Quality of care is deemed a concept of immense importance, but also of great difficulty to define and analyse. This study proposes the development of a novel statistical approach to healthcare modelling which overcomes the need to define quality of care by treating it as a hidden layer in a special type of markov model. The study setting for this research is the Italian healthcare system, in particular admissions into geriatric wards of the Lombardy region of Italy during 2009. The Coxian phase-type distribution was applied to this dataset and shown to give the best representation of the flow of patients. Covariates were then incorporated into this distribution and applied to the data. A simulation study of Coxian phase-type distribution with covariates was also undertaken. The main purpose of this research was to develop the theory of the Coxian phase-type distribution by incorporating a hidden layer within it which can represent quality of care. In forming this model novel methodology was presented. A discrete-time and continuous-time version of the model were both applied to the data with the results analysed. A further extension of the continuous-time hidden Markov model with the Coxian phase-type distribution was developed whereby covariates where incorporated into the hidden element. The results of this model, with application to the Lombardy dataset was analysed followed by a simulation study of all the newly developed models presented. In addition to the hidden Markov model with Coxian phase-type distribution the model was extended to introduce a duration component within the hidden layer. This extension formed the hidden semi- Markov model which relaxes the strict Markov assumption. This model was also applied to the Lombardy dataset.

No description available.

This dissertation focuses on the impact of the restructuring of the Irish health system on the performance ofa· hospital. The general context of the research relates to the modernisation of public services, in particular health services, and the impact of resulting changes on managers and consultants. The theoretic perspectives inform the nature of the modern welfare state in the p.rovision of public services, health policy. formulatiQn and implementation; organisational design and organisational change; and the tensions that exist between managerial and professional staff. The methodology used generated multiple data streams - quantitative data on corporate and hospital performance pre and post restructuring and qualitative data provided a narrative on the impact of restructuring on the hospital, as perceived by consultants and managers. The findings show that the change expected by staff did not materialise and that the performance of the hospital, in terms of output, cannot be said to have been influenced by general organisational changes. However, bureaucratic changes imposed by the· new corporate management did cause irritation at hospital level and a loss of overall corporate reputation. The research also demonstrate~ that organisation type needs. to be factored into the design· of. national. reform· and transformational programmes if they are to be successfully implemented i.e. if the desired behaviour changes at hospital level are to be achieved and the services delivered by the hospital are to be improved. Some recommendations for future research are made.

Background: Ethical issues experienced by healthcare providers can be associated with detrimental outcomes, however, little is known about the nature of these issues within palliative care provision in nursing homes. Aim: To provide a comprehensive understanding of care providers’ experiences of ethical issues during palliative care provision in nursing homes in the United Kingdom. Methods: A two phase, exploratory, sequential, mixed methods design was utilised. Semi-structured interviews with 13 Registered Nurses and ten Healthcare Assistants were used to explore ethical issues during palliative care provision. An instrument was developed measuring the frequency and level of distress associated with these ethical issues and utilised in a cross-sectional survey with 69 RNs and 129 HCAs. Results: Three themes grouped experiences of ethical issues. Issues in practice were found when conflicts arose between what felt right and the duty of care. Within this theme, making decisions in the residents’ best interests to prevent them from coming to harm (Mean = 2.68; SD= 1.24) was most frequently reported. Relational issues focused on conflicts within interpersonal relationships. Caring for residents who were only accepting small amounts or refusing food/fluids (Mean = 2.71; SD= 1.19) occurred most frequently. Organisational issues resulted from the structure and quality of services. Poor staff communication (Mean = 2.48; SD= 1.39); and lack of time (Mean = 2.36; SD= 1.44) resulted in the highest distress scores. No significant differences were identified between RNs and HCAs in the frequency (t= -.85, d.f. =196, p=.40), or level of distress (t= -.24, d.f. =176, p=.81) associated with ethical issues. Conclusions: Ethical issues within the UK nursing homes focus on acting within the duty of care, interpersonal relationships, and coping with a routinized organisational structure. Improved communication between healthcare professionals, residents, and families, and palliative care training may improve the palliative care experience.

