Decisions concerning psychiatric medication are complex and often involve a protracted process of trial and error. The serious and enduring nature of side effects associated with psychiatric medication demands that medical and experiential expertise is shared in a way that is supportive of the longer term recovery journey. Historically poor concordance rates point to a lack of trust and difficulties in sharing decisions constructively. This Ph.D. explores views and experiences of shared decision making for psychiatric medication management amongst mental health service users and practitioners. The study was conducted in a community mental health service, in the UK. A participatory methodology was employed, within a social constructionist paradigm. Service users and a carer were involved in all phases of the research process. Thirty qualitative interviews were undertaken with different stakeholders: psychiatrists, community psychiatric nurses, and service users. A thematic analysis was employed. In addition, an applied conversation analysis was undertaken on four recorded outpatient medication related meetings. Enablers of and barriers to shared decision making were found at three levels of analysis: the interaction, the relationship, and the system. Many divergent discourses were apparent across these levels, both within and between the different stakeholder groups. A typology of involvement is proposed and discussed, from fractured passivity through to active self- management. The barriers to collaborative practice identified in these findings, and the structural factors at work in the mental health system in particular, were seen to explain the gap between policy ideals and current practice. Strong therapeutic relationships were found to be a vital enabler, comprising of: a formation of trust, practitioners knowing and believing in service users’ potential, and ‘walking the journey together’. Shared decision making in this study is found to be a dynamic process over time, involving two (or more) participants in a complex interplay. The thesis emphasizes the interaction between structure and agency in shared decision making in psychiatric medication management and highlights how power is enacted in the context of shared decisions in a community setting. Original theoretical, methodological and practical contributions to knowledge are presented and discussed.

Um dos elementos para melhoria da qualidade dos serviços farmacêuticos clínicos é medir a qualidade do cuidado prestado e os indicadores podem ser usados nesta avaliação. O presente trabalho teve como objetivos identificar estudos sobre indicadores de qualidade para serviços farmacêuticos clínicos e desenvolver e validar um instrumento de indicadores para avaliação dos serviços de acompanhamento farmacoterapêutico prestados para pacientes ambulatoriais. Para tanto, uma busca abrangente da literatura foi conduzida nas bases de dados PubMed/Medline, Scopus, Lilacs e DOAJ por esses estudos. Os instrumentos apresentados pelos estudos foram avaliados em relação à qualidade das propriedades psicométricas. A seguir, foi desenvolvido um instrumento de indicadores-chave de desempenho. O grupo de pesquisa estabeleceu sete indicadores possíveis para avaliação de especialistas da área através de duas rodadas da técnica Delphi para validação de conteúdo. Ainda, farmacêuticos foram convidados a participar por meio de um questionário para validação de construto e confiabilidade do instrumento. A busca bibliográfica identificou 3.276 registros, dos quais 12 estudos completaram os critérios de inclusão. No geral, o maior número de estudos foi baseado em pesquisas para avaliar a satisfação dos pacientes e usou a revisão da literatura combinada com opinião de especialistas para o desenvolvimento do instrumento. Todos os estudos apresentaram algumas propriedades psicométricas do instrumento. A consistência interna e a validade de conteúdo foram os critérios mais relatados dos estudos, e nenhum deles apresentou o critério de estabilidade. Onze (68,8%) especialistas participaram da primeira rodada da técnica Delphi e nove (81,8%) especialistas completaram as 2 rodadas. Um novo indicador foi desenvolvido após a avaliação do painel de especialistas na primeira rodada. No geral, a validade de conteúdo e construto foi alcançada para o instrumento final. Os resultados desta tese apontam que os instrumentos dos estudos identificados na revisão sistemática apresentaram propriedades psicométricas, porém de forma incompleta ou não satisfatória. Ainda, um instrumento com seis indicadores foi desenvolvido e validado para o Serviço de Acompanhamento Farmacoterapêutico prestado para pacientes ambulatoriais. / One of the elements of quality improvement of medication management services is measuring the quality of care and key performance indicators (KPIs) can be used in this assessment. The study is aimed to identify quality indicators instruments in pharmaceutical care services and to develop and validate KPI instrument for medication management services provided for outpatients. For this, comprehensive literature search was performed in databases PubMed/Medline, Scopus, and Lilacs. The psychometric quality of the instruments was determined. In addition, a key performance indicators instrument was developed. A working group established 7 possible KPIs for assessment of the expert panel through an internet based 2-round Delphi approach. An internet questionnaire was developed for pharmacists in order to construct validity and reliability of the instrument. The literature search yielded 3,276 records, of which 12 studies satisfied the inclusion criteria. Overall, the greatest number of studies were based surveys to assess patients\' satisfaction and used literature review combined with expert\'s opinion for the instrument development. All studies presented some psychometrics properties of the instrument. Internal consistency and content validity were the most reported criteria of the studies and none of them presented stability. Eleven (68.8%) experts participated in the Delphi round 1 and nine (81.8%) experts completed the 2 Delphi rounds. A new KPI was develop after expert panel assessment in the first round. Overall, content and construct validity were reached for final instrument. The results of this thesis point out that instrument of the studies identified in the systematic review presented some psychometrics properties, but did not describe them satisfactorily. In addition, a set of six key performance indicators was developed and validated for medication management services provided for outpatients.

