Continuous quality improvement in an acute hospital: a report of an action research project in three hospital departments

Using participatory research to identify actionable facilitators and barriers to effective inpatient interdisciplinary communication

BACKGROUND

Communication failures occur often in the inpatient setting. Efforts to understand and improve communication often exclude patients or are siloed by discipline.

OBJECTIVE

We aimed to identify barriers and facilitators to effective communication within interdisciplinary inpatient internal medicine (IM) teams using a participatory research approach.

DESIGN

We conducted a single-center participatory mixed methods study using group-level assessment (GLA) and concept mapping to iteratively engage stakeholders. Stakeholder groups included patients/families, IM faculty, IM residents, nurses and ancillary staff, and care managers. Stakeholder-specific GLA sessions were conducted. Participants responded to prompts addressing interdisciplinary communication then worked in small groups to synthesize the qualitative data into unique ideas. A subset of each stakeholder group then sorted ideas through a concept mapping exercise. Multidimensional scaling and hierarchical cluster analysis were used to generate a concept map of the data.

RESULTS

Participants generated 97 unique ideas that were then sorted. The research team chose an eight-cluster concept map representing patient inclusion and engagement, processes and resources, team morale and inclusive dynamics, attitudes and behaviors, effective communication, barriers to communication, the culture of healthcare, and clear expectations. Three larger domains of patient inclusion and engagement, organizational conditions and role clarity, and team dynamics and behaviors were noted.

CONCLUSION

Use of a participatory research approach made it feasible to engage diverse stakeholders including patients. Our results highlight the need to identify context-specific facilitators and barriers of interdisciplinary communication. The importance of clear expectations was identified as a prioritized area to target communication improvement efforts.

Perceived Quality and Users’ Satisfaction with Public–Private Partnerships in Health Sector

In Portugal, the government has accepted private management within public hospitals since 1996. The objectives of the state were to ensure more efficiency in resource management and maintain or increase the service quality provided to the users. Four public hospitals have been managed with a public–private partnership (PPP) approach. This study aimed to empirically analyse the degree of satisfaction of the Portuguese population regarding the service quality provided by PPP and Public Management Hospitals (PMH) within a structural equation model, and verify if people’s literacy level, age, education, and income moderate their opinions. The study used 2077 valid questionnaire responses applied in the four regions served by the eight hospitals. The results show that the users of the PPP hospitals are more satisfied than those from PMH with statistical significance. Literacy level moderates the relationship between perceived quality and users’ satisfaction, and education moderates the same relationship only in the context of PPP hospitals. More educated people with a high literacy level are more demanding, both regarding PPP and PMH hospitals. Nevertheless, the results are very beneficial to the PPP model; thus, improved decision-making regarding contract renewal might help policymakers consider the findings of this paper.

Adaptation of the balanced scorecard model to measure performance of the departments at Dr Zainoel Abidin Regional General Hospital, Banda Aceh

Purpose

This paper aims to determine the performance of the departments at Dr Zainoel Abidin Regional General Hospital, Banda Aceh, Indonesia, in 2016, based on the targets and realization of their work programs using balanced scorecard.

Design/methodology/approach

This study adopted qualitative and quantitative approaches.

Findings

The overall results of the performance appraisal using the balanced scorecard approach seen from the financial, internal business, customer and training and learning perspectives are good. Dr Zainoel Abidin Regional General Hospital has provided good services, and performance of its departments have generated the expected outcome, realized by the Hospital.

Originality/value

The novelty of the present study lies in its research model, where human resources (transformational leadership, organizational commitment and resource uniqueness) and financial management (business plans, budget and performance).

Sustaining improvement? The 20-year Jönköping quality improvement program revisited

BACKGROUND

There is scarce evidence of organization-wide and sustained impact of quality improvement (QI) programs in health care. For 20 years, the Jönköping County Council's (Sweden) ambitious program has attracted attention from practitioners and researchers alike.

METHODS

This is a follow-up case of a 2006 study of Jönköping's improvement program, triangulating data from 20 semi-structured interviews, observation and secondary analysis of internal performance data.

