Despite the ongoing initiatives of quality improvement collaboratives in healthcare which reflect various multifaceted intervention packages, clear evidence of the effectiveness of the model itself is lacking. Little is known about the true impact of the collaborative approach on improvement outcomes or how specific components are actually implemented within participating organizations. This dissertation reports on empirical qualitative research undertaken to investigate “how” healthcare providers and management describe the experience of being involved in a collaborative network for quality improvement. Using a process evaluation of a sample QI collaborative, this research reveals that frontline staff do not feel the need to conform or be identical to their peer organizations; rather they feel that by participating with them that their high level of care is finally recognized. In addition, the existing communication structure is ineffective for staff engagement and a “QI bubble” seems to exist in terms of knowledge transfer and the idea of collaboration bears out more internally in increased intra-team cooperation than externally between organizations or units. Selected theoretical perspectives from the fields of sociology and organizational behaviour are used as an analytic framework from which the author posits that based on the findings from this case study that in fact collaboratives may not actually function by any of the commonly held assumptions of legitimization, communication and collaboration. A conceptual framework for how these constructs are related in terms of QI collaborative design is proposed for future testing. With further work and on-the-ground testing of this model and relational hypotheses, this research can help the QI community develop a more functional theory of collaborative improvement and use mixed methods evaluation to better understand complex QI implementation.

Despite the ongoing initiatives of quality improvement collaboratives in healthcare which reflect various multifaceted intervention packages, clear evidence of the effectiveness of the model itself is lacking. Little is known about the true impact of the collaborative approach on improvement outcomes or how specific components are actually implemented within participating organizations. This dissertation reports on empirical qualitative research undertaken to investigate “how” healthcare providers and management describe the experience of being involved in a collaborative network for quality improvement. Using a process evaluation of a sample QI collaborative, this research reveals that frontline staff do not feel the need to conform or be identical to their peer organizations; rather they feel that by participating with them that their high level of care is finally recognized. In addition, the existing communication structure is ineffective for staff engagement and a “QI bubble” seems to exist in terms of knowledge transfer and the idea of collaboration bears out more internally in increased intra-team cooperation than externally between organizations or units. Selected theoretical perspectives from the fields of sociology and organizational behaviour are used as an analytic framework from which the author posits that based on the findings from this case study that in fact collaboratives may not actually function by any of the commonly held assumptions of legitimization, communication and collaboration. A conceptual framework for how these constructs are related in terms of QI collaborative design is proposed for future testing. With further work and on-the-ground testing of this model and relational hypotheses, this research can help the QI community develop a more functional theory of collaborative improvement and use mixed methods evaluation to better understand complex QI implementation.

This research examined the impact of ED process complexity on hospital quality outcomes. Nine emergency department nurse managers from hospitals in Mississippi, Alabama, and Louisiana were interviewed regarding processes of registration, laboratory testing, medication administration, radiology, and discharge. Interview data was coded according to variables in proposed equations for patientocused, providerocused, and overall process complexity. Hospital quality was measured using existing process of care, outcome of care, and patient satisfaction standards. Results showed a strong negative correlation between process complexity and overall quality, suggesting that hospitals with lower process complexity experience higher quality outcomes. Regression analysis showed that the average number of patient steps in a process and the overall complexity the registration process were significant predictors of overall quality. Methods of reducing patient steps and registration process complexity are discussed.

Magister Commercii - MCom / The South African democratic government is mandated by the constitution to provide quality healthcare services to the citizens of the country. Therefore, healthcare in South Africa is considered as a basic human right. The existing healthcare system exhibits extreme inequality, which translates into inequity in health outcomes across different demographic factors. Even though quality healthcare is a basic human right, problems related to the quality of healthcare remain, which poses a major challenge for the South African government. This dissertation investigates patient perceptions of the quality of public healthcare in South Africa, using General Household Survey data (2009-2016), with the objective of determining the level and trends of patient satisfaction and complaints reported when accessing public healthcare services in South Africa and identifying the correlates of these perception. This study found that patient satisfaction with public healthcare services in South Africa has increased over time while complaints have decreased over time. This study refrains from drawing conclusion on these findings at face value, since they may be other factors that explain the observed trends. The most common complaint was long waiting time at public healthcare facilities. On average, White individuals, male household heads, individuals residing in rural areas and individuals from smaller household were more likely to report to being satisfied with healthcare services received at public healthcare facilities in South Africa. Therefore, patient satisfaction survey approach should be used in conjunction with other healthcare quality measures such as direct observation, vignettes and standardised or mystery patient.

