Quality programs are not new to Saudi hospitals. The first known quality program was started in ARAMCO Hospital in 1982. Besides the Ministry of Health, the main provider of health care, more than 15 providers share in the delivery of the health care in Saudi Arabia. Quality activities being sporadic, with no national control, the programs depend'heavily on the top management commitment and support. The success of quality programs varies among the different health care providers. Hence the need to investigate the knowledge, attitude and practice of the senior and middle managers (HSMM) towards quality programs. The findings of their investigation could throw some light on some incorrect concepts and explain the reasons behind the ineffective practice of quality. Two studies were conducted simultaneously for this research. A descriptive study to investigate the knowledge, attitude and practice of the HSMM, for which two data collecting tools were used. The HSMM self administered questionnaire was completed by the HSMM of 20 selected hospitals in the Eastern Saudi Arabia; 173 HSMM responded to the study giving response rate of 86.5%. The other tool used for the descriptive study was a check list completed by the researcher on each studied hospital. The other part of this research was the action research aimed at exploring the amount of the support HSMM extends to these activities in order to enhance quality services in their hospitals. The study revealed that a majority of senior and middle managers had enough knowledge to initiate very promising quality programs, but there seemed to be a problem with their attitude on quality which affected the implementation of the quality program. Attending training courses on quality subjects made a significant difference to the general information, factor enhancing quality program, causes of quality program failure and the ranking of HSMM towards quality programs. Combining all of these significant variables and classifying them based on their relation with the patient, quality program and staff gave a clear indication that most were related to attitude. The study concluded " that the input and the output of the hospital had less impact on quality programs compared to the process reflected by the knowledge, attitude and practice of the HSMM. Recommendations cover the input, output and the process of quality programs, with more emphasis on the process. The HSMM should pave the way for a quality culture in the hospital which pays proper attention to the development of the skills of the staff and their orientation to the quality environment.

The management and control process in an Accident and Emergency (A/E) department of a District General Hospital is investigated and the functional relationship between the A/E department and the inpatient hospital service is discussed. Attention is focused on resource allocation and methods are proposed towards reconciling levels of service and resource utilisation. Within the framework of control problems inside the A/E department, a computerised patient record system has been designed and implemented, on an experimental basis, to allow easy access to patient-related information for performance evaluation. Established statistical techniques are employed to demonstrate how such information can be utilised in medium-term management activities in the A/E department and to provide a sound basis for defining areas where specific problems arise. A method is developed, which uses patient data to the extent that they are routinely available through the patient record system, for allocating physicians to weekly shifts in a way which takes account of the fixed number of physician hours per week; of physician preferences with regard to shifts; and of the patient assessment of the service provided. With regard to the role of the A/E department as an essential link between the community at large and the hospital service, a simulation model is developed for determining the number of beds in hospital inpatient departments on the basis of expected demand and according to a pre-specified set of measures of hospital efficiency. The measures used are the rapid admission of emergency patients; high occupancy rates; and short lengths of waiting lists. A further study on bed capacity planning concerns the contemplated development of an observation ward in the A/E department. Owing to the increased uncertainty in planning for prospective units, approximation is accepted for the sake of procedural simplicity and an analytic infinite server queueing model is employed to evaluate various numbers of beds for the unit interms of the average occupancy rates and of hourly and daily service levels.

