In the early 2010s, competitive market logic was introduced into healthcare systems so as to achieve rapid improvements. This took place as improvement policies began to emphasize the notion of collaboration as a method of ensuring patient safety across organizational boundaries. This thesis addresses how staff, in their practical improvement work, balance economic values, on the one hand, against meaningful solutions for the patient, on the other. The research interest focuses on the particular interpretations about improvements that emerge in negotiations about change. These interpretations are foundational to the learning that simultaneously takes place. The aim of the thesis is to analyse and explain the pedagogical conditions that take place in improvement practices in a healthcare system in the 2010s. The thesis takes its theoretical point of departure in a pedagogical theory that describes how contextual conditions influence learning processes in a specific practice where communication is foundational for learning. The thesis uses critical discourse analysis as a methodological point of departure and builds on a model of improvement work, namely, the clinical microsystem. The first study consists of a literature review of the microsystem framework. Subsequently, three case studies were conducted at Jönköping county council, Sweden. Discussions of improvements at clinical meetings and improvement coaches’ reflections over their pedagogical approaches provide the empirical data for the case studies. The findings show that market logic gives rise to a number of displacement effects with respect to learning processes. Short-term profits are shown to supersede goals of a more profound development of knowledge. The composition of an improvement practice is of critical importance to the nature of the negotiation that takes place, and thus how the practice comes to successfully challenge things that are taken for granted and the power structures that exist within the practice. Improvement coaches themselves become pedagogical prerequisites under the influence of the prevailing conditions, as they promote different learning organizations. This thesis develops the conceptual framework that is instantiated by the clinical microsystem, and it also contributes to the social constructionist field of improvement science by establishing pedagogical and discursive perspectives on improvement and change. / Bridging the Gaps

This dissertation describes a case study comparing the effectiveness of twoinformation systems that assess the quality of surgical care, the National SurgicalQuality Improvement Program (NSQIP) and the University HealthSystemConsortium Clinical Database (UHCCD). For the comparison, it develops aframework for assessing contextual data quality (CDQ) from the decision maker'sperspective. The differences in quality assessment systems to be studied areposited to be due to the differing contexts in which the data is encoded,transformed and managed impacting data quality for the purpose of surgicalquality assessment.Healthcare spending in the United States has risen faster than the rate of inflationfor over a decade and currently stands at about fifteen percent of the GrossDomestic Product. This has brought enormous pressures on the healthcareindustry to reduce costs while maintaining or improving quality. Numeroussystems to measure healthcare quality have been, and are being, developedincluding the two being studied. A more precise understanding of the differencesbetween these two systems' effectiveness in the assessment of surgical healthcarequality informs decisions nationally regarding hospital accreditation and qualitybasedreimbursements to hospitals.The CDQ framework elaborated is also applicable to executive informationsystems, data warehouses, web portals, and other information systems that drawinformation from disparate systems. Decision makers are more frequently havingdata available from across functional and hierarchical areas within organizationsand data quality issues have been identified in these systems unrelated to thesystem performance from which the data comes.The propositions explored and substantiated here are that workgroup contextinfluences data selection and definition, the data entry and encoding process,managerial control and feedback, and data transformation in information systems.These processes in turn influence contextual data quality relative to a particulardecision model.The study is a cross-sectional retrospective review of archival quality datagathered on 26,322 surgical patients at the University of Kentucky Hospital alongwith interviews of process owners in each system. The quality data includepatient risk/severity factors and outcome data recorded in the National SurgeryQuality Improvement Program (NSQIP) database and the UniversityHealthSystem Consortium Clinical Database (UHCCD).

