Previous research has established a consensus that in-hospital adverse events are ubiquitous, cause significant harm to patients, and have important financial consequences. However, information on the extent, consequences and costs of adverse events in Canada is limited. For example, there is, as yet, no published study that has investigated the costs of adverse events in a Canadian context. This dissertation aims to redress this situation by providing Ontario-based estimates of the impact of eleven nursing sensitive adverse events on cost, death, readmission, and ambulatory care use within 90 days after hospitalization. This dissertation also aims to contribute more broadly to the patient safety literature by quantifying the impact of diagnostic coding error in administrative data on estimates of the excess costs attributable to adverse events. Given the increasing importance of these estimates in Canada and elsewhere for hospital payment policy and for assessments of the business case for patient safety, this is an important gap in the literature. Each of the adverse events was associated with positive excess costs, ranging from $29,501 (metabolic derangement) to $66,412 (pressure ulcers). Extrapolation from the study hospitals yielded a provincial estimate of $481 million in annual excess costs attributable to the adverse events, which represents 2.8 percent of Ontario’s total hospital expenditures. Several of the adverse events were also associated with significant excess rates of death, readmission, and ambulatory care use. These results suggest that there are economic as well as ethical reasons to improve patient safety in Ontario hospitals. Estimates of adverse event costs were highly sensitive to coding error. The excess cost of adverse events is likely to be significantly underestimated if the error is ignored. This finding, coupled with the observation that the likelihood of error is ignored in most studies, suggests that previous assessments of the business case for patient safety may have been biased against the cost effectiveness of patient safety improvements. Furthermore, the observed extent of institutional level variation in adverse event coding indicates that administrative data are an inadequate basis for adverse event payment policies or for public reporting of adverse event rates.

This study is a prospective longitudinal outcome study investigating the presence of response shift in disease and generic functional outcome measures in 105 patients undergoing spinal surgery. The then-test method which compares pre-test scores to retrospective pre-test scores was used to quantitate response shift. There was a statistically significant response shift for the Oswestry Disability Index (ODI) (p=0.001) and the Short Form-36-PCS (p=0.078). At three months, seventy-two percent of patients exhibited a response shift with the ODI. Fifty-six and 21 percent of patients exhibited a response shift with the SF-36 physical and mental component scores respectively. When accounting for response shift and using the minimal clinically important difference, the success rate of the surgery at 3 months increased by 20 percent. The presence of response shift has implications for the measurement properties of standard spinal surgery outcome measures including the effect size of treatment and the number of responders to treatment.

PURPOSE: The objective was to determine if particular magnetic resonance, clinical and demographic findings were associated with functional status prior to surgery and predictive of functional outcomes at follow-up. RESULTS: The study included 65 consecutive CSM patients. The modified Japanese Orthopaedic Association Scale (mJOA) was used as the primary outcome measure. Higher baseline mJOA scores were associated with younger age, shorter duration of symptoms, fewer compressed segments and less severe cord compression. Better post-operative mJOA scores were associated with younger age, shorter duration of symptoms and higher baseline scores. Using multivariate analysis, baseline and follow-up mJOA scores adjusted for baseline mjOA score were best predicted by age. CONCLUSION: Age and clinical severity scores at admission can both provide valuable information. However, MR imaging features of the spinal cord before surgery cannot accurately predict the functional prognosis for patients with CSM and hence alternative imaging approaches may be required.

This study is a prospective longitudinal outcome study investigating the presence of response shift in disease and generic functional outcome measures in 105 patients undergoing spinal surgery. The then-test method which compares pre-test scores to retrospective pre-test scores was used to quantitate response shift. There was a statistically significant response shift for the Oswestry Disability Index (ODI) (p=0.001) and the Short Form-36-PCS (p=0.078). At three months, seventy-two percent of patients exhibited a response shift with the ODI. Fifty-six and 21 percent of patients exhibited a response shift with the SF-36 physical and mental component scores respectively. When accounting for response shift and using the minimal clinically important difference, the success rate of the surgery at 3 months increased by 20 percent. The presence of response shift has implications for the measurement properties of standard spinal surgery outcome measures including the effect size of treatment and the number of responders to treatment.

