Acute medical patients constitute the single largest group of patients in hospitals. The processes by which they are cared for in the United Kingdom (UK) have changed over the past few decades and now the majority of acute medical care is delivered within acute medical units (AMUs). The AMU model is also increasingly being adopted outside of the UK, including in Ireland, Australasia and Europe. AMUs emerged as a result of local service innovations and there is evidence to suggest that care within AMUs varies across settings. Although there are published recommendations for care delivery, empirical evidence is lacking. In this thesis I aim to examine the concept of the AMU model with regard to the literature; its definition; its components; and how these components are delivered across Scottish sites. This is with the aim of informing service provision and contributing to the development of an evidence base relating to AMUs. Firstly, I undertook a systematic review of the evidence relating to the effectiveness of and variation in the AMU model. I found limited, observational and possibly confounded evidence that the AMU model was associated with reductions in hospital length of stay and mortality compared to other models of care in European and Australasian settings. I also found variation in the admission criteria, entry sources, functions and staff work patterns across the 12 AMUs described in the literature. Given this finding that AMUs do not operate in a uniform way, I undertook a second systematic review to assess the published evidence evaluating different methods of delivery of care within AMUs. I identified nine studies of ten interventions. From this I concluded that there was little discerning evidence pertaining to how best to deliver care in AMUs. This led me to undertake a qualitative descriptive study of all the AMUs in Scotland with the aim of further delineating the AMU model. During a visit to each AMU, I collected data through semi-structured interviews with healthcare professionals working in the units. This totalled 171 interviews of 275 participants across 29 sites. I used this data to provide a report detailing how care was delivered in each AMU. I then thematically analysed these reports using framework analysis. There were three principal findings from this qualitative study. Firstly, I found that acute medical care was delivered in acute medical services rather than single AMUs. Secondly, I identified a framework of 12 key components of AMU care that were integral to the functioning of the AMU irrespective of the setting. Examples include nurse staffing and the physical areas contained within the AMU. Lastly, I described how these components were delivered across Scottish AMUs and, where possible, identified distinct models of care delivery. For example, I identified 13 models of AMU functions and seven models of consultant work patterns. In summary, I found that care in Scottish AMUs is delivered variably. The reasons for the variation are unclear. The findings of this thesis are the first in-depth study into AMUs. They provide a useful foundation for discussions and onward planning of resources, capacity and standards of care at both a national and local level. These findings are also an impetus for further research to delineate how best to deliver care in AMUs, and form an essential precursor to such work.

No

<p>The settings investigated were departments of internal medicine (IM), orthopaedics and surgery in acute care hospitals in Sweden. The objective was to identify exogenous and endogenous determinants of accessibility of health care. Both qualitative and quantitative analysis of utilisation was performed on national and regional level of data aggregation. The study proposes that accessibility to acute health services is influenced by exogenous factors, partly outside the control of health care professionals, such as season, physical proximity and overall supply. Organisational properties such as availability of inpatient beds, hospital and physician specialisation and the degree of system integration between provides of emergency care have effects on the quality of care. The novel finding is the strong association between acute readmissions and remaining inpatient utilisation indicating effects of bed supply on global use within IM. These conclusions follow: </p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>There are conflicts between accessibility, efficiency and appropriateness of settings calling for attention to capacity to benefit in addition to needs as priority criteria.</p> / <p>De studerade enheterna var kliniker för internmedicin, ortopedi och kirurgi vid akutsjukhus i Sverige. Studiernas syfte var att identifiera exogena och endogena determinanter av tillgänglighet till sjukvården. Kvalitativa och kvantitativa analyser av vårdutnyttjande utfördes på nationell och regional nivå av dataaggregering. Studierna utmynnar i slutsatsen att tillgängligheten till akutsjukvården påverkas av exogena faktorer, delvis utanför kontrollen för de professionella inom sjukvården, såsom säsong, fysiskt avstånd och totalt utbud. Organisatoriska egenskaper som tillgången till vårdplatser, sjukhusens och läkarnas specialisering och graden av systemintegration mellan producenter av akutvård har effekter på vårdens kvalitet. Det nya fyndet utgörs av upptäckten av en stark association mellan akuta återinskrivningar och övriga inskrivningar. Sambandet indikerar effekterna av vårdplatsutbudet på totalt slutenvårdsutnyttjande inom internmedicinen. Slutsatserna är som följer:</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>Det finns uppenbara konflikter mellan tillgänglighet, produktivitet och vårdgivarens ändamålsenlighet. Det fordras större uppmärksamhet på kapaciteten att tillgodogöra sig behandling utöver behov som ett kriterium för prioritering mellan patientgrupper.</p>

