Service Improvement Programme Research Articles

The CORE Service Improvement Programme for mental health crisis resolution teams: study protocol for a cluster-randomised controlled trial.

BackgroundAs an alternative to hospital admission, crisis resolution teams (CRTs) provide intensive home treatment to people experiencing mental health crises. Trial evidence supports the effectiveness of the CRT model, but research suggests that the anticipated reductions in inpatient admissions and increased user satisfaction with acute care have been less than hoped for following the scaling up of CRTs nationally in England, as mandated by the National Health Service (NHS) Plan in 2000. The organisation and service delivery of the CRTs vary substantially. This may reflect the lack of a fully specified CRT model and the resources to enhance team model fidelity and to improve service quality. We will evaluate the impact of a CRT service improvement programme over a 1-year period on the service users’ experiences of care, service use, staff well-being, and team model fidelity.Methods/designTwenty-five CRTs from eight NHS Trusts across England will be recruited to this cluster-randomised trial: 15 CRTs will be randomised to receive the service improvement programme over a 1-year period, and ten CRTs will not receive the programme. Data will be collected from 15 service users and all clinical staff from each participating CRT at baseline and at the end of the intervention. Service use data will be collected from the services’ electronic records systems for two 6-month periods: the period preceding and the period during months 7-12 of the intervention. The study’s primary outcome is service user satisfaction with CRT care, measured using a client satisfaction questionnaire. Secondary outcomes include the following: perceived continuity of care, hospital admission rates and bed use, rates of readmission to acute care following CRT support, staff morale, job satisfaction, and general health. The adherence of the services to a model of best practice will be assessed at baseline and follow-up. Outcomes will be compared between the intervention and control teams, adjusting for baseline differences and participant characteristics using linear random effects modelling. Qualitative investigations with participating CRT managers and staff and programme facilitators will explore the experiences of the service improvement programme.DiscussionOur trial will show whether a theoretically underpinned and clearly defined package of resources are effective in supporting service improvement and improving outcomes for mental health crisis resolution teams.Trial registrationCurrent Controlled Trials ISRCTN47185233Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1283-7) contains supplementary material, which is available to authorized users.

Do multimorbidity and deprivation influence patients’ emotional expressions and doctors’ responses in primary care consultations? – An exploratory study using multilevel analysis

ObjectiveTo explore whether and how patient multimorbidity and socioeconomic deprivation might influence patients’ emotional expression and doctors’ responses in the general practice (GP) consultations. MethodsVideo recordings of 107 consultations (eight GPs) were coded with the Verona Coding Definitions of Emotional Sequences (VR-CoDES). Multilevel logistic regressions modelled the probability of GP providing space response, considering patient multimorbidity, deprivation conditions and other contextual factors. Further multinomial regressions explored the possible impact of multimorbidity and deprivation on expression of and specific responses to patients’ emotional distress. ResultsIt was less likely for GPs to provide space as the consultation proceeded, controlling for multimorbidity and deprivation variables. Patients with multimorbidity were less likely to express emotional distress in an explicit form. GPs were more likely to provide acknowledgement to emotions expressed by patients from more deprived areas. ConclusionMultimorbidity and deprivation may influence the dynamics of the GP consultations in specific ways. Rigorous methodologies using larger samples are required to explore further how these two variables relate to each other and influence cue expression, provider response and subsequent patient outcomes. Practice implicationsUnderstanding how multimorbidity and deprivation impact on GP consultations may help inform future service improvement programmes.

Developing junior doctors as leaders of service improvement

Purpose – This paper aims to provide an overview of the design and initial outcomes of a leadership and service improvement program for junior medical staff. Design/methodology/approach – This paper describes the rationale, initial set-up, structure, program outcomes and future directions of the Medical Service Improvement Program for junior doctors. This program is a recent initiative of the Western Australian public healthcare system. Findings – The Medical Service Improvement Program illustrates a successful approach to developing junior doctors to lead improvements in health service delivery. The program has resulted in tangible personal outcomes for participants, in addition to important organisational outcomes. Practical implications – This paper provides an evidence-based structured approach to developing the leadership abilities of junior medical staff. It provides practical information on the design of the leadership program that aligns the participant learning outcomes to postgraduate medical competencies. The program has demonstrated clear service outcomes, confirming that junior medical staff is both capable and committed to leading service improvement and reform. Originality/value – This paper provides clear evidence for the benefits of providing dedicated non-clinical time for junior medical staff to lead quality and improvement initiatives. This case study will assist hospital administrators, postgraduate education units and those involved in designing and administering clinical leadership development programs.

