Continuity of patient care is an essential element of primary care because it should result in better quality care and disease management, especially for older adults who often have multiple chronic illnesses. Even though continuity of care has been studied for decades, it remains difficult to define and quantify and, there is no consensus about best practices for assessing whether or not a patient experiences it or a practitioner provides it. Moreover, no theoretically-driven measures for the assessment of continuity of care exist, and there have been few rigorous evaluations of its association with subsequent health and health service utilization outcomes. The principal purpose of this dissertation research was to better understand continuity of care for older adults by identifying the components of the patient-provider relationship that are important from the patient perspective, understanding how commonly used provider-proxy continuity measures relate to the patient experience, and evaluating whether the patient experience or provider-proxy assessments are associated with improved health and health services utilization. I used survey data from the 2,997 Medicare beneficiaries who participated in the 2004 National Health and Health Services Use Questionnaire (NHHSUQ) linked to their Medicare claims for 2002-2009. The NHHSUQ contained patient-reported data on usual primary provider, usual place of care, and the quality and duration of the relationship with their provider. By linking this information to their Medicare claims, I was able to evaluate both patient-reported and provider-proxy (claims-based) measures of continuity of care from two years prior to the survey, and evaluate the impact of continuity on health and health service utilization for five years after the survey. Study results indicate that the older adult patient experience of continuity is reflective of both relationship duration and patient-provider interaction during the care visit, and that most provider-proxy continuity assessments did not relate to patient perceptions. And, the patient and provider-proxy experiences of continuity had different relationships with important health outcomes. These results enhance our understanding of continuity of care for older adults and inform policymakers and researchers about aspects of continuity that are important for the health of older adults and the appropriate use of health care resources.

The recent reports by Institute of Medicine, `To Err is Human' and `Crossing Quality Chasm', revealed a large prevalence of medical errors and substandard care in US hospitals. Since then there has been a substantial increase in the efforts to measure and improve quality of care. The objective of this study was to compare the quality of care across hospitals using available performance indicators and examine the association between organizational factors and hospital performance. The main focus of this study was on important structural attributes of hospitals, namely - teaching status, location and market competition. The Nationwide Inpatient Sample for years 2003 and 2005, and the State Inpatient Database for years 2004 to 2006 were used for analyses. Two types of hospital performance indicators were examined to compare quality of care - Patient safety indicators developed by Agency for Healthcare Research and Quality, and process of care indicators developed by Centers for Medicare and Medicaid services. Multivariable regression analyses were performed using generalized estimating equations and random effects regression models. Several organizational factors as well as patient characteristics were included in the multivariable models as control variables. Overall, the results from this study showed an inconsistent relationship between teaching status, location of hospitals or market competition and quality of care in hospitals. In addition, the results demonstrated that isolating potential effects of hospital structure on outcomes requires controlling for the variation in patient characteristics, such as age and comorbidities, which increase patients' risk for incurring patient safety events. The findings from this study provide useful insight into the areas where the patient safety and quality initiatives should be focused. Moreover, the results identified the organizational factors that are relevant to certain types of hospitals and which should be considered before evaluating quality of care and enacting any policies about publicly reporting of performance or payment initiatives that are relevant to these hospitals.

