published_or_final_version / Nursing Studies / Master / Master of Nursing

published_or_final_version / Dentistry / Doctoral / Doctor of Philosophy

Introduction Accessibility to care is a key measure for quality health care. Waiting list resulted due to disequilibrium between demand and supply. Waiting time is a common issue in public health care services. Long waits and delays dissatisfy patients, affect clinical outcome and increase health care costs. Access management is therefore important to enhance patient safety, increase satisfaction and reduce service inefficiency. In Hong Kong, waiting lists for public specialist out-patient services have been increasing over the past years. Promotion of appropriate referrals and appropriate utilization between primary and secondary care was identified as one of the current strategies for service demand management. Referral guidelines were introduced to define the clinical conditions to be referred. Appropriate work up and trial of treatment was recommended before referral to specialist care. They were translated into standard referral letter templates and built into the existing electronic medical record system as an execution platform to facilitate workflow and enhance compliance. This electronic referral system was piloted since January 2010 in Department of Accident of Emergency and General Out-patient Clinic at one local public hospital in Hong Kong. Methods The objective of the study was to evaluate the effectiveness of current strategy in access management to public specialist out-patient services. All new case referrals to Medical and Surgical Specialist Out-patient Clinics (SOPC) of the pilot hospital from January 2010 to December 2010 were examined. While, the new case booking data from January 2009 to December 2009 in respective units of the same hospital was used as control group for comparison. Potential changes in number and distribution of new case bookings at medical and surgical SOPC as well as their corresponding waiting time were looked into. Comparison of referral pattern before and after the implementation of new referral system was performed. Results Changes in referral pattern in terms of distribution of triage categories have been observed. Number of semi-urgent cases was significantly increased in 2010 compared with 2009 in both Medical and Surgical SOPC (p=0.006 and p=0.048). Shortening of overall median waiting time was also seen in both Medical and Surgical SOPC of the pilot hospital in 2010. Consistent reduction with statistically significance was noted in all triage categories of both specialist clinics, except urgent cases in Surgical SOPC. Larger effect was seen in non-urgent cases, with 9 weeks and 4 weeks shortening of waiting time in Medical and Surgical SOPC respectively. For overall distribution of waiting time, persistent multimodal patterns were observed in both Medical and Surgical SOPC during the study period. Major peaks were identified within 2 and 8 weeks time of appointment, while scattered clustered bookings were seen along the timeline with waiting time up to years. Discussion The observed result was reinforcing the direction on current strategy, despite direct causal relationship could not be established at the moment. Changes in referral pattern could possibly be explained by the behavioral change of clinicians upon referral and triage of patients due to the introduction of the new referral system. Potential Hawthorne effect during the pilot period should therefore be considered. In view of the complexity and interconnectedness of various service components in the health care system, further studies should be of value to identify the change agent in the system and look into the efficiency gain as well as outcome improvement. Long term and regular monitoring mechanism of waiting time with specific set of performance indicators has to be in place for continuous quality improvement. Taking the public health approach by applying operational studies and simulation models should therefore be the way for further improvement of operational efficiency and service planning in the whole public health system. Conclusion Appropriateness of referrals and utilization between primary and specialist services was introduced for access management of public specialist out-patient services in Hong Kong. Changes in referral pattern with shortening of waiting time were observed. In order to manage the accessibility issue effectively, a balanced approach on demand, queue and capacity management was suggested to be adopted at the organizational level. Collaboration across sectors particularly with the direction to strengthen primary care would also be needed globally at the system level for a healthy, equitable and sustainable system. / published_or_final_version / Public Health / Master / Master of Public Health

In Hong Kong, access to elective surgeries in public hospitals is often associated with lengthy waiting times. Facing resource constraints and increasing demands from a rapidly ageing population, the Hospital Authority (HA) is constantly confronted by the healthcare rationing dilemma. To date, publicized data on elective surgery waiting times at the HA remain limited, and a standardized way of measuring waiting time is currently lacking. Recognizing that the definition of waiting time will form the basis for future policies in addressing the issue, a three-step approach will be taken in this paper. First, a comparison will be drawn for the varying definitions of waiting time worldwide. Next, a suitable definition will be proposed for Hong Kong, followed by analysis of where policy interventions are most needed for reducing waiting times. Finally, best practices for managing waiting times will be extrapolated from England, Canada, Australia, and Spain to serve as guidance for Hong Kong’s future policy direction. / published_or_final_version / Public Health / Master / Master of Public Health

This is a study of the impact of information technology on health care in Great Britain. Its major aim is to identify means by which information technology may improve the quality of health care in specific areas within the health services.The study concentrated upon general practice and was split into three stages. The first was a survey of general practice computing, conducted to give an overview of the use of computers in general practice. Following this, was a more detailed study of general practice miniclinics. The final stage was an in-depth investigation into the use of computers in the care and treatment of diabetes.