PURPOSE: The objective was to determine if particular magnetic resonance, clinical and demographic findings were associated with functional status prior to surgery and predictive of functional outcomes at follow-up. RESULTS: The study included 65 consecutive CSM patients. The modified Japanese Orthopaedic Association Scale (mJOA) was used as the primary outcome measure. Higher baseline mJOA scores were associated with younger age, shorter duration of symptoms, fewer compressed segments and less severe cord compression. Better post-operative mJOA scores were associated with younger age, shorter duration of symptoms and higher baseline scores. Using multivariate analysis, baseline and follow-up mJOA scores adjusted for baseline mjOA score were best predicted by age. CONCLUSION: Age and clinical severity scores at admission can both provide valuable information. However, MR imaging features of the spinal cord before surgery cannot accurately predict the functional prognosis for patients with CSM and hence alternative imaging approaches may be required.

Background: Children exposed to pesticides are susceptible for neurodevelopmental disruption. Data from developing countries are scarce. Aim: Assessing long-term and recent pesticide exposure in Nicaraguan children in relation to parental pesticide use and examining potential associated neurobehavioral effects. Methods: In the first study, pre- and post-spraying urinary residues of the chlorpyrifos metabolite TCPY and diazinon metabolite IMPY were measured among 7 subsistence farmers and 10 plantation workers, and in one child per worker. In the second study, for 110 children in an agricultural village and 22 in a non-agricultural village, aged 7-9, parental pesticide use was assessed by hours of spraying and kilograms of active ingredients during pre-and-postnatal time windows, as proxies for children’s long term pesticide exposures. Urinary TCPY, 3-PBA (pyrethroid metabolite), and 2,4-D were determined in 211 samples of 74 children of the agricultural village. IQ components and total IQ (WISC-IV) were evaluated in all agricultural village children. Behavior was evaluated with the Conners’ Teacher Rating Scale-Revised: Short. Multivariate linear regression models assessed associations between long-term and recent exposure to organophosphates and pyrethroids and cognitive and behavioral scales. Results: In study 1, post-spraying urinary levels of pesticide metabolites of subsistence farmers and their children were highly correlated (r=0.85), but not those of plantation workers and their children. In study 2, a wide range of exposures was reported by parents for all pesticides and time windows. The median urinary TCPY (3.7 μg/g creatinine), 3-PBA (2.8), and 2,4-D (0.9) were comparable to other studies for TCPY and 3-PBA but high for 2,4-D. Maximum levels were the highest reported for all compounds. Prenatal use of organophosphates affected working memory, and methamidophos also verbal comprehension and total IQ. Urinary TCPY was associated with poorer working memory. Organophosphate exposures were not associated with children’s behavior. Pyrethroid exposure during the first year of life associated with poorer perceptual reasoning and behavior, and urinary 3-PBA with a number of cognitive functions and ADHD in girls but not in boys. Conclusion: Nicaraguan children in poor agricultural areas are highly exposed to pesticides, which is influenced by parental pesticide use in subsistence farms. Organophosphate and pyrethroid exposures adversely affect their neurobehavioral development.

Therapeutic alliance has been consistently demonstrated as a robust predictor of treatment outcomes, though the time in psychotherapy at which therapeutic alliance best predicts outcomes is unclear. Unfortunately, evidence suggests that racial and ethnic minority clients typically form weaker therapeutic alliances in treatment. The weaker development in therapeutic alliance among racial and ethnic minority clients may mediate discrepancies in treatment outcomes, including higher dropout rates. The purpose of this study was to explore this possibility by (1) investigating the temporal relationship between therapeutic alliance and treatment outcomes and (2) examining differences in therapeutic alliance ratings and treatment outcome, including unilateral termination, among racial and ethnic minority clients. The findings of this study may be integral to identifying and addressing psychotherapy treatment disparities that are tied to racial or ethnic minority status.

Aim: The aim of this study was to develop a targeted health information package for women to use specifically as a reference during their return to health following a hysterectomy and to subsequently test its usefulness. Method: A quasi-experimental design measured the effectiveness of this package in improving the health and satisfaction outcomes of women compared to those who received the standard information. Women undergoing a hysterectomy for benign reasons who were between the ages of 20 and 60 years were included. There were 55 participants recruited into the control group and 44 into the intervention group. Participants completed a self-administered questionnaire both prior to and 14-16 weeks post-surgery. Results: The study found that there were no statistically significant differences between the two groups for their self-reported health, the time taken to return to usual activities and the number of symptoms experienced after surgery. Clinical improvements, however, were noted in the intervention group. A statistically significant difference was found between the groups for the amount written information that they would have preferred for their recovery (X2 8.26 df2 p=0.011). Ninety percent (90%) of the women who received the intervention wanted the same amount of written information to take home whilst 40% of the control group would have preferred more written information. This indicated a positive effect from the intervention. An unexpected finding in this study was that almost 40% of both groups wanted more verbal information and discussion prior to discharge. Conclusion: A valuable aspect of this study was its usefulness in identifying the clinical importance of discussion as part of the discharge process. These findings will be important for health professionals to utilise in their clinical practice for women undergoing a hysterectomy.

