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Abstract This thesis measures safety climate in a sample of Scottish acute hospitals. It demonstrates how staff perceptions related to safety issues are linked to their safety behaviours and also to the consequences, both for the workers and the patients. Following a review of the industrial and healthcare safety climate literatures, a theoretical model was proposed to investigate the underlying mechanisms between safety climate and safety outcomes. Based on this review, the Hospital Survey on Patient Safety Culture (HSOPSC) was selected as part of a questionnaire to measure safety climate, safety behaviours and safety outcomes. A total of 1969 clinical staff from seven Scottish acute NHS hospitals were surveyed. The psychometric analysis, using EFA and CFA, showed that the original 12 factor structure of the HSOPSC scale was replicated. A focus group study (n = 25) was conducted in two of the hospitals to extend the survey findings. The qualitative data supported the theoretical model proposed based on the literature review by demonstrating the role of managerial practices on safety-related issues. The group discussions further contributed to a wider conceptualization of safety culture by illustrating the multi-level perspective of staff on safety-related issues, including both the external influences and the individual factors. Using structural equation modelling on the same quantitative data set, managerial aspects of safety climate were examined in relation to safety outcomes (safety behaviours, worker and patient outcomes). Results demonstrated the effects of managerial commitment to safety at hospital and unit level on safety outcomes. It also showed the intervening role of safety compliance and safety participation between supervisory practices and self-reported injuries, both for workers and patients. Overall, this thesis provided a psychometrically robust safety climate measurement tool tested in Scottish acute hospitals, and showed the influence of safety-related managerial activities at different levels of the organization on safety outcomes for workers and patients separately.

The 1984 Auditor Genera1's report on energy~thrift in the Health Service claimed that energy~thrift programmes in hospitals were not achieving their performance targets. In order to determine the reasons for this failure, twenty hospital energy~audits were analysed. It was discovered that the two principle factors impairing the performance werez- (a) The thermal conflict between thrift measures implemented on the same thermal system, and, (b) inefficient implementation strategies. In order to investigate the influences of thermal conflict and implementation strategy on the out~comes of energy~thrift programmes,four objectives were defined:~ (i) To develop a computer model which was capable of simultaneously thermally modelling the implementation of energy-thrift measures on several hospital sites. (ii) To use the model to predict the thermal and financial out~comes of various implementation strategies. (iii) To test the sensitivity of the outrcomes to changes of unit fuel prices and capital costs, and, (iv) to compare the predicted results with those actually obtained. Data from four hospital sites and ninety thrift measures were entered into the model for analysis. It was deduced that a law of diminishing returns existed between capital investment and annual savings and that thermal conflict was responsible for an average annual financial loss of 15.5%. The financial returns on the capital invested were considerably enhanced (in one case by 3ÖØ%) by spreading the financial resources over all four sites rather than by concentrating the same capital outlay on a single site. Furthermore it was discovered that there was a level of capital investment that yielded an optimal net present value over the selected project life. The programmes were more sensitive to reductions of unit fuel prices than increases of capital costs. Most of the thrift programmes remained viable (N.B. N.P.V. > Ø using the public sector discount rate _of 5% and a project life of 5 years) after the unit fuel prices had been reduced by 5Ø% of their 1985 levels. When the results of the implemented programmes were compared with the models' predictions, the accuracy of the estimated savings ranged from a 4.5% under-estimate t 2.5% over-estimate. The software was designed to find the best-fit Ventilation rate and`base temperature for each hospital site and for each thermal zone within the hospital. When the post-implementation assessments of overall air-change rate and site base temperature were compared with those predicted, the model detected changes closely matching the predictions. â The results indicated that the technique developed in this thesis has potential as a monitoring and targeting system as well as a thermal model for predicting the out- comes of energy-thrift programmes.

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Psychiatry Johannesburg, 2013 / The aim of this study was to establish whether the management of dual diagnosis patients in an integrated psychiatric unit influenced relapse and readmission rates. A retrospective record review was conducted to illustrate the influence of an admission to the Dual Diagnosis Unit (DDU) at Sterkfontein Hospital (SFH) on readmission rates of patients. These results were compared to readmission rates of a matched standard care (SC) group. Statistical data analysis revealed a larger presence of schizophrenia in the SC group, likely explained by the DDU’s patient selection procedure. Though not significant, readmission rates in the DDU group were lower than in the SC group, even though substance use levels in the DDU group was higher. This demonstrates the potential positive impact of the DDU program. The findings presented in this paper warrant further investigation in assessing the effectiveness of a DDU, using a larger sample size.

