Magister Public Health - MPH / Long waiting times have, for many years, been synonymous with primary health care in South Africa, and this is evident by the long queues and consistent client dissatisfaction. There are multiple contributing factors that exacerbate waiting time in Primary Health Care (PHC) facilities such as shortage of health care providers, increase in the uninsured population and South Africa’s quadruple burden of diseases. Health establishments have initiated numerous strategies to reduce long waiting times with varying degrees of success. These strategies have mostly been quantified and linked to indicators to measure their level of success in relation to quality healthcare. This research explores the clients’ perception of one such intervention, which is the implementation of an appointment system in primary care facilities in the City of Cape Town. Qualitative, exploratory descriptive methods were used to gain understanding of the impact the appointment system has had on the clients’ experience of attending health care services. The researcher also explored how clients perceive their role with regard to the shaping of their clinic’s appointment system. Semi-structured in-depth interviews were conducted with fifteen purposively sampled clients from five City Health clinics, who have implemented an appointment system through the guidance of the Appointment System Learning Initiative (ASLI). Maximum variation in sampling ensured the inclusion of small, medium and larger facilities within different geographical settings. Data analysis was done using a thematic coding approach, the themes were derived from the emerging data and were used to guide the researcher in gaining a rich picture of the clients’ experiences within the clinics. Ethical approval was requested and received from both the University of the Western Cape (UWC) and City Health prior to engaging any participants.

Thesis advisor: Barbara E. Wolfe / Patient quality outcomes in the United States (U.S.) healthcare system are largely stagnant or making minimal improvements, resulting in unnecessary morbidity, mortality, and costs (AHRQ, 2012 National Healthcare Quality Report). As the US implements the 2010 Patient Protection and Affordability Act, there is fiscal pressure to attain and sustain significant improvements to patient quality outcomes. This necessitates an understanding of how the processes and structures of care influence patient quality outcomes (Donabedian, 1966) in a complex care environment. To begin addressing this gap, this investigation examined the influence of unit-level authentic leadership (AL) and structural empowerment (SE) on staff nurse decisional involvement (DI) and patient quality outcomes on general care units in the acute-care hospital setting. This study used a cross-sectional survey design. Participants were staff nurses working on 105 general care units across eleven US hospitals. The surveys measured staff nurse perceptions of AL, SE, and DI at the care unit level. The patient quality outcomes of interest were falls with injury, hospital acquired pressure ulcers and patient satisfaction. Care unit level AL and SE had a significant influence on actual staff nurse DI (p = .002 and < .001, respectively) and the degree of dissonance between actual and preferred DI (p < .001). AL and SE had a significant inverse relationship with patient falls with injury (p = .017 and .028, respectively), yet a positive relationship with HAPU rates (p = .051 and .026, respectively). While AL did not have a significant relationship with any of the three patient satisfaction metrics, a significant positive relationship with SE was found (p = .002, .001, and .002, respectively). There was no support for a relationship between actual staff nurse DI and any of the patient quality outcomes. This study extends previous research in this area in that it is the first to examine actual patient quality outcomes at the care unit level. These findings provide support for the unique contributions to patient quality outcomes at the care unit level, indicating the need to develop AL among front-line nurse managers and SE in nurse work environments. / Thesis (PhD) — Boston College, 2015. