Treating chronic health conditions consumes a significant portion of the health care resource. Two–thirds of UK hospital admissions consist of people with chronic conditions (Singh, 2005). To date, health management has tended to focus on service redesign, rather than focusing on the patients, as a way to facilitate improved outcomes and control costs. Typically, these management approaches are premised on the patient as a consumer/end user. An alternative view to the patient being a consumer is that of the patient being a co–producer of the service. Co–production recognises the client (patient) as a resource, in that value cannot easily be created or delivered, unless the patient actively contributes to the service (Alford, 1998). Patients gain health value when they are well and are independent of the health care system and its costs. Health care organisations gain economic value, when chronic patients require less health care. This thesis examines co–production, in the context of contemporary patient involvement and heath services management. ‘Knowing the People Planning’ (KPP), an innovative health management method, is evaluated for its patient management co–production potential. KPP is based on ten key features of service provision. Four of the key features relate to the patient, whilst the remaining six features relate to the organisation. It is the management of these patient and organisation features that better facilitates chronic long-term mental health patients as co–producers. The empirical findings, from this evaluation of KPP provide evidence for the efficacy of co–productive health management theory and practice. Patient health value and health care organisation economic value are created, when both the organisation and the patient co–produce the health service. KPP was initially implemented by eight of New Zealand’s 21 District Health Boards. Socio-ecological action research methodology was used to evaluate KPP — by taking a ‘people-in-environments’ approach. The evaluation covers fourteen action research cycles for 2,021 chronic long-term patients over four years. Measurements include the amount of time these long-term patients spent in hospital and employment rates. The integration of the action research cycles, using the socio-ecological method supported the generation of (what I have called) ‘co–productive health management theory’. Analyses of secondary data, across organisational and patient domains, supplement the action research findings, in order to assess for confounding factors. The organisation outcomes relate to costs and staff turnover. Patient outcomes relate to service utilisation measures, for approximately 60,000 adult patients per year, who access New Zealand’s secondary mental health services. A pivotal finding of this research was that, as the rate of patients with treatment plans increased from 50% to 90%, inpatient bed use decreased by 26%. However, increased funding for mental health services had only a minor impact on decreasing inpatient bed use. Patient employment rates increased, whilst the number of patients who required access to general practitioners and changes to their housing situation, decreased. The patient management co–production view offers a significant opportunity for health care managers and researchers to significantly improve both patient and organisation value. Co–production views the patient as a resource, who contributes to her/his health outcome, rather than a person who simply consumes services. The better patients can co–produce their health outcome the better their health, and the lower their demand for health services.

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. / PhD Doctorate

The objectives for this study were to develop a continuity of care scale, to assess the mean level of continuity of care, to assess association between demographic variables and clinical variables with continuity of care, and to assess association between continuity of care and medication adherence among Medicare beneficiaries. A retrospective cohort study was conducted to achieve the objectives using data from the 2015 to 2017 Medicare Current Beneficiaries Survey (MCBS). To be included in the sample, beneficiaries had to have a hyperlipidemia diagnosis, be continuously enrolled in Medicare Part D for six months from start of medication adherence, be continuously enrolled in Medicare Part A and Part B in the preceding year, and had to have at least two prescription claims for hyperlipidemia medications. Beneficiaries were excluded if they had a proxy responder, had an Alzheimer’s disease or dementia diagnosis, were enrolled in Medicare due to end-stage renal disease or disability, or were residing in a long-term care facility. Among 2,120 beneficiaries that met sample selection criteria, 57 percent were aged 75 years or older, 57 percent were female, and 87 percent were White. An overall continuity of care scale was developed using MCBS items that asked respondents about their care experience. Exploratory factor analysis was used to determine subscales of continuity of care using a randomly selected 60 percent of the sample, which yielded three subscales of continuity of care: relational continuity (Factor 1), informational continuity (Factor 2), and management continuity (Factor 3). Confirmatory factor analysis conducted using the remaining 40 percent of the sample validated factor structure of the continuity of care scale. The mean level of overall continuity of care among Medicare beneficiaries was 3.26 out of 4. Medication adherence was assessed using proportion of days (PDC) covered for anti-hyperlipidemia medications. Beneficiaries with a PDC of 80 percent or more were considered medication adherent. Approximately, 81 percent of beneficiaries were adherent to prescribed hyperlipidemia medications. Association between demographic variables and clinical variables with overall continuity of care was assessed using multivariable logistic regression based on purposeful selection of variables method. Older age, low perceived health status, and lower number of prescribed medications were associated with low overall continuity of care. Race and marital status were found to have interaction effect on overall continuity of care. Among non-white beneficiaries, married beneficiaries reported higher overall continuity of care than not-married beneficiaries. Among married beneficiaries, whites reported lower overall 12 continuity of care than non-whites. Association between overall continuity of care and medication adherence was assessed using multivariable logistic regression with purposeful selection of variables method. There was no association found between overall continuity of care and medication adherence.