RESULTS

In 2010, clinical outcomes had clearly improved in 2 departments (pediatrics, intensive care), while process improvements were evident in many departments. In an overall index of the 20 Swedish county councils' performance, Jönköping had improved its ranking since 2006 to lead in 2010. Five key issues shaped Jönköping's improvement program since 2006: a rigorously managed succession of chief executive officer; adept management of a changing external context; clear strategic direction relating to integration; a broadened conceptualization of "quality" (incorporating clinical effectiveness, patient safety, and patient experience); and continuing investment in QI education and research. Physician involvement in formal QI initiatives had increased since 2006 but remained a challenge in 2010. A new clinical information system was being deployed but had not yet met expectations.

CONCLUSIONS

This study suggests that ambitious approaches can carry health care organizations beyond the sustainability threshold.

Trans-disciplinary community groups: an initiative for improving healthcare

PURPOSE

In the context of budget constraints and the current quality crisis facing UK healthcare, the purpose of this paper is to examine the use of trans-disciplinary community groups (TCG)--an innovative and inexpensive initiative for improving patient care.

DESIGN/METHODOLOGY/APPROACH

Using an action research study, TCG was implemented within a private healthcare firm for vulnerable adults. Qualitative data were gathered over 12 months from 33 participants using depth interviews and focus groups.

FINDINGS

TCG led to improved patient activities and increased patient decision-making and confidence in self-advocacy. Key prerequisites were top management commitment, democratic leadership and employee empowerment. However, staff nurses resisted TCG because they were inclined to using managerial control and their own independent clinical judgements.

RESEARCH LIMITATIONS/IMPLICATIONS

Whilst the findings from this study should not be generalized across all healthcare sectors, its results could be replicated in contexts where there is wide commitment to TCG and where managers adopt a democratic style of leadership. Researchers could take this study further by exploring the applicability of TCG in public healthcare organizations or other multi-disciplinary service contexts.

PRACTICAL IMPLICATIONS

The findings of this research paper provide policy makers and healthcare managers with practical insights on TCG and the factors that are likely to obstruct and facilitate its implementation.

ORIGINALITY/VALUE

Adopting TCG could enable healthcare managers to ameliorate their services with little or no extra cost, which is especially important in a budget constraint context and the current quality crisis facing UK healthcare.

Obstacles to TQM success in health care systems

PURPOSE

Many healthcare organisations have found it difficult to implement total quality management (TQM) successfully. The aim of this paper is to explore the barriers to TQM successful implementation in the healthcare sector.

DESIGN/METHODOLOGY/APPROACH

This paper reports a literature review exploring the major reasons for the failure of TQM programmes in healthcare organisations.

FINDINGS

TQM implementation and its impact depend heavily on the ability of managers to adopt and adapt its values and concepts in professional healthcare organisations. Unsuccessful TQM efforts in healthcare organisations can be attributed to the strongly departmentalised, bureaucratic and hierarchical structure, professional autonomy, tensions between managers and professionals and the difficulties involved in evaluating healthcare processes and outcomes. Other obstacles to TQM success include lack of consistent managers' and employees' commitment to and involvement in TQM implementation, poor leadership and management, lack of a quality-oriented culture, insufficient training, and inadequate resources. The review was limited to empirical articles written in the English language during the past 30 years (1980-2010).

PRACTICAL IMPLICATIONS

The findings of this article provide policy makers and managers with a practical understanding of the factors that are likely to obstruct TQM implementation in the healthcare sector.

ORIGINALITY/VALUE

Understanding the factors that obstruct TQM implementation would enable managers to develop more effective strategies for implementing TQM successfully in healthcare organisations.

A critical study of quality parameters in health care establishment: developing an integrated quality model

PURPOSE

The purpose of this article is to identify and critically analyze healthcare establishment (HCE) quality parameters described in the literature. It aims to propose an integrated quality model that includes technical quality and associated supportive quality parameters to achieve optimum patient satisfaction.

DESIGN/METHODOLOGY/APPROACH

The authors use an extensive in-depth healthcare quality literature review, discerning gaps via a critical analysis in relation to their overall impact on patient management, while identifying an integrated quality model acceptable to hospital staff.

FINDINGS

The article provides insights into contemporary HCE quality parameters by critically analyzing relevant literature. It also evolves and proposes an integrated HCE-quality model.

RESEARCH LIMITATIONS/IMPLICATIONS

Owing to HCE confidentiality, especially regarding patient data, information cannot be accessed.

PRACTICAL IMPLICATIONS

The integrated quality model parameters have practical utility for healthcare service managers. However, further studies may be required to refine and integrate newer parameters to ensure continuous quality improvement.

