Research report presented to SBL, Unisa, Midrand. / No abstract

Currently, UK healthcare is encountering an unprecedented quality crisis, especially considering the overwhelming challenge of improving patient care in the face of growing demands and limited resources. Although past efforts to adopt Total Quality Management (TQM) initiatives have failed to produce desired results, this thesis investigates the limitations of TQM applicability and explores the development of an innovative Quality Improvement model germane to a healthcare context. By integrating TQM with concepts from Corporate Social Responsibility (CSR), Complexity Theory (CT) and Knowledge Management (KM) a novel TQM conceptual framework, called EALIM—Ethical, Adaptive, Learning and Improvement Model—was devised. Using an Action Research (AR) study, EALIM was implemented within a private healthcare firm by working collaboratively with organisational members over a period of eighteen months. The study included gathering qualitative data in three AR cycles: 1) pre-implementation, 2) implementation and 3) post-implementation. The first cycle involved gathering data to form a baseline assessment of the organisation, which was used to provide feedback to top management on areas for improvement. In the second cycle, an action plan was developed with top managers and EALIM’s implementation was examined. In the third cycle, further data were gathered and findings were evaluated against the baseline assessment from the first cycle to identify the overall impact of EALIM on the organisation. Findings indicated that EALIM’s adoption generated a moral perception of the organisation, a learning culture, increased organisational commitment and an improvement in patient self-advocacy and independence. Factors that contributed to these outcomes were top management commitment, employee empowerment, the use of trans-disciplinary groups and practice-based training. However, other findings indicated that poor leadership and staff nurses’ use of managerial control created variability in service quality. These findings suggest that while EALIM can lead to organisational improvement, the commitment of all internal stakeholders is required to achieve sustainable quality patient care.

Healthcare in the UK is a very important sector; it provides state of the art accommodation that meets the need of patients, visitors, medical professionals and other staff. The UK Government is currently cutting costs within the different sectors of the economy, while there are raising figures in UK National Health Service (NHS) spending. These are due to a growing and ageing population, advancement in modern healthcare delivery and special needs for different facility users. There is a UK Government proposal set out that requires the delivery of ??15-20 billion in efficiency savings over the three year period from 2011 (Department of Health, 2010-2015). This study has understood that cost savings can be achieved by adopting and implementing a framework that supports refurbishment, flexibility, standardisation and Building Information Modelling (BIM). These cost savings can be achieved through Mechanical Engineering and Plumbing (MEP) clash detections using (BIM). 65% of hospital designs are centred on MEP services (interviews). The NHS needs to save cost when responding to possible future changes without compromising the quality of standard provided to the public. A change-ready healthcare facility is proposed to address the issue of change and the design of quality spaces that can enhance effectiveness and efficiency in the delivery of health and social care. A change-ready healthcare facility can be described as a facility that accommodates known or proposed future changes creating novel pathways to increase the quality and life span of facilities. There is also a large chunk of NHS estates that is underutilised EC Harris, (2013). Therefore, healthcare facilities need to respond to future changes in order to optimise their spaces. To achieve quality and cost efficiency in healthcare buildings, key considerations are refurbishment and reconfiguration, optimisation of flexibility, maximising standardisation and implementation of BIM. This research explores opportunities to save costs, time and improve quality of healthcare facilities by making emphasis on the design delivery process. Therefore, the new RIBA Plan of Work 2013 was used as a mechanism to help translate ideas into physical form and yet has been hindered by lack of development and ability to keep up with technological development such as BIM. This is the rationale for developing a framework. The RIBA Plan of Work is accepted nationally. Due to the UK BIM mandate by 2016, this research is focused on the use of BIM to support both space standardisation and space flexibility within a refurbished or new building. Space is a vital component competent in every healthcare facility. It provides the environment for healthcare services to be performed, and links one functional space to another, it can be designed for multifunctional usage. Healthcare spaces are complex entities due to the range of services and technology they support and the number, variety and quality of requirement combined with a rapidly changing environment. Flexibility enables a facility to easily respond to changes, while the introduction of standardisation supports staff performance by reducing the reliance on memory which will reduce human error. But the main question that emerges from current literature is how healthcare designers and planners manage healthcare spaces that cannot easily be standardised due to the constraints of existing structures, diversity in patient and staff needs? With analysis of different flexibility frameworks in the Architecture, Engineering and Construction (AEC) industry, there is a need to improve the existing frameworks. Therefore, a framework for designing a change-ready healthcare facility was developed through a sequence of data analysis starting with literature, preliminary data, questionnaire survey and interviews. Three frameworks for designing a change-ready facility were revised, organised and merged to produce a state of the art framework. Three frameworks were revised as different research methods were required. The successful framework can guide the design process of embedding different flexible design options for a defined project brief to save costs and improve design efficiency. The framework was validated with some of the top 100 architectural practices in the UK, NHS Estates, facility managers and the RIBA through an interview process. Further research and development arising from this research focuses on the process of applying BIM to record or identify key decisions taken for each of the different design options generated from a single brief to inform the designers, clients or other stakeholders involved while collaborating. Findings of this research are described in five peer-reviewed papers. The only certainty in healthcare is change Gressel and Hilands, (2008).

