The purpose of this practice inquiry project is to create a model for implementing an outpatient palliative care clinic within an organization of healthcare providers who participate in shared savings for Medicare patients, also known as, an accountable care organization (ACO). The goal of this project is that it can be used by future health care administrators to successfully create and implement an outpatient palliative care clinic. The philosophical nursing foundation for palliative care is discussed to set the groundwork for the model proposed. The benefits of palliative care nursing for patients, families and the ACO are discussed to support the importance of opening an outpatient palliative care clinic. A step by step model has been developed and presented on how to plan and implement an outpatient palliative care program. Tools have been proposed to help successfully and effectively create, implement and evaluate outpatient palliative care clinics within an ACO.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Syfte: Syftet med denna studie är att bland patienter med långvarig smärta, som är remitterade till en smärtmottagning, undersöka förväntningar avseende det första besöket, i vilken utsträckning patienterna anser att dessa uppfylldes samt att undersöka vilka förväntningar patienterna har på den fortsatta vården och kontakten med Smärtmottagningen. Metod: En empirisk studie med kvalitativ deduktiv ansats. Datainsamling skedde genom att tio personer intervjuades på Smärtmottagningen efter deras första besök. Materialet bearbetades med manifest innehållsanalys. Resultat: Patienter vid Smärtmottagningen hade i olika stor utsträckning förväntningar inför det första besöket och den fortsatta vården. Patienterna ansåg i varierande utsträckning att deras förväntningar på det första besöket hade uppfyllts, dock uttryckte alla patienter att minst någon förväntning uppfyllts. Gällande den fortsatta vården förväntade sig patienterna bland annat smärtlindring, stöd samt att upprätta en kontakt med Smärtmottagningen. Slutsats: Patienter vid en smärtmottagning har förväntningar på vården och att känna till dessa kan underlätta mötet med patienten för sjukvårdspersonalen. Föreliggande studie ger en inblick i tio patienters förväntningar och huruvida de blivit uppfyllda och tyder på att det är av värde att fråga patienter om deras förväntningar. Detta är något som smärtmottagningar kan överväga att implementera i vården. / Aim: The aim of this study was to investigate expectations on the first appointment among patients with chronic pain referred to an outpatient pain clinic. The aim was also to investigate to which extent the expectations on the first appointment were fulfilled and to investigate the patients’ expectations on the continuing care and contact with the outpatient pain clinic. Method: An empirical study with qualitative design was used. The data was collected through interviews with ten patients after their first appointment at the clinic. Data was processed using manifest content analysis. Result: The patients had expectations in various extents prior to their first appointment and on the further care. The patients thought that their expectations were fulfilled to various extent, however all patients expressed that at least one expectation had been fulfilled. Regarding the continuing care the patients expected, among other things, to receive functioning pain treatment and support as well as to establish a contact with the outpatient pain clinic. Conclusion: Patients have expectations and awareness of these among the medical staff might facilitate the meeting between the medical staff and the patient. This study provides an insight in ten patients’ expectations and to which extent they have been fulfilled. The study also suggests that it would be of value to ask patients about their expectations, which outpatient pain clinics can consider implementing.

The aim of the study – to assess the consultation service quality provided for patients in the maternity academic clinic. Methods. The anonymous poll has been proceeded in September, 2005. It included all physicians of the university clinic such as obstetricians and gynecologists (N=68, response rate - 94.4 %) and all patients visited in the clinic during the research period (N=334, response rate 81.1 %). The consultation service quality was assessed with the structured questionnaire by Ferguson et all. Data of respondents was analyzed and statistically justified by using the „SPSS 10.03“. Results. The study showed that majority of patients positively assessed the technical aspect of service quality. The patients were satisfied with clear indoor signs and references as well as with comprehended and obvious oral instructions. The majority of patients were also complied to the statements that the clothing and appearance and of clinic staff was clean and ordered, that health care means, methods and regulations are secured and appropriate for patients, that medical equipment is advanced and modern, that all physicians of the clinic are competent and qualified. We have also determined that 53.7 % of clinical workers accepted and 28.4 % rejected the statement that the equipment and indoor rooms were sterile and aseptic. The majority of patients and clinic staff members assessed positively the functional service quality in clinic: enough information about necessity and aims of... [to full text]

Enhancement of the quality of outpatient services and the problems of accessibility of services become more and more important part of the health care reform. The importance of increasing the provision of the services in outpatient institutions and developing of outpatient services of physicians-specialists are the priorities in the plan of re-structuring of health care. Aim of the study. To analyze the provision and tendencies of the secondary and tertiary level outpatient services to inhabitants of the area Vilnius Territorial Patient Fund in 2003-2005. Objectives. To evaluate the provision of the secondary level outpatient services by specialty, by municipalities and age groups. To analyze the tertiary level outpatient services by municipalities. To evaluate the changes and tendencies in providing secondary and tertiary level outpatient services. Materials and methods. Analysis was done using the data of health insurance information system SVEIDRA on inhabitants registered to primary health care institutions and outpatient services provided to inhabitants of the area of Vilnius Territorial Patient Fund in 2003-2005. In order to evaluate distribution of services by municipalities, the number of outpatient services per one inhabitant, registered to primary health care institution, was calculated. Four age groups (0-5, 5-18, 18-65, over 65 years old) were chosen to analyze distribution of services by age groups. The existence of statistically significant differences was... [to full text]

