abstract: This descriptive research used social network analysis to explore the influence of relationships and communication among hospital nursing (RN, LPN, CNA) and discharge planning staff on adherence to evidence-based practices (EBP) for reducing preventable hospital readmissions. Although previous studies have shown that nurses are a valued source of research information for each other, there have been few studies concerning the role that staff relationships and communication play in adherence to evidence-based practice. The investigator developed the Relational Model of Communication and Adherence to EBP from diffusion of innovation theory, social network theories, relational coordination theory, and quality improvement literature. The study sample consisted of 10 adult-medical surgical units, five home care agencies and six long-term care facilities. A total of 273 hospital nursing and discharge planning staff and 69 post-acute staff participated. Hospital staff completed a survey about communication patterns for patient care and patient discharge and about communication quality on the unit. Hospital and post-acute care staff completed surveys about relationship quality and demographic characteristics. Evidence-based practice adherence rates for risk assessment, medication reconciliation, and discharge summary were measured as documented in the electronic medical record. Social network analysis was used to analyze the communication patterns for patient care communication at the unit. These findings were correlated with (1) aggregate responses for communication quality, (2) aggregate responses for relationship quality, and (3) EBP adherence. Statistically significant relationships were found between communication patterns, and communication quality and relationship quality. There were ii two significant relationships between communication quality, and EBP adherence. Limitations in response rates and missing data prevented the analysis of all of the hypothesized relationships. The findings from this study provide empirical support for the role of social networks and relationships among staff in adoption of, and adherence to, EBP. Social network theory and social network analysis, especially the concept of knowledge sharing, provide ways to understand and leverage the influence of peer relationships. Future studies are needed to better understand the contribution that relationships among staff (social networks) have in the adoption of and adherence to EBP among nursing staff. Further model development and multilevel studies are / Dissertation/Thesis / Doctoral Dissertation Nursing and Healthcare Innovation 2016

abstract: The purpose of this paper is to present a case study on the application of the Lean Six Sigma (LSS) quality improvement methodology and tools to study the analysis and improvement of facilities management (FM) services at a healthcare organization. Research literature was reviewed concerning whether or not LSS has been applied in healthcare-based FM, but no such studies have been published. This paper aims to address the lack of an applicable methodology for LSS intervention within the context of healthcare-based FM. The Define, Measure, Analyze, Improve, and Control (DMAIC) framework was followed to test the hypothesis that LSS can improve the service provided by an FM department responsible for the maintenance and repair of furniture and finishes at a large healthcare organization in the southwest United States of America. Quality improvement curricula and resources offered by the case study organization equipped the FM department to apply LSS over the course of a five-month period. Qualitative data were gathered from pre- and post-intervention surveys while quantitative data were gathered with the Organization’s computerized maintenance management system (CMMS) software. Overall, LSS application proved to be useful for the intended purpose. The author proposes that application of LSS by other FM departments to improve their services could also be successful, which is noteworthy and deserving of continued research. / Dissertation/Thesis / Masters Thesis Construction 2017

ABSTRACT Modern society has a higher demand for quality than it had before. There is a Plethora of quality improvement techniques available which makes it harder for companies to decide which one to apply. They need support in this decision and in knowing how to apply the chosen techniques, if they want to improve their business and stay competitive. Six Sigma approach is a very successful manufacturing quality improvement tool. In the last two decades, it has helped many companies to success. Recently, the Six Sigma approach was introduced in the software development industry. Some software companies have been trying to adapt Six Sigma for their business and development processes. But there are misconceptions about the applicability of Six Sigma in software‟s. Furthermore there is no generic software quality improvement solution based on Six Sigma. So there is a demand to debunk the misconceptions related to the applicability of Six Sigma. And to develop a generic software company quality improvement solution based on Six Sigma approach. In this thesis we take a first step towards such a solution. The thesis starts from Six Sigma concept identification and manufacturing investigation. After conducting interviews, a case study and several case studies reviews, we detail our method. We expect thesis result to be useful for software companies when applying Six Sigma in their company for process improvement. Keywords: Software Quality, Quality Improvement Tool, Six Sigma and Process Improvement