The burden of adult asthma in a high GDP per capita country: the QASMA study

BackgroundAsthma is a major health problem worldwide. Suboptimal asthma care and poor asthma control are common even in developed countries. Qatar has the highest gross domestic product per capita in the world and high per capita health expenditure. No prior study has assessed the burden of adult asthma in this country. ObjectivesTo assess asthma control, patients' level of education about asthma, and level of asthma care in a country with the highest gross domestic product per capita in the world. MethodsA face-to-face, cross-sectional study of 520 adults with physician-diagnosed asthma conducted in various health care facilities in Qatar. ResultsThirty-three percent, 41%, and 26% of patients had uncontrolled, controlled, and partly controlled asthma, respectively. Only 4.9% of patients had previously received a written asthma management plan, 3.5% had a flow meter at home, and 37.2% had a spirometry performed in the previous 5 years. In addition, 42.9% misunderstood the role of reliever and controller medications. Inhaler technique was incorrect in 47% of these patients. There was a significant association between the type of physician practice and level of asthma control, with worst control being at the general practice level. Moreover, 57.3% of patients had at least 1 asthma-related visit to the emergency department in 1 year and 18.7% had more than 3 visits. ConclusionThe very high gross domestic product per capita in Qatar and the high health expenditure per capita do not seem to have led to better asthma care and control. A comprehensive national asthma service improvement program is much needed.

MEASUREMENT FOR IMPROVEMENT: END OF LIFE CARE IN ACUTE HOSPITALS

Background‘Measurement for improvement (MfI)’ is a structured methodology to develop and use metrics to support effective change management.1 2 It differs from measurement for accountability and approaches used in clinical...

TRANSFORMING END OF LIFE CARE IN ACUTE HOSPITALS – HOW TO SET UP A TRUST WIDE PROJECT WITH BOARD LEVEL SUPPORT

BackgroundThe Leeds Teaching Hospitals NHS Trust (LTHT) is a flagship Trust for the NHSIQ ‘Transforming End of Life Care (EoLC) in Acute Hospitals programme’ .Previous EoLC initiatives had been led...

P67 Using a service evaluation to drive change and improve quality

IntroductionDreams Come True is a national charity providing dreams for children age 2–21 with life-threatening and life-limiting conditions. As part of our overall commitment in our 25th year to improving...

Conséquences de la mise en place du programme Norwich de récupération accélérée après prothèse totale de hanche ou de genou

To report the analysis of the initial rehabilitation results of the Norwich Enhanced Recovery Programme (NERP), regime with increased postoperative physiotherapy input following total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed under spinal anaesthetic with wound catheter infiltration. A secondary analysis of a service improvement programme was undertaken from an acute national health service hospital in the United Kingdom. Ninety-five patients listed for THA ( n = 67) or TKA ( n = 28) were reviewed during the first six postoperative weeks. All received an enhanced postoperative programme including commencement of mobilisation 4 hours postoperatively and physiotherapy interventions a minimum of twice daily during hospital admission. The primary outcome measure was the Iowa Level of Assistance Score at discharge. Secondary outcomes included length of hospital stay (LOS), visual analogue scale pain at discharge and complications during the initial six postoperative weeks. The NERP is a successful rehabilitation regime for patients following THA and TKA, facilitating early safe discharge (mean LOS = 3.5 days) with minimal complications. Patients who commenced mobilisation on the day of the operation reported significantly reduced pain score ( p = 0.02) and length of stay ( p < 0.01) compared to those who did not. Thirty-four percent of patients were discharged with rollator frames. Whilst the early results of the NERP allow patients who have undergone THA or TKA surgery a short hospital length of stay, its demand on outreach physiotherapy suggests that the availability of such community services is imperative to ensure the appropriate progression of rehabilitation. Level IV – retrospective series.