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This study seeks to explain major shifts in health policy. It takes as case studies two governmentally-led hospital mergers in the 1990s - one in London and one in Reykjavik - when national governments, as part of broader administrative reforms, decided to merge teaching hospitals in their capitals. The decision to merge, and the implementation of the decision, followed a long history in both cities, in which the mergers had been repeatedly held up as highly desirable but had always been blocked or abandoned. The merger decisions in the 1990s represent “the impossible becoming possible”. And they stand out as defining moments because of the way they shape the successive course of events in the health care systems. By answering the empirical question why it was possible to merge these hospitals in the 1990s but not in the 1980s, the research aims to contribute to a body of literature that seeks to improve theoretical understanding about how health care systems are shaped by national governments. It carries out two sets of analysis: historical analysis of the main explanatory factors within the health care arenas in both cities; and political analysis of the degree of political authority and will for action of the governments of Britain and Iceland in the 1980s and 1990s. The research concludes that in both cases the merger decisions in the 1990s are best understood as resulting from a confluence of three main factors: 1) weakening cohesion inside the health care arenas; 2) national governments with a long-term hold on power providing an opportunity to consolidate political authority and will through which the wider context of the reform agenda was adopted, 3) the prolonged continuity of executive forces in the governments providing specific political actors with scope for action. In bringing these factors together, ideas which had once united and divided groups of actors in the health care arenas and caused fragmentations in the old order, became glue to the new structure. Theoretical interpretations of the findings suggest that public policies “happen”, as opposed to being made. The merger decisions can be seen more as indicative of past development within the health care systems than as directive themselves. Political interventions, however, changed the balance between groups of actors in the system resulting in strengthening of influence of particular groups of actors, who now possess ever greater control over where, how, when, how much and at what price medical services are provided.

The National Health Service (NHS) focuses on quality of care as a priority. With the NHS planning to go paperless by 2018, more hospitals in England are making the transition from paper to electronic prescribing (ePrescribing) systems. The aim of this programme of work was to understand and explore the influence different in-patient prescribing systems can have on key NHS healthcare professionals (doctors, nurses and pharmacists) working practices in England and quality healthcare. The programme of work, a three phase sequential design, used both qualitative and quantitative approaches. The first phase involved structured telephone interviews with chief pharmacists. Chief pharmacist interviews (n=65) focused upon the type of in-patient prescribing systems in use within each Trust and gained a management perspective of the different prescribing systems. Phases two and three were carried out at three acute NHS hospitals in England, at various stages of developing and implementing their prescribing systems. Phase two data were collected through multidisciplinary team (MDT) focus group discussions. The MDT discussions explored a number of areas associated with the prescribing systems in use: these included clinical workflow, communication, collaboration, patient safety and the use of a clinical indication on the prescription chart. Phase three data were collected using documentation analysis of the prescribing system and medical records, taken from patients cared for by the MDTs involved in phase two. Information extracted included any documentation made of a newly initiated medication, as well as the design of the prescribing system. The clarity and accuracy of documentation in the prescribing system and medical notes were compared to the GMC standards Good Practice in Prescribing Guidelines. Triangulation of data indicated how a change in prescribing system can impact upon individuals working practices by changing the design and clarity of the prescription chart, enforcing of regulations, accessibility and reliability, communication between key HCPs and the patient. These influences can be considered latent conditions in the systems that need addressing to prevent quality of patient care being compromised. The use of Socio-technical systems (STS) theory considered the interaction between humans and technology when using the prescribing systems. Understanding the issues where social and technical aspects interact in the prescribing system, emphasised where healthcare quality is impacted and therefore facilitated recommendations to improve working practices. The findings will help healthcare organisations to consider the impact a change in prescribing system can have on working practices and the latent failures that need consideration within the prescribing systems. The Electronic Prescribing and Medicines Administration (EPMA) system design must take into account the visual and physical needs of the user and consider how they can be improved to facilitate clinical workflow.

A continuing programme of NPM reforms, grounded in quasi-market modes of governance and private sector best practice, have been applied to English NHS hospitals over the last thirty years in response to concerns about their performance efficiency and accountability. However, in the transition to market modes of governance, the retention of hierarchical features gave rise to a multi-layering of accountability. From 2001-02 balanced scorecard inspired performance measurement systems (PMS), were introduced into the NHS, aimed at improving service standards through improved cost efficiency. Study 1 in this thesis finds that, in this context, the relationship between service standards and cost efficiency is positive and that, consistent with it being a more effective PMS, this was stronger for the ‘Annual Health Check’, a PMS characterised by features aimed at reducing manipulation, than the Star ratings, its predecessor. The approach to the manipulation of financial breakeven, a key accountability measure, was however more relaxed, particularly when service standards were under threat. The system of ‘financial support’ had its roots in previous hierarchical relationships and acted to shift revenue across the NHS in order to allow Trusts in financial difficulty to meet their financial objectives without damaging service standards. These transfers, which were effected through the revenue account, were generally reversed out in future years with the result that financial support accelerated revenue recognition in Trusts receiving it. In Study 2, the receipt of financial support by Trusts in financial difficulty was found to be associated with an improvement in service standards and in future financial performance but, in an increasingly demanding performance regime and multi-layered accountability, evidence was also found of opportunistic exploitation of the system. Financial support had a considerable impact on the accountability of both NHS Trusts and the wider NHS because of the limited transparency around financial support transactions.