In Bangladesh, research focusing on the quality of maternal and newborn health (MNH) services in hospitals remains neglected. There have only been a few studies conducted on quality issues and found the quality of MNH care provided at district and sub-district hospitals to be poor. The overall objective of this thesis was to develop, implement and evaluate a framework for quality improvement (QI) system for MNH care at the district and sub-district level government hospitals in Bangladesh. The thesis is comprised of four papers. Mixed methods were used in paper I and paper IV. In paper II quantitative methods were utilized, and to develop the “Model QI System”, exploratory methodological approaches were used and illustrated in paper III. Group discussions, focus group discussions, in-depth interviews, documents review and photography were utilised as qualitative data collection techniques. Through structured observation and exit interviews quantitative data were obtained. Findings of baseline survey identified several keyfactors that affected the quality of patient care: shortage of staff and logistics; lack of laboratory support; under useof patient-management protocols; lack of training; and insufficient supervision. The clinical performance of health care providers was found unsatisfactory. Utilizing the baseline survey findings and existing information on QI models, theories and QI intervention programmes implemented in defferent settings an adapted “Model QI System” and its implementation framework, guidelines and tools were developed. The key areas of this “Model QI System” included health system support, clinical service delivery, inter-departmental coordination; and utilization of services and client satisfaction. The adopted “Model QI System” was incorporated within the existing hospital management system and it was found that the quality of care improved. The evaluation of the study showed that the “Model QI System” was acceptable to the top health managers, health care providers and hospital support staff and feasible to implement in district and sub-district hospitals in Bangladesh.

Abstract The aim of the study was to evaluate the usefulness of customer satisfaction surveys and spontaneous customer feedback procedure in a university hospital laboratory. Questionnaires containing closed-ended statements and an open-ended question were used in the customer satisfaction surveys targeted at the clinical units of the university hospital and regional health centres. Customer feedback documents including the subject matters of the reports, the investigations carried out and the actions taken were analysed using qualitative content analysis. The highest dissatisfaction rates in the clinical units were recorded for computerised test requesting and reporting, turnaround times of tests, missing test results and the schedule of phlebotomy rounds. In addition, additional instructions were needed. The most common causes of dissatisfaction among regional health centres were related to electronic data transfer of laboratory test requests and reports between health centres and the university hospital laboratory, need of additional instructions for handling of samples and preparation patients for laboratory tests, problems with decentralised phlebotomy services to hospital outpatients, and unawareness of the schedule of some less common laboratory tests. Further clarifications with selected customers were needed to specify the causes of dissatisfaction. Erroneous, delayed and lacking test results were the most common errors or defects revealed in the investigations of the spontaneous customer feedback reports from both the clinical units and the external customers. The most common underlying causes of errors were unintended errors and non-compliance with operating instructions. Systematic errors were found in one-sixth of the cases. Corrective actions were carried out in three-fourths of the cases. Satisfaction survey can be used as a screening tool to identify topics of dissatisfaction. However, further clarifications are often needed to find out the customer-specific causes of dissatisfaction and to undertake targeted corrective actions. Every reported case of customer feedback should be investigated to find out possible errors and their underlying causes so that appropriate corrective actions can be taken.

