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.

Globalization and basketball in China: governance, market and culture

Chinese sports are developing under very complex and unique political, economic, and cultural circumstances in the global age. This study aims to investigate the process of globalization in basketball through an examination of its multidimensional manifestations. The study aligns itself with Ritzer’s (2003, 2007b) conceptualization of dichotomizing the process of globalization into grobalization and glocalization. On that basis, the trajectory of basketball globalization in China is identified as the result of a contextual and competing interplay between the penetration of the NBA and the consequent engagement of Chinese basketball. A qualitative methodological approach was conducted to achieve the research aim. Data were collected from a number of sources, including official documents and semi-structured interviews with relevant basketball participants. The study reveals that globalization and basketball in China, in the political and institutional dimension, is a conflicting process. The universalization of the NBA’s governance model could not be fully assimilated due to the centralization of power in the Chinese government, which is hindering the further professionalization and marketization of basketball. In the economic dimension, the globalization process is seen to interplay with the local basketball market, which is growing thanks to the adaption of the NBA’s marketing strategies. In the cultural dimension, the study demonstrates that the NBA has to some extent cosmopolitanized and consumerized Chinese basketball culture, while resistance from both the state and the Chinese people has risen, creolizing the globalization of basketball culture in China.

Reasoning about trust, entrepreneurial services, and the virtual team

This Portfolio of Exploration (PoE) tracks a transformative learning developmental journey that is directed at changing meaning making structures and mental models within an innovation practice. The explicit purpose of the Portfolio is to develop new and different perspectives that enable the handling of new and more complex phenomena through self transformation and increased emotional intelligence development. The Portfolio provides a response to the question: ‘What are the key determinants that enable a Virtual Team (VT) to flourish where flourishing means developing and delivering on the firm’s innovative imperatives?’ Furthermore, the PoE is structured as an investigation into how higher order meaning making promotes ‘entrepreneurial services’ within an intra-firm virtual team, with a secondary aim to identify how reasoning about trust influence KGPs to exchange knowledge. I have developed a framework which specifically focuses on the effectiveness of any firms’ Virtual Team (VT) through transforming the meaning making of the VT participants. I hypothesized it is the way KGPs make meaning (reasoning about trust) which differentiates the firm as a growing firm in the sense of Penrosean resources: ‘inducement to expand and a limit of expansion’ (1959). Reasoning about trust is used as a higher order meaning-making concept in line with Kegan’s (1994) conception of complex meaning making, which is the combining of ideas and data in ways that transform meaning and implicates participants to find new ways of knowledge generation. Simply, it is the VT participants who develop higher order meaning making that hold the capabilities to transform the firm from within, providing a unique competitive advantage that enables the firm to grow.

Citizenship education in Irish secondary schools: the influence of curriculum content, school culture and stakeholder perspectives

This research interrogates the status of citizenship education in Irish secondary schools. The following questions are examined: How does school culture impact on citizenship education? What value is accorded to the subjects, Civic, Social and Political Education (CSPE) and Social, Personal and Health Education (SPHE)? To what extent are the subjects of both the cognitive and non-cognitive curricula affirmed? The importance of these factors in supporting the social, ethical, personal, political and emotional development of students is explored. The concept of citizenship is dynamic and constantly evolving in response to societal change. Society is increasingly concerned with issues such as: globalisation; cosmopolitanism; the threat of global risk; environment sustainability; socio-economic inequality; and recognition/misrecognition of new identities and group rights. The pedagogical philosophy of Paulo Freire which seeks to educate for the conscientisation and humanisation of the student is central to this research. Using a mixed methods approach, data on the insights of students, parents, teachers and school Principals was collected. In relation to Irish secondary school education, the study reached three main conclusions. (1) The educational stakeholders rate the subjects of the non-cognitive curriculum poorly. (2) The subjects Civic, Social and Political education (CSPE), and Social, Personal and Health Education (SPHE) command a low status in the secondary school setting. (3) The day-to-day school climate is influenced by an educational philosophy that is instrumentalist in character. Elements of school culture such as: the ethic of care; the informal curriculum; education for life after school; and affirmation of teachers, are not sufficiently prioritised in supporting education for citizenship. The research concludes that the approach to education for citizenship needs to be more robust within the overall curriculum, and culture and ethos of the Irish education system.