No / Purpose of paper: This paper provides a critical evaluation of the impact of lean practices in informing healthcare policy. Methodology: Review of primary and secondary literature Finding: There has been considerable interest in the implementation of practices imported from manufacturing into healthcare as a solution to address rising healthcare spending and disappointing patient safety indicators. This encompasses a number of practices in Operations Management and Human Resource Management, including Just-in-Time (JIT), Total Quality Management (TQM), Total Productive Maintenance (TPM), employee empowerment, and extensive training. Used together there is great potential to improve overall firm competitiveness. However, despite widespread enthusiasm about the potential of lean management processes, evidence about its contribution to higher organisational performance remains inconsistent. Contribution to knowledge: Our paper contributes to the organisational management literature in healthcare by showing that even though lean management in healthcare appears to have the potential to improve organisational performance; there remain problems with its application.

Yes / There has been considerable interest in implementing practices imported from manufacturing into healthcare as a solution to rising healthcare spending and disappointing patient safety indicators. One approach attracting particular interest is Lean management, which is explored in this article. Design/methodology/approach: The exploratory research focuses on Lean management in the health sector. It is based on extensive secondary data and it is a practical in implication. Data provided both and context. Findings: Despite widespread enthusiasm about Lean management’s potential, evidence about its contribution to higher performance is inconsistent. Research limitations/implications: Major Lean operations management and human resource management concepts, including just-in-time (JIT), total quality management (TQM) and total productive maintenance (TPM) are explored. Practical implications: This article contributes to the healthcare organizational management literature by showing that although Lean management seems to have the potential to improve organizational performance; it is far from a panacea for underperforming hospitals. The article informs policy-making by suggesting that a progressive managerial philosophy has a stronger impact on healthcare performance than adopting practices from any particular managerial approach. Originality/value: A critical evaluation on Lean’s impact on informing healthcare policy is presented, which contributes to healthcare organisational management literature by showing that even though Lean management in healthcare appears to have the potential to improve performance; there remain problems with its application.

Yes / Objectives To investigate the impact of radiographer advanced practice on patient outcomes and health service quality. Methods Using the World Health Organisation definition of quality, this review followed the Centre for Reviews and Dissemination guidance for undertaking reviews in healthcare. A range of databases were searched using a defined search strategy. Included studies were assessed for quality using a tool specifically developed for reviewing studies of diverse designs and data were systematically extracted using electronic data extraction proforma. Results 407 articles were identified and reviewed against the inclusion/exclusion criteria. Nine studies were included in the final review, the majority (n=7) focussing on advanced radiography practice within the UK. Advanced practice activities considered were radiographer reporting, leading patient review clinics and barium enema examinations. The papers were generally considered to be of low to moderate quality with most evaluating advanced practice within a single centre. With respect to specific quality dimensions, included studies considered cost reduction, patient morbidity, time to treatment and patient satisfaction. No papers reported data relating to time to diagnosis, time to recovery or patient mortality. Conclusions Radiographer advanced practice is an established activity both in the UK and internationally. However, evidence of the impact of advanced practice in terms of patient outcomes and service quality is limited. Advances in knowledge This systematic review is the first to examine the evidence base surrounding advanced radiography practice and its impact on patient outcomes and health service quality. Powered by

Ambulatory surgery centers (ASCs) play an important role in providing surgical and diagnostic services in an outpatient setting. They can be owned by physicians who staff them. Previous studies focused on patient “cherry picking” and over-utilization of services due to physician ownership. Few studies examined the relationship between physician ownership and quality of care. Using a retrospective cohort of patients who underwent colonoscopy, this study examined the effect of physician ownership of ASCs on the occurrence of adverse events after outpatient colonoscopy. Agency theory is used to as a conceptual framework. Depending on the extent to which consumers are able to assess quality of care differences across health care settings, physician ownership can function as a mechanism to improve quality or as a deterrent to quality. Four adverse event measures are used in this study: same day ED visit or hospitalization, 30-day serious gastrointestinal events resulting in ED visit or hospitalization, 30-day other gastrointestinal events resulting in ED visit or hospitalization, and 30-day non-gastrointestinal events resulting in ED visit or hospitalization. Physician ownership status is determined based on a court decision in California in 2007. Data sources include the State Ambulatory Surgery Databases (SASD), State Inpatient Databases (SID), Emergency Department Databases (SEDD), State Utilization Data Files, the Area Resource File (ARF), and HMO/PPO data from Health Leaders. After controlling for confounding factors, the study found that colonoscopy patients treated at a physician-owned ASC had similar odds of experiencing same day ED visit or hospitalization and 30-day non-gastrointestinal events resulting in ED visit or hospitalization as those treated in a hospital-based outpatient facility. But the former had significantly higher odds of experiencing 30-day serious gastrointestinal events and 30-day other gastrointestinal events resulting in ED visit or hospitalization. The results are robust to changes in propensity score adjustment approach and to the inclusion of a lagged quality indicator. They suggest that physician ownership of ASCs was not associated with better quality of care for colonoscopy patients. As more complex procedures are shifted from hospital-based outpatient facilities to ASCs, expanded efforts to monitor and report quality of care will be worthwhile.

