Delivery Of Hospital Services Research Articles

Clinical Pharmacist Staffing Levels Needed to Deliver Clinical Services in Australian Hospitals

ABSTRACTBackgroundThe Society of Hospital Pharmacists of Australia's (SHPA) Standards of practice for clinical pharmacy list 10 activities pharmacists undertake to provide a comprehensive clinical service to inpatients and the staffing level needed to deliver this service (based on bed type). Time motion data from a recent Australian study could be used to elucidate the number of beds for which a pharmacist can provide clinical services (based on time taken for individual clinical activities).AimTo calculate the number of patients/inpatient beds for which a pharmacist can provide clinical services.MethodA profile of clinical pharmacy activities and how often they need to be delivered to meet the SHPA Standards was developed for different patient types. Formulae were developed and populated with the time motion data to calculate clinical pharmacist staffing levels.ResultsStaffing levels for 7 categories of patients/inpatient beds were elucidated. These calculations suggest the clinical pharmacist to bed type ratios described in the SHPA Standards considerably underestimate the time required to deliver a comprehensive clinical pharmacy service.ConclusionTimes per activity used in this exercise are conservative and provide the maximum number of patients for which a pharmacist can provide clinical services. These staffing levels could be used to allocate resources to achieve agreed clinical pharmacy service delivery in Australian hospitals.

Putting science to work for health care reform: how much research is available to support improvements to our hospitals?

To assess how much Australian research is available to inform reform of hospital services. Bibliographic analysis using a MEDLINE search to locate all research publications focused on the organisation and delivery of Australian hospital services for the period 1996 through 2007. Number of peer-reviewed articles published by year and categorised by: study design (descriptive, methodological, intervention); type of intervention; clinical focus; and funding source. 679 articles on the organisation and delivery of Australian hospital services were published in peer-reviewed journals from 1 January 1996 to 31 December 2007. Of these, 57% were empirical research reports and 43% were commentaries. There were, on average, 32 empirical research articles per annum. Of the empirical research articles, 70% were descriptive, 23% tested an intervention, and 7% were methodological. Research output increased over time with increases in commentary and descriptive research being the main contributors to this trend. The main funding bodies for this research were universities and government departments. A small but growing amount of local research is available to support reform of Australian hospital services. To boost the amount of relevant research evidence, we need to: build formal partnerships between researchers, policymakers, clinicians and health service managers; make targeted investment in health systems and services research; and increase the use of routinely collected data for research.

Antecedents of Medical Workplace Violence in South China

It has been noted that workplace violence most frequently occurs in hospitals. The purpose of this study was to explore antecedents of workplace violence in south China. The authors conducted face-to-face, in-depth, semistructured interviews with 30 hospital staff who had experienced at least one incident of workplace violence from patients during the past 12 months at three general hospitals in south China. The interviews were tape-recorded, then transcribed, and analyzed. The authors' analyses identified five major antecedents of workplace violence. First, 93.0% of medical workplace violence was related to insufficient communication between hospital staff and patients. Second, inadequate medical service quality was found to be a factor in 56.7% of the incidences. Third, unsatisfactory treatment outcome was reported in 60.0%. Fourth, heavy workload accounted for 43.3%. Fifth, patient frustration due to high medical expenses was reported in 40.0% of cases. The authors recommended a reengineering of hospital service delivery to create a more supportive and safer working environment for prevention of workplace violence.

