Trata-se de um estudo quantitativo com delineamento exploratório-descritivo, cujos objetivos foram conhecer a percepção dos trabalhadores de enfermagem de um hospital de ensino acerca da segurança do paciente, considerando-se as dimensões de cultura de segurança, e identificar os principais fatores que acarretam danos ao paciente na referida instituição. O estudo foi desenvolvido em um hospital público e de ensino, e a população constituída por 95 profissionais de enfermagem. A coleta de dados ocorreu entre os meses de maio a outubro de 2011, por meio de um questionário baseado na Agency Health Research Quality, empregando-se a escala de Likert e considerando-se as dez dimensões de cultura de segurança e duas variáveis de resultado: expectativas e ações dos supervisores e gerentes na promoção da segurança do paciente, aprendizado organizacional melhoria contínua, trabalho em equipe no âmbito das unidades, abertura para as comunicações, feedback e comunicação a respeito de erros, respostas não punitivas aos erros, pessoal, apoio da gestão hospitalar para a segurança do paciente, trabalho em equipe pelas unidades hospitalares, transferências internas e passagens de plantão, percepções generalizadas sobre segurança, frequência de relatórios de eventos. Os dados foram analisados em função testes estatísticos específicos. O instrumento de coleta de dados mostrou-se confiável, obtendo-se o Alpha de Cronbach igual a 0,88. Na caracterização dos sujeitos, foi verificado que 65,3% eram auxiliares de enfermagem, 26,3% enfermeiros e 8,4% técnicos de enfermagem; 73,7% do sexo feminino; 67,4% com idade entre 30 e 49 anos e com tempo de formação de 11 a 15 anos. Como principais resultados do estudo, podemos citar que, na dimensão abertura para as comunicações e comunicação a respeito dos erros, o maior índice encontrado foi de 35,8%, que afirmam que às vezes conversam livremente sobre algo que está errado e às vezes têm retorno sobre mudanças implantadas em função de eventos adversos notificados. Em relação à dimensão respostas não punitivas aos erros, 50,5% acreditam que seus erros podem ser usados contra eles; quanto ao número de eventos reportados, 76,8% nunca preencheram um relatório de eventos adversos. As dimensões que apresentaram percepção favorável foram o trabalho em equipe no âmbito das unidades e transferências internas e passagens de plantão, 64,2% consideram que os profissionais colaboram entre si quando há sobrecarga de trabalho e 44,2% afirmam que as informações sobre o cuidado do paciente não se perde com a passagem de plantão. Acreditamos que este estudo possa contribuir para as intervenções necessárias nas dimensões avaliadas e fornecer subsídios para o aprimoramento de processos assistenciais e gerenciais com foco na segurança do paciente / This is a quantitative study with descriptive exploratory design, which aimed to know the perception of nursing staff in a teaching hospital on patient safety, considering the dimensions of safety culture and identify the main factors that cause damage to the patient in that institution. The study was conducted in a public hospital and teaching and a population of 95 nurses. Data collection occurred between the months from May to October 2011, through a questionnaire based on the Agency Health Research Quality, using a Likert scale and considering the ten dimensions of safety culture and two outcome variables: expectations and actions of supervisors and managers in promoting patient safety, organizational learning - continuous improvement, teamwork within units, opening for communication, feedback and communication about error, non-punitive responses to errors, personnel, support hospital management to patient safety, teamwork by hospitals, internal transfers and tickets call, generalized perceptions about safety, frequency of events reported. The data were analyzed according to specific statistical tests. The data collection instrument was reliable, yielding a Cronbach\'s alpha equal to 0.88. The characterization of the subjects, it was found that 65.3% were nursing assistants, nurses 26.3% and 8.4% nursing technicians, 73.7% female, 67.4% aged between 30 and 49 years and training time from 11 to 15 years. As main results, we may mention that the size opening for communication and communication about the errors, the highest rate found was 35.8%, who say that sometimes talk freely about something that is wrong and sometimes has a payoff on changes implemented due to adverse events reported. In relation to the size non-punitive responses to errors, 50.5% believe that their errors can be used against them, on the number of reported events, 76.8% never filled out a report of adverse events. The dimensions that were presented favorable perception teamwork within units and internal transfers and tickets call, 64.2% believe that professionals collaborate with each other when there is extra work and 44.2% say the information about the patient care is not lost with the shift change. We believe this study contributes to the necessary interventions in the dimensions evaluated and provide subsidies for the improvement of care processes and management with a focus on patient safety