Um dos elementos para melhoria da qualidade dos serviços farmacêuticos clínicos é medir a qualidade do cuidado prestado e os indicadores podem ser usados nesta avaliação. O presente trabalho teve como objetivos identificar estudos sobre indicadores de qualidade para serviços farmacêuticos clínicos e desenvolver e validar um instrumento de indicadores para avaliação dos serviços de acompanhamento farmacoterapêutico prestados para pacientes ambulatoriais. Para tanto, uma busca abrangente da literatura foi conduzida nas bases de dados PubMed/Medline, Scopus, Lilacs e DOAJ por esses estudos. Os instrumentos apresentados pelos estudos foram avaliados em relação à qualidade das propriedades psicométricas. A seguir, foi desenvolvido um instrumento de indicadores-chave de desempenho. O grupo de pesquisa estabeleceu sete indicadores possíveis para avaliação de especialistas da área através de duas rodadas da técnica Delphi para validação de conteúdo. Ainda, farmacêuticos foram convidados a participar por meio de um questionário para validação de construto e confiabilidade do instrumento. A busca bibliográfica identificou 3.276 registros, dos quais 12 estudos completaram os critérios de inclusão. No geral, o maior número de estudos foi baseado em pesquisas para avaliar a satisfação dos pacientes e usou a revisão da literatura combinada com opinião de especialistas para o desenvolvimento do instrumento. Todos os estudos apresentaram algumas propriedades psicométricas do instrumento. A consistência interna e a validade de conteúdo foram os critérios mais relatados dos estudos, e nenhum deles apresentou o critério de estabilidade. Onze (68,8%) especialistas participaram da primeira rodada da técnica Delphi e nove (81,8%) especialistas completaram as 2 rodadas. Um novo indicador foi desenvolvido após a avaliação do painel de especialistas na primeira rodada. No geral, a validade de conteúdo e construto foi alcançada para o instrumento final. Os resultados desta tese apontam que os instrumentos dos estudos identificados na revisão sistemática apresentaram propriedades psicométricas, porém de forma incompleta ou não satisfatória. Ainda, um instrumento com seis indicadores foi desenvolvido e validado para o Serviço de Acompanhamento Farmacoterapêutico prestado para pacientes ambulatoriais. / One of the elements of quality improvement of medication management services is measuring the quality of care and key performance indicators (KPIs) can be used in this assessment. The study is aimed to identify quality indicators instruments in pharmaceutical care services and to develop and validate KPI instrument for medication management services provided for outpatients. For this, comprehensive literature search was performed in databases PubMed/Medline, Scopus, and Lilacs. The psychometric quality of the instruments was determined. In addition, a key performance indicators instrument was developed. A working group established 7 possible KPIs for assessment of the expert panel through an internet based 2-round Delphi approach. An internet questionnaire was developed for pharmacists in order to construct validity and reliability of the instrument. The literature search yielded 3,276 records, of which 12 studies satisfied the inclusion criteria. Overall, the greatest number of studies were based surveys to assess patients\' satisfaction and used literature review combined with expert\'s opinion for the instrument development. All studies presented some psychometrics properties of the instrument. Internal consistency and content validity were the most reported criteria of the studies and none of them presented stability. Eleven (68.8%) experts participated in the Delphi round 1 and nine (81.8%) experts completed the 2 Delphi rounds. A new KPI was develop after expert panel assessment in the first round. Overall, content and construct validity were reached for final instrument. The results of this thesis point out that instrument of the studies identified in the systematic review presented some psychometrics properties, but did not describe them satisfactorily. In addition, a set of six key performance indicators was developed and validated for medication management services provided for outpatients.

