Thesis (Ed. D.)--University of Missouri-Columbia, 2003. / Typescript. Vita. Includes bibliographical references (leaves 247-260). Also available on the Internet.

Thesis (Ed. D.)--University of Missouri-Columbia, 2003. / Typescript. Vita. Includes bibliographical references (leaves 247-260). Also available on the Internet.

Continuous Quality Improvement (CQI) is a set of constructs, principles, and tools aimed at continually improving organizational processes. While thousands of organizations worldwide have adopted CQI, there are still many gaps in our knowledge of how to get the most out of CQI efforts. This paper addresses several of these gaps, including the limitations of existing CQI theory and the inconsistencies regarding the implementation of CQI at team and departmental levels. After discussing the basic principles of CQI, a framework for understanding and utilizing CQI is offered. Then, the results of 102 interviews, conducted with team leaders and department heads in a large hospital in the Southwestern United States, are presented. These results suggest that CQI team effectiveness is most influenced by goal specificity, team composition, and team leader training in statistical process control (SPC). Other factors, including team leader attitude toward CQI and team CQI skills, were also related to CQI team effectiveness. Departmental results were less clear. Only department head attitude toward CQI was significantly correlated with departmental CQI implementation. Potential meanings and implications of these findings are discussed, suggestions for implementing CQI in teams and departments are offered, and directions for future research are provided.

La maîtrise de la résistance bactérienne passe par une amélioration de la prescription des anti-infectieux en pathologie humaine. L'objectif de ce travail était de mettre au point et d'évaluer l'impact d'une intervention destinée à améliorer la qualité de l'antibiothérapie, en ciblant en priorité les prescriptions hospitalières. Nous avons voulu utiliser des stratégies dérivées des sciences sociales et de l'industrie, notamment les techniques d'amélioration continue de la qualité, pour changer le comportement des prescripteurs. Nous avons ensuite ciblé une étape-clé de la prescription antibiotique, i.e. la réévaluation des antibiothérapies probabilistes 24-96 heures après leur initiation, que nous avons sélectionnée à l'issue d'une revue de la littérature et d'une analyse quantitative par questionnaire des perceptions, attitudes et connaissances des prescripteurs ; le questionnaire permettait également d'approcher les barrières locales à cette intervention. Puis nous avons mis au point des indicateurs de processus permettant de mesurer cette réévaluation des antibiothérapies. Enfin, nous avons étudié l'impact sur la qualité de l'antibiothérapie d'une intervention utilisant une stratégie d'audit et de retour d'information, visant à améliorer la documentation de la réévaluation des antibiothérapies par des médecins non-infectiologues dans deux services. En conclusion, les stratégies d'amélioration continue de la qualité s'avèrent utiles pour promouvoir le bon usage des anti-infectieux. / Antibiotic stewardship is essential to curb bacterial resistance in humans. Our aim was to design an intervention to improve the quality of prescription of antibiotics, focusing on the inpatient setting. We used strategies derived from the social sciences and the industry, particularly continuous quality improvement techniques, to lead the doctors to change their behaviour. We focused on a key process of antibiotic prescribing, i.e. reassessment of antibiotic therapies 24-96 hours after their start ; we selected this process based on a review of the literature and on the results of a survey designed to assess the perceptions, attitudes and knowledge of the prescribers. This survey also enabled us to approach potential barriers to the intervention. We designed then a set of process measures of quality of care in the reassessment of inpatient empirical antibiotic prescriptions. Finally, we assessed the impact of an intervention designed to improve the documentation of the reassessment of inpatient empiric antibiotic prescriptions on the quality of these prescriptions ; this intervention was conducted on two wards and targeted non-infectious diseases specialists, using an audit and feedback approach. In conclusion, continuous quality improvement strategies are a valuable tool to improve antibiotic use.