Health care administration programs have transitioned to using the competency approach to better prepare graduates for workplace success. The responsibility of preparing graduates lies with the program faculty, yet little is known about faculty perceptions of the competency approach. The purpose of this cross-sectional study was to assess the perceptions of graduate-level health care administration faculty about the competency approach, the approach's effect on graduate preparedness, and employer expectations. Adult learning theory and the theory of self-efficacy were used as the theoretical foundations for the study. Faculty demographics related to personal information, workplace/teaching experience, and program information served as the independent variables, while survey item perception ratings were the dependent variables. Nonprobability sampling of graduate-level health care administration faculty (n = 151) was used and data were collected using an online survey developed by the author. Descriptive statistics, independent samples t tests, correlation analyses, and multiple linear regressions were used to examine and describe faculty perceptions. Findings indicated that faculty generally support the use of the competency approach and that it effectively prepares graduates. Teaching in a CAHME-accredited program predicted perceptions about the approach adequately addressing employer expectations (β = .343, p < .05). Issues including need for standardization and use for accreditation versus educational purposes were identified. Social change implications include contributing to professional development efforts for faculty and improving the quality of health care administration graduates and the future leadership of the industry.

Immersed in a context of constrained health resources, nurse managers are at great risk of the experience and negative consequences of values clashes and ethical conflict, such as burnout and attrition. Replicating a qualitative descriptive study previously conducted in Canada (Gaudine & Beaton, 2002) this research is aimed at increasing knowledge of the experience of nurse managers’ ethical conflict with their health care organizations in New Zealand. Semi-structured interviews were used to gather data from eight nurse managers in New Zealand, which was analyzed using a general inductive approach to qualitative research. The experience of advocating for values that may be shared by both nursing and the health care organization, such as safety, teamwork and quality patient care, were revealed in the conceptual category of Nursing Management Advocacy. As with their Canadian study counterparts, Isolation was revealed as a key factor that made the experience of ethical conflict worse and involves the social experiences of silencing, employment barriers and invisibility. Support describes the factors that mitigated the experience of ethical conflict and involves personal, professional and organizational support, and are likewise similar to the experiences of Canadian nurse managers. The Bottom Line describes a focal point of the experience of ethical conflict where the health care organizations predominantly fiscal bottom line was confronted and challenged by nurse managers, and where the nurse manager might reach their own bottom line and choose to leave the organization. Being and Becoming Nursing Leaders describes the outcomes of ethical conflict for nurse managers who were not only transformed into nursing leaders, through learning, reflection, and growth but also counted the costs of nursing leadership. This study concludes that supportive colleagues, organizational structures and culture are essential to mitigating the experience of ethical conflict and isolation which nurse managers encounter. The study also concludes that reducing isolation and supporting nurse managers will ensure that nursing values are appropriately represented and articulated in the health care organization’s decision making systems and processes.

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. / PhD Doctorate

No description available.

No description available.

<div> <div> <div> <p>The following study used a liberal feminist lens to address a gap in the literature on contraceptive method use and romantic relationships by examining the association between contraceptive method use and both relationship satisfaction and balance of power. Specifically, it surveyed married women between the ages of 20-49 using either oral contraceptives (OCs) or natural family planning (NFP). Relationship satisfaction was measured using the Couple Satisfaction Index (CSI-4). Balance of power in the relationship was measured using the Relationship Balance Assessment (RBA). It was hypothesized that women using NFP would report higher relationship satisfaction and greater balance of power than women using OCs. Instead, results of the multiple regression analyses indicated that women using NFP experienced significantly lower rates of balance of power in their relationship. There was no significant difference in relationship satisfaction between groups. Additionally, control variables of religious importance and number of children were found to be associated with balance of power. Controls of age and religious importance were found to be associated with relationship satisfaction. Clinical implications, strengths and limitations, and future directions for research were discussed. </p> </div> </div> </div>