Observations are informatively censored when there is dependence between the time to the event of interest and time to censoring. When considering the time to death of patients on the waiting list for a transplant, particularly a liver transplant, patients that are removed for transplantation are potentially informatively censored, as generally the most ill patients are transplanted. If this censoring is assumed to be non-informative then any inferences may be misleading. The existing methods in the literature that account for informative censoring are applied to data to assess their suitability for the liver transplantation setting. As the amount of dependence between the time to failure and time to censoring variables cannot be identied from the observed data, estimators that give bounds on the marginal survival function for a given range of dependence values are considered. However, the bounds are too wide to be of use in practice. Sensitivity analyses are also reviewed as these allow us to assess how inferences are affected by assuming differing amounts of dependence and whether methods that account for informative censoring are necessary. Of the other methods considered IPCW estimators were found to be the most useful in practice. Sensitivity analyses for parametric models are less computationally intensive than those for Cox models, although they are not suitable for all sets of data. Therefore, we develop a sensitivity analysis for piecewise exponential models that is still quick to apply. These models are exible enough to be suitable for a wide range of baseline hazards. The sensitivity analysis suggests that for the liver transplantation setting the inferences about time to failure are sensitive to informative censoring. A simulation study is carried out that shows that the sensitivity analysis is accurate in many situations, although not when there is a large proportion of censoring in the data set. Finally, a method to calculate the survival benefit of liver transplantation is adapted to make it more suitable for UK data. This method calculates the expected change in post-transplant mortality relative to waiting list mortality. It uses IPCW methods to account for the informative censoring encountered when estimating waiting list mortality to ensure the estimated survival benefit is as accurate as possible.

High and equitable quality of care are core goals of the English National Health Service. Policy makers have experimented with various ways to improve quality, including use of financial incentives. The effects of these incentives on health outcomes and the distribution of care are not known. The aim of this study was to examine variations in hospital quality and outcomes at patient level under a financial incentive scheme in England. In October 2008 a financial incentive scheme under which quality of care was measured by process measures was introduced for 24 hospital Trusts in the North West of England. The process measures of care from this Advancing Quality initiative were linked at spell level to health outcomes and administrative hospital records. The data consisted of 252,284 spells between October 2008 and March 2013.First, I examined whether financially incentivised improvements in quality of care were associated with better patient outcomes. I examined how mortality and readmission were related to process measures using bivariate probit, probit, random effects and fixed effects estimations. I found that several of the incentivised process measures of care are associated with improved patient outcomes. I estimated that Advancing Quality saved 129 lives and avoided 121 readmissions over a four-and-a-half year period. Second I examined whether quality of care from a hospital incentive scheme is distributed equitably at a patient level. Multinomial and sequential logistic regressions were used to show that process measures of care overall were distributed in favour of patients from lower income score areas. Process measures of care delivered during an emergency admission were distributed in favour of patients from higher income score areas but this was driven by patient severity. Process measures based on advice appeared to be driven by capacity to benefit and were distributed in favour of patients from lower income score areas. Process measures of care for elective admissions regarding delivery of drugs were distributed equitably. Third, I examined if the quality of care was lower at the weekend. The in-hospital mortality rate is known to be higher for weekend admissions than for weekday admissions but it is not known whether this was due to lower quality of care. Using logistic regressions, incentivised quality of care was found to be consistent throughout the week. The weekend mortality effect can be explained by patient volume, which suggested that patient case mix may be different between weekdays and weekends. Overall, quality of care under an incentive scheme was found to positively impact on health outcomes, be distributed equitably, and be the same at weekends as weekdays. Further research is needed using quality of care indicators from all Trusts in the English National Health Service. Furthermore further research examining how trusts exclude patients from financial incentive schemes is also needed.