Bakgrund och problem: Med den ökande efterfrågan på vård men med begränsade möjligheter att utöka sjukvårdens resurser finns ett stort behov av förbättringskunskap inom vården. Det är allt vanligare att sjukvården hämtar inspiration till förbättringsarbete från industrin i syfte att öka effektiviteten och hålla en hög kvalitet. Syfte: Studiens syfte är att beskriva och analysera hur intensivvårdsavdelningen (IVA) på Danderyds sjukhus arbetar med löpande förbättringsarbete samt att baserat på analysen ge rekommendationer om hur detta arbete kan utvecklas. Ett bisyfte är att inom ramen för IVA:s förbättringsarbete undersöka det stöd från kvalitet- och verksamhetsutvecklingsfunktionen på Danderyds sjukhus som IVA kan nyttja och att ge förslag på hur detta stöd kan utvecklas. Metod: Denna kvalitativa fallstudie genomfördes på intensivvårdsavdelningen (IVA) vid Danderyds sjukhus. Datainsamlingsmetoderna som användes är semi-strukturerade intervjuer, dokumentstudier och observation. Analysen skedde genom mönsterjämförelse. Resultat: Det främsta förbättringsarbetet som genomfördes på IVA var genom förbättringsteam med ansvar över att utveckla vissa områden inom vården. I nuläget används inte det stöd som KVU kan erbjuda i någon större utsträckning. / Background: As a result of the increasing demand of healthcare and the limited possibilities to expand the healthcare’s resources, there is a great demand of knowledge of improvement within the healthcare. In order to increase the efficiency and maintain a high standard, it is becoming more common for the healthcare to gain inspiration for works of improvement from the industry. Purpose: The purpose of the study is to describe and analyze how the intensive care unit (IVA) at Danderyds Sjukhus deals with the continual work of improvement as well as, with a basis on the analysis, provide recommendations of how this work may be developed. A secondary purpose of the study is to, within the frames of IVA’s work of improvement, investigate the support from the quality and department’s development system at Danderyds Sjukhus which the IVA could take advantage of and provide suggestions of how the support can be improved. Method: This qualitative case study was performed at the intensive care unit (IVA) at Danderyds sjukhus. The methods of data collection that were being used include semi-structured interviews, case studies and observations. The analysis was made through a pattern comparison. Conclusion: The principal work of quality improvement that was performed at IVA was through improvement teams with the responsibility to develop certain areas within the healthcare. The support which KVU can provide is currently not being used to its full extent.

Darbo tikslas: Atskleisti „N„ organizacijos veiklos kokybės tobulinimo galimybes optimizuojant įstaigos procesus. Tyrimo uždaviniai: 1. Išskirti N organizacijoje vykstančius veiklos procesus. 2. Įvertinti organizacijoje vykstančius veiklos procesus pacientų ir darbuotojų požiūriu. 3. Nustatyti procesų tobulinimo galimybes. Tyrimo metodika. Tyrimas vykdytas 2014 metais Kėdainių PSPC. Pacientų ir sveikatos priežiūros specialistų nuomonių apklausai pasirinktas anoniminis anketinis apklausos metodas. Pacientams išdalinta 700 anketų, teisingai užpildytos ir grąžintos toliau analizei naudojamos 650 anketos. Atsako dažnis 92,8 %. Darbuotojams išdalintos 85 anketos, teisingai užpildytos ir grąžintos 75 anketos. Atsako dažnis 88,2 %. Rezultatai. Nuolatinis veiklos procesų tobulinimas sveikatos priežiūros įstaigų veiklų vertinime atspindi kaip kokybiškų paslaugų teikimą, pacientų lūkesčių ir poreikių patenkinimą. Tyrimo rezultatai parodė, kad pacientai 94,77 % ir darbuotojai 89,33 % sutinka, kad įstaigoje teikiamos paslaugos kokybiškos ir aukštą bendrą gydymo ir paslaugų kokybę vertina 95,4 % pacientų ir 97,3 % darbuotojų. Savo šeimos gydytoją pažystamiems rekomenduotų 88,2 % pacientų ir 92,0 % darbuotojų, įstaigą rekomenduotų - 92,0 % pacientų ir 96,0 % darbuotojų. Statistiškai reikšmingų skirtumų nenustatyta tarp pacientų 93,23 %, ir darbuotojų 93,33 % vertinant nuomonę apie registratorės suteiktą informaciją. Ir pacientai 69,38 % ir darbuotojai 92,0 % teigiamai vertina pateikiamą... [toliau žr. visą tekstą] / The objective: To show quality improvement opportunities of ,,N“ organization for optimizing the institution‘s processes. The research objectives: 1. To distinguish business processes occurring in organization „N“. 2. Evaluate business processes in terms of patients and staff in their organizations. 3. Identify process improvement opportunities. Methods of research: The research was carried out in primary health care center of Kėdainiai 2014. For the survey of the opinion of patients and health care professional’s anonymous questionnaire survey method was selected. 700 questionnaires were distributed to patients, 650 of which were correctly filled in and returned to continue the analysis. The response rate was 92.8 %. 85 questionnaires were distributed for workers, 65 of which were correctly filled. The response rate was 88.2 %. Results: Continuous business process improvement in activities reflects the quality of service delivery, patient’s expectations and satisfaction. The results showed that patients 94.77 % and employees 89.33 % agree that services provided are high-quality; 95.4 % of patients and 97.3 % of employess value treatment as high level and services as high quality. 88.2 % of patients and 92.0 % of employees would recommend their family doctor to their acquaintances 92.0 % of patients and 96.0 % employees would recommend institution to others. There were no statistically significant differences between patients 93.23 % and employees 93.33 % when assessing... [to full text]