The management of physical healthcare assets is vital for efficient delivery of healthcare services along with improving quality and productivity, amidst significant structural and funding re-organisation within the NHS. Capital allocations are under pressure and advanced strategic planning of healthcare infrastructure is required to maintain services. In doing so, the complexity of multiple interacting systems and mixed stakeholder expectations and competencies need to be addressed. The relationship between stakeholder public consultation and estates strategy development in theory and practice is poorly understood and further theoretical development is required to advance our knowledge in Strategic Asset Management (SAM). This thesis adopts an interpretivist paradigm, and an abductive approach with a case study design methodology. Data were collected from six case studies comprising 91 participants (focus groups and workshops); 6 unstructured interviews; 907 questionnaires; and observations resulting in over 30 hours of transcribed data, along with web-based document analyse (desk studies) within 149 NHS Trusts. The data were further analysed using thematic analyses. Findings reveal how localised conditions within individual healthcare Trusts influence the ways in which national initiatives are interpreted and incorporated; these impact existing ways of developing an estates strategy and in some cases, have implications on the usability of associated healthcare infrastructure spaces. This had clear implications on existing SAM practice, which were diverse, driven by individual project team competencies and associated project management practice. In practice, more focus was given to technical competencies (knowledge of SAM datasets and tools) and behavioural competencies were downplayed. Thus, the integrative Strategic Asset Management (iSAM) framework developed in this research, established a unique baseline to develop SAM plans from a complex interaction of care, estates and transport, providing a valuable resource for healthcare planning teams. Stakeholder consultation should be selective (representative sample) and the content of consultation should be appropriate at various SAM stages. Trusts should clearly indicate how their plans have been influenced, given the feedback from stakeholder consultation. Thus, moving it from a tick box exercise, to one that adds value in the decision making process. Empirical findings revealed that although literature promoted tools and methods to facilitate SAM, in practice, these were hardly used and most teams within English healthcare Trusts were not aware of best practice tools and solutions. Structuration theory was further used as a heuristic device to theoretically triangulate the empirical findings and contribute to a nuanced understanding of SAM within healthcare Trusts. In doing so, a middle range theory for integrative SAM (iSAM) was developed. It revealed that a dynamic system of individual action and organisational structure both constrained and enabled SAM. It was evident that the process of SAM is an open, emergent process of sense making rather than a pre-determined and closed process following prescriptive rules. This thesis has advanced knowledge in SAM and has raised the importance of front end project management within English healthcare Trusts. The new integrative and interdisciplinary iSAM framework facilitates the development of estates strategy and stakeholder consultation decision-making within healthcare Trusts.