As a facility that offers an important service to its users, a hospital can be considered as a production unit ; a unit that provides health-care service. Therefore, a range of factors that facilitate this service (i.e. healthcare) need to be considered when speaking of improving the productivity in a hospital ward. Evidence suggests that one of the main factors that affect the productivity level of a hospital ward is how the design of the hospital deals with access and circulation of the people inside the ward (e.g. Joseph and Ulrich, 2007). A productivity-oriented circulation system will need to improve staff performance; enhance patients safety, privacy and rate of recovery; minimise the risk of cross-infection; reduce the delay time of external service delivery; create a more welcoming environment for visitors; and reduce the evacuation time in emergency situations. Thus, the need to design ward layouts that benefit from the most effective circulation system cannot be over-emphasised. The study presented in this thesis focused on finding a method for identifying different systems of access and people circulation in hospital wards and how they could affect nursing staff productivity. The study comprised five main phases. The first phase involved a literature review of existing healthcare environments to identify different types of access and people circulation requirements. In the second phase, data on nursing staff s movements were collected from a case study. The third phase focused on categorising and modelling the existing approaches and layout design systems. Phase four provided a comparative study of different categories of people circulation designs and contrasted their advantages and disadvantages to improve access and people circulation. In the fifth and final phase, the study concluded with proposing guidelines for choosing between different layout options in the design of new hospital wards or the refurbishment of the existing ones. Findings of the study included: further empirical and analytical support for the impact of the ward design on nursing staff s performance; a ranking of the suitability of different design layouts for minimising staff s unnecessary walking in wards similar to the case study; the importance of considering different staff members needs in such analyses; and a ranking of the criticality of different routes within a ward.

The purpose of this study was to investigate the health service delivery by private health sector and develop guidelines to enhance provision of health service so as to increase their contribution in the country’s health system. Interviews with 1112 participants were conducted in phase I. Descriptive statistics, chi square tests and logistic regression analysis were used for analysis. Private health facilities (30.5%) were providing healthcare services in their own buildings that were constructed for that purpose while others work in a rented houses built for residence or others. Some facilities (11.7%) received loan services from financial institutions in the region. A significant association was found between obtaining loan and owning building for healthcare services delivery (x2=13.99, p<0.001). Private health facilities were mainly engaged in profit driven and curative services while their participation in the promotive and preventive services like FP, ANC HIV test, TB and malaria prevention and control was not minimal. Majority, 247 (96.5%) provide services for extended hours out of normal working time such as evening, weekends and holidays. Physicians, more than other professionals were found practicing part time work (dual practice). Service consumers of the private health sector were urban dwellers 417 (71.6%) and 165 (28.4%) rural residents. Nearly three-fourth (73.0%) of study participants had a history of multiple visits to both public and private health facilities for current medical condition. Median payment of patients in a single visit including diagnosis and medicine was 860 birr ($30.85) (IQR = 993 ($35.62). Only 2.1% have paid through insurance services while others through out of pocket payments. Price of services delivered in private health facilities were set mainly by owners’ will (91.4%) while others with established team. Satisfaction on the fairness of prices to services obtained from each facility were reported by 63.1% service consumers. Those patients without any companion (AOR=1.83, 95% CI=1.16-2.91) and no history of visit to other facilities (AOR=1.97, 95% CI=1.24-3.12) were more likely to be satisfied than those coming with companions and those with history of visit. In addition, as age of consumers increase, satisfaction to services prices tend to decline (AOR=0.97, 95% CI=0.96-0.99). Uncomplimentary regulatory system to private health facilities, lack of training and continuing education for health professionals, unavailability of enough health workforce in the market and shortage of supplies to private facilities were among main gaps disclosed. Based on findings, five guidelines were developed to enhance health services delivery in the private health sector, namely, increase facilitation for financial access to actors in the sector, increase facilitation to access regular updating trainings and continuing education for healthcare workers, enhance and scale up the capability of existing association in the private health sector, strengthen and support working for extended hours to promote user friendly services and accessibility of healthcare services for the poor through community based health insurance and exemption. Therefore, these recommendations to help enhance the private health sector for better performance and contribution. / Health Studies / D.Lit.Phil (Health Studies