Master of Pharmacy / Medicines are a fundamental healthcare intervention, but the benefits they provide depend entirely on the way in which they are used. This begins with prescribing, a complex task with substantial risks. Systematic evaluation of biomedical factors may be viewed as an essential component of this task, but prescribers also integrate an array of individual, social, cultural, environmental and commercial factors into their prescribing decisions. Furthermore, social and cultural characteristics of the prescriber’s workplace may influence how well prescribing decisions are carried out. Whilst numerous research efforts have helped to construct an in-depth understanding of non-biomedical influences on GP’s prescribing patterns, the characteristics of corresponding sorts of influences in teaching hospitals have not been well determined. In hospitals, supervised medical trainees, registrars and consultants prescribe within the framework of medicines management systems involving nurses, pharmacists and patients. Currently, little is known about whether each of these groups has distinct beliefs, attitudes and values that may affect either prescribing behaviour or how prescribing skills of medical trainees are acquired. The aim of this study was to explore the social and cultural dynamics of prescribing and prescriber training in teaching hospitals. To do this, established qualitative methods were employed. Junior doctors, registrars, consultants, nurses, and pharmacists from two metropolitan teaching hospitals were sampled purposively and invited to participate in semi-structured interviews. A brief questionnaire was used to collect demographic and contextual information. In the interviews, participants were asked about their attitudes towards prescribing, their perceptions of roles and responsibilities, how they communicated prescribing decisions, their perceptions of influences on prescribing, and their perceptions of factors contributing to prescribing errors. Participants were also asked for their opinions on various aspects of new prescriber training. Sampling proceeded until redundancy of themes was established. A pilot study was conducted with one participant from each professional group to optimise the interview schedule, and then using this tool, a further 38 participants were interviewed. In total, eight consultants, eight registrars, nine junior doctors, eleven pharmacists, and seven nurses participated. Using reiterative content analysis of a third of all transcripts, a coding scheme was developed, which was used to label and categorise the remaining transcripts. Categories were further developed and refined. The resultant core themes were cross indexed against the five different health professional types using thematic charts to explore patterns. The main lines of enquiry for this research were mapped, the properties of these categories and interrelationships explored in detail, and a model of the prescribing process was developed. Prescribing at the teaching hospitals was a complex process consisting of multiple steps undertaken by several different health professionals of varying levels of experience from three different health care disciplines. Because of the intricate separation of responsibilities, the operation of the process was highly reliant on the behaviours of each player and their relationships with each other. Key prescribing decisions associated with patient admissions were made, almost exclusively, by medical teams. Prescribing was therefore chiefly characterised by factors influencing the behaviours of the doctors. Their behaviours were influenced by factors relating to their individual characteristics (eg, knowledge, skills, experience); but also by a web of socio-cultural determinants inherent to the environment in which they worked. These factors were related to: the organisational structure of the prescribing process; the knowledge characteristics of the doctors; the communication patterns they used; the underlying assumptions they made about prescribing; and the work environment.

