Performance measurement in the health sector

This paper provides an overview of the development of performance measurement in the Irish health sector, drawing on reported developments in other health systems. Performance measurement has considerable potential in health service management in enabling national priorities for health reform to be translated into organisational and individual objectives, to provide a focus on results, and to enhance accountability. The paper begins by positioning the development of performance measurement within the range of recent policy and legislative changes in the Irish health sector. Drawing on the international literature, four key aspects of performance measurement are identified, which form the framework for the study: developing performance measurement systems; measure definition and data collection; developing the use of performance data; and co-ordinating performance measurement. Performance measurement was also reviewed at the national system level, the organisation level and the individual level. The range of approaches currently in place to measure performance is outlined, and includes: · systems to monitor health outcomes and progress against strategic priorities at the national level, such as the Public Health Information System (PHIS) and strategy indicators used for the National Cancer Register · systems to monitor the performance of programmes/service areas, such as the hospital inpatient enquiry system (HIPE) and datasets being developed for mental health services and intellectual disability services · systems to monitor performance at the health board and agency level, such as integrated management returns (IMRs) and service plan indicators. A comparative review was undertaken of the development of performance measurement systems in Australia, New Zealand, the United Kingdom, the USA and Canada. The report concludes that the focus of performance measurement across these countries is on improving health outcomes, improving the quality of care, achieving national priorities and reducing inequalities in health. The findings also suggest that performance measurement systems are largely evolving around: · developing national frameworks to define standards of expected performance · developing good measures and data collection systems · building managerial capacity to manage performance. The findings highlight the need for strong leadership in promoting the development of performance measurement and developing frameworks to ensure that health care providers comply with good performance standards. Currently, performance measurement tends to be focused around acute health care, but there is increasing interest in extending performance measurement to all parts of the health care system. The report looks at the approach taken across countries to developing performance measures. The concepts of performance measured include health improvement/outcomes, effectiveness and quality, the patient orientation of services, access and financial/resource management. Similar concepts are seen in the range of measures currently being used in the Irish health service, although coverage appears patchy. The area that needs to be developed in particular in the Irish health sector is the patient-orientation of services. The types of measures used across countries include rates; averages; medians or means; proportions; costs; composite measures; and other measures of performance. Similar measures are currently used in the Irish system although composite measures have yet to be developed. In terms of the development of performance measures the findings emphasise the need to move beyond an emphasis on finance and activity towards more balanced sets of measures and to focus on generating information that is useful to decision-makers. The findings also highlight the need to shift the emphasis from compliance with processes to focusing on results, and that performance measures should relate to key objectives in order to drive strategy forward. The report highlights the need to have good quality data available at all levels of the system to support performance measurement. In terms of collecting, aggregating and disseminating data it is reported that data management systems are largely underdeveloped and fragmented. The acute hospital sector is where performance measurement is most developed. The need for a co-ordinated approach to the development of data management systems across the health system is identified. The findings suggest that data currently available on performance is under-utilised and focused mainly on controlling expenditure. A number of points are raised about how the use of data can be improved. The decision-usefulness of data is an important issue. Data must be relevant to users and at the correct level of detail. Data also needs to be timely and easily accessible to those who need it. In addition, the managerial culture needs to be receptive to the importance of basing decisions on performance data, individuals need to feel empowered, and the appropriate skills and expertise are required to be able to interpret data and use the findings constructively. Data must be reliable and individuals need to have confidence in using it. At the individual level it is suggested that performance measurement needs to be developed and linked to performance management and personal development planning. The research found that performance measurement at the individual level is largely underdeveloped. The findings emphasise the need for improved co-operation and collaboration across the health sector in the development of performance measurement. A number of areas must be addressed in this regard, including the need for greater clarity in defining who is responsible for co-ordinating performance measurement across the system. The report concludes that the key issues to be addressed are: · clarifying responsibility for overall co-ordination of performance measurement · extending performance measurement to all areas of the health system · extending performance measurement to the individual level within organisations and linking it with performance managemen

Probing the dNTP Binding Region of \u3cem\u3eBacillus subtilis\u3c/em\u3e: DNA Polymerase III with Site-Directed Inhibitors: A Dissertation

