Critical Access Hospitals (CAHs) – the predominant type of hospital operating in rural areas – play an integral role in the US healthcare system, providing care for over 7 million rural residents each year who might otherwise have no local access to urgent care or inpatient services. This dissertation examines three aspects of care delivery in CAHs – effectiveness, cost/efficiency, and access – each of which has separate implications for policy and practice. The first study addresses effectiveness and evaluates the performance of CAHs on specific patient safety indicators compared to small Prospective Payment System (PPS) hospitals. A total of 35,674 discharges from 136 non-federal general hospitals with fewer than 50 beds were included in the analyses: 14,296 from 100 CAHs and 21,378 from 36 PPS hospitals. Outcome measures included six bivariate indicators of adverse events of surgical care that were developed from Agency for Healthcare Research and Quality Patient Safety Indicators. Multiple logistic regression models were developed to examine the relationship between hospital adverse events and CAH status. The results indicated that compared to PPS hospitals, CAHs are less likely to have any observed (unadjusted) adverse event on all six indicators, four of which are statistically significant. After adjusting for patient mix and hospital characteristics, CAHs perform better on three of the six indicators. Accounting for the number of discharges eliminated the differences between CAHs and PPS hospitals in the likelihood of adverse events across all indicators except one. Tele-emergency (tele-ED) services can address several challenges facing emergency departments (EDs) in rural areas. The second study investigates access and characterizes the impact of a rural-ED-based telemedicine program on discharge disposition in terms of patient transfer, local hospital admission, and routine discharge. This study tests the hypothesis that telemedicine enhances access by allowing patients to receive care in the local community, and does so by looking at the probability of transfer and local admissions before and after telemedicine was implemented in CAHs. The results indicate that in the post-telemedicine period, patients were 38% less likely to be admitted to the local inpatient facility than to be routinely discharged [aOR=0.62, 95%CI=(0.57,0.67)] after adjusting for age, sex, race, time of visit, clinical diagnosis, CPT code, number of diagnoses, and admitting hospital. The third study addresses cost and efficiency by modeling the financial implications of using the same telemedicine program to avoid transfers and estimating the costs and benefits associated with tele-ED implementation in CAHs. Analysis is based on 9,048 tele-ED encounters generated by the Avera eEmergency program in 85 rural hospitals across seven states between October 2009 and February 2014. For each non-transfer patient, physicians indicated whether the transfer was avoided because of tele-ED activation. The cost-benefit analysis is conducted from the hospital, patient, and societal perspectives, and includes technology costs, local hospital revenues, and patient-associated savings. The results show that 1,175 avoided transfers could be attributed to tele-ED. From a rural hospital perspective, tele-ED costs around $1,739 to avoid a single transfer but saves approximately $5,563 in avoided transportation and indirect patient costs. From a societal perspective, tele-ED results in a net savings of $3,823 per avoided transfer while accounting for tele-ED technology costs, hospital revenues, and patient-associated savings. This study highlights various stakeholder perspectives on the financial impact of tele-ED in avoiding patient transfers in rural EDs. Telemedicine has the potential to reduce the number of transfers of ED patients and generate some revenue for rural hospitals despite associated technology costs, while incurring substantial patient savings.

<p>The development and provision of equitable and acceptable standard of health services to all segments of the population has been the major objective of the 1993 Ethiopian National health policy. However, community based studies on satisfaction with public health care facilities reveal that the majority of the population are not satisfied with the services provided predominantly as a result of the long waiting times. Studies done on private health facilities on the contrary reveal that patients are satisfied with the service delivered within short waiting times in these clinics. Even though the speculated waiting time is thought to be long among the public health care facilities and short in private clinics, the actual waiting and service times have not been measured and compared. Aim: To determine the waiting and service times among the public and private health care facilities and measure the perceptions of &ldquo / acceptable&rdquo / waiting time among the providers and clients. Materials and methods: A cross sectional observational study using quantitative techniques was carried out amongst patients and staff at selected public and private health care facilities in Gondar District. Stratified sampling method was used to select facilities. All patients visiting the selected facilities and all staff who provided service to patients on the day of the study were included in the time-delimited sample. Data was collected by research assistants and health workers from all patients attending the health care facility by registering the arrival and departure time of each patient to the facility and to each service point on a patient flow card. Then data was cleaned and captured by a specific Waiting and Service Time database. Descriptive statistics was done on waiting and service times for each facility and this was summarized for each public and private health facility by using tables and graphs. Finally a comparison was made for private and public health facilities by using Wilcoxon-mann-whitney non parametric tests.</p>