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Introduction: Although drug-related problems (DRPs) are known to be prevalent in elderly patients, there are not many studies that have been performed in geriatric outpatients at public health facilities in South Africa. Thus, the prevalence of DRPs in elderly outpatients attending Addington Hospital was investigated and suitable preventive intervention strategies to overcome or minimise these DRPs were developed. Research Methodology: The study was conducted in two phases. Phase 1 was conducted in March and April 1998, during which 281 elderly patients on chronic medical treatment were chosen for the study by systematic random sampling, according to specific inclusion criteria. Data collection was via a retrospective review of the elderly patient's medical notes and by personally interviewing the patient. Two research instruments were used in this phase. The customised Patient Profile (PF) form helped to delineate DRPs in the elderly patients. A Prescription Intervention Form (PIF) was used to inform the prescriber of the DRP and to make recommendations to change the drug therapy in order to overcome the DRP. In phase 2 of the study, intervention strategies were devised to address some of the major DRPs identified in phase 1 of the study. A patient counselling leaflet, prescribing guidelines for geriatric patients and a protocol for counselling of in-patients were developed. In addition, two DRP reporting systems were developed for surveillance of adverse drug reactions and medication errors during dispensing. Results and Discussions: Most geriatric subjects suffered from multiple, chronic conditions, these being hypertension (64.8%) followed by ischaemic heart disease (43.8%), musculoskeletal disorders (arthritis or gout) (42.7%), diabetes (29.2%), chronic obstructive airways disease (13.2%), hypercholesteremia (11.7%) and arrythmias (atrial fibrillation) (11.0%). The 281 patients were taking 1730 prescribed drugs, with a mean of 6.2 (range 3 to 15) prescribed drugs per patient. An astounding 45.6% of the total geriatric patients were taking or using between 7 to 9 medicines and 10.3% were taking or using between 10 to 15 medicines. The antihypertensives (15.9%) were the most widely prescribed drugs followed by medicines acting on CNS (10.9%), coronary vasodilators (9.1%), diuretics (9.1%) and medicines acting on the musculoskeletal system (8.7%). A total of 856 actual DRPs experienced by 262 geriatric patients (93.2%) ranged from 1 to 11 DRPs. The greater the number of prescribed drugs the greater the actual DRPs experienced by geriatric patients (p = 0.000). The most common DRPs were those involved in drug safety (56.6%); effectiveness of the drug therapy (20.8%); compliance (7.8%) and indication of drug therapy (7.6%). 159 elderly patients (56.6%) experienced 223 adverse effects either with their current or past prescribed medicines. The most common ADRs were as follows: gastro-intestinal ulceration (11.0%), cough (9.3%), diuretic side effects (dehydration, fatigue, hypotension, etc) (7.1%), constipation (6.8%), equilibrium problems (6.4%) and headaches (6.4%). For those DRPs warranting interventions, the mean number of prescription interventions in the entire sample population of 281 elderly patients was 0.65 ± 1.16. 87 elderly patients (30.1 %) had from 1 to 4 interventions on their current prescription. The most common prescription interventions were on problems involving drug therapy monitoring (26.9%), safety of drug therapy (26.5%), indication of drug therapy (17.5%), prescribing errors (15.3%) and prescription information omission (11.1 %). The three intervention strategies and DRPs surveillance reporting systems were successfully devised and developed. Conclusions: A profile related to the elderly patient's medical history and pharmacotherapy was completed for each of the 281 patients. General trends of prescribing pattern prevalence of DRPs and the prescribed inappropriate medication was established. The interventions of problem prescriptions were based on a newly developed PIF. The development and implementation of suitable intervention strategies to minimise DRPs were as follows: a compliance information leaflet, prescribing guidelines and the protocol for counselling in-patients. A medication error form as well as an adverse drug reaction reporting forms was developed for surveillance of DRPs. The recommendations for clinical practice and directions for future research that are presented should help to make drug therapy in the elderly safer and more effective. / Thesis (M.Pharm.)-University of Durban-Westville, 2000.

