Families who are dissatisfied with the nursing home care of their family member may supplement their care by hiring a private companion. Families who have the financial resources pay for extra care, while families who cannot afford a private companion receive the current standard of care. Anecdotal evidence suggests that private companion use has increased over time. However, there is no research that examines private companions. The goal of this mixed methods study was to provide empirical evidence about who private companions are, what they do, and why they are needed. Andersen and Newman’s Health Service Utilization Model was used to understand private companion use. This study used both survey research and grounded theory. A mailed survey was completed by 280 of 432 family members of nursing home residents in a Toronto nursing home, yielding a response rate of 65 percent. Grounded theory principles were used to conduct interviews with 10 family members to understand why private companions were hired. Almost two-thirds of nursing home residents had a private companion. Family members reported that they paid about $475 per week for private companions who provided about 40 hours of care per week. Private companions were mostly women and immigrants. Private companions performed many activities including assisting with activities of daily living, toileting, feeding, escorting to activities, and providing social support. In the survey, family members reported hiring a private companion for reasons related to families’ needs (e.g. quality of care concerns), residents’ needs (e.g. deteriorating health); and staff recommendations. The family members reiterated these reasons in the interviews. Quality of care was the overarching theme that captured the reason for private companion use, which encompassed the following themes: inadequate staffing, unmet residents’ needs, overburdened family members, and suboptimal nursing home environment. The qualitative data emphasized the importance of building relationships with nursing home residents. The predictors of private companion use in the multivariate analysis were longer duration of nursing home stay, higher resident dependency, and family members’ concerns with quality of care. This research is among the first to study private companions, and has implications for research, policy, and practice.

Families who are dissatisfied with the nursing home care of their family member may supplement their care by hiring a private companion. Families who have the financial resources pay for extra care, while families who cannot afford a private companion receive the current standard of care. Anecdotal evidence suggests that private companion use has increased over time. However, there is no research that examines private companions. The goal of this mixed methods study was to provide empirical evidence about who private companions are, what they do, and why they are needed. Andersen and Newman’s Health Service Utilization Model was used to understand private companion use. This study used both survey research and grounded theory. A mailed survey was completed by 280 of 432 family members of nursing home residents in a Toronto nursing home, yielding a response rate of 65 percent. Grounded theory principles were used to conduct interviews with 10 family members to understand why private companions were hired. Almost two-thirds of nursing home residents had a private companion. Family members reported that they paid about $475 per week for private companions who provided about 40 hours of care per week. Private companions were mostly women and immigrants. Private companions performed many activities including assisting with activities of daily living, toileting, feeding, escorting to activities, and providing social support. In the survey, family members reported hiring a private companion for reasons related to families’ needs (e.g. quality of care concerns), residents’ needs (e.g. deteriorating health); and staff recommendations. The family members reiterated these reasons in the interviews. Quality of care was the overarching theme that captured the reason for private companion use, which encompassed the following themes: inadequate staffing, unmet residents’ needs, overburdened family members, and suboptimal nursing home environment. The qualitative data emphasized the importance of building relationships with nursing home residents. The predictors of private companion use in the multivariate analysis were longer duration of nursing home stay, higher resident dependency, and family members’ concerns with quality of care. This research is among the first to study private companions, and has implications for research, policy, and practice.

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.

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.