Master of Pharmacy / Medicines are a fundamental healthcare intervention, but the benefits they provide depend entirely on the way in which they are used. This begins with prescribing, a complex task with substantial risks. Systematic evaluation of biomedical factors may be viewed as an essential component of this task, but prescribers also integrate an array of individual, social, cultural, environmental and commercial factors into their prescribing decisions. Furthermore, social and cultural characteristics of the prescriber’s workplace may influence how well prescribing decisions are carried out. Whilst numerous research efforts have helped to construct an in-depth understanding of non-biomedical influences on GP’s prescribing patterns, the characteristics of corresponding sorts of influences in teaching hospitals have not been well determined. In hospitals, supervised medical trainees, registrars and consultants prescribe within the framework of medicines management systems involving nurses, pharmacists and patients. Currently, little is known about whether each of these groups has distinct beliefs, attitudes and values that may affect either prescribing behaviour or how prescribing skills of medical trainees are acquired. The aim of this study was to explore the social and cultural dynamics of prescribing and prescriber training in teaching hospitals. To do this, established qualitative methods were employed. Junior doctors, registrars, consultants, nurses, and pharmacists from two metropolitan teaching hospitals were sampled purposively and invited to participate in semi-structured interviews. A brief questionnaire was used to collect demographic and contextual information. In the interviews, participants were asked about their attitudes towards prescribing, their perceptions of roles and responsibilities, how they communicated prescribing decisions, their perceptions of influences on prescribing, and their perceptions of factors contributing to prescribing errors. Participants were also asked for their opinions on various aspects of new prescriber training. Sampling proceeded until redundancy of themes was established. A pilot study was conducted with one participant from each professional group to optimise the interview schedule, and then using this tool, a further 38 participants were interviewed. In total, eight consultants, eight registrars, nine junior doctors, eleven pharmacists, and seven nurses participated. Using reiterative content analysis of a third of all transcripts, a coding scheme was developed, which was used to label and categorise the remaining transcripts. Categories were further developed and refined. The resultant core themes were cross indexed against the five different health professional types using thematic charts to explore patterns. The main lines of enquiry for this research were mapped, the properties of these categories and interrelationships explored in detail, and a model of the prescribing process was developed. Prescribing at the teaching hospitals was a complex process consisting of multiple steps undertaken by several different health professionals of varying levels of experience from three different health care disciplines. Because of the intricate separation of responsibilities, the operation of the process was highly reliant on the behaviours of each player and their relationships with each other. Key prescribing decisions associated with patient admissions were made, almost exclusively, by medical teams. Prescribing was therefore chiefly characterised by factors influencing the behaviours of the doctors. Their behaviours were influenced by factors relating to their individual characteristics (eg, knowledge, skills, experience); but also by a web of socio-cultural determinants inherent to the environment in which they worked. These factors were related to: the organisational structure of the prescribing process; the knowledge characteristics of the doctors; the communication patterns they used; the underlying assumptions they made about prescribing; and the work environment.

abstract: The objective of this research is to understand how a set of systems, as defined by the business process, creates value. The three studies contained in this work develop the model of process-based automation. The model states that complementarities among systems are specified by handoffs in the business process. The model also provides theory to explain why entry systems, boundary spanning systems, and back-end control systems provide different impacts on process quality and cost. The first study includes 135 U. S. acute care hospitals. The study finds that hospitals which followed an organizational pattern of process automation have better financial outcomes. The second study looks in more depth at where synergies might be found. It includes 341 California acute care hospitals over 11 years. It finds that increased costs and increase adverse drug events are associated with increased automation discontinuity. Further, the study shows that automation in the front end of the process has a more desirable outcome on cost than automation in the back end of the process. The third study examines the assumption that the systems are actually used. It is a cross-sectional analysis of over 2000 U. S. hospitals. This study finds that system usage is a critical factor in realizing benefits from automating the business process. The model of process-based automation has implications for information technology decision makers, long-term automation planning, and for information systems research. The analyses have additional implications for the healthcare industry. / Dissertation/Thesis / Ph.D. Information Management 2011