With a rise in the length of time that people are living, comes an increase in the pressure which hospital departments face in providing care for elderly patients. The research presented in this thesis introduces the conditional Coxian phase-type distribution, a novel methodology which may be used to describe the movement of elderly patients between various stages of hospital and community care. The rate parameters governing the movement of patients within each stage of care are conditioned on the length of stay experienced at the previous stage of care. Two additional methodologies are presented, extending the conditional Coxian phase-type distribution to account for the natural heterogeneity present in elderly patient length of stay in care. Firstly, a phase-type survival tree is used to partition elderly patients into subgroups (or cohorts), before the conditional Coxian phase-type distribution is used to model the pathway of each patient subgroup through the remaining stages of care. Secondly, patient covariates are included directly into the probability density function for the conditional Coxian phase-type distribution; through the use of log- linear equations, further reducing the assumption of homogeneity. To illustrate the results, a separate methodology is presented, alongside the aforementioned approaches, which allows the estimation of predictive intervals, to predict when a new elderly patient admission or discharge is likely to leave a given stage of care. Such an approach would enable patient-centred length of stay predictions to be made at the beginning of each stage of care. This would mean that community care may be organised ahead of time and according to these predictions so that instances of hospital bed blocking, together with the number of potential readmissions, may be reduced. Two sets of elderly patient hospital readmission data, from the Lombardy and Abruzzo regions of Italy, are used as applicative examples of each approach.

There are national and local concerns about a policy-practice gap in healthcare services which bring into question the effectiveness of traditional mechanisms for policy implementation. Using clinical governance as a focus, this report describes the rationale, development and evaluation of an alternative approach designed to integrate health policy with practice within a Mental Health and Learning Disability NHS Trust through a programme of social opportunities. A number of methodological compromises were made due to the pragmatic nature of the project and limited availability of resources to undertake the evaluation. Not all disciplines and services were involved in the approach so different methods may be needed to engage these groups. However, the potential impact of the process for local policy, practice and aspects of practice culture has been critically evaluated using a framework for policy analysis and mixed methods for implementation, data collection and analysis. The findings suggest that the intervention was successful in providing an opportunity for practitioners to meet, network and discuss policy and practice issues and virtually all attendees valued the opportunity to participate. Contextually, the key focus was on meeting the needs of different client groups, i.e. working age adults, older people, children and people with a learning disability. Generally, all practitioners value the principles of user-centred, safe and effective practice that underpin national policy although some are valued more than others and practice in all areas can be improved. Personal responsibility is accepted and satisfactory levels of support are available and accessed. However, culturally there is evidence of conflict created by perceived differences between practitioner and organisational values, increased workload without added value and a need for improved interdisciplinary working and better service integration. This is particularly evident in the adult community mental health services. A theoretical model and process to integrate policy and practice is presented that needs embedding within an organisational approach to learning that provides supportive structures, processes and cultures requiring time, leadership and management commitment. Recommendations are made for the dissemination of findings, further development and testing of the theoretical model and process.

The study of service improvement within healthcare is no longer in its infancy. A plethora of books and journal publications have presented their own interpretations of the meanings, significance and application of service improvement. Despite such endeavours, there are still few studies that look at how we measure the impact of such service improvement to quantify the practical effect of improvement. At organisational level, organisations and project leaders often undertake evaluation in a piecemeal way, as part of a project or initiative. Whilst this can help assess the benefits or otherwise of a particular piece of work, the findings of the evaluation often remain within the project and are not disseminated across the wider organisations. This, in turn, means that opportunities for learning are diminished. This project builds on previous work and adds a new and unique contribution to the body of service improvement knowledge. It critically reviewed existing evaluation frameworks to inform the development of a unique balanced framework for service improvement initiatives, which is accessible and usable for change agents and their colleagues to evaluate effectiveness. The project began with an examination of the political environment surrounding the evaluation of service improvement, followed by a review of both existing service improvement evaluation frameworks. The review yielded few resources and highlighted a gap in the body of knowledge. Following this, primary data was collected from the organisation, which led to the following research questions: – What is understood by measurement and evaluation? – Are measurement and evaluation, interdependent, or mutually exclusive? – What elements are missing from the current evaluation models presented? – Could an evaluation framework model work in practice? This led to a qualitative action research, which used focus-group meetings and one-to-one discussions to provide observation, reflection and feedback, in order to develop an understanding of measurement and evaluation, in relation to organisational improvement and to provide a robust evaluation framework for organisational use. The findings were analysed, using thematic analysis and revealed the need for an evaluation framework that is user-friendly, replicable and incorporates the views of users and carers. On the basis of the findings, recommendations are made for the improvement of practice and also the need for further longitudinal research, in relation to embedding and evaluating the impact of the framework within the organisation.