Objective: determine whether accreditation through Accreditation Canada is associated with more favorable resident safety in Ontario LTC homes and which facility characteristics are predictive of accreditation. Methods: logistic regression was used to determine predictors of accreditation. To examine the association between accreditation and safety, safety was operationalized as five MDS-RAI quality indicators: prevalence of falls, restraints, catheters, pressure ulcers, and infections. Separate multivariable models were developed for each indicator. Results: the odds of accreditation were approximately six times smaller for municipal (p < 0.001) and non-profit facilities (p < 0.001) relative to for-profits; three times greater for chains relative to non-chains (p < 0.001); and twice as large for urban relative to rural facilities (p = 0.04). Of the five quality indicators examined, only one (falls) was associated with accreditation. After adjusting for confounders, accredited homes were estimated to have 8% lower fall rates than non-accredited homes (p = 0.01).

Development of an automated method for classifying digital images using a combination of image quality modification and Bayesian classification is the subject of this thesis. The specific example is classification of images obtained by monitoring molten plastic in an extruder. These images were to be classified into two groups: the “with particle” (WP) group which showed contaminant particles and the “without particle” (WO) group which did not. Previous work effected the classification using only an adaptive Bayesian model. This work combines adaptive image quality modification with the adaptive Bayesian model. The first objective was to develop an off-line automated method for determining how to modify each individual raw image to obtain the quality required for improved classification results. This was done in a very novel way by defining image quality in terms of probability using a Bayesian classification model. The Nelder Mead Simplex method was then used to optimize the quality. The result was a “Reference Image Database” which was used as a basis for accomplishing the second objective. The second objective was to develop an in-line method for modifying the quality of new images to improve classification over that which could be obtained previously. Case Based Reasoning used the Reference Image Database to locate reference images similar to each new image. The database supplied instructions on how to modify the new image to obtain a better quality image. Experimental verification of the method used a variety of images from the extruder monitor including images purposefully produced to be of wide diversity. Image quality modification was made adaptive by adding new images to the Reference Image Database. When combined with adaptive classification previously employed, error rates decreased from about 10% to less than 1% for most images. For one unusually difficult set of images that exhibited very low local contrast of particles in the image against their background it was necessary to split the Reference Image Database into two parts on the basis of a critical value for local contrast. The end result of this work is a very powerful, flexible and general method for improving classification of digital images that utilizes both image quality modification and classification modeling.

Patient safety is of particular importance within intensive care units (ICUs), where critically ill, vulnerable patients receive complex multidisciplinary care. Prior research has indicated that improving patient safety and reducing errors within healthcare requires a focus on systems and organisational culture issues. This thesis was concerned with three studies. One focused on assessing the patient safety culture and two on quality improvement initiatives within an intensive care unit (ICU) of a large teaching hospital. The first study involved a survey of ICU consultant, registrar and nursing staff regarding aspects of safety culture. This was conducted using an existing Hospital Survey on Patient Safety Culture. Of the twelve patient safety culture composites assessed, eight had scores lower than 50%, highlighting these as areas for improvement. Overall, while the survey results revealed that teamwork within the ICU was considered a strength, event reporting and patient care handovers and transitions were both considered areas with potential for improvement. The second study focused on the evaluation of a change initiative designed to improve the handover of patient clinical information in the ICU. This study involved a survey and interviews with consultant, registrar and nursing staff before and after the introduction of a Patient Management, Plan and Progress (PMPP) document. Examination of the survey responses involved both quantitative and qualitative analysis; respondent interview transcripts were analysed using thematic analysis. The results of this study revealed resistance to, and criticisms of, the introduction of the PMPP document; the initiative failed and use of the document was discontinued. The second initiative concerned an evaluation of the impact of a hospital-wide document on improving documentation of withdrawal of patient treatment within the ICU. This involved both quantitative and qualitative analysis, with a patient medical record audit of decisions to withdraw patient treatment within the ICU before and after the introduction of an Advance Care Plan (ACP) document. ICU consultant, registrar and nursing staff were interviewed regarding the process of withdrawal of patient treatment within the ICU. Interview transcripts were analysed using a modified grounded theory approach. Results revealed that the attempt to improve the documentation of withdrawal of treatment within the ICU failed, with the ACP document remaining unused in 89% of cases and incomplete in the remaining 11%. Also, documentation of decision-making and of the process within the medical records did not improve. Before-introduction findings revealed that only 26% of medical records met the pre-existing requirements for treatment withdrawal in the ICU, and after-introduction findings revealed that only 19% of medical records audited met the requirements of the ACP document. After-audit findings also revealed significant and inappropriate increases in the involvement of an ICU registrar both as primary and secondary decision-makers. In spite of an increased awareness of ICU staff concerning the importance of improving documentation, the medical record audit revealed less compliance with the standards required for documentation. Possible reasons for the document remaining essentially unused, as revealed from interviews with staff, included: previous criticisms by the coroner when they failed to complete a similar formalised document properly; perceived logistical issues associated with obtaining required staff signatures; disagreement concerning who should be involved in documenting the withdrawal of treatment process; and the existence of an ICU subculture of practice that, in one particular aspect of documentation, was not consistent with established hospital and ICU protocol and documentation requirements. The final chapter of this thesis considered implications of the results of the studies for the planning, development, implementation and evaluation of improvement programs within the ICU setting. The results were considered within the context of organisational change management theory and research, including factors that have been found to be critical in the success or failure of change programs, such as resistance to change, the involvement of key stakeholders in the change process, leadership, communication and organisational culture. It is suggested that management consultants with organisational change expertise in the planning, development, implementation and evaluation of such programs should be involved in future quality improvement initiatives. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1297608 / Thesis (Ph.D.) -- University of Adelaide, School of Psychology, 2007