Older individuals overwhelmingly prefer to receive long-term services and supports (LTSS) in home and community-based settings. Medicaid elderly 1915(c) waivers have become the primary mechanism that states use to provide home and community-based services (HCBS) to older individuals. Given the positive effects elderly waivers have on the quality of life of older individuals, I examined why states adopt elderly waivers; the extent of the substantive differences in program quality across elderly waivers; and the factors associated with elderly waiver program quality, contrasted with the factors associated with elderly waiver program size (i.e., number of participants and expenditures). I examined how state contextual, institutional, and political factors, as well as factors external to the states, including neighboring state and federal policy activity, influenced state policy decisions pertaining to elderly waiver adoptions and program quality and size. First, I performed a retrospective analysis using state-level longitudinal data from 1992-2010 to conduct a discrete time-series repeated event history analysis (EHA) to identify the variables associated with state adoptions of elderly waivers. Second, I created a measure of elderly waiver program quality consisting of four equally weighted components of waivers thought to be associated with the provision of higher quality HCBS to older individuals, including: eligibility criteria, self-determination supports, range of services provided, and participant protections. Using correlational analyses, I examined the relationships between program quality and size. Third, I performed retrospective ordinary least squares (OLS) analyses using waiver program-level data from 2015 to examine elderly waiver program quality and size and fixed-effects OLS using data from 1993-2010 to examine elderly waiver program size. I identified 63 elderly waiver adoptions across 35 states between 1992 and 2010, which were significantly associated with state contextual and external factors. Consistent with previous research, I found that contextual factors, including the number of older individuals, the supply of long-term care facilities and whether the state already had an elderly waiver program, affected state decisions to adopt elderly waivers. There was significant variation in each of the four component and overall quality scores and weak associations between program quality and size. I found that state contextual factors, including market and Medicaid program characteristics, influenced elderly waiver program quality and size. In addition, program quality was shaped by the capacity of state policymaking institutions (e.g., governorships and legislatures), while program size was shaped by neighboring state and federal policy activity. The findings from this research suggest that elderly waiver adoptions and program quality and size are shaped through different policymaking pathways. Efforts to improve the quality of elderly waiver programs should consider the capacity of state executive officials in addition to contextual determinants and focus on improving existing elderly waiver programs. Given that most waivers scored well on eligibility and participant protections, efforts to improve the quality of elderly waiver programs should focus on expanding self-direction supports opportunities, the types of waiver services, and eliminating restrictions placed on service delivery (e.g., waiting lists).

Background: Many innovative ideas have been proposed to manage and improve the quality and cost of clinical care. For many innovations, like Total Quality Management (TQM), the &quotblack box&quot of implementation process is not well understood. Empirical work on the process of innovation implementation in health care is limited. Objective: This study was designed to explore how one organisation, Intermountain Health Care (IHC), an acute and primary health care provider in the USA, innovates in implementing TQM organisation-wide to improve and manage clinical quality. More broadly, the study aims to identify factors that contribute to innovation implementation in health care for clinical quality improvement, and to generate a model of innovation implementation in health care for clinical quality improvement. Method: This thesis takes a case study approach using multiple research methods. The main methods used comprise interviews with key personnel, assessment of organisational documents and a survey of clinicians' and managers' attitudes and beliefs. Findings: The main finding of the research is that innovation implementation at IHC was a journey, not a destination. Embedded in the journey were five periods and many actions and interactions, grouped into eleven elements. The five periods were: exposing to an innovative idea, embracing the idea, extending knowledge and experience on the idea, emerging of strategies to implement the idea organisation-wide, and enacting and adapting the strategies. The eleven elements were: gestation, shocks, plan, proliferation, fluid participation, setbacks, criteria shift, top executive involvement, relationships and infrastructure building, and adoption. To implement TQM organization-wide, integrated structures and systems were being instituted. The study found that resistance to change came from not only some physicians but also hospital administrators. The study also found that supportive environments played a critical role in the journey. While the TQM implementation at IHC resulted in some cost savings and some behavioural changes including clinical practice change, cultural change at the level of values and beliefs had yet to occur. Conclusion: A process-oriented integrative model of clinical service management is proposed. The elements of an innovation, the temporal change processes, lead to formation and changes of the ongoing organisational processes, which in turn evaluate and improve the important clinical processes. These processes integrate TQM with other quality improvement approaches; also ensure that quality is part of the dialogue between key stakeholders who are responsible for managing and improving clinical quality and costs. These processes also are capable of dealing with dilemmas faced in health care and the constantly created managerial ideas and clinical knowledge. Key Words: Innovation, Clinical Outcomes, Knowledge, Quality and Costs, TQM Management