M.Cur. / The intensive care nurse practising respiratory nursing care, is responsible for giving high quality nursing care. Due to the rising cost of health care more pressure is placed on the nurse to provide a high quality nursing care (Sanazaro, 1986:27) Bruwer (1986:220-245) states that there is a need for an orderly, methodical qua l Ity assurance approach on all nursing levels in South Africa, based on a South African model, as well as the development of nursing standards for public and private hospitals. Mechanical ventilation forms an important part of the nursing of the adult critically ill patient in the intensive care unit. To ensure that the patient benefits from mechanical ventilation and does not suffer from complications due to mechanical ventilation, standards must be developed to ensure the giving of a high quality of nursing care. Without these standards it is impossible to determine the quality of their nursing care given. The quality can furthermore,only be questioned and not be determined scientifically. Standards for providing high quality nursing care to mechanically ventilated patients do not exist in South Africa. The quality of the nursing care that these patients receive is therefore questioned.

The evolution of e-health has the potential to assist in the management of scarce resources and the shortage of skills, enhance efficiencies, improve quality and increase work productivity within the healthcare sector. As a result, an increase is seen in e-health solutions developments with the aim to improve healthcare services, hospital information systems, health decision support, telemedicine and other technical systems that have the potential to reduce cost, improve quality, and enhance the accessibility and delivery of healthcare. However, unfortunately their implementation contiues to fail. Although there are several reasons for this, in this study a lack of project quality management is viewed as a key contributor to the failure of e-health solutions implementation projects in rural hospitals. This results in neglected aspects of quality assurance (QA), which forms an integral part of project quality management. The purpose of this study is to develop a Genertic Quality Assurance Model (GQAM) for the successful acquisition (i.e. development and implementation) of e-health solutions in rural hospitals in the Eastern Cape Province to enable improved quality of care and service delivery. In order to develop and test this model it was necessary to identify the QA methodologies that are currently used in rural hospitals and to evaluate their strengths and weaknesses, as well as their impact on project success. The study is divided into four phases; in each phase different study designs were followed. The study used triangulation of qualitative and some elements of quantitative research approaches, in terms of which a case study approach was adpoted to answer the research questions. This study did indeed develop a GQAM that can be used to ensure e-health solution success in rural hospitals. Furthermore, to aid in the implementation of this model, a set of QA value chain implementation guidelines were developed, as a framework, to inject the nodel into typical (SDLC) phases.

The quality of service from a hospital is the number one factor that will either turn a customer/patient away or make one for life. More and more hospitals are competing for greater shares in the market and customer-driven quality management is becoming the preferred method for improving their performance. Awali hospital is a private hospital in the Kingdom of Bahrain. It is a small 35-bed hospital that offers private medical services to the public. The hospital was originally built to serve the Bahrain Petroleum Company (Bapco) refinery workers but later opened its doors to the public. With the introduction of private patients came higher expectations of quality and higher demands on the overall services. A number of service quality shortfalls were identified over the years but never identified quantitatively by a patient evaluation survey. An English and Arabic version of the questionnaire based on SERVQUAL (Zeithaml, Parasuraman and Berry, 1988) was developed and placed in Awali hospital to test these service quality shortfalls. This study intends to evaluate these areas by answering questions about the relevant areas of service provided by the hospital. It measured patient satisfaction by looking at human aspects of