Bakgrund: Hemsjukvård är en vårdform som ökar och även fortsättningsvis förväntas göra så. Patientsäker är en nationell och internationell prioritet där läkemedelshantering är ett riskområde såväl inom hemsjukvård som slutenvård. Tidigare forskning har i högre utsträckning fokuserat på patientsäkerhet inom slutenvården och att belysa patientsäkerhet inom hemsjukvård och vad sjuksköterskor kan göra för ökad patientsäkerhet är därför av vikt. Syfte: Att undersöka patientsäkerhetsrisker avseende läkemedelshantering inom hemsjukvården samt vad sjuksköterskor kan göra för att öka patientsäkerheten inom området. Metod: Studien har genomförts som en litteraturöversikt och resultatet baseras på 14 vetenskapliga artiklar. Litteratursökning har utförts i databaserna Cinahl och PubMed och innehållsanalys användes för artiklarnas resultat. Resultat: Nio patientsäkerhetsrisker identifierades där brist på kompetens, brister i kommunikation, delegeringsprocessen, komplexa sjukdomstillstånd och informationsöverföring är några av dessa. De identifierade riskerna delades vidare in i tre olika huvudområden beroende på bakomliggande orsak: Sjuksköterskor och annan vårdpersonal; Patient och hemmiljön; Organisation och system. Konklusion: Läkemedelshantering är ett betydande riskområde inom hemsjukvården där många faktorer påverkar patientsäkerheten. Att sjuksköterskor och annan personal inom hemsjukvården är väl medvetna om dessa risker ger en bra förutsättning för att kunna arbeta preventivt och minimera att vårdskador relaterat till läkemedelshantering uppstår. / Background: The number of patients receiving medical care in their own home is increasing. Home health care is a trend that is expected to continue. Patient safety is a national and international priority, where medical management is a risk area both in home and institutional care. Previous research has focused more on patient safety in institutional care. Highlighting patient safety and what nurses can do to increase patient safety in home care is therefore important. Aim: The aim of this study was to explore patient safety risks regarding medical management in home health care and what nurses can do to increase patient safety in the area. Method: This study was conducted as a literature review and the result is based on 14 scientific articles. The searches were performed in the databases Cinahl and PubMed. Result: Nine patient safety risks were identified where lack of competence, shortcomings in communication, the delegation process, comorbidity and information transfer are some of them. The identified risks were further linked to three main areas depending on the underlying cause: Nurses and other health professionals; Patient and the home environment; Organisation and systems. Conclusion: Medical management is a significant risk area in home health care where many factors affect patient safety. That nurses and other home care professionals are well aware of these risks provide a good prerequisite for preventing and minimizing the incidence of medical related adverse events.

Class of 2013 Abstract / Specific Aims: To compare the Comprehensive Medication Review (CMR) rate for Workflow Model #1 (used in 2010) to the CMR rate for Workflow Model #2 (used in 2011) at the Medication Management Center (MMC). Methods: A retrospective database analysis was completed in which Comprehensive Medication Review (CMR) completion rates for 2010 and 2011 were assessed. Comparison included only Center for Medicare and Medicaid Services (CMS) contracts that the Medication Management Center (MMC) provided Medication Therapy Management (MTM) services for both in 2010 and 2011. Data was used to determine the effect a process change had on CMR participation rate at the MMC and best practices for improving the rate of Medication Therapy Management Program (MTMP) beneficiaries participating in a CMR. Main Results: In 2010, patient participation and response to a CMR offer letter was low (0.2%). The changes in process yielded an increase in the CMR completion rate (6.93%); this in turn yielded higher performance measurements for prescription drug plans. Conclusion: Workflow modifications, including a pro-active secondary CMR offer, led to a marked increase in member participation and CMR rates. Patients are more apt to consent to a CMR if they are called for a specific medication related problem. It is recommended to continue to convert TMR calls to CMRs whenever possible, monitor CMR rates at least quarterly, and make cold calls where needed to increase CMR percentages.

No description available.

Medication complexity and nonadherence are significant risk factors for avoidable hospitalizations and health care spending for older adults in the United States. However, limited empirical research has investigated pharmacist-run telephonic medication management programs as a potential solution to the problem of reducing medication complexity while improving medication adherence. This quantitative study employed the behavioral change model to analyze archival data from a sample of 1,148 participants, examining the relationship of a pharmacist-run telephonic consulting program on medication adherence and medication complexity for one pharmacy benefit management firm's Medicare Part D recipients. The primary research questions investigated the relationship of medication therapy management programs to medication adherence and complexity. Data were assessed using correlation and regression analysis to determine the association between receiving pharmacist counseling, medication adherence, and medication complexity, and to assess the strength of any relationships identified. No linear relationship was found between pharmacists' counseling, medication complexity, and medication adherence. However, the study found a weak correlation between medication complexity and comorbidities, and between medication complexity and medication adherence. This study promotes positive social change by identifying information that can be used to reduce pharmaceutical industry liability by improving proper management of medications, by reducing the burden of comorbidities related to poor management of chronic disease, and streamlining health services and improving their outcom