The costs of healthcare in the United States are of national concern. The systematic review of the literature (SRL) explored the practice-focused nursing question regarding the relationship between the use of acuity-based staffing (ABS) models and positive patient outcomes. Analyzing the impact of ABS models on patient quality outcomes and the potential economic value could provide evidence essential for the healthcare executives responsible for fiscally prudent labor management and for creating an evidence-based business case for adequate, patient-centric nurse staffing. The synergy model for patient care and Covell's nursing intellectual capital theory guided the doctoral project. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review process steps were completed to organize the SRL and report findings. A comprehensive review of the literature yielded 527 articles, with 5 studies that met inclusion criteria in the final review. Analysis and synthesis of the SRL identified several patient outcomes that were significantly correlated with ABS staffing, including medication errors, falls, patient safety incidents, missed care, and mortality. The current body of evidence was insufficiently robust to demonstrate ABS staffing was superior to other nurse staffing models. The implications of this project for positive social change include demonstrating a need for additional research on ABS and the impact of ABS on patient outcomes.

Concern beliefs in medicines are patients' anxieties about the harmful effects of a specific prescribed medication. Three papers examined the importance of concern beliefs in medicine, specifically its relationship to patient outcomes such as self-reported adverse drug events (ADEs) and symptom attribution, and the factors that might drive a change in concern beliefs over time. For the first and second paper, a cross-sectional internet survey of Medicare enrollees who were English speakers, 65 years and older and enrolled in the Medicare Part D program was done. In the third paper, a longitudinal internet survey of the same sample was done before Medicare Part D in 2005 and after Medicare Part D in 2007, and adults 40 years and older with physical limitations were interviewed using telephone. Multiple logistic regressions showed that having stronger concern beliefs in medicine and more symptoms was related to self-reported ADE, rather than using an inappropriate medicine or the number of inappropriate medicines used. Using independent sample t-tests, concern beliefs in medicine were found to be unrelated to symptom attribution for any causal reason, irrespective of whether there was patient-clinician agreement on attribution. Multiple linear regressions showed that concern beliefs changed over time for some older adults and having an ADE in the past year was related to this change. Among adults with physical limitations, though concern beliefs changed for some individuals; only one factor included in this study, changes in number of medicines, was related to this change. Establishing the importance of concern beliefs in medicines as a socio-psychological variable to consider in medication use outcomes will enhance the understanding of clinical researchers and practitioners concerning the mechanism of ADEs and symptom reporting.

Research Abstract Purpose: to explain how there is a direct correlation between nursing staff ratios and patient results regarding mortality, infection, poor patient safety, and other sentinel events. Aims: how is patient care compromised by nursing staff shortage? Methods: observational studies from public information records such as Medicare patient claims, AHA, and surveys from RNs working at acute care hospitals. Results: certain groups are more susceptible to sentinel events. Patients with chronic diseases, elderly, patients needing intensive care, or overall unstable patients are examples of patients who fall under this category. Studies show that patients are at higher risk for receiving detrimental care due to poor nurse to patient ratio. Conclusions: adding to a nurse’s workload increases patient mortality in length of stay in hospitals due to hospital administration only needing to meet the minimum staffing requirements. The minimum staffing required for operations still does not meet the recommendations provided by the Safe Staffing Act. Key Words: nurse shortages, patient safety, patient outcomes, healthcare quality, workload, hospital acquired infections, staffing, CAUTI, VAP, CABI