Client satisfaction is an outcome measure of quality care. Therefore, health care providers (HCP) have a responsibility to provide quality care services in order to satisfy clients’ health needs. The aim of this study was to establish the satisfaction level of persons with disabilities regarding health services provided at primary health care centres (PHCC) in Ndola, Zambia. The study employed a crosssectional descriptive design and quantitative research method. The sample comprised 200 male and female persons with disabilities aged between 18-65 years old, selected using a convenience sampling technique. The clients were health care service beneficiaries from four PHCCs and four community based rehabilitation centres (CBR). The self-administered General Practice Assessment Questionnaire (GPAQ) was used to collect data on client satisfaction.The results showed that majority of clients were dissatisfied with availability of health services. There was a significant association between care providers’ skills and clients’ satisfaction level at p<0.0001. There is need to increase and assign specifically trained health professionals to health centres. Besides this, a multi-disciplinary approach that incorporates other professionals might help to deliver quality care services to persons with disabilities.

The overall aim of this thesis was to describe quality of care from different perspectives in the psychiatric setting, to develop an instrument for measuring quality of care from the in-patient perspective and to use this instrument empirically. A qualitative descriptive design involving a phenomenographic analysis was used in Studies I, III and IV, and a descriptive and comparative design with statistical analysis in Study II. In Study I, 20 patients were interviewed. The results showed that quality of care was perceived as a positive, normative concept namely as good quality of care. Five descriptive categories emerged: the patient’s Dignity is respected; the patient’s sense of Security with regard to care; the patient’s Participation in care; the patient’s Recovery; and the patient’s care Environment. In addition, two conceptions that had not explicitly emerged in previous studies on quality of care were identified: Being helped to reduce the shame and Being looked upon as like anyone else. In Study II a definition of quality of care from a patient perspective was formulated on the basis of the results in Study I. A two-part instrument the Quality in Psychiatric Care (QPC) was developed for measuring the patients’ expectations regarding quality of care (QPC-1) and their subsequent experience of it (QPC-2). One hundred and sixteen patients answered both parts of the instrument. Overall, the quality of care was rated high in both parts. However, experienced quality of care was significantly lower than the patient’s expectations in all the dimensions of the instrument: Total dimension, Dignity, Security, Participation, Recovery and Environment. Patients who perceived that the time of discharge was consistent with the stage of their illness experienced significantly higher Recovery; patients with good psychiatric health also experienced this, but had in addition significantly higher levels of Participation. This new instrument exhibited too high Cronbach’s alpha values (QPC-1 0.87–0.98, QPC-2 0.85–0.98), which means the instrument needs to be further tested in order to improve its psychometric properties. Twelve next of kin were interviewed in Study III. The next of kin described quality of care mainly from their own perspective, but also to a large extent from the patient’s perspective as well. They described it in both positive and negative terms. Five descriptive categories resulted: Dignity, Security, Participation, Recovery and Health-promoting surroundings. Good relations and communication between staff, patients and next of kin emerged as the central factors regarding the quality of care. The next of kin asked for information about mental illnesses and wanted to co-operate and participate in the patient’s care. They avoided telling others about their family member’s psychiatric illness because of a feeling of shame and guilt. In Study IV, 20 care staff and care associates were interviewed. They described quality of care both from the patient’s perspective and from a professional perspective. They perceived the concept as a positive one and as being of great importance for the patient’s health and life situation. Four descriptive categories resulted: the patient’s Dignity is respected; the patient’s Participation in the care; the patient’s Recovery; and the patient’s care Environment plays an important role. The main contribution of this thesis with regard to the concept of quality of care in the psychiatric setting is its emphasis on the significance of the different perspectives described above, as such knowledge is vital when planning and implementing and evaluating quality of psychiatric care. In addition, the descriptive categories that emerged in this thesis clearly highlight the importance of interpersonal relationships in the care situation. The new instrument (QPC) needs psychometric testing before it routinely can be used as a self-rating instrument for the purpose of improving psychiatric inpatient care and help guide the proper allocation of care resources.