none

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: There is little information on how the quality of oral health services in long-term care (LTC) facilities is conceptualized or assessed. Objectives: This study aims to develop a model for assessing the quality of oral healthcare services in LTC facilities. Methods: This study is divided into four main steps. Firstly, I examined literature for existing concepts relating to program evaluation and quality assessment in healthcare to build a theoretical framework appropriate to dental geriatrics. Secondly, I explored as an ethnographic case study a comprehensive oral healthcare program within a single administrative group of 5 LTC facilities in a large metropolis by interviewing 33 participants, including residents and their families, nursing staff, administrators and dental personnel. I also examined policy documents and made site visits to identify other attributes influencing the quality of the program. Thirdly, I drafted the assessment model combining a theoretical framework with empirical information from the case study. And lastly, I tested the feasibility and usability of the model in another dental geriatric program in northern British Columbia. I applied the assessment model by conducting 15 interviews with participants in the program, made site-visits to the 5 facilities, and reviewed documents on the development and operation of the program. Results: A combination of theory-based evaluation and quality assurance provided six sequential and iterative steps for quality assessment of oral health services in LTC. The empirical information supported the theoretical framework that a program of oral healthcare in a LTC context should be assessed for quality from multiple perspectives; it should be comprehensive; and it should include the three main attributes of quality - capacity, performance, and outcomes. Participants revealed 20 quality indicators along with suggested program objectives which encompass eight quality dimensions such as effectiveness, efficiency, and patient-centered. Conclusion: The model provides a unique system for assessing the quality of dental services in LTC facilities that seems to meet the needs of dental and non-dental personnel in LTC.

Background: We evaluated the validity of a set of 11 quality indicators for prostate cancer radiotherapy and radical prostatectomy by examining their association with outcomes. The selected indicators were: hospital volume, pre-treatment risk assessment, patient consultation with a radiation oncologist, appropriate follow-up care, leg immobilization during radiotherapy, bladder filling during radiotherapy, portal film target localization, use of nerve sparing surgery, operative blood loss, margin status and pelvic lymph node dissection. The selected outcomes were: cause-specific survival, disease-free survival, late morbidity (urinary incontinence, gastrointestinal and genitourinary morbidity), change in node stage from clinical N0 to pathologic N1, and margin status. Methods: Our study sample consisted of 1570 prostate cancer patients who were diagnosed in Ontario between January 1, 1990 and December 31, 1998 who received radical prostatectomy within 6 months of diagnosis (n=646), or curative radiotherapy within 9 months of diagnosis (n=924). Quality of care, outcomes, and potential confounders were measured using patient chart and administrative data. Regression techniques were used to evaluate the associations between quality indicators and relevant outcomes. Results: For patients treated surgically, hospital volume met our test of validity. Patients treated in the lowest volume hospital (0-1 RP/month) were at greater risk of prostate cancer death than patients treated in the highest volume hospitals (7+ RP/month) (HR=5.37 95% CI=1.23-23.46). For patients treated with radiotherapy, leg immobilization and bladder filling during radiotherapy met our test of validity. Patients treated without leg immobilization were more likely to experience urinary incontinence (RR=2.18, 95% CI=1.23-3.87) and genitourinary late morbidities (RR=1.72, 95% CI=1.16-2.56) than patients who received leg immobilization. Patients who were treated with an empty bladder were more likely to experience GU late morbidities (RR=1.98, 95% CI=1.08-3.63) than those treated with a full bladder. The remaining indicators did not meet our test of validity. Conclusion: Our results support the validity of one surgical quality indicator and two radiotherapy quality indicators. Explanations for our non-significant findings, including limited study power, data quality, our definition and measurement of indicators, and a true failure to predict outcome(s) are discussed, and recommendations for further research are presented. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2011-09-07 20:26:34.461