service (responsiveness, reliability, empathy and assurance) with only one factor of the instrument being devoted to the non-human aspect of care rendered (tangibles). The SERVQUAL instrument has five dimensions that were measured by 21 pairs of item statements. One statement from each pair reflects perceptions, the other expectations. Measurement was accomplished by subtracting expectation from perceptions resulting in a service quality score. Positive or zero scores would reflect ideal or adequate service quality offered by the hospital. A negative score would be indicative of a service experience that did not meet customer expectations. Using the SERVQUAL questionnaire provided, quantifiable reasoning to the research questions in each dimension could be obtained so that precision, objectivity and rigour replaced hunches, experience and intuition as a means of investigating problem areas. Customers were first asked to supply some additional demographic information, for example gender, number of hospital visits, nationality, patient type (Bapco worker, general practitioner referred or private) and type of visit (inpatient, outpatient or both). They werethen asked to rate the hospital service on a 7-point Likert scale ranging from Strongly Agree (7) to Strongly Disagree (1). At the end of the questionnaire was space to write open comments. In total 600 paper questionnaires were distributed in the hospital, 300 English and 300 Arabic. Another 150 electronic questionnaires via emails were sent to refinery workers. Of the total 750 questionnaires distributed 162 were returned of which 156 (or 21.6%) could be statistically analysed. The empirical data results showed that the perception scores were significantly different at the p < 0.05 level from expectation scores. All the service quality differences (SQ=P-E) were negatively scored. This indicated that patients were not satisfied in all five dimensions of services offered by the hospital. Of the five dimensions responsiveness had the largest difference with assurance and reliability following with no significant differences between them. The demographic information revealed some interesting differences between the groups. Of all the demographic groups the most significant differences were between groups, “patient types” and “types of visit”, which showed differences between private patients and refinery workers and patients who used the hospital only as an outpatient and patients who used both services, outpatient and inpatient. In terms of the managerial implications, it was recommended that Awali hospital look to closing Gaps 1-4 of the SERVQUAL gap model which would result in closing the consumer gap, Gap 5. A process model for continuous measurement and improvement of service quality was recommended that looks at asking questions about how the hospital is performing. By adopting some of the recommendations identified in the research questions, Awali hospital could improve their quality of service, and as a consequence, their customer satisfaction and loyalty.

Low back syndrome affects 20% of people, and it is estimated that 30% of patients are unable to return to work after surgery. The monitoring of health care outcomes could improve the delivery of health services. The health performance conceptual framework, derived from the Donabedian model, was used to evaluate the functional outcome, clinical recovery, response to surgery, and physician performance of the surgical management of lumbar spine degeneration. A quantitative study (n=685) was undertaken using an administrative database in a repeated-measures design. The clinical and functional outcome improvements were analyzed using t tests. Surgical complexity on health outcome was examined with ANOVA. Predictors of patient satisfaction was explored using Pearson's correlation and regression analyses. The results demonstrated highly significant improvements in functional (mean change 30%; ODI=16.79 -± SD 19.92) and clinical recovery (mean change 50%; modified-JOA=6.983 -± SD 2.613) with surgery at 3 months; a >50% positive response to surgery; and a > 90% patient satisfaction, sustained over a 2 year period. Complexity of surgery did not impact health performance. Strong correlations between the health performance metrics were detected up to 6-months from surgery. Poor clinical recovery and persistent functional disability were predictive of patient dissatisfaction. The social change implications for health policy are that a constellation of health performance metrics could predict the potential for functional and clinical recovery based on presurgery disability while avoiding medical expenditures for procedures with no health benefit; aid in health quality monitoring, peer comparisons, revision of practice guidelines, and cost benefit analysis by payers.