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Thesis advisor: Kathleen McInnis-Dittrich / Cancer caregivers are key stakeholders across the cancer trajectory, particularly in the final weeks of life and the bereavement period that follows. Current measures are limited in capturing caregiver assessment of the quality of end-of-life (EOL) care. Because none include caregiver perception of patient suffering or prolongation of death, the author sought to develop and validate a new measure of caregiver-perceived quality of EOL care that includes these dimensions. Data for this study comes from Coping with Cancer (CwC), a multisite, prospective, longitudinal study of advanced cancer patients and their caregivers (N=275 dyads). CwC investigators interviewed cancer patients and caregivers prior to the patient's death, and then caregivers again following the patient's death, on a range of psychosocial issues related to EOL care and bereavement. The present study represents a refinement of the author's previous work in developing and validating the Caregiver Evaluation of Quality of End-of-Life Care (CEQUEL) scale, a comprehensive measure of caregiver-perceived quality of EOL care. Factor analysis revealed four distinct factors: Prolongation of Death, Perceived Suffering, Shared Decision-Making, and Preparation for the Death. Each item loaded strongly on only a single factor. The author examined the new measure's factor structure, and evaluated its reliability (using Cronbach's α) and convergent validity (via associations between CEQUEL and key EOL outcomes). CEQUEL and its subscales showed moderate to acceptable Cronbach's α (range: 0.52-0.78). Higher scores (indicating better perceived quality of care) were positively associated with therapeutic alliance (ρ=.13; p≤.05) and hospice enrollment (z=-2.09; ≤;.05), and negatively associated with bereaved caregiver regret (ρ=-.36, p≤.001) and a diagnosis of Posttraumatic Stress Disorder (z=-2.06; p≤.05). Scores did not vary by caregiver characteristics other than religious affiliation, with Catholics scoring lower than non-Catholics, and those without religious affiliation scoring lower than those with an affiliation. Models predicting CEQUEL scores were compared using multiple regression analysis and AICc values. In unadjusted analyses, dying in a hospital, inpatient hospice length of stay (LOS) < 1 week, patients feeling seen as a whole person by their physician, and caregiver religiosity predicted CEQUEL scores. Only dying in a hospital (B=-1.65, SE=0.42, p=0.000) and inpatient hospice LOS < 1 week (B=-1.87, SE=-.69, p=0.008) remained significant in adjusted analysis. These findings suggest that CEQUEL is a brief, valid measure of quality of EOL care from the caregiver's perspective. This study also identifies key factors that can be modified to improve caregiver evaluation of quality of care and associated bereavement outcomes. CEQUEL is the first scale of its kind to include perceived suffering and prolongation of death. If validated in future work, it may prove a useful quality indicator for the delivery of EOL care and a risk indicator for poor bereavement adjustment. Implications for research, clinical practice and policy are discussed. / Thesis (PhD) — Boston College, 2013. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

