The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.

Design history: exploring corporate communities

A design history is a narrative involving a multitude of social groups, interpretive flexibility, and eventual stabilization of shared understanding. Design history surfaces the practices that help shape and define engagements and can increase not only our theoretical understanding of what design is, but also our capacity to realize this understanding in practice. We use a design history perspective to examine how corporate technology initiatives establish and support open source communities and the crafting of relevant design practices that enable their advancement. We foster an evolving expression of design research that treats artifacts not as stable objects to be singularly evaluated, but as evolving systems contingent on historical trajectories.

Dealing with emergent design science research projects in IS

Multiple models, methods and frameworks have been proposed to guide Design Science Research (DSR) application to address relevant classes of problems in Information Systems (IS) discipline. While much of the ambiguity around the research paradigm has been removed, only the surface has been scratched on DSR efforts where researcher takes an active role in organizational and industrial engagement to solve a specific problem and generalize the solution to a class of problems. Such DSR projects can have a significant impact on practice, link theories to real contexts and extend the scope of DSR. Considering these multiform settings, the implications to theorizing nor the crucial role of researcher in the interplay of DSR and IS projects have not been properly addressed. The emergent nature of such projects needs to be further investigated to reach such contributions for both theory and practice. This paper raises multiple theoretical, organizational and managerial considerations for a meta-level monitoring model for emergent DSR projects.

Practice-based personas: integrated user and practice models

Practices are routinised behaviours with social and material components and complex relationships over space and time. Practice-based design goes beyond interaction design to consider how these components and their relationships impact on the formation and enactment of a practice, where technology is just one part of the practice. Though situated user-centred design methods such as participatory design are employed for the design of practice, demand exists for additional methods and tools in this area. This paper introduces practice-based personas as an extension of the persona approach popular in interaction design, and demonstrates how a set of practice-based personas was developed for a given domain – academic practice. The three practice-based personas developed here are linked to a catalogue of forty practices, offering designers both a user perspective and a practice perspective when designing for the domain.