Impact of published clinical outcomes data: case study in NHS hospital trusts

Objective To examine the impact of the publication of clinical outcomes data on NHS Trusts in Scotland to inform the development of similar schemes elsewhere. Design Case studies including semistructured interviews and a review of background statistics. Setting Eight Scottish NHS acute trusts. Participants 48 trust staff comprising chief executives, medical directors, stroke consultants, breast cancer consultants, nurse managers, and junior doctors. Main outcome measures Staff views on the benefits and drawbacks of clinical outcome indicators provided by the clinical resource and audit group (CRAG) and perceptions of the impact of these data on clinical practice and continuous improvement of quality. Results The CRAG indicators had a low profile in the trusts and were rarely cited as informing internal quality improvement or used externally to identify best practice. The indicators were mainly used to support applications for further funding and service development. The poor effect was attributable to a lack of professional belief in the indicators, arising from perceived problems around quality of data and time lag between collection and presentation of data; limited dissemination; weak incentives to take action; a predilection for process rather than outcome indicators; and a belief that informal information is often more useful than quantitative data in the assessment of clinical performance. Conclusions Those responsible for developing clinical indicator programmes should develop robust datasets. They should also encourage a working environment and incentives such that these data are used to improve continuously

Organisational culture and quality of health care

concerned with assessing and improving the quality of health care. The USA, in particular, has identified specific concerns over quality issues1 2 and a recent report from the Institute of Medicine pointed to the considerable toll of medical errors.3 In the UK a series of scandals has propelled quality issues to centre stage4 5 and made quality improvement a key policy area.6 But how are quality improvements to be wrought in such a complex system as health care? A recent issue of Quality in Health Care was devoted to considerations of organisational change in health care, calling it “the key to quality improvement”.7 In discussing how such change can be managed, the authors of one of the articles asserted that cultural change needs to be wrought alongside structural reorganisation and systems reform to bring about “a culture in which excellence can flourish”.8 A review of policy changes in the UK over the past two decades shows that these appeals for cultural change are not new but have appeared in various guises (box 1). However, talk of “culture” and “culture change” beg some diffi- cult questions about the nature of the underlying substrate to which change programmes are applied. What is “organisational culture” anyway? It is to this issue that this paper is addressed

Synthesis and chemistry of highly distorted polycyclic aromatic hydrocarbons

A significant feature of smaller cyclophanes and buckminsterfullerenes is the presence of nonplanar aromatic rings. Such compounds are of considerable interest due to both the synthetic challenge they pose and to their unusual conformational, spectroscopic, and chemical behavior. A great deal of work has focussed on determining the extent to which an aromatic ring can be distorted from planarity while remaining isolable under ambient conditions. Although this question has been examined in detail for isolated benzene rings (for example, through investigations of [n]paracyclophanes), analogous studies of polycyclic aromatic hydrocarbon (PAH) frameworks have never been pursued. -- Here the first systematic examination of the distortion from planarity of a PAH moiety is reported. The synthesis of a number of [n](2,7)pyrenophanes from [3.3]dithiacyclophane precursors is described. Some physical, spectroscopic, and chemical properties of these molecules are also described, and a number of X-ray structures of markedly nonplanar aromatic moieties are reported. From this data, it is concluded that the end-to-end bend of the most strained pyrenophane prepared is greater than the average end-to-end bend of the pyrene moiety. However, POAV analysis of the pyramidalization of pyrenophane sp² carbon atoms reveals markedly lower pyramidalizations than are observed in D₅h C₇₀. Attempts at the functionalization of [n](2,7)pyrenophanes in the hope of using them as precursors for larger nonplanar PAHs were made. However, suitable conditions for functionalization of pyrenophanes were not found. A synthetic approach to a C₂-chiral 1,6-[n]pyrenophane is also described. -- An attempted synthesis of a derivative of the buckybowl pinakene using a tandem Bergman cycloaromatization/free radical conjugate addition is presented. -- The experimental work is preceded by reviews of the literature concerning the concept of aromaticity, nonplanar aromatic molecules (especially [n]paracyclophanes) and fullerene fragments

Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies

Background: Recent high-profile reports into serious failings in the quality of hospital care in the NHS raise concerns over the ability of trust boards to discharge their duties effectively. Objectives: Our study aimed to generate theoretically grounded empirical evidence on the associations between board governance, patient safety processes and patient-centred outcomes. The specific aims were as follows: (1) to identify the types of governance activities undertaken by hospital trust boards in the English NHS with regard to ensuring safe care in their organisation; (2) in foundation trusts, to explore the role of boards and boards of governors with regards to the oversight of patient safety in their organisation; (3) to assess the association between particular hospital trust board oversight activities and patient safety processes and clinical outcomes; (4) to identify the facilitators and barriers to developing effective hospital trust board governance of safe care; and (5) to assess the impact of external commissioning arrangements and incentives on hospital trust board oversight of patient safety. Methods: The study comprised three distinct but interlocking strands: (1) a narrative systematic review in order to describe, interpret and synthesise key findings and debates concerning board oversight of patient safety; (2) in-depth mixed-methods case studies in four organisations to assess the impact of hospital board governance and external incentives on patient safety processes and outcomes; and (3) two national surveys exploring board management in NHS acute and specialist hospital trusts in England, and relating board characteristics to whole-organisation outcomes. Results: A very high proportion of trust boards reported the kinds of desirable characteristics and board-related processes that research says may be associated with higher performance. Our analysis of the symbolic aspects of board activities highlights the role and differences in local processes of organising the governance of patient safety. Most boards do allocate considerable amount of time to discussing patient safety and quality-related issues and were using a wide range of hard performance metrics and soft intelligence to monitor its organisation with regard to patient safety. Although the board of governors is generally perceived to be well-meaning, they were also considered to be being largely ineffective in helping to promote and deliver safer care for their organisations. We did not find any statistically significant relationship between board attributes (self-reported) and processes and any patient safety outcome measures. However, we did find a significant relationship between two dimensions of the Board Self-Assessment Questionnaire and two specific-and-related national staff survey organisational ‘process’ measures: (1) staff feeling safe to raise concerns about errors, near-misses and incidents and (2) staff feeling confident that their organisation would address their concerns, if raised. We also found that contracting and external financial incentives appeared to play only a relatively minor role in incentivising quality and safety improvement. Conclusions: Our research is the first large-scale mixed-methods study of hospital board activity and behaviour related to the oversight of patient safety in the English NHS and the key findings should be used to influence the design of future governance arrangements as well as the training and support of board. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Decentring patient safety governance: case studies of four English Foundation Trust hospital Boards

This chapter focuses on the decentred governance literature as a framework to examine the enactments of Board governance of patient safety at several Foundation Trust hospitals within the English National Health Service (NHS). It describes conceptual framings of corporate governance that may inform local practices, and outlines the regulatory context of patient safety governance within the English NHS. The chapter explores the situated agency of Board members in relation to the governance of patient safety within case study sites. It also focuses on the findings from a larger National Institute for Health Research funded study of the governance of patient safety. A range of competing conceptual framings have been used to understand the governance role of Boards, and which inform the situated agency of local actors. Local hospital Trust Boards were first introduced in the English NHS in 1990. Public service reforms in England typically emphasise performance and accountability, rather than renewal and entrepreneurship

Enacting corporate governance of health care safety and quality: a dramaturgy of hospital boards in England

The governance of patient safety is a challenging concern for all health systems. Yet, while the role of executive Boards receives increased scrutiny, the area remains theoretically and methodologically underdeveloped. Specifically, we lack a detailed understanding of the performative aspects at play: what Board members say and do to discharge their accountabilities for patient safety. This article draws on qualitative data from overt non-participant observation of four NHS hospital Foundation Trust Boards in England. Applying a dramaturgical framework to explore scripting, setting, staging and performance, we found important differences between case study sites in the performative dimensions of processing and interpretation of infection control data. We detail the practices associated with these differences - the legitimation of current performance, the querying of data classification, and the naming and shaming of executives – to consider their implications

Meta-regulation meets deliberation: situating the governor within NHS foundation trust hospitals

NHS Foundation Trust (FT) Hospitals in England have complex internal governance arrangements. They may be considered to exhibit meta-regulatory characteristics to the extent that Governors are able to promote deliberative values and steer internal governance processes towards wider regulatory goals. Yet, while recent studies of NHS FT Hospital governance have explored the role and experience of FT Governors and examined FT hospital Boards to consider executive oversight, there is currently no detailed investigation of interactions between Governors and members of hospital Boards. Drawing on observational and interview data from four case-study sites, we trace interactions between the actors involved; explore their understandings of events; and consider the extent to which the benefits of meta-regulation were realised in practice. Findings show that while Governors provided both a conscience and contribution to internal and external governance arrangements, the meta regulatory role was largely symbolic and limited to compliance and legitimation of executive actions. Thus while the meta-regulatory ‘architecture’ for Governor involvement may be considered effective, the soft intelligence gleaned and operationalised may be obscured by ‘hard’ performance metrics which dominate processes and priority setting. Governors were involved in practices that symbolised deliberative involvement but resulted in further opportunities for legitimising executive decisions.