In 2014, Louisiana experienced substantive issues with quality of care in nursing homes. The state had the lowest nurse staffing level among all states, and 7,666 deficiencies for immediate jeopardy violations were recorded from 2011 to 2013. Despite ample research on nurse staffing and quality of care, there is no consensus on how higher nurse staffing relates to quality. The purpose of this quantitative, correlational research was to determine the relationship between nurse staffing levels and quality measures in Louisiana. Donabedian's category structure, process, and outcome was the conceptual framework used to develop the research questions. The data included the quality of care deficiency score and the quality measures found in the Centers for Medicare and Medicaid datasets. The quality measures were the deficiencies and the prevalence of nursing home residents with pressure ulcers, urinary tract infections, and physical restraints. Generalized linear models were used to analyze the relationship between nurse staffing levels and the quality measures. The findings suggested that RNs, nonprofits, chain-affiliated nursing homes, and smaller facilities are important to improve the quality of care in Louisiana nursing homes. These variables were associated with fewer quality of care deficiencies and fewer pressure ulcers. These findings have implications for social change. This information may help inform and direct policy makers in the development and implementation of Medicaid-managed long-term services and supports programs in order to improve the quality of care of a vulnerable population: the elderly and disabled.

The need to address the issue of quality in aged care service provision in Australia has received increasing emphasis in recent decades. Particularly since the 1980s, the federal government has played a key role in ensuring that this is the case through the implementation of various reforms and regulatory strategies. In 1998, the national standards monitoring system which had been in place since the mid 1980s was replaced with a new system based on an accreditation model. In contrast to the former system which was wholly controlled by government and involved one-off inspections by government standards monitors, responsibility for managing the new system has been devolved to an independent body, the Aged Care Standards and Accreditation Agency. One of the Agency's primary functions is to assess compliance with the accreditation standards. A key component of the new system is its emphasis on continuous improvement which has been incorporated into the accreditation standards. As a consequence, the new system requires a much greater level of involvement and commitment by providers than previously. In order to continue receiving government funding all facilities had to be accredited by January 1st 2001. This study represents an evaluation of the accreditation system based on the views and experiences of service providers in Western Australia. It explored a number of issues relating to the basic philosophy and principles underlying the new system, the implementation process, the accreditation standards that are used as a basis for assessing service quality and the overall impact of the system on providers. It also sought providers' views about the strengths and limitations of the system and any areas in need of change or improvement. A descriptive design, using in-depth interviews as the method of data collection, was adopted for the study. / Participants from three levels of service provision, namely, facilities, organisations and peak bodies were selected on a stratified purposive basis. A total of 45 informants were interviewed. The findings indicated that, overall, as a regulatory approach the accreditation system was generally supported by providers and was regarded as having a number of positive features, particularly in comparison to the previous system. At the same time a number of concerns were identified. These related in particular to the assessment process, specifically the lack of consistency amongst assessors and the self assessment tool, and to the extent of information and guidance provided by the Agency. Concerns regarding the latter's role in relation to, and extent of independence from, the federal government were also identified. The study also found that the introduction of the system had impacted on providers in a variety of ways, both positive and negative, but particularly in terms of the demands on staff and financial resources. A number of 'broader' level factors, such as funding, nursing shortages and other often competing demands (e.g. assessing residents according to the Resident Classification Scale) were also felt to be impacting on providers' capacity to meet the requirements of the system. These concerns, along with concerns about the way in which the system would develop in the future, appear to have created a degree of uncertainty and in some cases apprehension amongst many providers. Although this study has focused on the experiences of Western Australian service providers, evidence from other reviews of the accreditation system where providers' views have been sought has indicated a widespread similarity in perceptions. This suggests, therefore, that there is a need for further review and refinement of certain aspects of the system as it moves into the second round.

The researcher examined the experiences of three directors of child care centers that had been accredited by the National Association for the Education of Young Children (NAEYC) and six directors of child care centers that had not yet reached accreditation status. The nature and meaning of these experiences was explored through interviews with each of the directors individually, and then with each mentor and her two protégés. The purpose of this study was to understand how a mentoring program promotes change in child care programs and how that change impacts the quality of care, if, in fact, it does. Using the constant comparative method, three major findings emerged. The first finding was the critical issue of identifying, screening, and selecting protégés to participate in the Director's Mentoring Project (DMP). Factors that result in protégés remaining in the program include self-selection, having previously met or heard of the mentors themselves, awareness of accreditation standards and procedures, and knowledge of and concern about quality care for young children. The second and third findings were intertwined. They had to do with the models of mentoring used and the nature of the relationship between the mentors and protégés. The mentors and the protégés utilized a model of mentoring that was based on their understanding that the primary goal of the DMP was to either gain NAEYC-accreditation status for the center itself or to provide professional and personal support to the protégé directors. While all the mentors began the program with accreditation as their primary goal, those who developed a close and empathic relationship with their protégés came to believe that support of the directors was primary. The former utilized a more goal-oriented model of mentoring; the latter utilized a more affective model of mentoring. The nature of the mentor-protégé relationship formed a continuum from instrumental to personal and developmental. Where the mentors and protégées fell on the continuum paralleled their understanding of the purpose of the project and the model of mentoring that was adopted.