This thesis is anchored in improvement science, the research field of improvement. Improvement science describes and explores improvement in real-life contexts and “system of profound knowledge” (Deming, 2000) is a cornerstone. Performance measures, including their variation over time, are fundamental in the research and evaluation of outcomes of continuous quality improvement efforts (CQI efforts). However, the strong emphasis on operationalisations and measurements risks overshadowing other kinds of outcomes to which CQI efforts can lead. Research has shown that it is advantageous that those performing change have some kind of “sharedness”, e.g. shared cognitions, understanding, knowledge, interpretations or frame of reference. Despite the diversity of concepts and scientific studies, “sharedness” is mainly described as a prerequisite for change. This thesis addresses the call to broaden the scientific approach in improvement science and to take advantage of knowledge developed since Deming's time. It has a point of departure in the presumption that CQI efforts also lead to intangible outcomes; qualitative effects that are not easily captured with traditional performance measures. The concept “Expressions of shared interpretations” is used to study “sharedness” as intangible outcomes. The overall aim with this thesis is to explore Expressions of shared interpretations as intangible outcomes of CQI efforts from the perspective of clinical microsystems and healthcare professionals. The specific aims are to examine and establish how Expressions of shared interpretations develop, influence CQI efforts and change over time. Using a qualitative approach, this thesis comprises four papers, based on three studies. The empirical context is healthcare and welfare organizations providing care: hospital clinics in county councils/regions and nursing homes in municipalities. The studies include time periods from one to three and a half years, totalling six years. Expressions of shared interpretations inherently mean that the methods for data analysis need to be based on commonalities or patterns in the data. In this thesis three methods are used: qualitative content analysis, thematic analysis and directed content analysis. To examine time-related changes, year-to-year comparative analyses of themes and categories are done. To explore Expressions of shared interpretations, different theoretical frameworks are used: team cognitions (Paper 1), sensemaking theory (Paper 2), cognitive shifts (Paper 3) and programme theories (Paper 4). A directed content analysis is applied in a meta-analysis of the results presented in the four papers. The results indicate that Expressions of shared interpretations develop as intangible outcomes of CQI efforts and a general programme theory of CQI efforts in health- and elderly care is developed, illuminating how Expressions of shared interpretations change and influence CQI efforts. The general programme theory incorporates the PDSA cycle and describes the complex, interconnected and continuous development of Expressions of shared interpretations. It also illuminates how Expressions of shared interpretations provide change performers with momentum to engage in forthcoming PDSA cycles and how sensemaking is a central activity. CQI efforts in health- and elderly care are characterised by a “just get on with it” attitude, while in this thesis, thoughtfulness is emphasized. Existing improvement tools support collaboration, creativity and analysis of critical aspects of the operations, yet none of the improvement tools help change performers gain understanding of the CQI effort as such. To address this, this thesis suggests that change performers complement the use of improvement tools with an inquiring mind, that they collaborate in thoughtful dialogues and that leaders function as inquirers. To support this posture, the widely used Model for improvement is complemented with a fourth question: What are our assumptions? The question pinpoints the need to be thoughtful in every step of the CQI effort, not just in the analysis of the problem at hand.

Medical devices are used to diagnose, treat, or prevent a disease or abnormal physical condition without any chemical action in the body. They can also result in unintended incidents and other errors. This thesis was divided into three chapters: i) a systematic review on the recognition, reporting and resolution of incidents related to medical devices and other health technologies; ii) telephone interviews with physicians and registered nurses (RNs) to solicit information on the resolution, reporting and resolution of medical device-related incidents based on their professional experience; and iii) a case study to review the continuous quality improvement (CQI) data retrieved from the wireless smart infusion pump system at The Ottawa Hospital (TOH) and to propose a CQI data analysis process. The systematic review included 30 studies on factors that influence the recognition, reporting and resolution of incidents in hospitals and interventions to improve patient safety. Central themes that emerged for incident reporting were personal attitudes, awareness and perception of incident reporting systems, organizational culture, and feedback to healthcare professionals. In our telephone interviews, physicians and RNs attributed incident recognition to devices not operating based on the manufacturer’s instructions, and to the hospital staff’s knowledge of and professional experience with the use of the medical device, and clinical manifestations of patients. Suggestions to improve medical device safety surveillance centered on education and training to ensure that the staff is able to use the medical device properly and know what would be considered an error, and how to report these errors. The results of the systematic review and interviews helped to inform the design of a medical device surveillance framework in a hospital setting. Our case study assessed the Dose Error Reduction Software compliance and frequency of soft and hard limit alerts with wireless smart infusion pump systems over a one year period. A CQI data analysis process to monitor the performance of wireless smart infusion pumps is proposed. The findings of this doctoral thesis can contribute to the development of a medical device surveillance system that would help to improve health care delivery and patient safety in a health care institution.