Performance management is a holistic approach to organisational improvement that integrates individual and organisational goals and fosters cooperation between supervisors and employees to develop a shared understanding of work expectations. The literature further clarifies a performance management system as having four practices – goal setting, performance appraisal, employee development, and rewards. The conceptualisation of performance management draws on the dominant HRM framework of bundles of “high commitment” work practices whereby an organisation involves employees in its goals and activities to promote their discretionary motivation towards desired outcomes and overall improvement. However, there has been limited research on fully theorising performance management with the four key components. Although some empirical studies have tested the performance management concept, they focus narrowly on only a few of these components. Moreover, empirical research has omitted the role of organisational commitment in explaining the commitment based mechanisms in which the performance management bundle operates to inspire employees to improve their contributions in a workplace. To address these gaps, this study proposes a conceptual model to empirically investigate the linkages between performance management and three employee outcomes of task performance, organisational citizenship behaviour (OCB), and turnover intention as mediated by two focal bases of organisational commitment – affective and continuance dimensions. These relationships are explored in the Thai Police Service. The mediating effects are based on the argument that satisfactory work conditions inherent in performance management may carry perceptions of both organisational care and support and also accumulated investments underlying the development of the affective and continuance dimensions, respectively. While both mediators are hypothesised to decrease turnover, affective commitment tends to increase task performance and OCB, and continuance commitment tends to be either unrelated or negatively related to both performance variables. Furthermore, because organisational characteristics in police forces are generally distinct from others, police culture was included in the conceptual model to examine the incremental contribution of performance management to changes in the employee outcomes. This research embraced three related studies. Four focus groups of 27 patrol officers were conducted in Study 1 to explore key dimensions of police culture and examine officers’ understanding of performance management practices. Having developed a written questionnaire to test the conceptual model, Study 2 surveyed 161 patrol officers returning 152 usable questionnaires in order to assess the meaning equivalence and applicability of the translated measures of all constructs (from English to Thai) in the model, and to determine their validity and reliability. In the third and main study, a revised questionnaire was used to survey 516 patrol officers, 454 of which returned usable questionnaires that were half split randomly (224 and 230) to enable the analysis in two parts. Based on structural equation modeling (SEM), the first part allowed the measurement properties to be re-explored due to questionnaire revisions, and then confirmed, using both respective samples. The second part was based on the Partial Least Squares (PLS) technique for testing the conceptual model using the second sample. Overall, the empirical analysis shows that performance management not only accounted for affective commitment but also, to a lesser extent, continuance commitment. Performance management also was related both directly with task performance and indirectly through affective commitment, only directly with OCB, and only indirectly (fully mediated) with turnover intention through continuance commitment. Even after controlling for the impact of police culture and demographic characteristics, the predictive strength of performance management remained significant. The hypothesized relationships of affective commitment to OCB and turnover, however, were not supported. The follow up analysis revealed that the positive relationship between the former actually existed, but was conditional upon a high level of continuance commitment. Some of the major theoretical implications include the conceptualisation of performance management as confirmed with four components, a better understanding of the role of organisational commitment in explicating the high commitment mechanisms of performance management and the impact of organisational culture on the operation of performance management. From a practical perspective, organisations are encouraged to establish the holistic process of performance management to elevate employee performance and overall productivity and to emphasise voluntary and supportive aspects of the implementation of performance management to ensure its positive effects through affective rather than continuance commitment. For police organisations particularly, management should strive for interventions that reinforce values of progressive thinking, people-centred operations, and cooperation to supplement the performance management system. Finally, the conclusion discusses limitations and directions for future research.