Background: In health care services, equity is the delivery of similar care for similar needs (horizontal equity), and the delivery of more care for higher needs (vertical equity). This study assessed the extent to which primary care provision is equitable across gender, age and socioeconomic groups, and whether any observed disparity is associated with the type of primary care remuneration model to which a family practice belongs. Remuneration models include Fee For Service in which the physician is paid for each encounter, Salary where payment is fixed for the number of hours worked, and Capitation where payment is tied to the number of patients under the care of the provider, and very little or no additional compensation is provided for each patient encounter. // Methods: This thesis used data from a cross sectional study of 5,361 patients receiving care from practices (n) in which primary care providers were remunerated by Fee For Service (35), Salary (35), or Capitation (68). Multi-level linear or logistic regressions were used to assess the impact of gender, age and socioeconomic strata on quality of care. The quality of health service delivery and health promotion were assessed through surveys based on the Primary Care Assessment Tool (n=5,111). The quality of preventive care (n=4,108) and chronic disease management (n-514) were evaluated through chart abstraction using the Canadian recommendations for care as the standard. The analyses were conducted stratified by remuneration model to allow the impact of the model on the extent of disparity in quality of care between social strata to be assessed. // Results: Men and women reported similar quality of health service delivery. Women were significantly more likely to be up to date on their preventive care, but adherence to recommended guidelines for chronic disease management was better for men in the Fee For Service practices. Older individuals reported better health service delivery than younger ones. The quality of chronic disease management was also age dependent with better care delivered to individuals ages 60-69. Individuals of low income and education had better accessibility than those not disadvantaged in the Salaried model and Fee For Service, but not Capitation model. Despite their higher health risks, these individuals were not more likely to receive healthy lifestyle counseling. // Conclusions: Significant inequalities in the care of patients were found across social strata. In some cases, these inequalities are deemed appropriate; a justifiable response to differing health care needs. In other cases, they are deemed inappropriate and representing inequities in the delivery of care. Some of the observed disparities were present in one remuneration model but not others, suggesting that the payment approach may be contributing to these differences. The results raise the concern that the capitation remuneration structure may compromise accessibility.

This study examined the potential impact on processes of care and patient outcomes upon exposure of supportive and concurrent care provided by primary care providers (PCPs) to their hospitalized patients. A secondary objective was to describe the PCPs who conduct these services, and the patients who receive them. There was a marked, observable trend that PCP visits to their hospitalized patients is on the decline (dropped 10% between 2003 and 2009). The patients who received in-hospital visits from their PCPs had more disease burden and were hospitalized longer than the control group. Patients who received and in-hospital visit from their PCP were more likely to receive home care services and PCP visits post-discharge [adjusted OR 1.20 (95% CI 1.12-1.28)]. They were also less likely to experience the composite outcome of death, hospital readmission, or emergency department visit [aOR 0.95 (95% CI 0.91-0.98)].

This study examined the potential impact on processes of care and patient outcomes upon exposure of supportive and concurrent care provided by primary care providers (PCPs) to their hospitalized patients. A secondary objective was to describe the PCPs who conduct these services, and the patients who receive them. There was a marked, observable trend that PCP visits to their hospitalized patients is on the decline (dropped 10% between 2003 and 2009). The patients who received in-hospital visits from their PCPs had more disease burden and were hospitalized longer than the control group. Patients who received and in-hospital visit from their PCP were more likely to receive home care services and PCP visits post-discharge [adjusted OR 1.20 (95% CI 1.12-1.28)]. They were also less likely to experience the composite outcome of death, hospital readmission, or emergency department visit [aOR 0.95 (95% CI 0.91-0.98)].

Patients are the recipients of the provision of healthcare and an invaluable source when evaluating the quality of healthcare provided in our hospitals. There is limited research evaluating patient perceptions of overall quality of healthcare. A larger study Convergence and Divergence in Perspectives in Quality represented the first Saskatchewan effort to explore patient perceptions and what aspects patients indicate as important when evaluating the provision of quality of care. In the larger study, patients hospitalized with one of four tracer conditions (cerebral vascular accident, myocardial infarction, prostate disease and hysterectomy) were surveyed about their involvement in and satisfaction with the provision of healthcare. The present study, using a data subset of the larger study, specifically explored patients perceptions on their involvement in decision-making, feelings of being well informed of ones medical condition, and sources of health information. These perceptions were correlated with the overall ratings of quality of care. Findings indicated a moderately high overall rating of quality of care. Increased involvement in decision making regarding medical care and options for treatment, and the feelings of being fairly or well informed were associated with higher ratings of overall quality of care. While few of the correlations reached greater than moderate effect, it is still clear that opportunities for patients participation in decisions related to their medical care and patients feelings of being fairly or well informed contributed to overall perceptions of quality of care. The majority of patients preferred their doctor or nurse to provide information about their medical condition, thus indicating the human touch is still preferred. Nurses can use these results to advocate for time to ensure patients have access to correct information and are included in decisions about their care.