Rehabilitation implications during the development of the Norwich Enhanced Recovery Programme (NERP) for patients following total knee and total hip arthroplasty

To report the analysis of the initial rehabilitation results of the Norwich Enhanced Recovery Programme (NERP), regime with increased post-operative physiotherapy input following total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed under spinal anaesthetic with wound catheter infiltration. A secondary analysis of a service improvement programme was undertaken from an acute National Health Service Hospital in the United Kingdom. Ninety-five patients listed for THA (n=67) or TKA (n=28) were reviewed during the first six post-operative weeks. All received an enhanced post-operative programme including commencement of mobilisation four hours post-operatively and physiotherapy interventions a minimum of twice daily during hospital admission. The primary outcome measure was the Iowa Level of Assistance Score at discharge. Secondary outcomes included length of hospital stay (LOS), visual analogue scale pain at discharge and complications during the initial six post-operative weeks. The NERP is a successful rehabilitation regime for patients following THA and TKA, facilitating early safe discharge (mean LOS=3.5days) with minimal complications. Patients who commenced mobilisation on the day of the operation reported significantly reduced pain score (p=0.02) and length of stay (p<0.01) compared to those who did not. Thirty-four percent of patients were discharged with rollator frames. Whilst the early results of the NERP allow patients who have undergone THA or TKA surgery a short hospital length of stay, its demand on out-reach physiotherapy suggests that the availability of such community services is imperative to ensure the appropriate progression of rehabilitation. Level IV-retrospective series.

P94 Transforming acute care in COPD: findings from a national programme of service improvement

IntroductionRespiratory disease presents a significant financial burden to the UK. 40% of the cost of managing respiratory disease is spent on hospital admissions. Admissions for respiratory disease account for 12%...

The experience of patients with complex wounds and the use of NPWT in a home-care setting

To explore the experience of patients living with complex wounds and the impact of undergoing negative pressure wound therapy (NPWT) as part of their treatment. Qualitative data were collected from eight patients, using semi-structured interviews. A purposive, stratified sampling approach was used to identify participants with a range of wound types, as well as age and gender. Participants were recruited from one primary care trust and were interviewed, following 10 days of treatment with NPWT. The matrix-based 'Framework' approach, from the National Centre for Social Research, was used to structure the analysis. Of the eight participants recruited, five were female and three male, with an age range of 46-77 years. Five overarching categories, with their constituent themes, were identified from the data. The first, developing a wound through crisis, has three themes: a failing body, missed diagnosis and failed professional intervention. The second category, decreased control, has four related themes: poor communication; failed wound healing; poor discharge planning and failure to recover. The third category, increased control, has four themes: understanding what is happening; symptom control; positive professional relationships and returning to health. The fourth category, using NPWT, has two themes: information and understanding of NPWT and expectations and experience of NPWT. The final category sets out participant recommendations about the device and has two themes: device issues and improving professional practice. This study investigated the experience of patients undergoing NPWT for complex wounds in the home setting and reveals a number of the psychosocial effects of using this therapy in this environment. Participants saw NPWT as an active intervention, associated with improved wound healing and symptom control. The participant experience described in this study, and the recommendations they make, provide a valuable resource to inform service improvement programmes and wound research. This study was supported by a research grant from Smith & Nephew Ltd.

Improving teamwork, trust and safety: An ethnographic study of an interprofessional initiative

This study explored the perceptions of staff in an interprofessional team based on a medical rehabilitation ward for older people, following the introduction of a service improvement programme designed to promote better teamworking. The study aimed to address a lack of in-depth qualitative research that could explain the day-to-day realities of interprofessional teamworking in healthcare. All members of the team participated, (e.g. nurses, doctors, physiotherapists, social worker, occupational therapists), and findings suggest that interprofessional teamworking improved over the 12-month period. Four themes emerged from the data offering insights into the development and effects of better interprofessional teamworking: the emergence of collegial trust within the team, the importance of team meetings and participative safety, the role of shared objectives in conflict management and the value of autonomy within the team. Reductions in staff sickness/absence levels and catastrophic/major patient safety incidents were also detected following the introduction of the service improvement programme.