Hintergrund: Patient:innensicherheit nimmt als ethischer Grundpfeiler medizinischen Handelns sowie als Gut öffentlichen Interesses eine Schlüsselposition in der Gesundheitsversorgung ein. Die Patient:innensicherheit der stationären Akutversorgung soll unter anderem durch legislativ verbindliche Qualitätssicherung und -indikatoren sowie mittels Durchsetzung leistungsberechtigender Mindestfallmengen bei komplexen medizinischen Fällen gewährt und kontinuierlich verbessert werden. Medizinische Fälle unterscheiden sich in ihrer Komplexität im Hinblick auf Alter, Geschlecht und Komorbiditäten. Das stationäre Versorgungssetting unterscheidet sich beispielsweise im Aufnahmezeitpunkt und Aufnahmeanlass, durchgeführter (chirurgischer) Prozedur und der Anzahl an der Versorgung beteiligten Stationen. Stationäre Versorger selbst weisen Unterschiede unter anderem hinsichtlich Versorgungsfähigkeit und -auftrag, Trägerschaft, Bettengröße, Personalschlüssel und -qualifikation sowie Fallmenge auf. Fallindividuell werden in der Qualitätssicherung und in Fallmenge-Outcome-Analysen die Risiko-faktoren Alter, Geschlecht und Komorbiditäten statistisch berücksichtigt, jedoch nicht das rahmengebende Versorgungs- oder Versorgersetting. Fragestellung / Hypothese: Das Ziel dieser Dissertation war es, den Einfluss von Versorger- und Versorgungs-variablen auf multiple Patient:innensicherheitsoutcomes mehrerer stationär behandelter Indikationen unter Nutzung unterschiedlicher Daten und Methoden zu analysieren. Für den stationären Versorgungskontext steht der Aufnahmeanlass als Surrogatvariable für die Akuität des Falls (Forschungsziel 1) im Fokus. Für die stationären Versorger sollte aufgrund der legislativen Implikation der Einfluss der Fallmenge untersucht werden (Forschungsziel 2). Aus diesen zwei Forschungszielen wurden drei Einzelfrage-stellungen abgeleitet, analysiert und im Rahmen von drei Publikationen beantwortet: (1) Ist das Geburtsoutcome bei Niedrigrisiko-Geburten mit der Fallmenge des Krankenhauses assoziiert? (2) Welche Zusammenhänge bestehen zwischen Versorger- und Versorgungsvariablen bei der Patient:innensicherheit kolorektaler Resektionen? (3) Welche Rolle nimmt der Versorgungskontext als Risikofaktor bei der Inzidenz von Dekubitalulcera ein? Material und Methoden: Publikation (1) - Systematisches Review Publikation (1) wurde als systematisches Review konzipiert. Zu den Einschlusskriterien gehörten die Analyse von Einflüssen der Fallmenge (Exposition/ Vergleichsgröße) auf die Mortalität (primäres Outcome), Komplikationen/ Kaiserschnitten (sekundäres Outcome) bei Mutter und Kind bei Niedrigrisiko-Geburten (Population) in analytisch ausgewerteten Primärstudien (Studientyp). Vor dem Hintergrund internationaler Vergleichbarkeit musste die Studie in einem Land mit Neonatalmortalität <5/1000 gemäß UN Child Mortality Report durchgeführt, in englischer oder deutscher Sprache verfasst und ab dem 01. Januar 2000 veröffentlicht worden sein. Das systematische Review wurde gemäß den Berichts- und Qualitätsstandards der „Preferred Reporting Items for Systematic Reviews and Meta-Analyses“ (PRISMA) und der zweiten Version des „A MeaSurement Tool to Assess systematic Reviews“ (AMSTAR 2) Instrumentes durchgeführt. Es wurde a priori ein Reviewprotokoll im International Prospective Register of Systematic Reviews (PROSPERO) veröffentlicht. Die Identifikation relevanter Literatur beinhaltete eine maschinelle Suche in Medline und Excerpta Medica Database (EMBASE) via OVID, eine Handsuche referenzierter und referenzierender Artikel in den eingeschlossenen Studien sowie den Einbezug klinischer Experten. Einschluss, Extraktion und Qualitätsbewertung wurden doppelt unabhängig durchgeführt. Publikation (2) und (3) - Querschnittstudien Für die explorativen Fragestellungen der Publikationen (2) und (3) wurde jeweils ein Querschnittdesign mit unterschiedlichen Datenquellen angwendet. Publikation (2) untersuchte explorativ unter anderem die Assoziationen zwischen Aufnahmeanlass sowie Fallmenge und Mortalität, post¬operativem Lungenversagen, Nierenversagen und postoperativen Wundinfektionen nach kolorektalen Resektionen in 232 Krankenhäusern. Zur Analyse konnten Abrechnungs¬daten nach §21 Krankenhaus-entgeltgesetz (KHEntgG) aus den Jahren 2016 - 2018 verwendet werden. Für eine korrekte Definition kolorektaler Resektionen (German Inpatient Quality Indicators), Komorbiditäten (Elixhauser Comorbidity Index) und den nicht letalen Patient:innensicherheitsoutcomes des postoperativen Lungenversagens, Nierenversagens und postoperativen Wundinfektionen konnten validierte und publizierte Definitionen herangezogen werden. Die statistische Analyse erfolgte mit einer Mehrebenen¬regression zur Abbildung der verschiedenen Ebenen zwischen individuellem Fall, Versorgungs- und Versorgersetting. Publikation (3) untersuchte in einem monozentrischen Setting mit gematchten klinischen Daten und Abrechnungsdaten nach §21 KHEntgG des Universitätsklinikums Dresden (2014 - 2018) die Assoziationen zwischen Dekubitusinzidenz und beispielsweise Aufnahmeanlass, Anästhesiedauer Anzahl behandlungsbeteiligter Stationen. Mit dem zusätzlichen Ziel, die Prädiktierbarkeit inzidenten Dekubitus auf Grundlage der assoziierten Risikofaktoren zu analysieren, kam mit Bayesian Additive Regression Trees (BART) ein Machine-Learning-Ansatz zum Einsatz. Ergebnisse: In Publikation (1) zeigten die nach einem Title-Abstract-Screening mit 7.955 Einträgen 13 eingeschlossenen Beobachtungs- und Registerstudien eine akzeptable Studienqualität. Eine quantitative Auswertung (Meta-Analyse) wurde aufgrund heterogener Definitionen bei Population, Fallschwellen, Outcomes und statistischer Methodik nicht durchgeführt. Die Fallmenge war protektiv mit der perinatalen Mortalität in der Mehrheit der Studien assoziiert. Für die weiteren Outcomes Totgeburt, Neonatalmortalität, maternale Mortalität, Kaiserschnitte oder Komplikationen bei Mutter oder Kind zeigte das Review keinen über die Mehrheit der Studien konsistenten Fallmengeneffekt. Die Analyse von 54.168 Kolonresektionen (209 Versorger) und 20.395 Rektum-resektionen (200 Versorger) in Publikation (2) identifizierte Aufnahmen als Notfall oder Zuverlegung und Wochenendchirurgie als durchgehend signfikanten Risikofaktor für die Patient:innensicherheit (Mortalität, postoperatives Lungenversagen, Nierenversagen und postoperative Wundinfektionen) bei Kolon- sowie Rektumresektionen. Fallmenge und Patient:innensicherheit waren mehrheitlich insignifikant mit Kolonresektionen und protektiv mit Rektum¬resektionen assoziiert. In der Auswertung von insgesamt 149.006 stationär behandelten Fällen, inklusive 4.663 inzidenten Dekubitusfällen aus Publikation (3), war Dekubitus mit der Auf¬nahme als Notfall oder Zuverlegung und einer OP-Dauer >50 Minuten assoziiert. Die Prädiktierbarkeit erwies sich aufgrund einer hohen Anzahl von falsch-negativen Werten als eingeschränkt. Schlussfolgerungen: Die Ergebnisse der publizierten Analysen dieser Arbeit weisen darauf hin, dass der Aufnahmeanlass als Teil des Versorgungssettings trotz umfassender Adjustierung durchgängig als Risikofaktor mit der Patient:innensicherheit assoziiert war. Bezüglich dem Einfluss der Fallmenge auf die Patient:innensicherheit zeigten sowohl das systematische Review (Publikation (1)) zur Niedrigrisiko-Geburtshilfe als auch die Querschnittstudie zur Patient:innensicherheit kolorektaler Resektionen (Publikation (2)) heterogene Ergebnisse. Im Rahmen der Untersuchung von Fallmenge-Outcome-Vergleichen konnten unter anderem die Risikoadjustierung, die Definitionen von Populationen und Outcomes sowie die Detailtiefe des