A synonym for "dealing with", "coping up" is a common Zambian expression in the 1990's' as households face pressing problems in the context of economic hardship and HIV/AIDS. Through the lens of seven rural households in Chiawa (a chieftaincy on the banks of the Zambezi River), this thesis explores the capacity of households to deal with a series of adversities and changes over a period of four years. The influence of locality and, at another level, national trends are taken into account, but the focus is on how and how well each household has coped in the face of four separate adverse events, a dysentery epidemic, a drought, the introduction of fees in government health facilities and schools, and the terminal illness and untimely death of a young adult. The capacity of households to deal with the HIV/AIDS epidemic is then examined.Overall the households differ in their capacity to deal with these events, but, though each event demands particular responses, resources and strategies, the pattern that emerges is, with the important exception of HIV/AIDS, consistent. Leaving the latter aside, it is possible to rank the households along a scale of high to low capability, to reveal how some households slide up and down the scale over time, and to tease out which resources determine coping well and coping badly in a Chiawa context.HIV/AIDS however, is unlike other adversities. Households ranked as the most capable in relation to the other events are not necessarily able to protect themselves against HIV infection - indeed it is sometimes their relative success in other spheres that puts them at particular risk. The thesis concludes that even 'high capability' households have yet to adapt to the presence of HIV/AIDS in their community, and to develop support systems to prevent its further spread.A parallel theme in the thesis is the capacity of anthropology and anthropologists to conduct research which is ethically sensitive and can usefully be applied to HIV/AIDS interventions.

This thesis presents the notion that paid elder care work is often more involved with ordering individuals, than caring for them. It discusses this issue via ethnographic data about care assistant and nursing auxiliary work, which was collected in two elder care homes: Hazelford Lodge residential home and Bracken Court nursing home. The thesis uses care, control, and knowledge as the main themes for the discussion of work in both homes. The first chapter sites the thesis within the context of the academic literature on the discourses of the body, the nature of care work and residential care. It focuses especially upon care work as body labour. Chapter two presents the ethnographic methodological approach of the thesis, in two sections. Firstly, the use of the Foucauldian notion of discourse is explained, and secondly, the research process and research relationships are explored through a reflexive account. Chapters two and three present social, structural and spatial aspects of the two settings. They discuss the different ways in which the homes were organised, and that spaces were utilised and had different meanings, within the homes. Chapters four and five are based upon data from Hazelford Lodge residential home, and illustrate the care assistants' work as centred upon created order in the home, based upon the typification of residents and others. Chapters six and seven explore the auxiliaries' work in Bracken Court and present three control issues as central to their jobs. Firstly the overt ordering of patients around spaces in the home. Secondly, the normalisation of individuals into patient, and objects, of body work. Thirdly, the auxiliaries' resistance to heir role and status. Chapter eight compares the work of the assistants and auxiliaries in terms of resident and patient construction, the nature of the two forms of work, their knowledge, and lastly, their constructions of place and status. The thesis argues that both groups of workers are involved in ordering bodies that they perceive to be problematic and degenerating. In Hazelford Lodge order and discipline is practised as care and in Bracken Court the auxiliaries use more overt forms of control, but both 'caring' and controlling are effective methods of creating order. By introducing notions of body labour and ordering, the thesis presents a unique critique of paid care.

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The recent trend in health care has been on the development and implementation of clinical guidelines to support and comply with evidence-based care. Evidence-based care is established with a view to improve the overall quality of care for patients, reduce costs, and address medico-legal issues. One of the main questions addressed by this thesis is how to support guideline-based care. It is recognised that this is better achieved by taking into consideration the provider workflow. However, workflow support remains a challenging (and hence rarely seen) accomplishment in practice, particularly in the context of chronic disease management (CDM). Our view is that guidelines can be knowledge-engineered into four main artefacts: electronic health record (EHR) content, computer-interpretable guideline (CiG), workflow and hypermedia. The next question is then how to coordinate and make use of these artefacts in a health information system (HIS). We leverage the EHR since we view this as the core component to any HIS. / Thesis (PhDInformationTechnology)--University of South Australia, 2005.

Workflow in healthcare, particularly for the shared and coordinated management of chronic illnesses, is very difficult to model. It is also difficult to support via current Clinical information Systems and current information technologies. This dissertation contributes significant enhancements to the current methodologies for designing and implementing workflow Management Systems (WfMSs) suitable for healthcare. The contribution comprises three interrelated aspects of workflow system architecture as follows:- Firstly, it shifts the emphasis of workflow modelling and enactment to a focus on goals, and the monitoring and facilitation of their achievement. Secondly, it introduces the concept of self-modifying workflow in the context of health care planning, whereby explicit tasks in the goal-based care plan are devoted to assessing and modifying downstream workflow. Thirdly, this dissertation proposes methodologies for identifying and dealing with tasks which overlap, subsume or interfere with other tasks elsewhere in a given workflow. / Thesis (PhDInformationTechnology)--University of South Australia, 2005.