Patients and next of kin in intensive care often experience powerlessness, anxiety and distress and intensive care staff are repeatedly exposed to traumatic situations and demanding events. Empowerment has been described as a process of overcoming a sense of powerlessness and a model through which people may develop a sense of inner strength through connections with others. The aim of this thesis was to describe empowerment as experienced by patients, next of kin and staff in intensive care and to compare patient's experiences with staff and next of kin beliefs. Empowerment is reflected in this thesis as experiences of inner strength and power and of participation/self-determination. The study was based on open-ended interviews with 11 patients, 12 next of kin and 12 staff members from two intensive care units in southern Sweden. A phenomenological perspective was applied in three studies, while a qualitative content analysis was used in the forth study. Findings showed that nourishing relationships were of crucial importance, and contributed to every participant's experiences of empowerment regardless of whether he/she was an intensive care patient, a next of kin or a staff member. Patients were found to be strengthened and empowered by a positive environment where their own inherent joy of life and will to fight was stimulated, where they felt safe and a sense of value and motivation were encouraged and where they were taken seriously and listened to. Next of kin were extremely important to patients' experiences of safety, value, human warmth and motivation, and patients were strengthened when their next of kin were acknowledge and welcomed by staff. Next of kin in intensive care were strengthened and empowered by a caring atmosphere in which they received continuous, straightforward and honest information that left room for some hope and in which closeness to the patient was facilitated and medical care was experienced as the best possible. Some informants were also empowered by family support and/or participation in caring for the patient. Intensive care staff were empowered by both internal processes such as feelings of doing good, increased self-esteem/self-confidence and increased knowledge and skills, and by external processes such as nourishing meetings, excitement and challenge, well functioning teamwork and good atmosphere. When comparing patient experiences with staff and next of kin beliefs, there was agreement regarding joy of life and will to fight being essential to patients' experiences of inner strength and power, but staff and next of kin seemed to see this as a more constant individual viewpoint or characteristic than the patient did. Next of kin, and especially staff, seemed to regard the patient as more unconscious and unable to participate in the communication and interaction process than the patient him/herself experienced. A mutual and friendly relationship was experienced by the patients as highly empowering, while a more professional relationship was emphasized by the staff. These findings could serve as a basis for reflection about patient, next of kin and staff experiences of strength and power and if empowerment is seen as a dimension in quality of care, the findings from this thesis ought to be taken into consideration to increase the quality of care in intensive care. / Patienter och närstående inom intensivvård upplever ofta maktlöshet, oro och inre stress. Upplevelser från intensivvårdstiden har visat sig kunna påverka patienters och närståendes psykologiska välbefinnande under lång tid, även efter det fysiska tillfrisknadet. Intensivvårdspersonal utsätts mer eller mindre frekvent för svåra och traumatiska händelser, vilket kan orsaka stress och utbrändhetssymtom. Empowerment har beskrivits som en process för att övervinna upplevelser av maktlöshet eller en modell genom vilken människor kan utveckla en känsla av inre styrka. Syftet med denna avhandling var att beskriva patienters, närståendes och personals upplevelser av empowerment inom intensivvård. Syftet var också att jämföra patienters upplevelser med vad närstående och personal tror att de upplever. Med empowerment avses här upplevelser av inre kraft och styrka samt av delaktighet/självbestämmande. Avhandlingen är baserad på öppna intervjuer med 11 patienter, 12 närstående och 12 personal vid två intensivvårdsavdelningar i södra Sverige. Alla intensivvårdspatienter upplevde att den egna livsgnistan och kämparvilja var avgörande för deras upplevelser av inre kraft och styrka och inverkade på deras möjlighet att tillfriskna. Livsgnistan och kämparviljan påverkades i sin tur av vad som hände runt omkring patienterna. En positiv atmosfär där de kände sig trygga, betydelsefulla och blev lyssnade på, stärkte deras livsgnista och kämparvilja, liksom extra omsorg, uppmuntran och stärkt motivation. Närstående spelade en viktig roll i att förstärka patienternas upplevelser av trygghet, värde och motivation och öka deras upplevelse av inre kraft och styrka. Atmosfären hade stor betydelse för närståendes upplevelser av kraft och styrka och de påverkades mer av hur något utfördes än av vad som utfördes. Det var viktigt för närstående att känna att det fanns både en kapacitet och en vilja att hjälpa och lindra och de upplevde det stärkande att känna att personalen brydde sig såväl om patienten som om dem. En kontinuerlig, rak och ärlig information som lämnade rum för hopp, tillsammans med möjlighet att få vara nära den svårt sjuke familjemedlemmen samt en upplevelse av att patienten fick bästa möjliga medicinska vård, upplevdes av närstående som stärkande. Några stärktes även av stöd från andra familjemedlemmar och av att få vara delaktiga i vården. Vårdpersonalen fick kraft och styrka både av interna och externa processer. Exempel på stärkande interna processer var upplevelsen av att göra gott, av att ha kunskaper och färdigheter för att klara de uppgifter och utmaningar man ställdes inför, samt av att känna sig trygg både i sig själv (självkänsla) och i det man gjorde (självförtroende). Närande möten med närstående och patienter, spänning och utmaningar, välfungerande teamarbete och en positiv atmosfär är exempel på externa processer som bidrog till personalens upplevelse av inre kraft och styrka. När patienternas upplevelser jämfördes med vad närstående och personal trodde att de upplevde, fanns en samsyn i att patienternas egen livsgnista och kämparvilja hade stor betydelse för deras upplevelse av kraft och styrka. Närstående och personal betraktade emellertid patientens livsgnista och kämparvilja som ett tämligen statiskt karaktärsdrag, medan patienterna själva menade att livsgnistan och kämparviljan i hög utsträckning påverkades av atmosfären runt omkring dem och av hur de blev bemötta. Närstående och personal, tycktes betrakta patienterna som mer omedvetna och oförmögna att kommunicera och samverka med omgivningen än vad patienterna själva upplevde. Patienterna upplevde det som ytterst stärkande när de fick känna sig som medlemmar i vårdteamet och inte ”bara som en patient”.