verwendeten Datensatzes als zu berücksichtigende Faktoren identifiziert werden und unterstreichen die Notwendigkeit umfassender und gründlicher Risikoadjustierungen. Qualitätssicherung und Mindestmengen besitzen eine hohe versorgungs- und gesund-heitswirtschaftliche Relevanz. Im Sinne Evidenzbasierter Medizin sind entsprechende Ansätze oftmals auf die Beforschung durch Beobachtungsstudien als bestverfügbare Evidenz angewiesen. Gemessen an der skizzierten Relevanz von externer Qualitätssicherung und Mindestmengen definiert diese Arbeit auf Grundlage einer umfassenden inhaltlichen und statistischen Analyseplanung die Notwendigkeit einer gründlichen (risikoadjustierten) Analyse von Fall-, Versorgungs- und Versorgervariablen als relevante Risikofaktoren der Patient:innensicherheit.:Inhaltsverzeichnis Zusammenfassung III Summary VII Abbildungsverzeichnis X Tabellenverzeichnis XI Abkürzungsverzeichnis XII 1 Einführung in die Thematik - Begriff und Relevanz der Patient:innensicherheit 1 1.1 Patient:innensicherheit und Qualität im deutschen Gesundheitswesen 4 1.2 Patient:innensicherheit im Rahmen der (externen) Qualitätssicherung 4 1.3 Mindestmengen als Instrument der Patient:innensicherheit 6 1.4 Risikoadjustierung: ein Schlüsselelement in Qualitätssicherung und (Fall-)Menge-Outcome-Analysen 7 1.5 Versorgungs- und Versorgersetting in der Risikoadjustierung 8 2 Forschungsziele und Einzelfragestellungen 10 3 Methoden, Ergebnisse und Publikation 13 3.1 Methodische Überschneidungen 13 3.2 Systematisches Review 15 3.3 Querschnittstudie 16 3.4 Einzelfragestellung (1): Ist das Geburtsoutcome bei Niedrigrisiko-Geburten mit der Fallmenge des Krankenhauses assoziiert? 17 3.5 Einzelfragestellung (2): Welche Assoziationen bestehen zwischen Versorger- und Versorgungsvariablen und Patient:innensicherheitsoutcomes bei kolorektalen Resektionen? 19 3.6 Einzelfragestellung (3): Welche Rolle nimmt der Versorgungskontext als Risikofaktor bei der Inzidenz von Dekubitalulcera ein? 22 3.7 Übergreifende Einordnung 25 4 Publikationen und Impact-Faktoren nach Journal Citation Report 26 4.1 Publikation (1): Are birth outcomes in low risk birth cohorts related to hospital birth volumes? 27 4.2 Publikation (2): The relationships between multiple patient safety outcomes and healthcare and hospital-related risk factors in colorectal resection cases: Cross-sectional evidence from a nationwide sample of 232 German hospitals 51 4.3 Publikation (3): Prediction of Inpatient Pressure Ulcers Based on Routine Healthcare Data Using Machine Learning Methodology 91 5 Diskussion und Ausblick 112 5.1 Zusammenfassung der drei Publikationen 112 5.2 Stärken und Limitationen der Publikationen 114 5.3 Implikationen für externe Qualitätssicherung und Mindestmengen 116 5.4 Ausblick - Versorgungssteuerung und Evidenzgrad 117 Literaturverzeichnis 119 Darstellung des Eigenanteils XIII Peer-Review-Veröffentlichungen und Vorträge XIV Danksagung XIX Anlage 1 - Erklärungen zur Eröffnung des Promotionsverfahrens XX Anlage 2 - Erklärungen über die Einhaltung rechtlicher Bestimmungen XXII

The extent to which customers are satified with the care they receive from the health professionals has been an important area of interest for researchers, managers and health care workers. The physiotherapy cerebral palsy clinic at Mulago Hospital in Kampala Uganda provides physiotherapy services for parents/caregivers of children with cerebral palsy. The parents/caregivers visit the clinic seeking physiotherapy services that will address their problems and those of the child. The purpose of this study was to explore the satisfaction that the parents/caregivers of children with cerebral palsy get from utilising the physiotherapy services at the clinic and to identify the barriers/problems that they encounter that might affect their attendance.