Medically-managed Hospital in the Home: 7 year study of mortality and unplanned interruption

Hospital in the Home (HIH) research is characterised by small samples in new programs. We sought to examine a large number of consecutive HIH admissions over many years in an established, medically-managed HIH service in to determine whether: (1) HIH is a safe and effective method of delivering acute hospital care, under usual operating conditions in an established unit; and (2) what patient, condition and treatment variables contribute to a greater risk of failure. A survey of all patients admitted to a medically-managed HIH unit from 2000-2007. A total of 3423 admissions to HIH were examined. Of these 2207 (64.5%) were admitted directly into the HIH from Emergency Department or rooms, with the remainder admitted from hospital wards. A total of 26,653 HIH bed days were delivered. with a mean of 9.3 nursing visits and 4.1 medical visits per admission. A total of 143 patients (4.2%) required an interruption via an unplanned return to hospital; 106(3.1%) did not subsequently return to HIH. The commonest reason for unplanned returns to hospital were: no clinical improvement; cardiac conditions; fevers; breathlessness and pain. Patients over the age of 50, and those receiving intravenous antibiotic therapy, were more likely to require a return to patients died unexpected mortality rate of 0.15%. This sample of HIH patients is five time the number of HIH patients ever enrolled in randomised trials studies of this area. Further, outcomes were achieved in 'ordinary' working conditions over a long time period. Care was completed without interruption (return to hospital) in 95.8% of all episodes. Interruption was associated with patients referred from impatient wars, older patients who were treated with intravenous antibiotics, Patients referred from Emergency Departments experienced fewer interruptions. Nursing home residents were no more likely to required an interruption to their HIH care.

Autonomy and Control in Public Hospital Reforms in Singapore

The Singapore government began to reform public hospitals in the mid-1980s because of mounting public expenditures on health care. It granted public hospitals managerial autonomy and required them to compete for patients' fees. Correspondingly, patients were required to pay a larger proportion of the costs. When subsequent evidence showed that costs were increasing rather than decreasing, in the mid-1990s the government began to reassert its control while retaining the essence of the earlier reforms. In recent years, the reforms have emphasized management autonomy coupled with strong government guidance. This article assesses the autonomy and control mechanisms in place to promote effective service delivery in public hospitals in Singapore and concludes that reliance on market competition requires more state intervention than often realized. For market competition to deliver outcomes that are not only economically efficient and consumer-friendly but also politically acceptable, constant governmental oversight and coordination is essential.

Tendências na assistência hospitalar

This paper analyses trends in the delivery of hospital services in Brazil, considering the setting, the current situation and its challenges, examining what still remains to be done. The variables studied for the analysis of the setting are: demography, epidemiological profile, human resources, technology, medicalization, costs, review of the role of the citizen, legislation, equity, hospital-centricity and regionalization, care fractioning and bed availability. The Brazilian setting was studied through the supplementary healthcare model, financing and the healthcare area production chain. The observations of the current situation present external evaluation models, outsourcing, public-private relationships, de-hospitalization and financing. The analysis of the challenges examines the need for long range planning, the quest for new legal models for the 'business', the use of information and information systems, cost controls and the need for enhanced efficiency and compliance with legal directives, guaranteed universal access to full healthcare facilities, the inclusion of primary prevention in healthcare procedures, integrating the public and private sectors and engaging physicians in solving problems.

What is the effectiveness of acute hospital treatment of older people with mental disorders?

To appraise the effectiveness of acute hospital service delivery in old age psychiatry. A systematic literature search of the Medline, PsycINFO, CINAHL, EMBASE and Cochrane Collaboration databases was undertaken to obtain articles published in English from 1966 to May 2004 about old age psychiatry services. Articles were excluded if they did not focus on subjects over 60 years of age, did not include quantitative data on outcomes, or if the intervention was purely pharmacological or a specific non-pharmacological technique. The two authors independently assessed data quality. The overall quality of the evidence for the effectiveness of old age mental health service delivery was rated on an evidence hierarchy that has four levels of evidence. Forty-six studies were identified that met our criteria. The only randomized controlled trials (RCTs) were of consultation/liaison service provision and delirium prevention and hence the best quality evidence is for interventions to prevent delirium, reduce costs and length of stay (LOS) in medical wards (level II). There is lower quality (level III/IV), albeit consistently positive, evidence that acute hospital treatment by old age psychiatry services is effective. By contrast, there is no evidence (level I) that non-psychiatric hospital medical services improve mental health outcomes. There are gaps in our knowledge regarding the effectiveness of acute hospital treatment of mental disorders in old age. Multicenter studies involving comparisons of day hospitals, multidisciplinary community teams and acute hospital settings (old age mental health and adult mental health, with and without post-discharge community care) are required.

