This dissertation aims to examine the collection and use of digital patient-generated health data (PGHD) in real-world settings, including existing barriers from the perspectives of patients and healthcare providers, and possible approaches to optimizing the process. In Chapter One, the potential of PGHD to improve health and wellness, particularly for individuals with chronic conditions, as well as known barriers to PGHD collection and use, are described. One chronic condition in particular, atrial fibrillation (AF), is then introduced as a use case for PGHD. Chapter Two contains an integrative review synthesizing findings from eleven studies reporting patients’ and providers’ needs when collecting and using PGHD, and identifying convergence and divergence between needs. Chapter Three contains a quantitative evaluation of sustained engagement, currently a major barrier to collection of PGHD, in a group of adults self-monitoring AF, as well as predictors and moderators of engagement that come from an adapted version of the Unified Theory of Acceptance and Use of Technology (UTAUT). These individuals were previously enrolled in the randomized, controlled trial, the iPhone® Helping Evaluate Atrial Fibrillation Rhythm through Technology (iHEART). In Chapter Four, the adapted UTAUT model is explored in more detail through a qualitative investigation of sustained engagement with patients, healthcare providers, and research coordinators involved in the iHEART trial. Chapter Five summarizes the findings of this dissertation, including strengths and limitations, and elicits implications for the intersection of health policy and clinical practice, design, nursing, and future research from the findings.

Hospital personnel are commonly tasked with implementing innovative and evidence-based practices. However, successes are often limited and short-lived. One likely explanation is that implementation processes vary between sites, leading to differences in implementation outcomes. In this dissertation, I built on the organizational and implementation science literatures to improve our understanding of implementation processes and how they unfolded in small, rural hospitals in Iowa. I adopted two theoretical perspectives – process and variance models. Process models explain change as a series of steps or phases that organizations go through when implementing changes, while variance models explain variation in change outcomes as a relationship between variables. More specifically, I examined Kotter’s process model of change and tested the proposition that performance on earlier steps influences performance on subsequent steps. I then built on the literature on the Promoting Action on Research Implementation in Health Services (PARIHS) framework to examine the implementation processes from the variance model perspective. I first developed a typology of internal facilitation activities that hospital change agents engaged in throughout the implementation process, and then built on organizational implementation models to assess the influence of management support, time availability and team viability on sustainment and non-sustainment of facilitation activities. This study was based on a qualitative longitudinal evaluation of TeamSTEPPS implementation in critical access hospitals in Iowa. Our research team recruited 17 hospitals attending TeamSTEPPS Master Training in 2011, 2012 and 2013 and followed them for a period of two years, interviewing key informants quarterly to inquire about their goals, strategies and activities, barriers and facilitators, and the progress they were making. My analytic samples for the dissertation included 8-10 hospitals and varied depending on the research questions. For each construct, a group of student coders read and coded the interview transcripts (two coders per transcript) using both inductive and deductive coding approaches. The coded content was reviewed and disagreements discussed in a group meeting until differences have been resolved. To examine the Kotter model, hospitals were scored on their performance on the three phases, which allowed for assessing whether their performance was consistent across the three phases as the model proposes. To develop the typology of facilitation activities, I compared and contrasted the different types of activities to identify the characteristics that distinguish them. To test sustainment of facilitation activities, I used the fuzzy-set Qualitative Comparative Analysis method to calibrate and test the relationships using set-theoretic methods. As needed, I also qualitatively re-examined the cases to identify exemplar cases or identify additional factors that helped develop our understanding of the implementation processes. I found that the Kotter model helped explain the implementation processes in half the hospitals, while the other hospitals followed different trajectories, depending on implementation scope. Next, four types of facilitation activities were identified – Leadership, Buy-in, Customization and Accountability. They are distinguished by who engaged in the activities, what or whom they targeted, and the timing patterns of the activities. I also found that facilitation activities were sustained in hospitals with both senior and middle manager support and whose facilitator team remained viable throughout the implementation process. These findings contributed to our understanding of implementation processes. Individual findings and their implications were discussed. Overall, both process and variance model perspectives provide useful but different insights into implementation processes. I concluded that both perspectives are needed to inform practice and future research.

Within the last decade there has been considerable national attention focused upon hospital quality and patient safety performance. Improvements in performance have been realized, but the rate of improvement has been slow. There is an increasing consensus that new ideas and national strategies are needed to accelerate improvement efforts in addressing quality/safety issues. Currently, within the hospital setting more attention is being paid to the role of leadership starting with the board of trustees in addressing gaps in performance. Organization-wide awareness of critical gaps in performance, accountability structures, and organizational ability are considered critical facilitators of improvement efforts. The characteristics of awareness, accountability, ability, and action are components of a "4A" conceptual framework that is used most prominently by the National Quality Forum (NQF) in their Safe Practices for Better Healthcare toolkit to frame governance and leaderships' responsibilities in establishing leadership structures and systems to ensure the safety of patients and staff. This study utilizes the National Quality Forum's version of the 4A model to frame an empirical examination of the relationship between leadership structure and system characteristics and hospitals' implementation of the medication reconciliation innovation. A Patient Safety, Culture, and Leadership survey was used to capture Iowa hospital CEO/Quality Leaders' perceptions of board and leadership awareness and accountability characteristics. And, on a quarterly basis since mid-2006 a separate web-based survey has captured Iowa hospital Quality Leaders' perceptions of medication reconciliation implementation. Both cross-sectional and longitudinal analyses were conducted to examine the relationship between leadership structures and systems and hospital-wide deployment of the medication reconciliation initiative. This study finds evidence that board-level awareness characteristics - the time the board spent in meetings on quality and safety issues, and the frequency of board receipt of a formal quality/safety report - were positively related to hospitals' early efforts to deploy the medication reconciliation initiative. Over time hospitals' financial ability was positively related to deployment of this initiative. Further research should focus on how healthcare governance and leadership teams can use the elements of leadership structures and systems safe practices to effectively create and sustain a culture of safety.