Due to rapid change of healthcare environment and the awakening consciousness of health service consumers, healthcare quality becomes a major concern of hospital administrators. In 1999, Taiwan Joint Commission on Hospital Accreditation cooperated with Maryland Hospital Association and then implemented Taiwan Quality Indicator Project (TQIP). On the other hand, within the years 1998~ 2000, Taiwan College of Healthcare Executives developed a localized healthcare indicator series (referred to as Taiwan Healthcare Indicator Series, THIS, afterwards) aiming at providing a better system for monitoring medical care quality for the long run. Nevertheless, relevant reports show that so far not many hospitals actively participate in the THIS. The main purpose of this study is to explore those factors which might influence a district hospital¡¦s decision of whether participating in the THIS no not. Hospital administrators were the subjects of this study. Mailing survey was adopted to collect the data. In May, 2004, a total of 436 questionnaires were mailed out. 147 hospitals responded (i.e. a response rate of 33.72%). The key variables of interest may be classified into three groups-- hospital characteristics, perception of THIS, and professional technique related to THIS. Descriptive analyses showed that more than 60% district hospitals did not participate in the THIS; the reasons are listed in order as follows: lack of budget, lack of quality assurance specialists, indicator unable to meet hospital¡¦s requirement, human resource shortage, annual fee too expensive. As for those hospitals participating in THIS, their considerations are showed in order as follows: better reimbersencement, meeting the requirement of assessment, complying with regulation of the authority, and meeting the requirement of hospital policy and patient needs. Besides, a logistic regression analysis indicated that the most important factor influencing hospitals¡¦ participation in THIS is ¡§whether any medical quality related activity is implemented within the hospital.¡¨ With a response rate of 33.72% and with responding hospitals relatively restricted to Kaohsiung-Pingtung area, a careful generalization of results is needed. Further, it is suggested that a qualitative study design along with a higher response rate of quantitative analysis might help enhance the generalization for future study.

Yes / Despite many benefits offered by Health Information Technology (HIT) systems, new technology brings new and unforeseen risks to healthcare quality and patient safety if they're not properly planned, designed, implemented, and managed. This study examined health information technology-related (HIT) incidents to identify patient details-related issues, their association with contributing factors, and outcomes. Sources of information comprised retrospectively collected incident reports (n = 95) using two sampling methods, i.e., purposive and snowball sampling. The incident reports were analyzed using both the inductive method (thematic analysis) and the deductive approach using an existing framework, i.e., the International Classification for Patient Safety. The studies identified 90 incidents with 120 patient details-related issues-categorized as either information-related (48%) or documentation-related (52%) problems; around two-thirds of the 120 issues were characterized by human factors. Of the total sample, 87 contributing factors were identified, of which "medical device/system" (45%) and "documentation" (20%) were the most common contributing factors. Of 90 incidents, more than half (59%) comprised patient-related outcomes-patient inconvenience (47%) and patient harm (12%) and the remaining 41% (n = 37) included staff or organization-related outcomes. More than half of the incidents resulted in patient-related outcomes, namely patient inconvenience and patient harm, including disease risks, severe health deterioration, injury, and even patient death. Incidents associated with patient details can cause deleterious effects; therefore, characterizing them should be a routine part of clinical practice to improve the constantly changing healthcare system. / A publishing grant has been received from Linnaeus University as a part of the University Library’s research support.

Nature of the inquiry: My research inquiry investigated how qualities of personal interaction shape and affect the promotion of research utilisation for quality improvement in the US healthcare sector. The research investigated my own professional practice of consulting, teaching, and research regarding the improvement of healthcare practices and outcomes. Efforts to improve the quality of healthcare services are often difficult to realise and sustain. The quality improvement movement in the USA and elsewhere has not conducted much self-examination of its own processes for sources of these perennially problematic results. Relevance: The quality of healthcare services can be readily understood as having consequences of life or death, wellness or suffering. Healthcare expenditures in the USA are estimated at 16% of GDP and over 9% in the UK. Improving healthcare quality improvement efforts is a matter of profound human and social significance. Approach: The DMan research methodology is a reflexively aware process conducted as a cohort and as small learning groups of researchers during the three-year programme. The research inquiry used the complex responsive process of relating theory of learning as emergent changes of meaning or, equivalently, knowledge. As a social science of qualities, it uses the qualities of human interaction as the unit of analysis. The research utilised an interdisciplinary approach drawing upon: healthcare quality improvement literature; organizational discourse studies; research on strategy as practice; performance management; communications theories; the theory of mindful learning; interpersonal neurobiology; figurational sociology; and American pragmatist philosophy. The methodology employs a mindful reflexivity research strategy related to concepts from mindful learning and social neuroscience literature. Central methods included iterative peer and supervisor debriefing and iterative reflexive narrative practice. Findings: A contribution is made to the healthcare literature by describing how ordinary qualities of social coordination dynamics affect the promoters of healthcare research, not just potential users of research. A contribution is made to professional practice by providing a new perspective from which to analyse the sources of performance challenges prevalent in healthcare quality improvement efforts. The research findings indicate how applications of substantial organisational and social resources to promote research utilisation in the US health sector can be co-opted and dissipated away from ostensive substantive objectives. This occurs by research promoters‟ organizational discourse efforts to favourably shape power relating and other qualities of interaction of improvement initiatives. These efforts restrict the emergence of learning about the promoted changes.