6-(p-Hydroxyphenylhydrazino) uracil (H2-HPUra) is a selective and potent inhibitor of the replication-specific DNA polymerase III (pol III) of Gram+ bacteria such as Bacillus subtilis. Although a pyrimidine, H2-HPUra derives its inhibitory activity from its specific capacity to mimic the purine nucleotide, dGTP. The project described in this thesis dissertation involves the use of H2-HPUra-like inhibitors to probe the structure and function of the pol III active site. It consists of two separate problems which are summarized below. Production of a potent bona fide dGTP form of inhibitor. A method was devised to successfully convert the H2-HPUra inhibitor prototype to a bona fide purine, using N2-benzyl guanine as the basis. Structure-activity relationships of benzyl guanines carrying a variety of substituents on the aryl ring identified N2-(3,4-dichlorobenzyl) guanine (DCBG) as a compound equivalent to H2-HPUra with respect to potency and inhibitor mechanism. DCBdGTP, the 2\u27-deoxyribonucleoside 5\u27-triphosphate form of DCBG, was synthesized and characterized with respect to its action on wild-type and mutant forms of pol III. DCBdGTP acted on pol III by the characteristic inhibitor mechanism and formally occupied the dNTP binding site with a fit which permitted its polymerization. The latter experiment identified the site for the binding of the inhibitor\u27s aryl moiety as a distinct site located at a distance of approximately 6-7 Å from the base-paired 2-NH group of a bound dGTP. Attempt to covalently label amino acid residue 1175, a putative participant in inhibitor binding. Azp-12, a point mutation of serine 1175, yields a form of pol III whose inhibitior sensitivity varies specifically as a function of the composition of the para substituent of the inhibitor\u27s aryl ring. On the basis of the latter behavior, residue 1175 was hypothesized to be a residue directly involved in the binding of the inhibitor\u27s aryl moiety. To test this hypothesis, residue 1175 was specifically mutated to either cysteine or lysine, each of which presents a side chain amenable to covalent bond formation with appropriately reactive inhibitor forms. Of the two mutant pol III forms, only the cysteine form (pol III-cys) was catalytically active. The kinetic properties and inhibitor sensitivity profile of pol III-cys identified it as a target suitable for potentially irreversible inhibitor forms containing the following groups in the meta position of the aryl ring: -CH2Br, -CH2C1, and -CH2SH. None of the several inhibitors tested selectively or irreversibly inactivated pol III-cys. Possible bases for the failure of this group of inhibitors and for the redesign of more useful covalently reactive inhibitor forms are considered

Exploring Trauma: Lived Experiences of Foster Parents in the Foster Care System

This qualitative transcendental phenomenology study explored the lived experiences of foster parents who care for traumatized children. Children in the foster care system are often exposed to trauma before and after entering the foster care system. Therefore, the trauma that foster children experience can impact them emotionally, psychologically, and cognitively. Unfortunately, foster parents are often unequipped to deal with these issues when these children enter their homes. The gap this study aimed to address was that foster parents did not have opportunities to share their experiences on what it was like to provide care for traumatized foster children. Husserl’s phenomenology theory guided this exploration and provided an in-depth, comprehensive description of foster parents’ experience in the foster care system. The study’s design and framework were used to address the research question, how does a foster parent describe their experience of providing care for children who have experienced trauma? In the rural region of Atlanta, Georgia, seven foster parents participated in semi-structured face-to-face interviews. The data were analyzed and coded. Four themes emerged: challenges in being a foster parent, the impact of fostering traumatized children, factors contributing to foster parents’ resilience, and recommendations for supporting foster parents. The themes provided insight into what it was like to provide care for foster children in the foster care system and shed light on foster parents’ challenges and needs in caring for traumatized children. The themes revealed that caring for traumatized children can be stressful. The foster parents did not receive sufficient communication about the children’s trauma background or training in managing the children’s trauma. Training and workshops were recommended because the foster parent can experience burnout without developing resiliency and support

All hayll, all hayll, both blithe and glad : Direct Address in Early English Drama, 1400-1585

This dissertation examines direct address in English drama from 1400 to 1585. All 91 non-fragmentary plays from this period were used in order to enable a comprehensive understanding of the technique. While direct address is widely acknowledged as a fundamental technique in early English drama, it is almost never studied, its effects and functions being assumed to be \u27obvious\u27 and \u27natural,\u27 and therefore neither requiring nor meriting focused consideration. This study shows that direct address was used systematically in early drama, and its effects could be quite sophisticated. To see this, it is crucial to consider the use of rhetorical markers (vocatives, second person pronouns, and imperatives). Some direct address contains such \u27markers\u27 and is thus clearly directed to the audience, for these rhetorical markers explicitly acknowledge the audience; other direct address does not. Early English drama used both marked and unmarked direct address carefully, reserving marked direct address for moments of particular importance, and using unmarked direct address for more commonplace functions like exposition. An outline of the dissertation is as follows. Chapter 1 describes the critical history of direct address and the project\u27s methodology. Chapter 2 considers asides, showing that they were atypical in medieval drama but became common during the sixteenth century. Chapter 3 examines how direct address is used by special personages (Expositors, Prologues), showing how special personages in medieval drama speak of themselves as one of the actors, but sixteenth-century special personages do not, which may result from the influence of classical drama. Chapter 4 considers compound direct address, a form of marked direct address in which speeches are simultaneously addressed both to another character and to the audience, arguing that that this form of direct address is very potent and hence its usage was restricted to moments of intense significance (for example, obtaining salvation). Chapter 5 looks at the use of direct address by characters in medieval drama, showing its effects in particular plays such as the York Cycle, in which direct address is used to rhetorically embody the incarnation. Chapter 6 examines direct address by characters in sixteenth-century drama, showing that the shift in dramaturgy from direct address to soliloquy (meaning \u27thinking aloud\u27) happened much later than is generally assumed; by 1585, soliloquy was only emerging as a technique and was far from common, let alone dominant. Chapter 7 concludes the project, bringing together its findings and looking ahead to the possibilities for further research in this area