Several studies show that the clinical reality in psychiatric care does not correspond to the demand of consumer participation from a variety of policy documents that has been produced recently. Studies also show that there is a lot to do in improving, patients with sever mental illness, becoming more involved in their own care. The nurse has a central role in this work. The Norwegian nursing theorist Jan-Kåre Hummelvolls holistic, existentialistic model for psychiatric nursing were used as theoretical ground. The aim of this study was to examine how nurses in psychiatric outpatient units, caring for patients with psychotic disorders, experiences consumer participation. Qualitative phenomenological method was used. Semi-structured interviews with six nurses caring for patients suffering from psychotic disorders in outpatient units were conducted. The interviews were recorded and transcript by the author and then analyzed using qualitative content analyze. Two themes were identified: To follow the road chosen by the patient and When consumer participation risks failing. The result of this study shows that there are several factors that influences nurses job to involve patients in their care. The interviews also showed that there were areas where consumer participation was more problematic. To share a decision with the patient is a way to improve consumer participation. Shared decision making is a complicated process where the nurse needs support to succeed. In pharmacological issues nurses must continue working with consumer participation.

Introduction Health-care service in South Africa, especially in the public sector, is fraught with numerous problems, including ineffective operations management in health care facilities. This contributes to poor service delivery and a lackluster work environment. Non-value-adding activities result in, inter alia, long cycle and waiting times, and low staff morale. With Lean thinking, health care managers could tackle specific issues to improve operational efficiency. Aim The purpose of the study was to apply Lean thinking, and to determine its effect on efficiency and staff morale within the outpatient department at Catherine Booth Hospital, in order to inform recommendations to improve operational efficiency in rural district hospital outpatient departments. Methods An operational action-research study design was used. The study sample consisted of all service nodes and employees of the outpatient department in Catherine Booth Hospital. Cycle and waiting times were iteratively measured for all service nodes. Statistical analyses on pre- and post-intervention results were carried out. Results Cycle and waiting time targets were met and exceeded in three service nodes, but only the Investigations node showed statistically significant results (cycle time reduced from 16.7 to 12.2 minutes; p=0.04; and waiting time reduced from 11.93 to 10 minutes; p=0.03). The waiting time for Consulting Rooms improved significantly (80.95 to 74.43 minutes; p<0.0001). Significant decreasing trends in waiting times over the study period were found in Patient Administration (p=0.04), Patient Screening (p<0.0001) and Consulting Rooms (p<0.0001). The trend in average operational efficiency improved over time from 16.35% to 20.13%. The implementation of Lean had a positive impact on the proportion of OPD staff satisfied with their jobs (increased from 21.1% to 77.8%; p<0.0001) and proportion of staff that felt motivated (increased from 15.8% to 77.8%; p<0.0001). Discussion Rural public sector hospitals require a novel and evidence-based approach to improving operational efficiency and staff morale in OPDs and other departments. Lean implementation had a positive impact on cycle and waiting times in all service nodes. Attitude towards teamwork and communication strength are positively impacted by the process of Lean implementation. However, factors such as differing priorities and logic among staff in the OPD and management negatively affect the outcomes of Lean implementation. Conclusion and recommendations The application of Lean principles, tools and techniques is possible in a rural district hospital OPD, without any demands on staff in terms of learning and adopting a new quality-improvement management approach by which to improve operational efficiency. The lessons learnt from the implementation of Lean thinking at a rural hospital used in this study may be emulated for quality improvement across similar hospitals and its sustainability can be assessed further. / Thesis (M.Med.Sc.)-University of KwaZulu-Natal, Durban, 2013.

This thesis aims to make contributions at substantive, methodological and theoretical levels. First, the findings from three observational studies are combined to identify obstacles to the use of shared decision-making in modern psychiatric practice. Particular attention is paid to how patients' choices about their treatment are facilitated or constrained by the actions of mental health professionals. A typology of pressure is constructed, based on detailed analyses of how pressure is applied and resisted in routine encounters (outpatient consultations) and "crisis' situations (assessments for compulsory admission to hospital, and ward rounds in acute inpatient care). Findings from two ethnographies and one conversation analysis (CA) study are presented. 'Meaning' is central to the write-up of each set of findings, however while the analytic focus of the ethnographies is 'insider' knowledge and meanings, in the CA study it is gn the activities that make those meanings possible in the first place. The methodological contribution of the thesis stems from its demonstration of how to produce a coherent, unified research account from two very different versions of qualitative inquiry. Despite the potential for analytic inconsistency, the thesis arguably has far greater force and persuasiveness as a result of the attempt to combine, compare and contrast findings from three studies. It is contended that a sound theoretical base for sociological research may be created by combining Goffman's micro-sociology with Foucault's analyses of disciplinary power/knowledge in one of a number of ways. A Goffmanian 'home base' is adopted for this thesis, with Foucauldian thinking applied to add a historical, 'macro' dimension to the analysis that Goffman's work so conspicuously lacks. Foucault's work also provides the conceptual tools for examining the more subtle form of control through expertise that would be missed in a purely Goffmanian study.