European Cystic Fibrosis Society Standards of Care: Quality Management in cystic fibrosis

Since the earliest days of cystic fibrosis (CF) treatment, patient data have been recorded and reviewed in order to identify the factors that lead to more favourable outcomes. Large data repositories, such as the US Cystic Fibrosis Registry, which was established in the 1960s, enabled successful treatments and patient outcomes to be recognized and improvement programmes to be implemented in specialist CF centres. Over the past decades, the greater volumes of data becoming available through Centre databases and patient registries led to the possibility of making comparisons between different therapies, approaches to care and indeed data recording. The quality of care for individuals with CF has become a focus at several levels: patient, centre, regional, national and international. This paper reviews the quality management and improvement issues at each of these levels with particular reference to indicators of health, the role of CF Centres, regional networks, national health policy, and international data registration and comparisons. 

Towards a Contingency Theory perspective of Quality Management in Enabling Strategic Alignment

The aim of this paper is to explore the role of Quality Management (QM) theory and practice using a contingency theory perspective. The study is grounded in the role of QM in improving strategic alignment within Small and Medium Sized Enterprises (SMEs) using Contingency Theory rather than adopting best practice approaches. An inductive theory building research methodology was used involving multiple case analyses of five SMEs, involving repeat interviews (n=45), focus groups (n=5) and document analysis. From the findings, it was found that Contingency Variables (strategy, culture, lifecycle and customer focus) and their respective typologies were found to interact with QM practices in helping to shape strategic alignment between the SMEs and their environments. This shaping process based on contingency approaches occurred in a manner unique to each SME and their respective environments rather than in an overarching best practice manner.

Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy

Background: This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010.
For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established.

Objectives: To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications.

Search methods: Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012.

Selection criteria:Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy.

Data collection and analysis:Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information.

Main results: One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012.
Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study.
Weight loss was greater for the NG group at six weeks post-treatment than for the PEG group (P = 0.001). At six months post-treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post-treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively.
We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review.

Authors' conclusions: There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.

Emergency Management in Developed Countries: An Investigation of Hazard Risk, Vulnerability and Government Response in the UK and USA

During the summer of 2007 the United Kingdom experienced some of the worst flooding in its history, with the city of Hull amongst the worst affected. Meanwhile, the city of New Orleans, USA was subject to severe flooding in August 2005 as a result of Hurricane Katrina. The study has found that both the UK and US government disaster management programmes were ill prepared for these flood events. Many parallel issues have been discovered and discussed. The conditions of vulnerability that are evident in developing countries are not widely present in the UK or US but this must not be allowed to lead to complacency and lack of preparation and awareness. The cost in terms of mortality is relatively low compared to similar events in developing countries; however, the economic implications are considerable and must be addressed.

The role of operations management in public sector policy and practice alignment: a local government analysis

In responding to the demand for change and improvement, local government has applied a plethora of operations management-based methods, tools and techniques. This article explores how these methods, specifically in the form of performance management models, are used to improve alignment between central government policy and local government practice, an area which has thus far been neglected in the literature. Using multiple case studies from Environmental Waste Management Services, this research reports that models derived in the private sector are often directly ‘implanted’ into the public sector. This has challenged the efficacy of all performance management models. However, those organisations which used models most effectively did so by embedding (contextualisation) and extending (reconceptualisation) them beyond their original scope. Moreover, success with these models created a cumulative effect whereby other operations management approaches were probed, adapted and used.

Quality Management and Managerialism in Healthcare:: A Critical Historical Survey

Quality Management and Managerialism in Healthcare creates a comprehensive and systematic international survey of various perspectives on healthcare quality management together with some of their most pertinent critiques. Chapter one starts with a general discussion of the factors that drove the introduction of management paradigms into public sector and health management contexts in the mid to late 1980s. Chapter two explores the rise of risk awareness in medicine; which, prior to the 1980s, stood largely in isolation to the implementation of managerial performance targets. Chapter three investigates the widespread adoption of performance management and clinical governance frameworks during the 1980s and 1990s. This is followed by Chapters four and five which examine systems based models of patient safety and the evidence-based medicine movement as exemplars of managerial perspectives on healthcare quality. Chapter six discusses potential future avenues for the development of alternative perspectives on quality of care which emphasise workforce involvement. The book concludes by reviewing the factors which have underpinned the managerialist trajectory of healthcare management over the past decades and explores the potential impact of nascent technologies such as 'connected health' and 'telehealth' on future developments.