The primary motivation of this PhD by publication has been the apparent disconnect between the metrics of hospital quality of care at national and board level and patients’ experiences. Exploration of the gap led to the realisation of two key points. Firstly, the concept of healthcare quality continually evolves. Secondly, the NHS Scotland Measurement Framework does not include a measure of patient experience at the microsystem level (e.g. hospital ward). This is needed to counterbalance easier to obtain metrics of quality (e.g. waiting times). Resource tends to follow measurement. Papers 1 and 2 were exploratory, investigating theoretical and practical aspects of measuring quality of hospital care at the clinical microsystem level. With the associated Chapters, they highlighted both the necessity and the possibility of measuring the patient experience at the micro level of the healthcare system. They also drew attention to the inadequacy of “satisfaction” as a metric, leading to closer examination of “experience” as the decisive metric. This required the development of a systematic review protocol (Paper Three), then a systematic review (Paper Four). The review (Paper Four) examined the utility (validity, reliability, cost efficiency, acceptability and educational impact) of questionnaires to measure the patient experience of hospital quality of care, with a newly devised matrix tool. Findings highlighted a gap for an instrument with high utility for use at the clinical microsystem level of healthcare. Paper Five presents the development and preliminary psychometric testing of such an instrument; the Care Experience Feedback Improvement Tool (CEFIT). The thesis provides, as well as the matrix tool and CEFIT, theoretical and methodological contributions in the field of healthcare quality. It contributes to an aspiration that the patient’s voice can be heard and acknowledged, in order to direct improvements in the quality of hospital care.

Healthcare is continuously changing through means of project work. Small projects in healthcare settings are of particular interest since they are usually not adequately supported by the health institution, and present many challenges of their own. However, collective successful completion of small projects has the potential to significantly impact and improve health service delivery. This thesis examined the common and successful project management practices in small projects in Canadian hospital settings to acquire new knowledge on this understudied kind of project and propose basic project management practice guidelines for future small projects conducted within these settings. Data collection was conducted in two hospitals in the form of 23 semi-structured interviews with five interprofessional project teams composed of 4-10 healthcare professionals. Each project was considered as the unit of analysis. Qualitative within-case and cross-case inferential processes were applied and a consolidated list of 43 project management practices deemed important by the majority of participants from all cases was revealed and could serve as basic project management practice guidelines for future small projects conducted in hospitals. Findings also shed light on the beneficial value of adapting principles of project management to small projects in hospital settings. Given the bottom-up nature of small projects, results suggest it is of significant importance to clearly define and understand the small project, as well as perform a thorough stakeholder analysis to be able to gain the right approvals. Insufficient time dedicated to small project management governed these shortcomings, thus team members need to regularly allot time to managing their small project. Lastly, the presence of a team leader was a significant factor influencing continuous project execution. Future studies should take into consideration allied disciplines’ contributions such as organizational behaviour to help explain the interplay between group dynamics and small project outcome.

The purposes for this study were: (a) to establish benchmark metrics for selected variables related to characteristics of physical therapy education programs; and (b) to determine how well a subset of the variables predicted group membership based on first-time pass rates (FTPRs) on the National Physical Therapy Examination (NPTE). The population was defined as all physical therapy programs in the United States and Puerto Rico accredited by the Commission on Accreditation in Physical Therapy Education. Questionnaires soliciting data related to the variables were mailed to the entire population (N = 177). Fifty-eight (32.8%) of the programs returned the questionnaire, with 51 (29%) having provided enough information for inclusion in the study. Characteristics of the sample were compared to known population characteristics in order to determine the extent to which the sample represented the population. Pearson product-moment correlation resulted in a coefficient of .993, indicating that the two groups were similar. Descriptive statistics were calculated. Values for the variables were tabulated in various ways, based on the nature of sponsoring institution, regional location, degree offered, and grouping based on FTPRs, in order to facilitate comparisons. A single institution was selected and comparisons made to demonstrate the utilization of benchmark metrics. Chi-squared tests were conducted to study the relationship between curriculum model, degree offered, and grouping. The resulting values of c 2 indicated that these variables were independent of each other. Classification accuracy was determined through discriminant analysis. Results indicated 80% accuracy for this sample; however, the accuracy was only 47% on cross-validation. Structure coefficients were calculated to determine the relative contribution of each variable to the prediction. The findings demonstrate the usefulness of benchmark metrics for facilitating quality improvement in physical therapy education programs. There is, however, need for improvement in the process, and further research should be conducted to develop a realistic model for predicting group membership based on FTPRs.