Patient‐centred improvements in health‐care built environments: perspectives and design indicators

To explore patients' perceptions of health-care built environments, to assess how they perceived health-care built facilities and designs. To develop a set of patient-centred indicators by which to appraise future health-care designs. Qualitative and quantitative methodologies, including futures group conferencing, autophotographic study, novice-expert exchanges and a questionnaire survey of a representative sample of past patients. The research was carried out at Salford Royal Hospitals NHS Trust (SRHT), Greater Manchester, UK, selected for the study because of planned comprehensive redevelopment based on the new NHS vision for hospital care and service delivery for the 21st century. Participants included 35 patients who took part in an autophotographic study, eight focus groups engaged in futures conferencing, a sample of past inpatients from the previous 12 months that returned 785 completed postal questionnaires. The futures group provided suggestions for radical improvements which were categorized into transport issues; accessibility and mobility; ground and landscape designs; social and public spaces; homeliness and assurance; cultural diversity; safety and security; personal space and access to outside. Patients' autophotographic study centred on: the quality of the ward design, human interactions, the state and quality of personal space, and facilities for recreation and leisure. The novices' suggestions were organized into categories of elemental factors representing patient-friendly designs. Experts from the architectural and surveying professions and staff at SRHT in turn considered these categories and respective subsets of factors. They agreed with the novices in terms of the headings but differed in prioritizing the elemental factors. The questionnaire survey of past patients provided opinions about ward designs that varied according to where they stayed, single room, bay ward or long open ward. The main concerns were limitation of private space around the bed area, supportive of privacy and dignity, ward noise and other disturbances. Patients perceived sustainable health-care environments to be supportive of their health and recovery. The design indicators developed from their perspectives and from their considerations for improvements to the health-care built environment were based on their visions of the role of the health-care facilities. These were homely environments that supported normal lifestyle and family functioning and designs that were supportive of accessibility and travel movements through transitional spaces.

What experts say about managing hospitality service delivery systems

An extensive review of literature was conducted to see if there was evidence indicating there are differences in the management of hospitality organizations and manufacturing organizations. The literature was divided into three areas: organizing, staffing, and commanding. The results of the review indicate that there are a number of differences between managing a manufacturing firm and a hospitality firm. The review serves as a foundation for managers and researchers to better understand the unique challenges of managing hospitality organizations.

A management information system to plan and monitor the delivery of health-care services in government hospitals in India.

Governments all over the world are getting increasingly concerned about their ability to meet their social obligations in the health sector. In this paper, we discuss the design and development of a management information system (MIS) to plan and monitor the delivery of healthcare services in government hospitals in India. Our MIS design is based on an understanding of the working of several municipal, district, and state government hospitals. In order to understand the magnitude and complexity of various issues faced by the government hospitals, we analyze the working of three large tertiary care hospitals administered by the Ahmedabad Municipal Corporation. The hospital managers are very concerned about the lack of hospital infrastructure and resources to provide a satisfactory level of service. Equally concerned are the government administrators who have limited financial resources to offer healthcare services at subsidized rates. A comprehensive hospital MIS is thus necessary to plan and monitor the delivery of hospital services efficiently and effectively.

Educating for rural nursing practice.

