BACKGROUND/OBJECTIVES: A variety of interventions have been proposed to manage rising demand for Emergency and Urgent Care, described by an NHS England review as unsustainable in the long term. However it is unlikely that any suggested approach will be equally suitable for the diverse population of ED users.We aimed to understand the patterns of demand amongst different types of patients attending ED. We also sought to understand the intended and unintended effects of demand management initiatives. Our study combined insights from routine data, a survey of ED patients, and qualitative interviews with ED staff. This paper describes the results of our analysis of the interviews. METHODS: We conducted semi-structured interviews with 25 ED and Urgent Care Centre staff across 7 hospital sites in Yorkshire and Humber between 25 April and 11 July 2016. The interview topic guide asked about 4 broad areas; job role, description of patients and their impact on demand, description of inappropriate attendance, and current/future initiatives to deal with rising demand. Interviews were transcribed verbatim and analysed using framework analysis. We analysed the results to identify groups of patients with different patterns of use of ED services. We also explored ED staff experiences of demand management initiatives, and their suggestions for future initiatives. RESULTS: Although we did not ask specifically about patients' age, our analysis revealed that ED staff categorised attenders as children and young people, working age people, and older people. These groups had different reasons for attendance, different routes to the ED, different rate of non-urgent attendance, and different issues driving demand. Staff also described variation in the time taken to treat patients of different ages, with the oldest and youngest patients described as requiring the most time.There was no consensus amongst staff about the effectiveness of initiatives for managing demand. A strikingly wide variety of initiatives were mentioned including patient education, co-location of other services with ED ('ED hubs'), and extending community-based services. CONCLUSION: ED staff attribute distinctly different patterns of ED attendance to patients of different age groups, including reasons for attending ED, the route to the ED, and the rate of non-urgent attendance. Given this variation, proposed demand management interventions are likely to impact differently on different age groups, and one solution is unlikely to be optimal for all ages. Therefore a number of different approaches will be needed to manage ED demand among different age groups