Abstract not available

Maori health development advanced with the Hui Taumata (1984) and with the emergence of by Maori for Maori health service delivery. Rapua te ora, by Maori for Maori health service delivery. Rapua te ora, by Maori for Maori health service delivery is an expression of tino rangatiratanga. The case study of budget holding presents a Maori analysis of contemporary health services delivery to meet the needs of Maori. Maori engage in research as dynamic participants who define their roles. Maori provide new analyses of health whilst adding to the diversity of views within health research, health services administration, and health services management. Nested case study method is used to prepare this thesis. Methods nested within the case study are a literature review; empowerment evaluation, information systems strategy, provider profile method, and structural analysis. Kaupapa Maori theory, which underpins the Maori centered research approach, is used to ensure the research objectives are relevant and meet needs of Maori. Budget holding is a mechanism for provider development, systematically linking national public health oblectives to local and regional needs. At different levels of development Maori providers, new to public health, require careful anf thoughtful administration, where necessary, thoughtful management. The benefits for administrating the provision of public health services for Maori are clear vertical accountability to the purchaser, clear local accountabilities, and provider development consistent with local Maori health needs. Conclusions drawn from this case study are that Maori provider development is a response to health reforms characterised by multiple transformations of health service funding. Provider development and meeting disparate accountabilities are important issues for sustainability and the development of Maori providers for public health, and are applicable to the wider community, both national and international.

Thesis (Ph. D.)--York University, 1998. Graduate Programme in Philosophy. / Typescript. Includes bibliographical references (leaves 351-366). Also available on the Internet. MODE OF ACCESS via web browser by entering the following URL: http://wwwlib.umi.com/cr/yorku/fullcit?pNQ27298.

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Thesis (PhD)--University of South Australia, 2001

This study explores how formal and informal social networks and decision making about resources in the hospital setting are related. Over the last few years, tensions between new public management of hospitals and increased demands has led to an increase in bottlenecks, stagnation of patient flow, and overcrowded emergency departments. These problems have led to an increase in access block for patients attempting to access the public hospital system. The introduction of Patient Flow Units has instigated the formalisation of a nurse manager function to coordinate patient flow. Nurses in such a pivotal position and who greatly influence hospital operations, tend to have special characteristics and use these to “get things done”. This thesis investigates interpersonal associations between professional (e.g. doctors and nurses) and functional groups (e.g. clinicians and managers), when making clinical and operational decisions when transferring a patient from the emergency department to a ward bed. By employing a mixed methodology, this thesis first sought to establish a snapshot of organisational culture in three hospitals. Drawing on Degeling et al. (1998) and Fitzgerald (2002), an organisational cultural survey was distributed to a total of 1750 participants. The response rate was 11.65% This survey particularly addressed five cultural constructs including a sense of organisational commitment, perceptions of managerial role characteristics, perceptions of currently pursued organisational goals, perceptions of orientation to work values when choosing a job, and interactions with various professional constituencies. In addition, 18 interviews were conducted and a total of 150 hours of observation of work processes, interactions between staff and environmental conditions were studied. This investigation largely confirmed earlier studies by Degeling (2002) and Fitzgerald (2002) that professional groups believed that their organisation primarily exhibited an Elite style of management, that financial viability is the most important goal their organisation is pursuing, and staff welfare was a low priority. In addition, it found significant differences in cultural footprints between the small hospital, which had a more integrated culture, and the large hospital, which was more fragmented in nature. However, the major contribution of this investigation is demonstrated in the qualitative chapter. This thesis found that the role of “who matters the most” in relation to decision making about patient flow, changes depending on the stage of the decision making process. It also found that non-managerial nursing staff with no formal power or legitimacy could affect urgency. The thesis comprises eight chapters. Following the introductory chapter, Chapter 2 considers the literature associated with the public health system in Australia with a focus on public hospitals in NSW. Chapter 3 critically examines the literature describing organisational culture, with an emphasis on subcultures. Chapter 4 contains a review of professional identity and roles, networks and alliances, social capital, deep smarts, and stakeholder theory. Description and justification of the research method selected to explore the thesis proposition follows in Chapter 5. Chapter 6 contains an outline of the findings concerning the analysis of the survey questionnaire to determine a cultural footprint of the three hospitals studied. Chapter 7 considers the different roles of professional groups (doctors, nurses, and others) and functional groups (clinicians and managers) in the operational phase of patient flow and in doing so contributes to knowledge. Finally, in Chapter 8, a discussion summarises the thesis findings, describes the implications, acknowledges limitations of the study and identifies avenues for future research. / Doctor of Philosophy (PhD)