ORIGINALITY/VALUE

This article adds a new perspective to understanding quality parameters and suggests an integrated quality model that has practical value for maintaining HCE service quality to benefit many stakeholders.

Private healthcare quality: applying a SERVQUAL model

PURPOSE

This paper seeks to develop and test the SERVQUAL model scale for measuring Malaysian private health service quality.

DESIGN/METHODOLOGY/APPROACH

The study consists of 340 randomly selected participants visiting a private healthcare facility during a three-month data collection period. Data were analyzed using means, correlations, principal component and confirmatory factor analysis to establish the modified SERVQUAL scale's reliability, underlying dimensionality and convergent, discriminant validity.

FINDINGS

Results indicate a moderate negative quality gap for overall Malaysian private healthcare service quality. Results also indicate a moderate negative quality gap on each service quality scale dimension. However, scale development analysis yielded excellent results, which can be used in wider healthcare policy and practice.

RESEARCH LIMITATIONS/IMPLICATIONS

Respondents were skewed towards a younger population, causing concern that the results might not represent all Malaysian age groups.

ORIGINALITY/VALUE

The study's major contribution is that it offers a way to assess private healthcare service quality. Second, it successfully develops a scale that can be used to measure health service quality in Malaysian contexts.

Determinants of quality management systems implementation in hospitals

OBJECTIVE

To identify the problems and facilitating factors in the implementation of quality management system (QMS) in hospitals through a systematic review.

METHOD

A search strategy was performed on the Medline database for articles written in English published between 1992 and early 2006. Using the thesaurus terms 'Total Quality Management' and 'Quality Assurance Health Care', combined with the term 'hospital' and 'implement*', we identified 533 publications. The screening process was based on empirical articles describing organization-wide QMS implementation. Fourteen empirical articles fulfilled the inclusion criteria and were reviewed in this paper.

RESULTS

An organization culture emphasizing standards and values associated with affiliation, teamwork and innovation, assumption of change and risk taking, play as the key success factor in QMS implementation. This culture needs to be supported by sufficient technical competence to apply a scientific problem-solving approach. A clear distribution of QMS function within the organizational structure is more important than establishing a formal quality structure. In addition to management leadership, physician involvement also plays an important role in implementing QMS.

CONCLUSIONS

Six supporting and limiting factors determining QMS implementation are identified in this review. These are the organization culture, design, leadership for quality, physician involvement, quality structure and technical competence.

The impact of multi-skilled staff availability on day surgery cancellations

This paper outlines a study undertaken by Helen Lloyd to assess the impact of multi-skilled theatre practitioners on reducing cancellations in stand alone day surgery units in England and Wales. The author provides the background to the study together with an overview of the results. The literature review undertaken before the study is published in full. It identifies what factors influence the efficiency of day surgery and operating theatre facilities, traditional staffing of operating theatres and day surgery facilities, together with other influencing factors for theatre utilisation. The author recieved partial funding from ERFF to complete her MBA in Health Service Management at Greenwich School of Management (accredited to University of Hull) in 2007.

Project management and action research: two sides of the same coin?

PURPOSE

To put forward the, to date, unidentified viewpoint that organisational action research and project management have many shared properties--making it a useful exercise to compare and contrast them in relation to organisational management structures and strategies.

DESIGN/METHODOLOGY/APPROACH

A conceptual exploration, drawing on a wide range of supporting literature, is used here.

FINDINGS

Project management represents a mainstay strategy for much of the organisational research seen in health care management--and has done for many years. More recently, the exploratory literature on project management has identified many limitations--especially when matched against "traditional" examples. Many health services have witnessed a more recent organisational management drive to seek out alternative strategies that incorporate less hierarchical and more participatory research methods. Action research certainly fits this bill and, on further examination, can be incorporated into a project management ethos and vice versa.

RESEARCH LIMITATIONS/IMPLICATIONS

The views expressed here are of a theoretical construct and have not been implemented, as they are presented in this paper, in practice. The intention, however, is to do so in some of the author's future studies.

PRACTICAL IMPLICATIONS

If the management of health service organisations are to evolve to incorporate desirable structures that promote consumer-oriented empowerment and participation (where the consumers also include the workforce), then having a wider array of research tools at one's disposal is one way of facilitating this. Incorporating action research principles into project management approaches, or the other way round, or marrying them both to form a "hybrid" research strategy--it is argued here--represents an appropriate and representative way forward for future organisational management studies.