The Effective Use of Competencies In the Irish Civil Service

This research explores the development of competency-based human resource management (HRM) in the Irish civil service. It builds on the research outlined in three previous CPMR discussion papers, on key HRM challenges facing the Irish public service, flexible working in the public service and the development of personnel management in the civil service. The paper begins by exploring some of the concepts of competency-based approaches to HRM. Three issues outstanding in the literature are identified: · whether competencies should be understood as behavioural traits or personal dispositions, or whether they should relate to a specific body of knowledge and skills required to do a job effectively · whether competencies should refer to a minimum standard required or to the characteristics of proficient or excellent performance · how broad or narrow competency statements should be, the danger being that if too broad they can be difficult to apply to specific situations, but if broken down into too many criteria they can become atomised or result in unmanageable lists. Current thinking is explored on the potential of competency-based management (CBM) to enable organisations respond to the challenges presented by globalisation,increased competition and constant change. It is suggested that CBM can enable organisations to build internal capacity to respond to such changes by identifying,building and leveraging new competencies, empowering individuals within organisations and encouraging innovation. Changing perspectives on HRM are explored as is the shift towards ‘soft’ approaches aimed at unleashing the potential that each individual can bring to the organisation. In addition, the review examines the role of competencies in the development of integrated HRM. In the same section of the report, current thinking on approaches to developing competency profiles and identifying competencies is discussed, in order to develop a framework for the effective use of competencies which can inform employee development and employee resourcing activities. The research then explores the development of competency-based HRM in the Irish civil service. Recruitment and selection is the area where most development in this regard has taken place. Currently, competencies are used as the basis for all aspects of recruitment to most civil service positions and to several local government and specialist positions. Competencies are also used in open competitions for promotion and for some internal promotions. The findings suggest that, in general, the approach has been well accepted by those who have been involved in the process to date, either as interviewers or interviewees. The perceived benefits of the approach include the provision of a holistic view of the person and a greater focus on the fit between what the person can do and the requirements of a job, and greater transparency, fairness and objectivity in the process. Nonetheless, it is also suggested that the process could be improved, particularly in relation to improving its predictive reliability. The research also outlines competency frameworks developed in three departments. The focus is on how these systems were promoted within departments, the range of competencies identified within frameworks and the process of using competencies. Also included in the review of competency-based HRM is the development of the Performance Management and Development System (PMDS), which was launched by the Taoiseach in May 2000. In the light of the development of an integrated competency-based approach to HRM, as outlined in Chapter Two of this paper and in the Programme for Prosperity and Fairness (PPF), a comparison is undertaken of the competencies found in the PMDS and those found in other competency frameworks used in the civil service. This comparative review highlights the similarities that exist between the various competency frameworks. Integration of the frameworks is possible, but integration should allow departments the flexibility to tailor generic competencies towards the business that they do. Achieving a balance between developing competencies that are relevant to those using them, and competencies that are sufficiently generic to preserve the civil service as a unified system in HR terms, is identified in the research as a particular challenge for managers. The research also explores current thinking and current trends in the development of competencies in other public administrations, with a view to informing thinking on how CBM might be developed further in the Irish civil service. The critical success factors in the development of approaches to CBM highlighted on the basis of international experience to date relate to: · leadership and top-level commitment to the process and employee participation in the development of frameworks · effective communication at all levels in the development of profiles and regular feedback to individuals on their performance · clear links between competencies, business plans and organisational objectives, and clarity about roles, work responsibilities and standards of behaviour required of employees · clarity about the roles of managers and employees in the CBM approach · an emphasis on training and developing people, rewarding good performance and dealing with underperformance · integration of competencies and CBM into HR strategies · monitoring and evaluation of the effectiveness of the approach and its implementation and integration

“All hayll, all hayll, both blithe and glad” : Direct Address in Early English Drama, 1400-1585