PENGARUH KUALITAS PELAYANAN SAMSAT DRIVE THRU TERHADAP KEPUASAN MASYARAKAT DI POLDA METRO JAYA

Quick Wins program that prioritizes transparency is a program to improve job performance by means of maximizing public services. One of the police service improvement program to the public is the process of issuance of Vehicle registration plates (vehicle registration). This is accomplished by holding Samsat Drive Through; the vehicle registration renewal management services by using information technology facilities. Generally, This study aims to measure public satisfaction regarding the services of Samsat Drive Thru given by Polda Metro Jaya (Jakarta Police Department). This study uses quantitative approach with survey methods. Results of the study proved a link between the quality Samsat Drive Thru service and satisfaction the user community at Polda Metro Jaya. Furthermore there is a strong enough influence between quality Samsat Drive Thru service and public satisfaction in the Polda Metro Jaya. While the factors that affect the quality of Samsat Drive Thru service to the public satisfaction at Polda Metro Jaya is community participation, awareness of law and public compliance with laws and legislation especially in the field of traffic is increasing.

A major trauma centre is a specialty hospital not a hospital of specialties

High estimates of preventable death rates have renewed the impetus for national regionalization of trauma care. Institution of a specialist multidisciplinary trauma service and performance improvement programme was hypothesized to have resulted in improved outcomes for severely injured patients. This was a comparative analysis of data from the Royal London Hospital (RLH) trauma registry and Trauma Audit and Research Network (England and Wales), 2000-2005. Preventable mortality was evaluated by prospective analysis of the RLH performance improvement programme. Mortality from critical injury at the RLH was 48 per cent lower in 2005 than 2000 (17.9 versus 34.2 per cent; P = 0.001). Overall mortality rates were unchanged for acute hospitals (4.3 versus 4.4 per cent) and other multispecialty hospitals (8.7 versus 7.3 per cent). Secondary transfer mortality in critically injured patients was 53 per cent lower in the regional network than the national average (5.2 versus 11.0 per cent; P = 0.001). Preventable death rates fell from 9 to 2 per cent (P = 0.040) and significant gains were made in critical care and ward bed utilization. Institution of a specialist trauma service and performance improvement programme was associated with significant improvements in outcomes that exceeded national variations.

The Prostate Care Questionnaire for Patients (PCQ-P): Reliability, validity and acceptability

BackgroundIn England, prostate cancer patients report worse experience of care than patients with other cancers. However, no standard measure of patient experience of prostate cancer care is currently available. This paper describes an evaluation of the reliability, validity and acceptability of the PCQ-P, a newly developed instrument designed to measure patient experience of prostate cancer care.MethodsThe reliability, acceptability and validity of the PCQ-P were tested through a postal survey and interviews with patients. The PCQ-P was posted to 1087 prostate cancer patients varying in age, occupation, and overall health status, sampled from five hospitals in England. Nonresponders received one reminder. To assess criterion validity, 935 patients were also sent sections of the National Centre for Social Research Shortened Questionnaire; and to assess test-retest reliability, 296 patients who responded to the questionnaire were resent it a second time three weeks later. A subsample of 20 prostate cancer patients from one hospital took part in qualitative interviews to assess validity and acceptability of the PCQ-P. Acceptability to service providers was evaluated based on four hospitals' experiences of running a survey using the PCQ-P.ResultsQuestionnaires were returned by 865 patients (69.2%). Missing data was low across the sections, with the proportion of patients completing less than 50% of each section ranging from 4.5% to 6.9%. Across the sections of the questionnaire, internal consistency was moderate to high (Cronbach's alpha ranging from 0.63 to 0.80), and test-retest stability was acceptable (intraclass correlation coefficients ranging from 0.57 to 0.73). Findings on criterion validity were significant. Patient interviews indicated that the PCQ-P had high face validity and acceptability. Feedback from hospitals indicated that they found the questionnaire useful, and highlighted important considerations for its future use as part of quality improvement initiatives.ConclusionThe PCQ-P has been found to be acceptable to patients and service providers, and is ready for use for the measurement of patient experience in routine practice, service improvement programmes, and research.