Background: UK primary care accounts for 90% of patient contacts in the NHS, and over 300 million consultations every year. Consequently, when primary is suboptimal it has important impacts on population health. At the same time, virtually all general practices use electronic health records (EHR) to capture patient data. Clinical Decision Support (CDS) systems use it to highlight when individual patients do not receive care consistent with clinical guidelines, though ignore the wider population. Electronic Audit and Feedback (e-A&F) systems address the wider population, but their results are difficult to interpret. EHR data has the richness to suggest ways in which care quality could be improved, though this is currently not exploited. The aim of this thesis was to make progress towards better use of primary care EHR data for the purposes of quality improvement (QI) by focusing on e-A&F as a vehicle. Research Objectives were: 1) Develop a model and recommendations to guide EHR data analysis and its communication to health professionals; 2) Use these models and recommendations to develop a system for UK primary care; 3) Implement and evaluate the system to test the models and recommendations, and derive generalisable knowledge. Methods: The overall approach of this thesis was informed by guidance from the Medical Research Council on the development of complex interventions, and Boyrcki et al.’s evidence-based framework for the development of health information technologies (Chapter 2). Theory was first identified through a critical examination of the empirical and theoretical literature regarding CDS and e-A&F systems (Chapter 3), then built upon in a systematic literature search and metasynthesis of qualitative studies of A&F (and e-A&F) interventions (Chapter 4). This resulted in the development a new theory of A&F (Clinical Performance Feedback Intervention Theory; CP-FIT), which was used to inform the development of an e-A&F system for UK primary care – the Performance Improvement plaN GeneratoR (PINGR; version 1). PINGR was then iteratively optimised through a series of three empirical studies. First, its usability was evaluated by software experts using Heuristic Evaluation and Cognitive Walkthrough methodologies (Chapter 5). GPs then performed structured tasks using the system in a laboratory whilst their on-screen interactions and eye movements were recorded (Chapter 6). Finally, PINGR was implemented in 15 GP practices, and CP-FIT used to guide the mixed methods evaluation including examinations of usage records, and interviews with 38 health professionals. Results: There are both empirical and theoretical arguments for combining features from CDS and e-A&F systems to increase their effectiveness; a key recommendation is that e-A&F systems should suggest clinical actions to health professionals (Chapter 3). This is supported by CP-FIT, which has three core propositions: 1) A&F interventions exert their effects through health professionals taking action; 2) Health care organisations have limited capacity to engage with A&F; and 3) Health care professionals and organisations have a strong set of beliefs and behaviours regarding how they provide patient care (Chapter 4). Based on these findings, the unique feature of PINGR is that it suggests improvement actions to users based on EHR data analysis (‘decision-supported feedback’). Key findings from PINGR’s usability evaluation with software experts translated into a set of design guidelines for e-A&F interfaces regarding: summarising clinical performance, patient lists, patient-level information, and suggested actions (Chapter 5). When tested with GPs, these guidelines were found to impact: user engagement; actionability; and information prioritisation (Chapter 6). Following its implementation in practice, PINGR was used on 227 occasions to facilitate the care of 725 patients. These patients were 1.8 (95% CI 1.6-1.9) times more likely to receive improved care according to at least one clinical guideline. Barriers and facilitators to its success included: the resources available to use it; its perceived relative advantages; how compatible it was with pre-existing beliefs and ways of working; the credibility of its data; the complexity of the clinical problems it highlighted; and the ability to act on its recommendations (Chapter 7). Conclusion: It is both feasible and acceptable to health professionals to make better use of EHR data for QI by enabling e-A&F systems to suggest actions for them to take. When designing e-A&F interfaces, attention should be paid to how they summarise clinical performance, and present patient lists and detailed patient-level information. Implementation of e-A&F interventions is influenced by availability of resources, compatibility with existing workflows, and ability to take action based on their feedback results. Unresolved tensions exist regarding how they may deal with patient complexity. Policymakers should consider the relevance of these findings for National Clinical Audits and pay-for-performance initiatives.