Nesta dissertação foi estudada a aplicabilidade de ferramentas e técnicas da qualidade em um hospital filantrópico, através da execução de projetos de melhoria seguindo a abordagem Lean. Objetivou-se verificar a possibilidade destas de ser uma solução para problemas de gestão de recursos enfrentados por hospitais públicos e filantrópicos brasileiros. Foi feita revisão de literatura sobre o assunto e um estudo de caso foi conduzido em uma Santa Casa de Misericórdia no interior do estado de São Paulo, onde foram aplicadas ferramentas lean. Foram relatadas diversas melhorias, dentre elas uma enorme redução de estoque, eliminação de desperdícios como excesso de deslocamento/transporte e fluxo contínuo. Foi possível concluir que o Lean foi efetivo no hospital estudado e que ainda possui grande potencial de exploração no contexto da gestão da qualidade. / In this master thesis presents the study of the applicability of quality tools and techniques in a philanthropic hospital, through the execution of improvement projects following the Lean approach. The objective was to verify the possibility of these as a solution to the problems of resource management, common problem faced by Brazilian public health hospitals. A literature review on the subject and a case study were conducted at a non-profit hospital in the interior of the state of São Paulo, where lean tools were applied. Several improvements have been reported, among them a huge reduction of stock, elimination of wastes such as excess displacement/transport and continuous flow. It was possible to conclude that the Lean was effective in the studied hospital and still has great potential for exploration in the context of quality management.

Governance of the healthcare systems is one of the most important challenges forWestern countries. Within this, an accurate assessment of the quality is key to policy makers and public managers, in order to guarantee equity, effectiveness and efficiency. In this thesis, we investigate aspects and methods related to healthcare evaluation by focussing on the healthcare system in Lombardy (Italy), where public and private providers compete with each other, patients are free to choose where to be hospitalized, and a pay-for-performance program was recently implemented. The general aim of this thesis is to highlight the role of statistics within a quality evaluation framework, in the form of advancing the statistical methods used to measure quality, of evaluating the effectiveness of implemented policies, and of testing the effect that mechanisms of competition and cooperation can have on the quality of a healthcare system. We firstly advance a new methodological approach for measuring hospital quality, providing a new tool for managers involved in performance evaluations. Multilevel models are typically used in healthcare, in order to account for the hierarchical structure of the data. These models however do not account for unobserved heterogeneity. We therefore propose an extension of the cluster-weighted models to the multilevel framework and focus in particular on the case of a binary dependent variable, which is common in healthcare. The resulting multilevel logistic cluster-weighted model is shown to perform well in a healthcare evaluation context. Secondly, we evaluate the effectiveness of a pay-for-performance program. Differently from the existent literature, in this thesis we evaluate this program on the basis of five health outcomes and across a wide range of medical conditions. Availability of data pre and post-policy in Lombardy allows us to use a difference-in-differences approach. The statistical model includes multiple dependent outcomes, that allow quantifying the joint effect of the program, and random effects, that account for the heterogeneity of the data at the ward and hospital level. The results show that the policy has overall a positive effect on the hospitals' performance. Thirdly, we study the effect of pro-competition reforms on the hospital quality. In Lombardy, competition between hospitals has been mostly driven by the adoption of a quasi-market system. Our results show that no association exists between hospital quality and competition. We speculate that this may be the result of asymmetric information, i.e. the lack of transparent information provided to citizens about the quality of hospitals. This is bound to reduce the impact of pro-competition reforms on quality and can in part explain the conflicting results found in the literature on this subject. Our results should motivate a public disclosure of quality evaluations. Regardless of the specifics of a system, hospitals are altruistic economic agents and they cooperate in order to improve their quality. In this work, we analyse the effect of cooperation on quality, taking the network of patients' transfers between hospitals as a proxy of their level of cooperation. Using the latest network models, we find that cooperation does lead to an increase in quality and should therefore be encouraged by policy makers.

Nesta dissertação foi estudada a aplicabilidade de ferramentas e técnicas da qualidade em um hospital filantrópico, através da execução de projetos de melhoria seguindo a abordagem Lean. Objetivou-se verificar a possibilidade destas de ser uma solução para problemas de gestão de recursos enfrentados por hospitais públicos e filantrópicos brasileiros. Foi feita revisão de literatura sobre o assunto e um estudo de caso foi conduzido em uma Santa Casa de Misericórdia no interior do estado de São Paulo, onde foram aplicadas ferramentas lean. Foram relatadas diversas melhorias, dentre elas uma enorme redução de estoque, eliminação de desperdícios como excesso de deslocamento/transporte e fluxo contínuo. Foi possível concluir que o Lean foi efetivo no hospital estudado e que ainda possui grande potencial de exploração no contexto da gestão da qualidade. / In this master thesis presents the study of the applicability of quality tools and techniques in a philanthropic hospital, through the execution of improvement projects following the Lean approach. The objective was to verify the possibility of these as a solution to the problems of resource management, common problem faced by Brazilian public health hospitals. A literature review on the subject and a case study were conducted at a non-profit hospital in the interior of the state of São Paulo, where lean tools were applied. Several improvements have been reported, among them a huge reduction of stock, elimination of wastes such as excess displacement/transport and continuous flow. It was possible to conclude that the Lean was effective in the studied hospital and still has great potential for exploration in the context of quality management.