Background: As a result of the changes in support for adults with Intellectual Disabilities (ID) and the increasing emphasis on independent living within the community, individuals commonly live in their own homes with support provided by voluntary or private services. As a result, support staff play a huge role in the lives of adults with ID and are often the mediators of interventions aimed at reducing distress or the occurrence of challenging behaviour. Issues relating to the well-being of support staff and how they manage behaviours that challenge services are central to the quality of the lives of adults with ID. Method: A systematic review was carried out regarding interventions aimed at reducing stress felt by staff supporting adults with ID, with the aim of informing the clinical practice of psychologists that work with such staff groups. An empirical study employing the qualitative methodology of grounded theory was also conducted to explore the experiences of staff working with clinical psychologists outside of their organisation in the development of support guidelines aimed at reducing challenging behaviour. Results: Findings from the Systematic Review highlighted the lack of high quality intervention studies aimed at reducing stress in staff. Some tentative support was found for interventions based on Acceptance and Commitment Therapy and those taking a more practical problem-solving approach. The empirical study resulted in a tentative model within which the role of expectations was highlighted as key to staff’s experiences of working with professionals. Conclusion: Further research is required in order to identify the most effective ways to reduce stress experienced by staff working with adults with ID. The constructed theoretical model suggests ways in which psychologists can understand the experience of staff and has implications for their practice.

This study proposed a new topic in exploring what factors cause most Chinese customers not continue to use their healthcare wearables after purchasing. Based on the framework of “the self-regulation of attitudes, intentions, and behavior” (Bagozzi, 1992), which is used to determine what factors impact satisfaction and how satisfaction can in turn impact stickiness, this study developed a new research model and proposed seven hypotheses. And based on the theories, firstly, this study used interview technique to understand what practical factors people think about would affect consumers’ satisfaction and stickiness towards healthcare wearables in China. Secondly, combined theories with all the hypotheses and the interview results, this study applied survey method to collect empirical data. As all the constructs were validated with exploratory factor analysis and reliability analysis, then the model was tested with linear multiple regression. The findings showed that the proposed research model fits in testing in this study, as three factors (value, quality and trust) have significant effects on Chinese consumers' satisfaction and stickiness towards healthcare wearables consumption. This study suggested that healthcare wearable companies need to put more emphasis on maintaining and increasing consumers’ trust, should continually improve consumers’ satisfaction, and should emphasize more on how to improve consumers’ attitudes of value and trust instead of putting more efforts on quality. These study results can help healthcare wearables companies make correct marketing strategies by putting efforts and resources on more valuable aspects, meanwhile, can help Chinese people to really improve health by using healthcare wearables.

Healthcare around the world is facing strenuous times, whereby there is a need for reduced costs, improved efficiency, and effectiveness. Digitalization is a transformational phenomenon argued to solve the many problems of healthcare. As of such, this thesis studies digitalization in a healthcare setting - considering how digitalization is achieved in practice, and what elements hamper and enable sociotechnical changes required for digitalization. To study these aspects, a qualitative case study was carried out on the recently implemented mandatory electronic dental card among the dental care professionals from a Baltic country. The study allowed contributions to digitalization research by looking at the phenomenon from industry-level analysis, also revealed the elements that hamper and enable digitalization, outlined the different digitalization patterns, and argued that digitalization relies on the extent by which the new system provides value to the users without interfering with professional expertise and ethics.