Culture change and teamwork are often cited in healthcare policy and research as central to improvements in patient care. A critical review of the literature suggests that theory is insufficiently used to inform culture change or team development interventions. Culture change interventions are rarely evaluated in implementation research with few rich qualitative accounts of clinical team development in context. This case study drew on the principles of realist evaluation to identify what worked, or did not work, for whom, in what circumstances in relation to an eighteen-month culture change intervention that had been carried out with a frontline clinical team identified as being in difficulty. It addressed the following research questions using multiple methods in a pragmatic and reflexive way: 1. How does a clinical team identified as being in difficulty experience a change process directed at changing team culture? 2. How do collaborative change processes engender culture change in the context of teams in difficulty? Conventional problem-solving approaches to team development were found to reinforce existing patterns of deficit relating leading to a critique of organization development practice. The project found that different contextualized experiences had different effects on the learning behaviour of the team and on the leadership-followership relationship. A critical appreciative approach and narrative methods were found to create psychological safety for a collaborative inquiry to take place. Building on previous theoretical research, the study proposes a reconceptualization of experiences of teamwork as emergent states of “knotworking” and “not working”. The project offers a framework for realist evaluation with clinical teams in difficulty. It recommends that intervention and evaluation are collapsed into a single approach of collaborative inquiry, and has provided easy to use resources for clinical teams to evaluate and improve their team culture in a climate of psychological safety. A practice model of creating a critically appreciative space is proposed and described. Narratives of patient care emerged as a source of generativity for team development, which led to reflections about how patient experience and involvement might support future team development interventions and directions for research.

I have analysed whether or not there is a moral obligation to involve the public in the planning and organisation of health services. I have concluded that there is a moral obligation to involve the public, but that this obligation is parti-resultant and only extends to morally constructed, deliberative processes that can meet democratic conditions for political equality, effective participation and enlightened understanding. I suggest that the public democratic right to directly influence the nature and design of health services is justified by the direct impact that health provision has on each individual's wellbeing and welfare. Health care provision is aimed at restoring and maintaining the health of the population. However, In order to meet population health needs it is necessary to understand what health is. I contend that the meaning of health is highly contested and subjective, therefore, in understanding what health is it is necessary to seek different perspectives from a broad cross section of the public. I suggest that current models of decision-making in health are not sufficiently well informed by the wider public perspective of health. Deliberative models of decision-making that involve the public as equal partners have the potential to bridge this deficit. However, involving the public in decision-making does not mean that the public could, or should, necessarily have their preferences met. Autonomous choice can be embraced within a deliberative decision-making model in this context but only if the conception of autonomy is relational autonomy. That is; choice can only be morally supported when made in relation to obligations and responsibilities owed to others. Public involvement, through deliberative fora, has the potential to engage individuals who have previously been marginalised or excluded from decision making in health and has the potential to transform services in the light of new perspectives. However, this will only be realised if there is a will to transform ways of working to enable different voices to compete with existing power structures and orthodoxies. However, if final decision-making continues to reside with politicians and bureaucrats, merely informed by the public through deliberative fora, the risk is that traditional decision-makers will continue to ignore the deliberations of the public and fail to transform services to better meet different public needs. Alternatively, if public decisions are to carry weight and promote change the public must accept the responsibility and accountability for that influence, and as yet there is no system for this level of accountability to occur. I conclude that although public involvement is morally justifiable, for the public to make any reliable impact there must be significant investment in creating a climate that supports and promotes effective involvement and this may be too prohibitive to engage with, except in limited and exceptional circumstances; leaving a representative model of decision-making with in-put from the public as the compromise, default position.

Social marketing is the latest public health strategy deployed against a wide range of health imperatives, especially ones associated with people’s behaviour. This investigation examines the ‘social’ in such social marketing, by focusing on the relationships between the people, communities, organizations, institutions and material of one such initiative. Most studies determine the ‘effectiveness’ of a social marketing programme according to measurable outcomes. However, this has created a gap in knowledge about what actually happens as a programme is initiated at a local level, how constantly-changing social contexts influence its delivery, and how social marketing impacts people, especially marginalised populations. Rather than viewing social marketing as a form of ‘intervention’, which is typical of the ‘conventional’ approach, this investigation examines social marketing as an iterative and social process. Launched in 2008, Change4Life (C4L) is the English Department of Health’s first anti-obesity social marketing programme. C4L multimedia advertising is found throughout the English landscape, converting the built and virtual environment into a moral space. However, a key characteristic is the way such a national remit is converted into a wide range of specific initiatives at local levels. This investigation considers four case studies within one region of the UK to explore the varied ways in which a general social marketing venture is translated and implemented. By building up ethnographic accounts using participant observation, in-depth interviews, and interpretative analysis, these case studies illustrate how local health officials responded to the local tensions created by the national all-encompassing C4L programme, particularly in their attempts to relate C4L to ‘hard-to-reach’ communities. The diversity of their efforts highlights the limited applicability of the ‘conventional’ approach to social marketing. This investigation therefore suggests an approach for developing a more ‘social’ form of social marketing and contributes to the greater discussion on how to develop public health strategies that actively solve the underlying social problems of public health.