Abstract Introduction Most countries including Australia are experiencing an ageing of their population, with an increasing proportion of frail older persons requiring hospitalisation from acute illness. The aging process places the older person at risk of geriatric syndromes, such as falling, dependency in performance of Activities of Daily Living and instrumental Activities of Daily Living, confusion, bladder and bowel incontinence. New or deteriorating geriatric syndromes are a frequent occurrence among hospitalized older patients. Hospital associated factors associated with these outcomes include complications of medical therapies; polypharmacy and excessive bed rest. Few studies have been conducted into factors predicting risk of negative outcomes in older patients admitted to medical units of acute care teaching hospitals. If available, a screening tool with few predictive factors, able to be administered close to the time of admission could be used to identify patients at lower and higher risk. It is imperative that such a tool is developed empirically and tested for its accuracy in identifying patients at high risk. Aims of the research The first aim was to identify the proportion of patients aged ≥ 70 years, admitted to acute care medical units that experienced a negative outcome. These outcomes included falls during hospitalisation, presence of new or a significant decline in existing pressure ulcers, significant decline in independently performing Activities of Daily Living (ADLs), requiring increased care needs at discharge, readmission to hospital with 28 days of the index hospitalisation, bladder and bowel incontinence, and delirium. The second aim was to identify factors predicting the risk of two of these negative outcomes: requiring a higher level of care at discharge, and experiencing a decline in independently performing ADLs. Based on the predictive factors, two screening tools to identify patients at risk were developed and validated. Method A prospective cohort study of 413 acute general medical patients, aged ≥ 70 years and consecutively admitted to an acute care metropolitan 700-bed teaching hospital was conducted. Consenting patients expected to remain in hospital for more than 48 hours were included. Patients were excluded if they were admitted to intensive or coronary care units, admitted for terminal care only or were transferred from a general medical to another unit within 24 hours of admission to the ward. Trained research nurses assessed patients and used the interRAI Acute Care instrument to collect information on candidate predictive variables and negative outcomes. Patients were assessed within 36 hours of admission and at discharge to obtain information on predictive variables and negative outcomes. Patients were also followed daily to identify any instances of transient negative outcomes during hospitalisation and at 28 days following discharge to identify any instances of readmission to hospital. The 413 cases were randomly split into 309 cases in the development cohort and 104 cases in validation cohort. Logistic regression models were used to identify the predictive factors independently associated with two negative outcomes, requiring a higher level of care at discharge and experiencing a decline in independently performing ADLs. Findings At least one negative outcome was experienced by 53% of the development and 63% of the validation cohort. The most common negative outcomes experienced were: delirium (27%; 23%), a significant decline in ADLs (19%, 22%), requiring a higher level of care at discharge (16%, 16%), and readmission to hospital within 28 days of discharge (17%, 28%) in the development and validation cohorts respectively. The logistic regression analysis identified four independent factors associated with requiring higher levels of care at discharge: ‘short term memory problems’ (OR 4.21, 95% CI 1.79, 9.89; p=0.001); ‘dependence in toilet use’ (OR 3.51, 95% CI 1.14, 10.84; p=0.029); ‘dependence in hygiene’ (OR 2.76, 95% CI 1.16, 6.56; p=0.021), and ‘use of community services prior to admission’ (OR 2.41, 95% CI 1.12, 5.16; p= 0.024). A screening tool developed to assess patients at lower and higher risk had a sensitivity, specificity, positive predicted value (PPV) and negative predictive value (NPV) of 77.27%, 73.66%, 36.56% and 94.29% respectively. Reasonable accuracy was evident when tested in the validation sample. Sensitivity, specificity, PPV and NPV were 60%, 76.32%, 33.33% and 90.63% respectively. Predictive factors associated with a significant decline in ADLs were: ‘history of falling’(OR 2.21, 95% CI 1.12, 4.36; p= 0.023), ‘no interest in things enjoyed normally’ (OR 4.30, 95% CI 1.92, 9.64; p=0.000), ‘dependence in management of finances’ (OR 3.93, 95% CI 1.63, 9.48; p =0.002) and ‘hearing problems’ (OR 2.38, 95% CI 1.05, 5.39; p =0.038). The screening tool had sensitivity, specificity, PPV and NPV in the development cohort of 74.55%, 69.13%, 36.6% and 92% respectively and 45%, 65.79%, 25.7% and 82% respectively in the validation sample. Conclusion The tools require further validation in larger samples in diverse settings. Future research should focus on developing a screening tool that could predict risk of a number of negative outcomes to enhance the provision of quality patient care.