Background: The goal of this study was to improve upon methodological limitations of previous studies to determine the existence and source of differences in the cardiac care of individuals with a history of depression or schizophrenia. The selected outcomes were three cardiac procedures: catheterization, percutaneous transluminal coronary angiography (PTCA), and coronary artery bypass graft (CABG); and three cardiac pharmaceuticals: beta-blockers, angiotensin converting enzyme (ACE) inhibitors and statins. Methods: This population-based retrospective cohort study consisted of 309, 790 individuals diagnosed with an AMI and admitted to an acute care hospital in Ontario between April 1, 1995 and March 31, 2009. The time-to-intervention for the depression and schizophrenia was estimated and compared to those without a mental disorder using Cox Proportional Hazards regression. Subgroup analyses were performed to evaluate the interaction between well-established confounders and the receipt of a cardiac intervention. Results: Persons with a history of depression were found to be more likely to receive a catheterization (HR=1.42, 95% CI=1.34-1.50) or PTCA (HR=1.48, 95% CI=1.40-1.57) if they had no previous CVD history, but were less likely to receive a catheterization (HR=0.71, 95% CI=0.51-0.99) or PTCA (HR=0.64, 95% CI=0.39-1.06) if they had a CVD history. In addition individuals with depression were less likely to receive a CABG, especially if they had a history of CVD (HR=0.38, 95% CI=0.24-0.60). Persons with a history of schizophrenia were found to be just as likely to receive a catheterization (HR=0.90, 95% CI=0.70-1.15) or a PTCA (HR=0.83, 95% CI=0.62-1.11). The likelihood of receiving a beta-blocker or statin was comparable or higher for persons with a history of depression (HR=1.07, 95% CI=1.03-1.11; 1.27, 95% ii i CI=1.22-1.32, respectively) and comparable for persons with a history of schizophrenia (HR=0.90, 95% CI=0.79-1.02; HR=0.97, 95% CI=0.83-1.14, respectively), with a small but significant prior drug use effect modification. Interpretation: Persons with depression or schizophrenia with no CVD history are just as likely to receive most recommended cardiac care interventions compared to those without a mental disorder. The source of the differences in care for individuals with a CVD history with depression and schizophrenia needs to be further explored. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-01-26 11:17:27.964

Maternal and perinatal mortality is one of the biggest challenges to public health, especially in developing countries. South Africa?s health care system is struggling to meet the “health for all” criteria against a backdrop of staff shortages (especially midwives) in an HIV/AIDS epidemic. These factors, together with the economic constraints of a developing country, places great demands on delivering cost–effective, safe, quality intrapartum care that exceeds expectations. The challenge for the manager is to organise the available resources to render the best quality of care cost effectively within the shortest period of time. Various reasons exist for the alarming shortage of nurses and midwives globally and also in South Africa. Unhealthy practice environments are the main cause of the problem as such environments have an impact on the job satisfaction of the midwives as well on patient satisfaction. In the turmoil of the health care system, patients are demanding greater quality of care and are insisting not only on excellent clinical skills, but also on empathetic and personalised care. This research was conducted to make a meaningful contribution to the body of knowledge, specifically knowledge related to quality intrapartum care through the development of a Quality Improvement Intervention Programme (QIIP?). The research was conducted in two phases including five objectives. The first objective gave a theoretical foundation of quality intrapartum care. The second objective included a situational analysis of the resources (personnel and equipment) and determine the quality improvement initiatives that could be implemented for intrapartum care. The third objective determined the practice environment in maternity units at Level 2 hospitals in the North West province that may influence quality intrapartum care. The fourth and last objective of Phase 1 determined the perceptions of management and midwives regarding the facilitating and impeding factors that influence the quality of intrapartum care. From the data that emerged from the first four objectives, specific themes kept repeating themselves, namely structure (what must be in place, e.g. infrastructure and human resources), process (what we do, e.g. life–long learning and implementation of policies) and outcome (the results, e.g. patient satisfaction and a positive practice environment). These collectively contribute to the quality of intrapartum care rendered. Phase 2 consisted of the development of a “Quality Improvement Intervention Programme (QIIP?)” for intrapartum care. In this phase the data from the first four objectives were used to develop the QIIP?. The QIIP? will be marketed as an accreditation tool for maternity units to measure themselves against the best in the world. Qualifying for QIIP? accreditation means improving the quality of intrapartum care resulting in satisfied patients, the establishment of a positive practice environment and a decrease in the Maternal Mortality Rate (MMR). / Thesis (Ph.D. (Nursing))--North-West University, Potchefstroom Campus, 2011.