The objective of this study was to examine the use of frequent, anonymous student course surveys as a tool in supporting continuous quality improvement (CQI) principles in online instruction. The study used a qualitative, multiple-case design involving four separate online courses. Analysis methods included pattern matching/explanation building, time series analysis, and thematic analysis. Findings suggested that instructors used student feedback to make course changes that alleviated technical difficulties, added and clarified content, and contributed to future course changes. Students and instructors responded positively to the opportunity to give and receive anonymous feedback and felt that it helped improve the course. It is uncertain, however, whether using CQI principles had an impact on end-of-semester teacher course quality ratings. An important finding from the research is that students like to be asked to help improve their learning experience, as long as the instructor listens and responds to their feedback. Evaluation is a valuable component of instructional design theories, which are based on the philosophy that the best designs result from an iterative process. Using a synergistic CQI approach, this study indicates that it is possible for changes to be made more quickly to a course when students are involved in the process. The combination of frequent student feedback with a willing and experienced instructor who can make expert course revision decisions allows the process of course improvement to be enhanced.

This thesis explores the process of accreditation within a government contracted social service agency in British Columbia, Canada. The agency is seeking accreditation from the Commission on Accreditation for Rehabilitation Facilities (CARF). Institutional ethnography is used to explicate the social relations of CARF - how it organizes frontline work with clients and how it re-organizes an agency’s relations to government funding and service delivery. Data include the author’s frontline work accounts, interviews with frontline workers and the Director, and textual documents used within frontline work. The research process traces specific reporting documents that connect frontline work to the agency’s funders, Community Living B.C. and the Regional Health Authority, and to CARF. This thesis makes visible how the accreditation discourse of measurement and continuous quality improvement shifts how frontline workers think about and do their work with clients in ways that align their priorities with those of government contract management.