Rural hospitals in Australia, as in many countries, face challenges in ensuring that appropriate, quality services are provided. The overall aim of this study was to explore the issues that impact on the ability of rural hospitals to provide effective health care. We used a qualitative descriptive method and purposive sampling, and conducted interviews in hospitals in rural Victoria, Australia. The data collected enabled major issues that impact on hospital service delivery to be identified. Using thematic analysis, global themes were extracted and organized around a thematic network. The workforce was an important theme. Whilst the impact of medical shortages on hospital function has been considered in other studies, little consideration has been given to the rural nursing workforce. The need to maintain an appropriately educated rural nursing workforce emerged as one of the major issues that impact on rural hospital service delivery. In Australia, there has been a great deal of discussion about the educational preparation required for rural nursing practice, with the emphasis on postgraduate study. However, the majority of rural nurses do not have postgraduate qualifications and face significant barriers in obtaining them. Although the vast majority of literature claims that postgraduate preparation is vital for rural nursing practice, this research suggests that the future rural nursing workforce will be recruited from undergraduate courses in regional universities. However, there is a need to include specific theoretical and operational preparation in undergraduate education, to enable nurses to make the transition to rural practice more readily. Rural nurses are central to the delivery of health services in rural hospitals. Future rural nursing recruitment and retention hinges on ensuring that they have the confidence, knowledge and skills to deliver safe, appropriate and effective care.

A question of place: medical power in rural Australia

In Australia, like many countries, government, medicine and the community have maintained an interdependent and symbiotic relationship based on mutual resource dependency and reciprocity. The services of medicine have been indispensable to government and the community and in return medicine has achieved power, elitism and financial gain. Traditionally, doctors have controlled and directed medical knowledge in an absolute manner and this has been the basis of increasing power and dominance. There are, however, claims that medicine's power and dominance over the health care system is being eroded by the emergence of major social trends. The corporatization of medicine, manageralism and proletarianization are touted as factors that are increasingly countervailing medical dominance and power. Whilst it could be suggested that as these trends become more firmly established government and the community gain greater discretionary control over how the resources of medicine can be allocated and utilized, this article argues that the geographic and social dimensions of the community in which doctors practice must be considered. Using a qualitative descriptive approach research was conducted in rural Victoria, Australia. The overall aim of the study was to identify the issues that impact upon service delivery in rural hospitals. The most significant issue that emerged related to medical relationships. The results of this research indicate that in this rural area the power of medicine is strengthened and institutionalized by geographically determined resource control. The sustainability of rural communities is linked to the ability of the town to attract and retain the services of a doctor. Crucial shortages of rural doctors provide medicine with a mandate to dictate the way in which medical resources will be allocated and used by hospitals and the community. Organizations that control critical resources are in an extremely powerful position to control others. Doctors in rural Victoria maintain a position of strength and use their power to exert control over the state, the community and the hospital. Although medical power and dominance may be declining in some areas, in rural Victoria it remains firmly entrenched.

The Culture of Male Supremacy and Emergency Obstetric Care: The Nigerian Experience

The maternal mortality ratio in Nigeria remains one of the highest in the world (WHO, 1990). Many intervention programs in this area have failed to achieve the desired purpose because efforts have been mainly in the area of hospital care or service delivery, without due cognisance being given to the androcentric behaviour which affects maternal roles, especially the dynamics of decision-making when emergency obstetric care service becomes necessary, Using findings from a recently concluded study, the paper looks at the impact of the culture of male gender supremacy on women's reproductive rights and their total well-being. It explores the gender myths about pregnancy, and pregnancy outcomes, and the central role played by men in emergency obstetric conditions. The study. which is an action-oriented study, was carried out in South-western Nigeria, by a multi-disciplinary research group, using a variety of data collection techniques – questionnaire survey, in-depth interview, Focus Group Discussions, direct observation, and exposure to educative materials – posters, talks/discussions, films, drama etc, Study findings showed that androcentric behaviour is a major determinant of pregnancy outcome, since men have almost absolute control over the choice of health care facilities used during pregnancy, the condition under which delivery takes place, diet during pregnancy, and the types of action taken in emergency obstetric conditions. Yet, the study found that most men lacked knowledge of what constitutes emergency obstetric conditions, appropriate actions to be taken, and a shallow knowledge of pregnancy, fertility and family planning. The study instituted an intervention program which was aimed at improving the knowledge of men in what constitutes emergency obstetric care. and also counselling on androcentric behaviours which may be detrimental to pregnancy outcomes, and the social dynamics of what constitutes a healthy family. (The African Anthropologist: 2002 9 (2): 157-182)

Assessment following deliberate self-harm: who are we seeing and are we following the guidelines?