The settings investigated were departments of internal medicine (IM), orthopaedics and surgery in acute care hospitals in Sweden. The objective was to identify exogenous and endogenous determinants of accessibility of health care. Both qualitative and quantitative analysis of utilisation was performed on national and regional level of data aggregation. The study proposes that accessibility to acute health services is influenced by exogenous factors, partly outside the control of health care professionals, such as season, physical proximity and overall supply. Organisational properties such as availability of inpatient beds, hospital and physician specialisation and the degree of system integration between provides of emergency care have effects on the quality of care. The novel finding is the strong association between acute readmissions and remaining inpatient utilisation indicating effects of bed supply on global use within IM. These conclusions follow: § § § § § § § There are conflicts between accessibility, efficiency and appropriateness of settings calling for attention to capacity to benefit in addition to needs as priority criteria. / De studerade enheterna var kliniker för internmedicin, ortopedi och kirurgi vid akutsjukhus i Sverige. Studiernas syfte var att identifiera exogena och endogena determinanter av tillgänglighet till sjukvården. Kvalitativa och kvantitativa analyser av vårdutnyttjande utfördes på nationell och regional nivå av dataaggregering. Studierna utmynnar i slutsatsen att tillgängligheten till akutsjukvården påverkas av exogena faktorer, delvis utanför kontrollen för de professionella inom sjukvården, såsom säsong, fysiskt avstånd och totalt utbud. Organisatoriska egenskaper som tillgången till vårdplatser, sjukhusens och läkarnas specialisering och graden av systemintegration mellan producenter av akutvård har effekter på vårdens kvalitet. Det nya fyndet utgörs av upptäckten av en stark association mellan akuta återinskrivningar och övriga inskrivningar. Sambandet indikerar effekterna av vårdplatsutbudet på totalt slutenvårdsutnyttjande inom internmedicinen. Slutsatserna är som följer: § § § § § § § Det finns uppenbara konflikter mellan tillgänglighet, produktivitet och vårdgivarens ändamålsenlighet. Det fordras större uppmärksamhet på kapaciteten att tillgodogöra sig behandling utöver behov som ett kriterium för prioritering mellan patientgrupper.

The pressure on the healthcare sector is increasing all over the world. The amount of treatable diseases increases and the time spent with each patient decreases. As a reaction towards the way the healthcare works today, patient-centred healthcare has become increasingly popular. Bringing the patient into the centre also needs changes in the staffs’ way of working. One way of making these changes is by implementing Lean healthcare. This thesis uses a systematic review approach to find out what organisational changes have been made at hospitals where they have implemented Lean healthcare and how the implementations were done. The results showed that the most important thing was to engage the staff at an early point. Those hospitals that had representatives from all the different categories of the staff were the ones who managed to make the modifications with less effort and they also had an easier way of maintaining them. The most obvious similarities in the organisational changes the hospitals had made were that they clearly defined who were supposed to do what and that they changed the work into multi-disciplinary teams. By that the hospitals saved a lot of time both for the staff and for the patients. Lean thinking has similarities theories of cognitive science, like distributed cognition and safety barriers and it could get inspiration from these areas to enhance the implementations. There are few articles concerning the organisational changes that have been made at hospitals when implementing Lean healthcare. However the results of this thesis was that the most important thing when implementing Lean healthcare is to involve everyone at an early stage and the only way to get Lean healthcare to really work is by changing the attitude and making people realise that improvement is a never ending process. The changes that were most common among the hospitals were to clearly define and document who was supposed to do what and to change the structure to multi-disciplinary teams working together.