Now will I praise those godly men, our ancestors, each in his own time... All these were glorious in their time, each illustrious in his day. Some of them have left behind a name and men recount their praiseworthy deeds (Sirach 44: I. 7-8) Direct address is widely acknowledged as a fundamental technique in early English, particularly medieval, drama. The observation that early English drama does not have the convention of the ‘fourth wall,’ and frequently speaks directly to and interacts with the audience would not be news to scholars o f this drama; many have mentioned it. A.R. Braunmuller, for instance, in 1990, says that “[s]uch later-Tudor Vices as Ambidexter (Cambises) or Revenge (Horestes) continue the medieval drama’s easy familiarity with the audience. Directly addressing the spectators or commenting ‘aside’ to them, these characters elide or obscure the differences between play and spectator” (83). Meg Twycross, in 1994, notes the preponderance of direct address in medieval plays, saying, “The true amount of direct address in these plays becomes apparent only when they are performed” (55). Suzanne Westfall, in 1997, comments that “early modem theater is full of what modem readers would consider breaches of fourth wall in the form of prologues and epilogues, verse designed to contact the audience directly with recommendation for their behavior, pleas for applause and reward, and straightforward flattery” (53). The sources in which these comments appear — The Cambridge Companion to Medieval English Theatre, A New History of Earlv English Drama, and The Cambridge Companion to English Renaissance Drama — demonstrate how accepted these ideas are among scholars of early English drama; edgy or highly controversial suggestions, areas of intense scholarly debate, do not tend to make it into the introductory guidebooks that we construct for our fields. The position of direct address as a foundational, widely used technique in early English drama is solid, perhaps as firmly in place as an assumption of our scholarship as it was in the dramaturgy in which it figures so prominently. Since the understanding that direct address is a fundamental technique in early English dramaturgy is widely held, it is therefore surprising that almost no scholarship exists that focuses upon direct address. Doris Fenton’s 1930 study, The Extra-Dramatic Moment in Elizabethan Plavs Before 1616, is the sole full-length consideration of this issue. Even if this study were thoroughly brilliant and pretematurally insightful about the uses of direct address, given how much we have learned about early drama since its publication, the time would assuredly be ripe for a reconsideration of its conclusions. As it is. Fenton\u27s consideration of direct address is disappointing in several ways. It focuses largely upon Elizabethan plays, providing only a cursory examination of medieval and Tudor plays, while nearly all contemporary scholars would agree that direct address is far more common in the earlier drama. In addition, Fenton’s analysis is solely formalistic. She describes and categorizes the purposes for which direct address can be used, but provides no further analysis. Moreover, the conceptual understanding o f direct address underlying her study — that direct address is by definition ‘extra-dramatic’ — is problematic; as we now know, there is no reason to assume that early English drama conceived of direct address as something that occurs ‘outside’ the normal drama. As David Klausner has noted, “This [characterization of direct address as extra-dramatic] can now be seen as a gross oversimplification of a device which both implies and provokes a considerable range of relationships between actor and audience” (2). Demonstrably problematic in concept, and analytically challenged in scope, Fenton’s study nonetheless has remained the last word on direct address for over seventy years. While Fenton’s is the only study that focuses upon direct address, other scholars consider direct address in some detail as a secondary focus, because their central topic of study is closely related to direct address; discussions of soliloquy, interaction with the audience, and improvisation all tend to contain some contemplation of direct address. Thus Neil Carson in “The Elizabethan Soliloquy — Direct Address or Monologue,” from 1976, focuses upon soliloquy, as one would expect, but considers as well the related issue of direct address. In her 1978 dissertation, “Soliloquies, Asides, and Audience in English Renaissance Drama,” Margaret Coleman Gingrich similarly focuses upon techniques related to direct address and considers direct address as it intersects with those issues, as does Lloyd A. Skiffington in his The History of the English Soliloquy from 1985. Likewise, in Themes and Conventions of Elizabethan Tragedy, from 1935, M.C. Bradbrook considers speech conventions, including soliloquies and asides, and, relatedly, direct address; since she considers soliloquies and asides as direct address, the connection here is quite close. In his 1966 dissertation, “The Comic Turn in English Drama, 1470-1616,” J.A.B Somerset includes a chapter on direct address. In his recent (2003) article “The Improvising Vice in Renaissance England,” David Kiausner touches upon direct address for its connection to improvisation. Other studies of Elizabethan soliloquies and asides, such as that found in Bernard Beckerman’s Shakespeare at the Globe (1962), tend to mention direct address largely to downplay the possibility that many soliloquies and asides could have been directed to the audience. However, even when we include the material in which direct address is considered as a secondary focus, the scholarship on this subject remains painfully thin

07. “All hayll, all hayll, both blithe and glad” : Direct Address in Early English Drama, 1400-1585

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