Telecare has been an approach to care that, internationally, has experienced a generally rapid development during the last ten years. There are many examples of successful pilot projects where ICT applications have been used in the care of elderly: for improved remote consultation with health professionals, to improve the communication and support of the elderly person’s social network, and as intelligent sensors intended to improve the safety of the elderly person. Despite these successes, implementation has been slow. This research project was set up to provide additional knowledge on some of the important questions regarding quality and implementation aspects of the use of ICT application on the care of frail elderly persons. The overall aim of the research project is to illuminate reasoning and experiences of using applications of telecare for frail elderly persons. The research project comprised five studies that were conducted using qualitative research methods. Four of them were carried out within the framework of three telecare projects. Different qualitative research approaches such as content analysis, phenomenological hermeneutics and conversational and discourse analysis were used, in accordance with the research questions of each study. The experiences revealed in the findings of the studies indicate that it is possible to have communication of good quality via videoconferencing with frail elderly persons, even those that have mild or mid-level dementia, provided the conditions are right. Technical limitations of the videoconferencing media in transferring communication cues and the limitations on what the camera can expose place special demands on those communicating with the frail elderly and on the general setting. On the other hand, these limitations on the context of interaction in some situations also seem to be an advantage for demented elderly persons and contribute to increased attention. One example of meaningful remote communication with frail elderly persons was family members’ videophone conversations with their demented relatives when they were placed in nursing homes or homes for respite services. This communication gave new possibilities of being involved in caring for, and of maintaining a relationship with, their demented relative. An introduction of teleconsultations in the care of frail elderly persons will, according to the experiences recorded, affect the professional role and the practical spheres of involved health professionals. The perceptions and experiences of participating health personnel indicate that in order for ICT applications to become valuable assets in the care of frail elderly persons they have to be part of a care alternative that is viewed by all concerned as the best alternative, as a whole, for all affected parties. Further research is needed in order to confirm or refute the findings of this thesis and in order to further broaden our understanding of the use of ICT applications in the care of frail elderly persons. This could facilitate a development of ICT applications suitable for the care of frail elderly persons and their introduction into regular care activities, to the benefit of both the frail elderly persons and their carers.