This thesis concerns an investigation of the tripartite arrangements between the government, the nursing and the medical sectors in New Zealand over the period 1984 to 2001 with a particular focus on primary health care. The start point is the commencement of the health reforms instituted by the Fourth New Zealand Labour Government of 1984. The thesis falls within a framework of critical inquiry, specifically, the methodology of depth hermeneutics (Thompson, 1990), a development of critical theory. The effects of political and economic policies and the methodologies of neo-liberal market reform are examined together with the concept of collaboration as an ideological symbolic form, typical of enterprise culture. The limitations of economic models such as public choice theory, agency theory and managerialism are examined from the point of view of government strategies and their effects on the relationships between the nursing and medical professions. The influence of American health care policies and their partial introduction into primary health care in New Zealand is traversed in some detail, together with the experiences of health reform in several other countries. Post election 1999, the thesis considers the effect of change of political direction consequent upon the election of a Labour Coalition government and concludes that the removal of the neo-liberal ethic by Labour may terminate entrepreneurial opportunities in the nursing profession. The thesis considers the effects of a change to Third Way political direction on national health care policy and on the medical and nursing professions. The data is derived from various texts and transcripts of interviews with 12 health professionals and health commentators. The histories and current relationships between the nursing and medical professions are examined in relation to their claims to be scientific discourses and it is argued that the issue of lack of recognition as a scientific discourse is at the root of nursing�s perceived inferiority to medicine. This is further expanded in a discussion at the end of the thesis where the structure of the two professions is compared and critiqued. A conclusion is drawn that a potential for action exists to remedy the deficient structure of nursing. The thesis argues that this is the major issue which maintains nursing in the primary sector in a perceived position of inferiority to medicine. The thesis also concludes that the role of government in this triangular relationship is one of manipulation to bring about necessary fundamental change in the delivery of health services at the lowest possible cost without materially strengthening the autonomy of the nursing or the medical professions.

published_or_final_version / Public Administration / Master / Master of Public Administration

No description available.

Introduction A plethora of health indicators have been added into the District Health Information System (DHIS) since its adoption and implementation as the routine health information for South Africa in 1999. The growing demand for the production and dissemination of routine health information has not been equally matched by improvements in the quality of data. In the health sector the value of monitoring and evaluation is not simply the product of conducting monitoring and evaluation but, rather from discussing and using performance indicators to improve health service delivery. Aim The aim of this study was to classify health care indicators in the national health data sets used for planning, monitoring and evaluation and to review the data management practices of personnel at provincial and district level. Methods An observational, cross sectional study with a descriptive component was conducted, in 2009, using a finite sample population from district and provincial level across eight provinces. The study participants completed a self-administered questionnaire which was e-mailed to them. Results A total of 32 (52%) participants responded to the questionnaire and of this total 21 (65.5%) responses were from district level and 11 (34.4%) from provincial level. The National Indicator Data Set, the key source for primary health care and hospital data, was implemented in 1999 with approximately 60 indicators. In less than 10 years it has grown in size and presently contains 219 performance indicators that are used for monitoring and evaluating service delivery in the public health sector. Whilst both district and provincial level personnel have a high awareness (83%) of the DHIS data sets there is variability in the implementation of these data sets across provinces. The number of indicators collected in the DHIS data sets for management decisions are “enough”, however a need was expressed for the collection of community health services data and district level mortality data. Similarities were noted with other studies that were conducted nationally with respect to data sharing, utilisation and feedback practices. Data utilisation for decision making was perceived by district level personnel to be adequate, whereas provincial level personnel indicated there is inadequate use of data for decision making. Whilst 87.1% of personnel indicated that they produce data analysis reports, 71.9% indicated that they never get feedback on the reports submitted. The top 4 data management constraints include: lack of human resources, lack of trained and competent staff, lack of understanding of data and information collected and the lack of financial and material resources. There was agreement by district and provincial level personnel for the need for additional capacity for data collection at health facility level. Discussion The increasing need for accurate, reliable and relevant health information for planning, monitoring and evaluation has highlighted critical areas where systems need to be developed in order to meet the information and reporting requirements of stakeholders at all levels in the health system Recommendations An overarching national policy for routine health information systems management needs to be developed which considers the following: emerging national and international reporting requirements, human resources requirements for health information and integration of systems for data collection. In the short-term a review of the National Indicator Data Set needs to be conducted. / Thesis (MMed.)-University of KwaZulu-Natal, Durban, 2010.