The underlying philosophy of patient-centred care (PCC) advocates for patients to have an active role in all areas of their care, including broader areas of the health care system such as planning and evaluation. Despite efforts made in the past decade that would see greater patient engagement, conventional evaluation approaches continue to dominate the landscape in health services evaluation. To date, limited empirical research has examined the effects of patient engagement or the best approach to engage patients (Abelson et al., 2015; Baker, 2014; Baker, Judd, Fancott, & Maika, 2016). Furthermore, a relative lack of collaboration and shared knowledge exists between the evaluation community and health sector in the rapidly developing area of patient engagement and the development of best practices. Consequently, health organizations continue to struggle with how best to involve patients (i.e., process) in health service improvement initiatives, as well as learn from patient experience (Baker, 2014; Baker, Judd, et al., 2016; Luxford et al., 2011). This dissertation responded to some of these challenges and through this intervention study, the specific purpose of the thesis study was to gain a better understanding of the process of patient engagement in planning and evaluation by addressing the following research questions: 1. What are the facilitators and barriers of engaging patients in planning and evaluation of health services and why? 2. What did the process of engagement look like with respect to Cousins and Whitmore’s (1998) three dimensions of collaborative inquiry? 3. What are the observed effects of the engagement process? This longitudinal qualitative case study began with the creation of the Patient and Family Engagement Committee (PFEC) at the Ottawa Hospital Psychosocial Oncology Program (PSOP) and completed an evaluation project over a period of six months. The research study occurred in parallel with the evaluation project and was designed to gain a better understanding of the process of patient engagement and the role that evaluation plays in this context. The study consisted of three phases and data collection relied on multiple sources. Facilitators that influenced the patient engagement process include: accommodating participant needs, commitment, orientation meeting, designated lead with evaluation skills, homework between meetings, and mutual respect. Having a designated lead, mutual respect, and commitment to the project were the three most highly endorsed facilitators at the end of the project. Conversely, barriers identified include time and resources, imbalanced participation, change in health status, and living at a distance. Time and resources was endorsed as the most significant barrier to the patient engagement process across all three phases of the study. Motivations for participant involvement revolved around giving back, improving health services, learning, commitment to research/evaluation, and providing or hearing a unique perspective. The study examined participatory aspects of the focal evaluation using Cousins and Whitmore’s (1998) three fundamental dimensions of process in collaborative approaches to evaluation: stakeholder diversity, control of evaluation process, and depth of participation. Findings revealed that intended benefits of participant involvement included reach to decision-makers, improved health services, increased diffusion of patient/family engagement, improved access/awareness of services, and a follow-up to assess influence of engagement. Participants’ experiences of being involved invoked enthusiasm for the project, were personally rewarding, instilled a sense of optimism that the project would have an influence, closed the loop on healing, contributed to a shift from a personal to broader health care focus, and contributed to learning. Further research is needed to gain a better understanding of the processes involved or evaluation approaches that could contribute to translating patient engagement into improved outcomes. The findings of this study have enhanced understanding of key contributions that patients, family members, health professionals, and evaluators bring to the patient engagement process, and enriched understanding of key facilitators and barriers to ensure successful patient engagement.

Background: Heart failure (HF) is the leading cause of hospitalization among older adults in the United States. Health systems target readmission rates for quality improvement and cost reduction. Local Problem: Heart failure core measure (CM) scores at our medical center were lower than the national average, and methods for capturing the appropriate documentation on HF patients to ensure CM compliance were not clear. Methods: An interdisciplinary team determined barriers to increasing CM scores, gathered baseline data, and identified gaps in the existing process. Interventions: The team implemented an accurate reporting system and error-proofing process, redesigned the process for identifying patients admitted with a HF diagnosis, and developed a patient appointment section before discharge in the electronic medical record. Results: There was a decrease in readmissions within 30 days of implementation from 12% to 8%, and HF CM compliance score increased from 88% to 100%. The percentage of HF patients not identified during hospitalization decreased from 17% to 0%. Heart failure patients discharged with a 7-day follow-up appointment increased from 88% to 98%. Conclusion: Through implementation of an interdisciplinary-led process improvement and lean methodologies, metrics and CMs were achieved.