Objective: determine whether accreditation through Accreditation Canada is associated with more favorable resident safety in Ontario LTC homes and which facility characteristics are predictive of accreditation. Methods: logistic regression was used to determine predictors of accreditation. To examine the association between accreditation and safety, safety was operationalized as five MDS-RAI quality indicators: prevalence of falls, restraints, catheters, pressure ulcers, and infections. Separate multivariable models were developed for each indicator. Results: the odds of accreditation were approximately six times smaller for municipal (p < 0.001) and non-profit facilities (p < 0.001) relative to for-profits; three times greater for chains relative to non-chains (p < 0.001); and twice as large for urban relative to rural facilities (p = 0.04). Of the five quality indicators examined, only one (falls) was associated with accreditation. After adjusting for confounders, accredited homes were estimated to have 8% lower fall rates than non-accredited homes (p = 0.01).

No description available.

No description available.

Syftet med denna uppsats var att få en ökad förståelse och kunskap för hemtjänstpersonalens upplevelse av mötet med kunderna utifrån aspekterna kvalitet, tid och makt. Vi har genomfört en kvalitativ intervjustudie med sex personer som arbetar inom hemtjänstverksamheten. Studiens resultat har analyserats och tolkats utifrån teorierna socialkonstruktionism och roll­teori samt begreppet relationell makt. Resultaten visar att tiden är central i mötet mellan hem­tjänstpersonal och kunder då den inverkar på när och hur länge insatserna ska utföras. Lyhörd­het och att utgå från kundens behov och önskemål definieras som god omsorgskvalitet medan maktförhållandet växlar mellan hemtjänstpersonal och kund utifrån varje unikt om­sorgs­möte. För att få en ökad förståelse och kunskap för hemtjänstpersonalens upplevelser av mötet med kunderna behöver aspekterna kvalitet, tid och makt belysas och analyseras i en och samma kontext. Resultaten visar att de tre aspekterna samverkar i mötet och analysen med­verkar till att nå en djupare förståelse för hemtjänstpersonalens upplevelser. / The purpose of this study was to gain a deeper understanding and knowledge of home based care giver´s experiences of the encounter with clients from three perspectives: quality, time and power. We conducted a qualitative interview study with six people working in home based care. Our results have been analyzed and interpreted by the theories social construc­tionism and role theory and the concept of relational power. The results of the study demon­strate that time is central for the encounter between home care giver´s and clients affecting both when and how long the care should be performed. Responsiveness and putting the client´s needs in focus are defined as good quality of care, while the power relationship between home care givers and clients changes between each unique encounter. To get a deeper understanding and knowledge of home care givers experiences of the encounter with clients the three aspects: quality, time and power, needs to be highlighted and studied in the same context. The results demonstrate that the three aspects interact in the encounter and analyzing these together creates a deeper understanding of home care giver´s experience of the encounter.