The issues surrounding health care and health care policy are of great concern to politicians and the public alike. Government efforts in restructuring medicare, the "jewel" of Canada's social safety net, also affects the medical profession. It has been argued that this once powerful and dominant profession is experiencing a decline in its powers and authority. Is this decline inevitable or can the medical profession adapt to government reforms in such way as to maintain and even strengthen its power base? This dissertation examines the themes of professional autonomy and professional resistance. The changing composition, and possibly the decline, of the medical profession's clinical, economic, and political autonomy, is analyzed through an historical case study of the British Columbia Medical Association (BCMA). Minutes from the BCMA's Board of Directors and Executive, along with interviews with doctors active in BCMA politics, and a media review, are used to generate a portrait of the social forces influencing medical politics in British Columbia from 1964 to 1993 and of the BCMA's relations with the various provincial governments of that period. The negotiating strategies of the BCMA and the decisions behind these strategies are the focal point for an examination of professional resistance, an area neglected in sociology. The dissertation looks at the external and internal conflicts that impact on the resistance tactics of the BCMA and at the various successes and defeats the medical profession experiences in its bid to maintain professional autonomy. During the time period under study, government intervention becomes more frequent and invasive. The BCMA has the least success in protecting the political dimension of professional autonomy and most success in controlling aspects of clinical autonomy. The vast variety of resistance strategies at its disposal distinguishes it from labour groups and most other professions. Forced to accept measures it once fought against, the BCMA's efforts become focused on ensuring that reform measures are under the control of doctors (rather than government) to the greatest extent possible. Although the BCMA has lost aspects of professional autonomy, it remains one of the few professional organizations today that can force compromise from the state.

This study examined hospital governance in British Columbia. Considered to be one of the most important issues facing the health care industry today, hospital governance is nevertheless an ill-defined and poorly understood concept. Foundational and exploratory in nature, the study’s primary objectives were: a) to define hospital governance within the context of British Columbia; b) to examine the structural and functional relationships among key participants; c) to investigate decision-making responsibilities; d) to investigate what, if any, variations exist in the governance of acute care, long term care, and specialized care hospitals; and e) to explore the critical issues which face hospital governance today and in the future under New Directions policy initiatives. All hospitals (N=107) in the province were studied, with the exception of diagnostic treatment centers, private for-profit facilities, military, and federal institutions. Utilizing documentary examination, survey administration, and interview techniques, the study included hospital chief executive officers (N=106), hospital board members (N=735), hospital board chairs (N=106), and selected high ranking senior officials from the Ministry of Health who had direct responsibility for hospital activities (N=15). Results of the study provide for in-depth demographic board profiles, and show that hospital governance is similarly defined across all hospital categories as “a complex relationship of overlapping structures and activities which has the responsibility and the authority to oversee the organization’s operation and to ensure its commitment of providing optimum health care to its residents.” The study identifies the key participants of hospital governance and delineates sixteen activities considered to be under the hospital board’s domain. Seven issues are identified as being critical for hospital governance in the future. Although there was general agreement as to the individuals most often responsible for recommending and implementing activities brought before the board, there were considerable perceptual differences between participants as to who possesses final decision-making responsibility. Data results consistently demonstrated important differences in responses between the hospital and Ministry populations. The study shows that overall, the participants of hospital governance are generally satisfied with the traditional roles and structures of hospital boards and are overwhelmingly dissatisfied with New Directions policy initiatives. This study further suggests that due to the discrepancies in priorities, perceptions, and ideologies of the hospital and Ministry populations, hospital governance is in a highly volatile and transitive state.