ORIGINALITY/VALUE

In terms of originality, this represents a conceptual piece of work that puts forward constructs that have, to date, not featured in the health care literature. Its value lies in suggesting further options for organisational-oriented health care research.

Smoking care provision in smoke-free hospitals in Australia

BACKGROUND

The study aimed to (1) determine the current routine smoking care that smoke-free public hospitals in New South Wales (NSW), Australia, provide to inpatients who are smokers; (2) determine current strategies supporting such care; and (3) examine the association between smoking care provision and hospital characteristics and support strategies.

METHOD

A cross-sectional survey of 169 senior hospital managers was undertaken. Survey items included smoking care practices such as identification of smoking status and provision of nicotine replacement therapy as well as hospital activities such as existence of policies and staff training. Hospital characteristics such as size and geographic location were also collected.

RESULTS

Twenty percent of respondents reported provision of minimally 'adequate' smoking care, defined as providing five or more smoking care items to 80% or more of patients. Larger hospitals were significantly less likely to provide adequate smoking care. Nurse training, the existence of signs indicating a smoke-free site and signs indicating location of designated smoking areas were also associated with smoking care provision. The existence of three or more support strategies was associated with smoking care provision.

CONCLUSION

Even in the context of a smoke-free hospital site, the majority of inpatients who are smokers receive inadequate smoking care. Considered investment is required for hospitals to implement strategies to institutionalise the routine provision of appropriate smoking care.

Hospital service quality: a managerial challenge

While much is known generally about predictions of customer-perceived service quality, their application to health services is rarer. No attempt has been made to examine the impact of social support and patient education on overall service quality perception. Together with six quality dimensions identified from the literature, this study seeks to provide a more holistic comprehension of hospital service quality prediction. Although 79 percent of variation is explained, other than technical quality the impact of the remaining factors on quality perception is far from constant, and socio-economic variables further complicate unpredictability. Contrary to established beliefs, the cost factor was found to be insignificant. Hence, to manage service quality effectively, the test lies in how well healthcare providers know the customers they serve. It is not only crucial in a globalized environment, where trans-national patient mobility is increasingly the norm, but also within homogeneous societies that appear to converge culturally.

Getting going together: can clinical teams and managers collaborate to identify problems and initiate improvement?

A clear aim is key for the success of improvement projects, yet many fail already at this stage. We studied how clinical teams and managers at a university hospital in Sweden identified problems and defined aims as they initiated 24 process improvement projects. Categorizing and comparing problems at 3 stages of problem definition, we found that the majority of problems fell into 1 of 3 categories: information issues, poor procedures, and waiting times. Going through these stages, managers and clinical teams prioritized waiting-time problems. We show how managers can ask such teams to quickly identify problems suited for improvement projects through this step-wise, facts-based approach. We conclude that they can add their management perspective when giving specific assignments, to harness the combined benefits of both a bottom-up and a top-down approach to improvement.

Autonomy and modernisation: the management of change in an English primary care trust

Recent New Labour policy for the 'modernisation' of Government places a good deal of emphasis on decentralisation. This emphasis is particularly marked in relation to the organisation of primary care. However, like hospitals and other National Health Service institutions, primary care trusts (PCTs) are subject to a substantial raft of centrally established performance targets and indicators, including those which contribute to the public award of between zero and three performance 'stars'. This raises questions about the extent to which employees can exercise autonomy in the context of rigid top-down directives. This paper presents findings from a study using participant observation and interviews to examine the impact of a training course aimed ostensibly at increasing employee autonomy in an English PCT. The suggestion is that attempts to make employees more autonomous can be seen as a strategy for increasing central control based upon the internalisation by the employees of centrally promulgated values. The attraction of such strategies is that they may be potentially more effective and less costly than alternative strategies of direct control. However, the study suggests that the outcome of attempts by such methods as programmes to increase employee autonomy may be very different from those intended.

Continuous quality improvement in pressure sore prevention

The final article in this series examining the draft national clinical guidelines for pressure sore prevention and management considers continuous quality improvement. Different professions use different terminologies to describe quality assurance: nurses link it to 'standard setting' whereas the medical profession uses the term 'medical audit'. This article discusses the concepts of quality and audit in relation to pressure sores and their prevention. In particular, it addresses the importance of scientific rigour and multidisciplinary team working and management involvement.