To determine whether assessments of patients admitted to a general hospital following deliberate self-harm (DSH) were in line with the Royal College of Psychiatrists guidelines. To examine the profile of cases and presentations and to make recommendations for improvements to the service. Clinical and demographic data recorded on 70 admissions after DSH during 1997-98 were analysed retrospectively. A checklist was also developed, using factors shown by previous research to be associated with future risk of suicide, to determine the quality of assessments. The majority (70%) of assessments took place within 24 hours of admission thereby meeting College recommendations. Medical personnel performed all adult assessments. Circumstances of the overdose, recent stresses, psychiatric diagnosis, immediate risk and follow-up arrangements were documented in the majority of cases. Family psychiatric history, past suicidal behaviour, alcohol and drug abuse history, and previous violence, were frequently not documented. A copy of a discharge summary to the GP was found in 41% of charts. Overdoses accounted for 93% of cases of DSH. The most frequently recorded problem (37.5%) was adjustment disorder. Despite evidence showing that non-psychiatric medical staff are competent in assessing DSH and guidelines encouraging multidisciplinary involvement, DSH assessments remain the preserve of the medical psychiatric team. Closer attention should be paid to all the risk factors associated with suicide by assessors; a checklist could prove helpful. There is room for improved communication between psychiatric services and GPs following DSH. The setting up of a self-harm service planning group could improve the co-ordination and efficiency of delivery of general hospital services to this patient group.

Who should see the elderly in general hospitals — Old age or consultation — Liaison psychiatry?

Background: The worldwide ageing of the population is mirrored in the general hospital where the proportion of elderly patients is increasing. In Australia 31% of hospital discharges and 46% of bed days were over 65 years of age in 1997–98. In the US, over the last 15 years the proportion of elderly referrals to consultation liaison (CL) services has increased from around 20–30% to over 50%. Both CL and old age psychiatry are involved in service delivery in Australia without clear direction about which should be primarily responsible.Objective: To determine the most appropriate model of mental health service delivery for the elderly in general hospitals.Method: Literature review utilising Medline, PsychoInfo and Ageline databases supplemented by a manual search of references from relevant literature for studies of CL psychiatry in the elderly.Results: Twenty-seven studies were found that described service delivery in general hospital, 15 by old age psychiatry services and 12 by CL services. The patient pr...

Consumer opinions with ancillary hospital services: improving service delivery in Turkish hospitals.

This article reports the results of 2,045 consumer interviews conducted after discharge from seven major public and private hospitals in the country of Turkey. The direct measurement of consumer-satisfaction and utilization of this information to improve service delivery is a relatively new phenomena for this country. Based on postdischarge consumer interviews information on satisfaction of several ancillary hospital service variables was identified and inclusion for achieving overall consumer satisfaction is emphasized. Two critical areas were examined: ancillary staff and consumer relations and overall impressions of the comfort of the facility. Relationships and percentages within and among these variables are reported. Overall, the majority of the complaints noted by consumers were not related to direct treatment rather they focused on interactions with the hospital's staff and other services provided by the facility (e.g., comfort, cleanliness, parking, etc.). When comparing the different hospitals across these variables significant differences were noted at the .05 level between the seven different hospitals examined. Findings and recommendations from this study are presented to assist in providing a basis for the development of improved consumer satisfaction.