Bakgrund Hög andel sena återbud och uteblivna besök, är ett problem vid psykiatriska kliniker och orsakar effektivitetsbrister då tillgängliga resurser inte används optimalt. Fysiska besök och telefonkontakter behöver kompletteras med fler mötesformer för att bättre möta patientens behov och öka tillgängligheten. Syfte Syfte och övergripande mål med förbättringsarbetet var att öka tillgängligheten till psykiatrisk öppenvård genom att erbjuda digitala vårdmöten. Syftet med studien av förbättringsarbetet var att identifiera erfarenheter från förbättringsarbetet som kan användas som lärdomar i fortsatt verksamhetsutveckling. Metod Nolans förbättringsmodell har används i förbättringsarbetet. Studien är en fallstudie, inspirerad av interaktiv ansats med kvalitativ metod. Resultat Genom utveckling och genomförande av 20 digitala vårdmöten är lärdomarna att digitala vårdmöten är ett komplement till besök på mottagning och att digital teknik stödjer arbetsprocessen. Studiens resultat visar att ledningen, strukturer och medarbetares delaktighet är centrala vid kvalitetsförbättringar. Slutsatser Inställning till patientens kapacitet och digital teknik är central för att erbjuda mötesformen. Tekniska lösningar måste vara lättillgängliga. För att dela kunskap, öka tryggheten i det nya sättet att mötas och undanröja hinder som uppstår är arbetsmöten viktiga. Ledningen utgör en central roll för att påverka förbättringskulturen och de värderingar och mönster som finns i verksamheten.

Bakgrund: Låg telefontillgänglighet till vårdcentralerna medför att alla patienter inte kommer fram till sin vårdcentral samma dag. Det kan vara en av orsakerna att patienterna blir missnöjda. Syfte: Förbättringsarbetet var att förbättra telefontillgängligheten i ett avgränsat geografiskt område i Västra Götalandsregionen. Delmål att 90 % av befolkningen skulle komma fram till sin vårdcentral samma dag o slutmål 100 % av patienterna skulle nå sin vårdcentral samma dag. Studiens syfte var att se hur samverkan fungerade mellan personal som inte sitter tillsammans och hur det påverkar telefontillgängligheten Metod: Studien är en explorativ fallstudie av en avgränsad kontext. Data från semisstrukturerade fokusgrupper analyserades med en induktiv ansats som var kopplade till förbättringsarbetet. Resultat: Telefontillgängligheten förbättrades till att börja med och detta visades med statistik från telefonsystemet som är tillgängligt i Västra Götalandsregionen. Personal visade en positiv inställning till den nya verksamheten. Slutsatser: Resultatet av studien och förbättringsarbetet indikerar att det går att förändra telefontillgängligheten med sjuksköterskor som stöttar olika vårdcentraler, trots att de inte är fysiskt på plats i verksamheten. Ett hinder för callcenter var journalsystemet. Trots att det var samma journal så är upplägget med exempelvis färgsättning av likande tidstyper olika på alla vårdcentraler. / Background: Low phone call accessibility to health centers entails that patients will not reach their health center on the day that they wish. This may be one of the reasons patients are dissatisfied. Purpose: The improvement study was to improve phone call accessibility in a limited geographical area in Västra Götaland. Sub-target: 90% of the population should reach their health center the same day. Main-target: 100% of the patients should reach their health center the same day. The purpose was to investigate weather cooperation could function between staff on separate locations and how this affects phone call accessibility. Method: Exploratory case study within a limited context. Data: semi-structured focus groups were analyzed using an inductive approach connected to the improvement study.  Results: Phone call accessibility improved to begin with which was presented using statistics from the phone system, available in Västra Götalandsregionen. Staff displayed positive attitudes towards the new call center. Conclusions: It’s possible to change phone call accessibility using nurses supporting different centers, despite not being employed by those centers. An issue for the center was the journal system where color codes had different meanings in the booking system.