Patient reported outcome (PRO) measurement of disability is integral to a patient-centered approach to health care and gauging the biopsychosocial impact of health conditions from the patient's perspective. This thesis investigates disability after proximal humerus, elbow and distal radius fractures; conditions that constitute a major burden in musculoskeletal health care and a substantial impact on health-related quality of life (HrQoL). Disability is defined by the World Health Organisation (WHO) International Classification of Disability, Functioning and Health (ICF) as ‘a multi-dimensional construct involving a dynamic interaction between impairment, activity limitations and participation restrictions, that are influenced by contextual factors'. This international, consensus-based framework acts as a guide for the application of outcome measures in performing scientific research. The WHO ICF also considers other patient perspectives on health and health care systems, including patient experience and patient activation within the contextual factors component. Patient experience encompasses aspects such as satisfaction, expectation management and confidence with care, and is measured using a variety of scales and questionnaires. Patient activation relates to 'the knowledge, skills and confidence a person has in managing their own health and health care'. This concept is quantified using patient activation measures (PAMs). The overarching goal of this thesis is to identify the most influential factors predicting disability after proximal humerus, elbow and distal radius fractures. This work also aimed to define the relationship between disability, experience and activation to inform the development of a patient-centred approach to managing these challenging injuries. The first systematic review highlights the dominance of psychosocial factors in influencing disability associated with a range of upper extremity conditions. Few studies have assessed this relationship in specific trauma populations. The second review underlines the paucity of upper extremity PRO measures incorporating fracture populations in their original development. It also reports the highly variable quality of initial studies introducing these measures. The final review demonstrates the superior measurement properties of computer adaptive tests (CATs), a contemporary form of PRO measurement, over fixed-scale instruments. Few studies apply CATs in trauma and few have been performed outside the U.S. These reviews collectively informed the selection of PRO measures for the experimental studies in this thesis. Firstly, a pilot study establishes a methodology for addressing the key objectives and the feasibility of using a web-based platform for measuring patient outcomes. Strong correlation between PROMIS Physical function CAT, a computer adaptive measure of physical function, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), a region-specific, fixed scale is observed. The core experiment (n=734) expands upon this work and demonstrates correlations between a range of generic and region-specific measures in an upper extremity trauma population. Disability is shown to correlate with satisfaction, and the strength of this correlation increases over time. Applying PRO measures of disability in populations with shoulder, elbow and wrist fractures show that self-efficacy (i.e. coping ability) within 6 weeks of injury was the strongest predictor of medium-term disability at 6-9 months. In proximal humerus and elbow fractures, kinesiophobia (i.e. fear of movement) within a week of injury was also a strong predictor of disability. The final study concludes that greater patient activation is associated with greater health-related and experiential outcomes. However, psychosocial factors including self-efficacy, superseded activation in predicting disability and satisfaction. This thesis contributes evidence for musculoskeletal health care professionals (HCPs) to consider specific psychosocial factors, such as coping abilities, and patient activation early in the recovery process to improve disability following these injuries.

Sustainability is a complex system of interaction between a hospital, individual, community, and environmental factors that is required to work in harmony to keep a patient healthy. With the complexities that exist within healthcare, the nurse leader is required to ensure that the care environment, processes and the safety behaviours required from nurses to provide safe healthcare is in place and sustained to contribute to the enhancement of patient safety, whilst in the care of the diverse nursing workforce. The aim of the study is to develop an action plan to sustain best safety culture practices for improved patient outcomes in hospitals with a culturally diverse nursing workforce. Methodology: A multiple method design was utilised to study the safety culture and positive work environment (hospital climate) that exists among culturally diverse nurses and how it is managed by the nurse managers in order to identify and describe actions that can be included in an action plan to sustain best safety culture practices for improved patient outcomes. Purposeful and convenience sampling methods were used in the study. Two hospitals, with a very diverse nursing workforce were purposefully selected to participate in the study. Pretesting of the questionnaire and e-Delphi embedded assessment validation instrument were done by participants not part of sample groups. Phase 1: The Hospitals outcomes data for nursing admission assessment within 24-hours, falls and hospital acquired pressure ulcer incidences and hand hygiene rates were collected on a checklist. Phase 2: Two questionnaires (1) nurses capturing: biographical data and culture, patient safety (nursing admission assessment within 24-hours, falls and HAPU and hand hygiene), and safety culture and positive work environment (hospital climate); (2) nurse managers capturing: biographical data and culture, patient safety (nursing admission assessment within 24- hours, falls and HAPU and hand hygiene), safety culture and Positive Work Environment (hospital climate) and just culture practices. Phase 3: the Draft e-Delphi action plan with embedded assessment validation instrument was developed. Phase 4: The panel experts selected to validate the e-Delphi draft action plan with embedded assessment validation instrument in pre-determined rounds. Data analysis: Phase 1: The outcomes data was displayed in bar graphs and illustrated that (1) the nursing admission assessment within 24 hour period not been sustained over time for the medical, surgical, paediatric and critical care areas; (2) a hundred and sixty two fall incidence; (3) ninety six HAPU incidences and (4) hand hygiene rate of between 80-94% being reported. Phase 2: A participation rate of 46.33% by nurses and 73.91% by nurse managers were achieved. The data for the 2 questionnaires indicated the need to include 54 action statement to address the culture, patient safety, hospital climate (PWE), safety culture and just culture gaps identified. Phase 3: the e-Delphi draft action plan developed based on literature review and data from phase 1 and phase 2. Phase 4: 100% participation rate was achieved. Consensus was reached within two rounds that the 54 action statements are essential and important for patient safety and identified the responsible persons required enacting on action statement and timeframe required to complete action. Recommendation: The Action Plan to enhance a sustainable Culture of Safety to improve patient outcomes were decided by panel experts. Plan to disseminate the plan among the CNO for implementation. / Health Studies / D. Litt. et Phil. (Health Studies)