This research investigates and develops a new approach to the management of service quality with the emphasis on patient and staff satisfaction in the healthcare sector. The challenge of measuring the quality of service in healthcare requires us to view the problem from multiple perspectives. At the philosophical level, the true nature of quality is still debated; at the psychological level, an accurate conceptual representation is problematic; whilst at the physical level, an accurate measurement of the concept still remains elusive to practitioners and academics. This research focuses on the problem of quality measurement in the healthcare sector. The contributions of this research are fourfold: Firstly, it argues that from the technological point of view the research to date into quality of service in healthcare has not considered methods of real-time measurement and monitoring. This research identifies the key elements that are necessary for developing a real-time quality monitoring system for the healthcare environment.Secondly, a unique index is proposed for the monitoring and improvement of healthcare performance using information-theoretic entropy formalism. The index is formulated based on five key performance indicators and was tested as a Healthcare Quality Index (HQI) based on three key quality indicators of dignity, confidence and communication in an Accident and Emergency department. Thirdly, using an M/G/1 queuing model and its underlying Little’s Law, the concept of Effective Satisfaction in healthcare has been proposed. The concept is based on a Staff-Patient Satisfaction Relation Model (S-PSRM) developed using a patient satisfaction model and an empirically tested model developed for measuring staff satisfaction with workload (service time). The argument is presented that a synergy between patient satisfaction and staff satisfaction is the key to sustainable improvement in healthcare quality. The final contribution is the proposal of a Discrete Event Simulation (DES) modelling platform as a descriptive model that captures the random and stochastic nature of healthcare service provision process to prove the applicability of the proposed quality measurement models.

This study is a mixed-method study that seeks to develop a set of institutional dementia care indicators to evaluate quality of care and inform the improvement of quality of life (QOL) for Taiwanese people with dementia living in care homes. It also uses comparative analysis to compare the different features of policy and its delivery in dementia care between Scotland and Taiwan, a comparison designed to aid the development of dementia care policy, and the establishment of quality indicators for institutional dementia care, in Taiwan. This study employed the person-centred care approach at the micro perspective, and the total quality management (TQM) approach at the macro perspective, in order to inform a seamless care model for people with dementia living in care homes. Data were collected in two stages: comments from experts in dementia care were recorded in an exercise using “Delphi” methodology; subsequently the opinions of service receivers were recorded in a fieldwork exercise. The Delphi exercise (stage one) acted as the pre-test, involving 24 experts in dementia care in Scotland and Taiwan in evaluating the usefulness and applicability of proposed quality indicators for institutional dementia care. Quantitative and qualitative data from the Delphi panel were analyzed. The fieldwork (stage two) collected 237 questionnaires (from 122 residents with dementia and 115 family members) in 14 Taiwanese care homes for people with dementia (including special care units within care homes). The field test data were analyzed using reliability and item analysis, confirmatory factor analysis (CFA), and descriptive and inferential statistics. Initially, 43 proposed quality indicators for institutional dementia care were identified through literature review. However, after two Delphi rounds, only six key dimensions (41 quality indicators) were identified by consensus as the important items for use in measurement of quality of care for people with dementia living in Taiwanese care homes. Through reliability and item analysis, and CFA, this research developed a model which is a three-factor structure (social care, health and personal care, and environment) with 18 quality indicators. The 18 quality indicators have high reliability, validity, and credibility and load onto a second order factor which represents quality of care for people with dementia living in care homes. Further analysis was then conducted to explore how relative ratings on these three factors differed according to measured characteristics of the residents and their family members. In general, only a few strong patterns of difference emerged and multiple linear regression analysis suggested that differences in ratings could not be attributed to influences of socio-economic and socio-demographic differences between respondents. The study concludes that the Delphi method could be used as a methodology for health services research to integrate the opinions of multidisciplinary dementia experts and that CFA is an effective technique to study the empirical factor structure. The findings suggest that the 18 quality indicators could be suitable criteria for people with dementia and their family members to evaluate care quality and select an appropriate care home. The indicators also have important policy implications for the Taiwanese Government and regulations intended to ensure that care homes meet the requirements of service receivers.

The problem of this study is to compare prior health care experience with satisfactory adjustment in a long-term care facility. Both quantity and quality of prior experience in a health care facility are examined in terms of the significance to successful relocation. Demographic data and perceived control of health are examined in relation to significance of the findings.