A RESEARCH REPORT SUBMITTED TO THE FACULTY OF HEALTH SCIENCES, UNIVERSITY OF THE WITWATERSRAND, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PUBLIC HEALTH IN THE FIELD OF HOSPITAL MANAGEMENT Johannesburg, September 2014 / Background: Although the Free State Psychiatry Complex has collected information on adverse events, the reporting processes have not been consistent, systematic or transparent and this information was not used in the planning process. In addition, there is also a perception that the rate of adverse events is increasing, that these adverse events are not managed adequately and the extent of the problem could not be determined. It was for this reason that this study was found to be necessary to investigate further on patterns of serious adverse event occurrence, to put the argu-ments to a scientific test and be certain about the extent to which contributory factors were associated with the occurrence of these events in the Free State Psychiatry Complex. Aim: The aim of the study was to describe the inpatient-related adverse events and factors contributing to these adverse events reported at the Free State Psychiatry Complex in order to develop effective strategies to prevent and reduce these ad-verse events. Methodology: This was a cross sectional study design based on a retrospective re-view of records of patients who were involved in these adverse events. The study was undertaken at Free State Psychiatric Complex which is a specialized Mental Health Care Establishment from 1 April 2008 to 31 March 2010. All records of re-ported adverse events of all inpatients at Free State Psychiatry Complex were re-viewed and no sampling was done. The study included review of routinely collected hospital information on patients’ records and registers and from the Advance Incident Management System (AIMS). Results: There were 419 Serious Adverse Events reported during 1 April 2008 to 31 March 2010. The most commonly reported SAE’s included Aggressor-Aggressor, Aggression-victim, Behaviour/Human Performance, Accident/occupational health and safety and falls. The Aggression related adverse event type was one of the most common types of SAE’s, constituting 40% of the Serious Adverse Events reported. The Behaviour /Human Performance adverse event type was second in frequency. Other common SAE’s reported during the study period included Medication, Pres-sure ulcer, Clinical Management and Organisation Management. These Serious Ad-verse Events occurred in 5% of the inpatients at Free State Psychiatry Complex and the findings showed an increase rate of 3.3%. Although more than 80% of the ad-verse events gave rise to moderate disability, 2% caused permanent disabling inju-ries and 2% led to death. However, only 15% of the SAE’s caused minor harm to pa-tients. The most Serious Adverse Events occurred in the months of March, Decem-ber and November which indicate that seasonal changes are associated with in-creased risk for Serious Adverse Events. Most SAE’s happened during the day-shift which might be ascribed to the organisational routines such as medication rounds, handover periods and mealtimes. Human and System Adverse Event Error Types accounted for more than 70% of these SAE’s. The study revealed a positive relationship between the patients in the Intellectual disability and Psycho-geriatric specialities and Accident/occupational health and safety as well as falls related adverse event types. There was also a posi-tive correlation between male patients in the age group of 9-38 in the Acute and Fo-rensic Specialities and Aggression- as well Behaviour Performance related Adverse Event Types. The patients diagnosed with Schizophrenia, Substance Induced Psy-chosis and Intellectual Disability was mostly associated with an increased risk for Se-rious Adverse Events. The results showed that co-morbidity, the patient’s disease profile, age, admission classification, organisational routines and seasonal changes are associated are contributory factors too Serious Adverse Events. It supports the premise that human and system errors as well as the profile of the patient are con-tributing to SAE’s. Conclusion: Safety issues in mental health are unique and are in that way different to the safety issues in medical care. Both the patient population and the environment make patient safety in mental health unique. The uniqueness is associated more with the diagnosis, the patient population and with the mental health setting. SAE’s included Aggressor-aggression, Aggressor-victim, Behavior Performance (abscond-ing, self-harm, suicide); Occupational health and safety, falls and other injuries are particularly prominent to mental health patients. Although patient safety in mental health was considered a field of importance, there is still a lack of awareness of the issues as well as a shortage of research and readily available information to guide patient safety systems, practices, policies, and care delivery in mental health. Work is required to establish a clear definition, set priorities, and develop strategies for re-sponding to patient safety concerns. Models of quality improvement are being uti-lized in psychiatry hospitals but the need for evidenced-based quality improvement models for inpatient psychiatric care still exist. Findings from my study showed that Serious Adverse Events are prevalent in Free State Psychiatry Complex and factors significantly associates with the frequency of aggression-, behavior/occupational health and safety and falls related adverse event types. Advancing a quality and safety research agenda for inpatient psychiatric care will guide practice, improve care, and help ensure efficient and effective care. Complicated problems such as the provision of acute psychiatric hospital services require solutions that incorporate depth of understanding the complexities of acute mental illness as well as changes in prevailing attitudes and systems. This study has also highlighted that Serious Adverse Events are contributed by a varied set of contributing and interacting elements, including patient factors, human factors, system factors, and environmental factors. A complex interaction between the mental health environment and the diagnosis/patient population was found which differentiates patient safety from other health sectors is. Understanding this interac-tion and its relationship to patient safety is very important. It is believed that research in scientific advances, systems analysis, education and development, dissemination of guidelines and improved standard of practice is required for reduction of SAE’s (Leappe et al. 1991) This was the first study to systematically evaluate adverse events in a mental health establishment in the Free State province. The researcher hopes that the Department of Health in the Free State Province would utilise the findings of this study to review and to improve the safety programmes on the care, treatment and rehabilitation of the mental health care services.

Thesis (M.S.)--Boston University

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01