Bakgrund:  Balanserat styrkort är en ledningsmetod och en styrfilosofi för att styra organisationer. Det fungerar som ett ramverk och verktyg för att mäta, följa upp och hantera prestationer. Enligt Kaplan och Norton innefattar balanserat styrkort fyra perspektiv, det finansiella perspektivet, kundperspektivet, processperspektivet samt utvecklingsperspektivet. Perspektiven utgör en hierarkisk ordning med ett kausalt samband mellan respektive perspektiv. Få studier har fastställt kausalitet i samband med användning av balanserat styrkort som Kaplan och Norton (1992) tidigare beskrivit vara en stor del av ett väl balanserat styrkort. Genom att undersöka en förvaltning i offentlig sektor erhålls därför en uppfattning kring hur det balanserade styrkortet är uppbyggt i dess verksamhet och om kausalitet råder mellan de fyra perspektiven. Studien fokuserar på en förvaltnings introduktion av det balanserade styrkortet och hur detta används och dess effekter, samt om offentliga sektorn innehar kausalitet mellan de fyra perspektiven.  Syfte:  Syftet med studien är att skapa en förståelse för hur det uppställda balanserade styrkortet används inom omsorgsförvaltningens aktiviteter och utreda om det råder kausalitet mellan perspektiven.  Metodval:  Forskningsstudiens tillvägagångssätt utgår från en kvalitativ metod, där en fallstudie har genomförts i Kristianstad kommuns omsorgsförvaltning. Insamlingen av det empiriska materialet har erhållits genom åtta semistrukturerade intervjuer, med fyra verksamhetsutvecklare, tre medarbetare samt en planeringschef för förvaltningen. Empirin har kompletterats med sex dokument från kommunen. Den teoretiska referensramen syftar till att skapa en förståelse för ämnet balanserat styrkort. Slutligen kopplas empirin till teorin i ett analysavsnitt.  Slutsats:  Det balanserade styrkortet tillämpas i omsorgsförvaltningens genom att i första hand fastställa kvalitetsmålen attraktivitet, trygghet, hållbarhet och ekonomi. Sedan tillämpas balanserat styrkort för att styra och följa upp verksamheternas aktiviteter genom att etablera nyckeltal med avseende på de fyra kvalitetsmålen. Styrkortet fungerar som en strategisk ram för hela förvaltningen som hjälper till att specificera och kommunicera målen samt koppla dem till konkreta indikatorer, det vill säga nyckeltal. Aktiviteterna i respektive perspektiv ger upphov till effekter i de andra dimensionerna i den hierarkiska ordningen, ett samband som tyder på kausalitet, en kedja aktiviteter som kan kopplas till en orsak-verkan-effekt. Genom att beakta kausaliteten mellan de fyra perspektiven som förekommer till följd av tillämpningen av balanserat styrkort kan förvaltningen uppnå sina mål på ett mer effektivt och strategiskt sätt. Det främjar en helhetssyn på verksamheten och hjälper till att skapa en balans mellan de olika dimensionerna. / Background: Balanced scorecard is a management method and a management philosophy for managing organizations. It serves as a framework and tool for measuring, tracking and managing performance. According to Kaplan and Norton, the balanced scorecard includes four perspectives, the financial perspective, the customer perspective, the internal business process perspective and the learning and growth perspective. The perspectives constitute a hierarchical order with a causality between them. Few studies have established causality associated with the use of the balanced scorecard that Kaplan and Norton (1992) previously described as a major component of a well-balanced scorecard. By examining an administration in the public sector, an idea is therefore obtained about how the balanced scorecard is structured in its operations and whether causality prevails between the four perspectives. The study will focus on an administration's introduction of the balanced scorecard and how this is used and its effects, as well as whether the public sector holds causality between the four perspectives.  Purpose:  The purpose of this study is to create an understanding of how a balanced scorecard is used within the activities of the care administration and to investigate whether there is causality between the perspectives.  Method:  The study's approach is based on a qualitative method, where a case study has been carried out in Kristianstad municipality's care administration. The collection of the empirical material has been obtained through eight semi-structured interviews, with four business developers, three employees and a planning manager for the administration. The empiricism has been supplemented with six documents from the municipality. The theoretical frame of reference aims to create an understanding of the subject of the balanced scorecard. Finally, the empirical evidence is linked to the theory in an analysis section.  Conclusion:  The balanced scorecard is applied in care management by primarily determining the quality goals of attractiveness, safety, sustainability and economy. A balanced scorecard is then applied to manage and follow up the operations' activities by establishing key performance indicators with regard to the four quality objectives. The scorecard functions as a strategic framework for the entire administration that helps specify and communicate the goals and link them to concrete indicators, i.e key performance indicators. The activities in each perspective give rise to effects in the other dimensions of the hierarchical order, a connection that indicates causality and a chain of activities that can be linked to a cause-effect-effect. By considering the causality between the four perspectives that occur as a result of the application of the balanced scorecard, management can achieve its goals in a more efficient and strategic way. It promotes a holistic view of the business and helps to create a balance between the different dimensions, such as the financial perspective, the citizen perspective, the employee perspective and the development perspective.