The policy and practice of RPL (Recognition of Prior Learning) remains a contested area in the higher education sector. While a growing body of research on RPL has become available, little is known about the quality assurance dimensions of this policy and its current expression in higher education practice. Accordingly, this study seeks to provide a comprehensive and detailed portrait of the manner in which RPL is implemented in the Faculty of Education at the University of Pretoria. The central question is does the RPL system that is in place at this institution meet national and international requirements for quality and quality assurance? If not, what are the reasons and how can the faculty improve its RPL practice? The research sub-questions addressed are the following: <ul> <li> What is the quality of the inputs used to design the RPL that is in place in the Faculty of Education at the University of Pretoria?</li> <li> How does the Faculty of Education at the University of Pretoria assess RPL candidates for their prior learning? </li> <li> What is the effect of the output of the RPL system on client satisfaction?</li></ul> A mixed methods research design was used for this study. A single Faculty (Education) was selected as the data collection site, to reveal the deeper and nuanced impact of the process of implementation of the RPL programme. A semi-structured interview schedule administered to the senior managers of the faculty was to elicit information on how the RPL system was conceptualised and designed. This process included the Dean (Faculty of Education); Head of Department (Curriculum Studies); Head of Department (Educational Management, Law and Policy Studies); Director (Centre for Evaluation and Assessment) and the Director (Centre for Joint Science, Mathematics and Technology Education). To determine whether there is a link between what the Quality Assurance Unit of the university promotes and application of such principles and procedures at service delivery level, an interview with the Director of the QA Unit was done. Other interviews involved students (undergraduates and postgraduates); the non-academic staff and lecturers within all the departments of the faculty, to determine whether they knew or were aware of RPL related activities in the faculty. An observation tool was constructed to examine the quality of the assessment process, which involved RPL learners, assessors, evidence facilitators, verifiers, moderators and RPL administrators. A questionnaire was administered to RPL learners involved in the assessment process to determine their satisfaction with the output of the RPL programme. Lecturers who participated in the RPL assessment process were interviewed to determine their experiences. Finally, an observational checklist was used to determine quality indicators at macro (administrative) and micro (academic) levels. The data was analysed using pattern matching, discrepancy, content and interpretational analyses methods. The research findings presented are in the form of a “thick” narrative on the quality of RPL implementation, that is, what the faculty should do to improve or strengthen the current system, and a portrayal of how the RPL programme truly operates. The findings indicate that a relatively good system of RPL provisioning is in place in the Faculty of Education, with a few areas of concern (weaknesses). The major problem is that this system is not benefiting the majority of people it was intended for. The system is “selective” and “exclusionary” in nature. There are clear procedures and processes for RPL assessment, which are adhered to strictly by faculty assessors. The RPL system that is currently in place is satisfactory to those who were assessed for prior learning during the period 2003-2006 and unsatisfactory at the level of the lecturers who participated in the assessment process. Most of them indicated that RPL is an add-on activity to their workloads, with very little incentives from management. To those who were not part of the assessment process, but were assumed to have received information from the faculty, the findings indicated that they knew very little about RPL and how it is being assessed in the faculty. From the client’s perspective, most (eighty four percent) said if they knew how this system operates in the faculty, they would want to be assessed for their prior learning. An extensive examination of the RPL practice in the Faculty of Education gave useful insights on the quality of RPL provisioning. Future research needs to concentrate on evaluations on how RPL is implemented in the other faculties of the university. Second to this, is to begin to provide answers as to what causes full-scale implementation of RPL problematic in the higher education sector, to provide empirical data to policy makers for decision-making purposes. Thirdly, to provide solutions towards the sustainability of the RPL system in the higher education sector, there is a need to do studies on the cost-effectiveness of RPL implementation. / Thesis (PhD (Assessment and Quality Assurance in Education and Training))--University of Pretoria, 2007. / Curriculum Studies / PhD / unrestricted

Submitted in fulfillment of the requirements for the Doctoral Degree in Nursing, Durban University of Technology, Durban, South Africa, 2016. / This mixed methods study aimed to assess the functioning and processes of the Fast Queue Service Point in order to analyse the quality of care rendered in primary health care (PHC) facilities in the eThekwini district of the KwaZulu­ Natal Province in South Africa. The Fast Queue Service Point provides service in PHC facilities for health care users requiring short consultations. Congestion of PHC facilities is a result of increased access to PHC services with the introduction of free PHC services. This congestion was aggravated by the decentralization of services from hospitals to PHC level such as the introduction on Nurse Initiated Management of Anti-Retroviral Therapy (NIMART). In 2010, the National Core Standards (NCS) for health establishments were formulated further to the PHC Service package, to address issues of quality. An explanatory sequential mixed methods study design was used and data collection was conducted in two phases; the quantitative data collection phase consisting of two subsets of observations namely; the retrospective record review and structured observations of the Fast Queue Service Point process. The Statistical Package for the Social Sciences (SPSS) version 22 was used to analyse data. During the second phase semi-structured interviews were conducted with PHC staff members to describe their experiences of the Fast Queue Service Point and to clarify issues from the quantitative phase. Although Fast Queue Service users received sufficient care, there were important care assessments that had been inadequately performed or omitted. These included discussing side effects of medications and or immunizations and management thereof. Childrens' weights were not interpreted, an important aspect for children under five years of age. There was also lack of supportive supervision coupled with shortage of resources and too many time-consuming written records that were required to compile accurate statistics. Retraining and in-servicing of health personnel and making resources available, would assist in strengthening patient assessment, management and recording thereof. While clinic managers require to offer supportive supervision to health care providers, provision of lower categories of staff would be beneficial in supporting PNs and ENs so that they have time to compile records for statistics purposes, which were found to be taking up the bulk of their time. The framework for continuous quality improvement in implementing a Fast Queue Service in PHC settings was developed based on the findings of the study / D