Sjuksköterskor har som uppgift att tillgodose patienters vårdbehov därav är det betydelsefullt att vara lyhörd och se varje patient som en unik person. Målet med hälso- och sjukvården är att tillgodose en god och säker vård till alla patienter. Sjuksköterskor ska värna om sin egen hälsa för att kunna bedriva en god vård vilken kan påverkas av stress. Hur stress bland sjuksköterskor kan påverka patientsäkerheten är betydelsefullt att belysa då det är av vikt att se hur påföljden blir för patienterna. Syftet med studien är att belysa sjuksköterskors upplevelser av hur arbetsrelaterad stress kan påverka patientsäkerheten inom hälso- och sjukvården. Den valda metoden är en litteraturöversikt som inkluderar 10 artiklar. Resultatet består av totalt 3 huvudteman och 6 underteman som belyser olika faktorer som kan påverka stressupplevelsen för sjuksköterskor och hur patienter blir påverkade av detta. Resultatet visar att stress är en individuell upplevelse och är ett vanligt förekommande problem bland sjuksköterskor. Stress på arbetsplatsen kan också medföra att sjuksköterskor får svårigheter med att upprätthålla en holistisk vård och tillgodose patienternas vårdbehov. Därutöver kan otillräckliga resurser, en bristande kommunikation och teamsamarbete medföra en försämrad vård för patienter och sjuksköterskors vilja att stanna kvar. Utifrån litteraturöversiktens resultat diskuteras det att stress kan medföra att sjuksköterskor begår misstag vilket kan påverka patienterna. Dessa negativa händelser kan medföra att sjuksköterskor upplever en moralisk stress då de förorsakat ett extra lidande för patienterna och därmed äventyrat patientsäkerheten. Med en ökad reflektion kan kunskapen utvecklas samt bidra till en ökad förståelse för hur rätt förutsättningar för sjuksköterskor kan bidra till en patientsäker vård. / Nurses are tasked with meeting patients' care needs, therefore it is important to be responsive and see each patient as a unique person. The goal of healthcare is to provide good and safe care to all patients. Nurses must take care of their own health in order to provide good care, which can be affected by stress. How stress among nurses can affect patient safety is important to highlight as it is important to see how the consequences will be for the patients. The aim of the study is to illustrate nurses' experiences of how work-related stress can affect patient safety in healthcare. The chosen method is a literature review that includes 10 articles. The result consists of a total of 3 main themes and 6 sub-themes that highlight various factors that can affect the stress experience for nurses and how patients are affected by this. The results show that stress is an individual experience and is a common problem among nurses. Stress in the workplace can also mean that nurses have difficulties in maintaining holistic care and meeting patients' care needs. In addition, insufficient resources, a lack of communication and teamwork can lead to a deterioration in patient care and nurses' willingness to stay. Based on the results of the literature review, it is discussed that stress can cause nurses to make mistakes, which can affect patients. These negative events can mean that nurses experience moral stress as they have caused extra suffering for the patients and thus endangered patient safety. With increased reflection, knowledge can be developed and contribute to an increased understanding of how the right conditions for nurses can contribute to a care with high patient-safety.