In this thesis we address capacity planning problems with different demand and service characteristics, motivated by healthcare applications. In the first application, we develop, implement, and assess the impact of analytical models, accompanied by a decision-support tool, for operating room (OR) staff planning decisions with different service lines. First, we propose a methodology to forecast the staff demand by service line. We use these results in a two-phase mathematical model that defines the staffing budget for each service line, and then decides how many staff to assign to each potential shift and day pair while considering staff overtime and pooling policies and other staff planning constraints. We also propose a heuristic to solve the model's second phase. We implement these models using historical data from a community hospital and analyze the effect of different model parameters and settings. Compared with the current practice, we reduce delays and staff pooling at no additional cost. We validate these conclusions through a simulation model. In the second application, we consider the problem of staff planning and scheduling when there is an accepted time window between each order's arrival and fulfillment, with the goal of obtaining a balanced schedule that focuses on on-time demand fulfillment but also considers staff characteristics and operational practices. Hence, solving this problem requires simultaneously scheduling the staff and the forecasted demand. We propose, implement, and analyze the results of a model for staff and demand scheduling under this setting, accompanied by a decision-support tool. We implement this model in a company that offers document processing and other back-office services to healthcare providers. We provide details on the model validation, implementation, and results, including a 25\% increase in the company's staff productivity. Finally, we provide insights on the effects of some of the model's parameters and settings, and assess the performance of a proposed heuristic to solve this problem. In the third application, we consider a non-consumable resource planning problem. Demand consists of a set of jobs, each job has a scheduled start time and duration, and belongs to a particular demand class that requires a subset of resources. Jobs can be `accepted' or `rejected,' and the service level is measured by the (weighted) percentage of accepted jobs. The goal is to find the capacity level that minimizes the total cost of the resources, subject to global and demand-class-based service level constraints. We first analyze the complexity of this problem and several of its special cases, and then we propose a model to find the optimal inventory for each type of resource. We show the convergence of the sample average approximation method to solve a stochastic extension of the model. This problem is motivated by the inventory planning decisions for surgical instruments for ORs. We study the effects of different model parameters and settings on the cost and service levels, based on surgical data from a community hospital.

Background: Healthcare-associated pneumonia (HCAP) guidelines were first proposed in 2005 but have not yet been validated. The objective of this study was to compare 30-day mortality and length of stay (LOS) in HCAP patients treated with either guideline-concordant HCAP (GC-HCAP) therapy or guideline-concordant community-acquired pneumonia (GC-CAP) therapy. Methods: We performed a retrospective cohort study of >150 hospitals in the Veterans Health Administration. Patients were included if they had ≥1 HCAP risk factor and received antibiotic therapy within 48 hours of admission. Patients were excluded if they received ICU care, had cardiovascular or respiratory organ failure, or received invasive mechanical ventilation and/or vasopressors. We determined independent risk factors for 30-day mortality with a multivariable logistic regression model including baseline characteristics, individual HCAP risk factors, comorbidities, and organ failure as dichotomous covariates. Propensity scores were calculated for the probability to receive GC-HCAP therapy and incorporated into a second logistic regression model. Results: A total of 15,071 patients met study criteria and received GC-HCAP therapy (8.0%), GC-CAP therapy (75.7%), or non-guideline-concordant therapy (16.3%). GC-HCAP patients were more likely to have neoplastic disease; whereas, GC-CAP patients had a higher prevalence of other comorbidities, tobacco use, and recent medication use. In multivariable regression, recent hospital admission (OR 2.47, 95% CI 2.10-2.91) and GC-HCAP therapy (2.13, 1.82-2.48) were the strongest predictors of 30-day mortality. Hematologic organ failure, non-invasive mechanical ventilation, neoplastic disease, renal organ failure, and cerebrovascular disease were also independent risk factors. Use of cardiovascular medications, inhaled corticosteroids, and tobacco were protective. GC-HCAP therapy continued to be an independent risk factor for 30-day mortality (OR 2.12, 95% CI 1.82-2.48) in the propensity score analysis. Conclusions: GC-HCAP therapy is not associated with improved survival in HCAP patients. / text

Contextual, personal, theoretical, and institutional forces intersect in the development of an intentional and ethical applied drama practice. This document charts several ethical signposts marking the development process of an applied drama project, Child-centered Improvisation, in a pediatric dialysis clinic. It argues for a deep understanding of the fields and contexts in which drama is applied and an awareness of the multiplicity of voices therein. The resulting discussion claims bewilderment as a productive space and privileges a narration of the complementary practices of an applied drama practice in a pediatric healthcare setting. The document concludes with recommendations specific to developing applied drama practices in such settings. / text