Adults with sickle cell disease: Psychological impact and experience of hospital services

Twenty-seven adults with sickle cell disease previously admitted to hospital during a painful sickling crisis were interviewed in order to explore their experiences of hospital haemoglobinopathy services and the psychological impact of the disease. Evidence was gained of global psychological distress, depression and anxiety in the sample. Patients also reported criticisms of hospital services particularly with regard to staff attitudes and the giving of analgesia. Recommendations are made for improving the delivery of hospital and community services for this population.

The Effectiveness of Inpatient Case Management

Production processes and service delivery in acute care hospitals can be fragmented. Inpatient case management has the potential to improve both processes and outcomes of hospital care. The author reports on 18 research studies that used inpatient case management as the treatment variable. These outcome studies, using case management, did not provide the evidence needed to address deficiencies in inpatient settings. However, these studies do provide clear direction for nurse administrators and nurse researchers to take concerning the next steps needed to address this critical issue.

Developing clinical work processes in a state psychiatric hospital: a case study.

The Texas Department of Mental Health and Mental Retardation applied the continuous quality improvement (CQI) concept of work process to the delivery of clinical services in each of its eight state psychiatric hospitals. Two different clinical processes were involved: (1) individualized psychiatric treatment and (2) medical treatment. The processes were then benchmarked against national leaders in the delivery of public psychiatric hospital services. This case study demonstrates the applicability of the work process concept to a clinical environment where it can function as a management tool that can significantly improve the quality and efficiency of services provided to individual patients.

Hospital services for rural children in Washington State.

To examine the current delivery of inpatient hospital services to a statewide population of rural children, define the types of pediatric conditions currently treated in rural hospitals or transferred to urban centers, and explore the role of rural pediatricians and family practitioners in the care of children in rural hospitals. Retrospective review of statewide hospital discharge data. All patients younger than 18 years of age with nonsurgical diagnoses discharged from both urban and rural civilian hospitals in Washington State during 1989 and 1990. Of 69690 pediatric hospital discharges during the study period, 16% were rural residents and 10% were from rural hospitals. Rural hospitals cared for 59% of hospitalized rural children. Marked differences were found between urban and rural hospitals in the diagnoses treated; more than two-thirds of all discharges for chemotherapy, psychiatric disorders, and neonates with multiple major problems were from urban hospitals; but the majority of the discharges for gastrointestinal diagnoses, respiratory conditions, or minor problems in the neonatal period were from rural hospitals. Rural hospitals with staff pediatricians had higher annual pediatric discharges, total charges, lengths of stay, and case mix with a higher proportion of neonates with complications, compared to hospitals without pediatricians. However, there was no evidence that these hospitals served as local referral centers for rural pediatric inpatients; the proportion of patients from outside the local hospital catchment areas was similar for rural hospitals with staff pediatricians and for those without. In rural hospitals, pediatricians and family practitioners were listed as the attending physician for 37% and 49% of discharges, respectively. The average rural pediatrician cared for five times as many inpatients as a rural family practitioner. Pediatricians cared for significantly more neonates with birth weights of less than 2500 grams, but otherwise had a similar case mix among inpatient discharges as rural family practitioners. Most rural children in Washington who require hospitalization for common problems receive their care in local rural hospitals staffed with pediatricians and family practitioners, although those with illnesses requiring a high level of specialty care are predominantly cared for in urban centers. Rural pediatricians make a substantial contribution to the care of rural children, especially in the area of neonatal care, although their presence in rural hospitals does not in itself create local referral centers. Inpatient volumes are higher for pediatricians, but their case mix is similar to that of rural family practitioners, except in the area of neonatology. These data support the recommendations that family practitioners contemplating rural practice receive training in general inpatient pediatrics (regardless of whether they are going to a site with pediatricians) and that pediatricians in rural practice be trained for a high volume of inpatient cases, including problems of low birth weight infants. Because systems of hospital care for rural children depend on regionalized programs, clinical and educational linkages between urban centers and rural providers should be developed and supported.