The Trauma Centre: a specialty hospital, not a hospital of specialties

Background Trauma is a leading cause of death and disability in England and Wales, with 16,000 injury deaths per year. High estimates of preventable death rates have renewed the impetus for national regionalisation of major trauma to specialist centres. We hypothesized that the institution of a specialist multidisciplinary trauma service and performance improvement programme had resulted in significant improvements in outcomes in excess of any observed national changes.

P-73 Podiatry training on the diabetic foot for nursing and medical staff in the Central East Division of Fiji

Our staff were invited to become involved in the Fiji Health Service Improvement Program, an AusAID funded program for the Central East Division of Fiji Ministry of Health. Interviews with key stakeholders and staff revealed that diabetic foot complications are a large concern for staff and locals, and a major burden on the Colonial War Memorial hospital in Suva. Podiatrists developed a training package on the diabetic foot covering basic anatomy, pathophysiology, diabetic foot complications, identification of the ‘at risk’ foot, infection, debridement and wound management skills including choice of appropriate wound dressings. This package was to be delivered to nursing and medical staff, as the podiatry profession is not currently supported in Fiji. Podiatrists conducted their 2 single day courses and additional time was allocated to visit wards, assist staff with outpatient management and meet key stake holders. Primitive means of wound management, along with a poor understanding of how diabetes affects the feet were identified, and infection was noted to be a major complication in many wounds. Three additional visits have been proposed for 2007-2008 but a number of trips have been cancelled due to the civil unrest in the country. The goals of podiatry intervention are to: 1. Specially train nursing staff at the National Centre for Diabetes in the management of the high risk foot including wound management, pressure care and dressings. 2. Educate staff from nursing stations in outlying communities on screening and early identification of diabetes and foot complications and appropriate referral. 3. Reduce hospital length of stay through improved management of foot complications. 4. Advocate for better dressings and equipment. 5. Be a resource for advising on the most effective allocation of the International Diabetes Federation funding that was recently granted to the area.

Use of electronic pagers to recall patients undergoing outpatient-based chemotherapy

Long waiting times while receiving chemotherapy in an outpatient setting have been identified as contributing to patient dissatisfaction and discomfort by a number of authors. Following an observation of this practice in a non-medical establishment, and as part of our service improvement program, we introduced the use of message pagers to recall patients in our chemotherapy outpatient service. We audited the impact of this intervention by means of questionnaires directed at patients and nursing staff. Our audit found that this intervention was particularly popular with female patients. Perceived benefits included more freedom of movement, less boredom, and peace of mind at being contactable. There were no reported problems with pager operation. Nursing staff were keen promoters of the pagers to patients as they felt that their use gave them more control over work intensity and less disruption from patients enquiring about remaining "waiting time". We concluded that this intervention may benefit other outpatient chemotherapy services.

LibQUAL+(™) 2002 at Vanderbilt University

The Jean and Alexander Heard Library at Vanderbilt University was one of 164 libraries that participated in the spring 2002 LibQUAL+(™) survey. Nine hundred and thirty-four individuals (27.2% response rate) responded to over 25 survey items measuring four dimensions of library service quality. Our analysis of the resulting data has allowed the Library to identify more clearly areas of service needing improvement to better meet our users' expectations. Additionally, we are able to consider our scores in comparison with other peer institutions. Library management will continue to analyze the results and consider additional service improvements. Meanwhile, two immediate actions are underway-the establishment of a 24-hour library facility on a trial basis and the development of a service improvement program across the Vanderbilt University library system.

Improving the effectiveness of banks' service guarantees: The role of implementation

The negative impact of frequent service delays on customer loyalty and retention is widely recognised. To address this issue, many banks have initiated some form of service improvement programme and attempted to communicate the change to their existing and prospective customers. Often, however, this rightfully sceptical audience continues to doubt the provider's ability to resolve the problem and may not notice service improvement even when it is achieved. Service guarantees are a powerful mechanism for firms to express their commitment to satisfaction as well as their willingness to compensate customers in the event of service failure. This paper presents the results of a multi-stage study of a major bank's effort to provide a wait-time guarantee. The potential value of the guarantee to customers, the impact of the guarantee on customer dissatisfaction following a negative service experience, and customers' willingness to invoke the guarantee are examined. The implications of the findings highlight the role of implementation in a successful guarantee programme. Recommendations for improving banks' service guarantees are provided.