Performance Management in the UK Public Sector: addressing multiple stakeholder complexity

Purpose The aim of this paper is to explore the issues involved in developing and applying performance management approaches within a large UK public sector department using a multiple stakeholder perspective and an accompanying theoretical framework. Design/methodology/approach An initial short questionnaire was used to determine perceptions about the implementation and effectiveness of the new performance management system across the organisation. In total, 700 questionnaires were distributed. Running concurrently with an ethnographic approach, and informed by the questionnaire responses, was a series of semi-structured interviews and focus groups. Findings Staff at all levels had an understanding of the new system and perceived it as being beneficial. However, there were concerns that the approach was not continuously managed throughout the year and was in danger of becoming an annual event, rather than an ongoing process. Furthermore, the change process seemed to have advanced without corresponding changes to appraisal and reward and recognition systems. Thus, the business objectives were not aligned with motivating factors within the organisation. Research limitations/implications Additional research to test the validity and usefulness of the theoretical model, as discussed in this paper, would be beneficial. Practical implications The strategic integration of the stakeholder performance measures and scorecards was found to be essential to producing an overall stakeholder-driven strategy within the case study organisation. Originality/value This paper discusses in detail the approach adopted and the progress made by one large UK public sector organisation, as it attempts to develop better relationships with all of its stakeholders and hence improve its performance. This paper provides a concerted attempt to link theory with practice.

From Quality Management to Socially Responsible Organisations: the Case for CSR

Purpose – The purpose of this paper is to focus on the growing interest of the role of business in society, commonly referred to as CSR. Historically CSR can be traced back to the 1950s, although in very recent times there has been a virtual explosion of interest in its use and applicability in organisations. However, there are many unresolved issues, most notably in terms of how CSR should or can be implemented and embedded in an organisation. This paper therefore seeks to explore the relationship and potential synergies between quality management and CSR. Design/methodology/approach – The qualitative exploratory study in this paper represents the first stage of an ongoing research programme, and is based on an in-depth analysis of quality award submission documentation from six case organisations that have recently been recognised as winners in relation to their quest for business improvement. Findings – The paper finds that substantial evidence from each of the case organisations demonstrates the breadth and depth of activities in which they are engaging under the broad headings of workplace, environment, social impact, and economic impact. However, whilst there is no doubting the sincerity of the actions, the approaches and activities, a strategic focus on CSR is still very much in its infancy. Research limitations/implications – In this paper there is a paucity of empirical research examining how existing management tools, techniques and methodologies can be used to further the CSR debate. This paper represents an important first step in redressing this imbalance. Practical implications – The paper suggests that the quality management and business excellence frameworks can offer a strong foundation from which to develop CSR strategies, behaviours and activities in an organisation. Originality/value – This paper represents an important first step in understanding how and where CSR “fits” into an organisation and potentially how existing quality methodologies, tools and frameworks can be used to aid the implementation of CSR.

Limitations of instantaneous water quality sampling in surface-water catchments: Comparison with near-continuous phosphorus time-series data.

The validity of load estimates from intermittent, instantaneous grab sampling is dependent on adequate spatial coverage by monitoring networks and a sampling frequency that re?ects the variability in the system under study. Catchments with a ?ashy hydrology due to surface runoff pose a particular challenge as intense short duration rainfall events may account for a signi?cant portion of the total diffuse transfer of pollution from soil to water in any hydrological year. This can also be exacerbated by the presence of strong background pollution signals from point sources during low flows. In this paper, a range of sampling methodologies and load estimation techniques are applied to phosphorus data from such a surface water dominated river system, instrumented at three sub-catchments (ranging from 3 to 5 km2 in area) with near-continuous monitoring stations. Systematic and Monte Carlo approaches were applied to simulate grab sampling using multiple strategies and to calculate an estimated load, Le based on established load estimation methods. Comparison with the actual load, Lt, revealed signi?cant average underestimation, of up to 60%, and high variability for all feasible sampling approaches. Further analysis of the time series provides an insight into these observations; revealing peak frequencies and power-law scaling in the distributions of P concentration, discharge and load associated with surface runoff and background transfers. Results indicate that only near-continuous monitoring that re?ects the rapid temporal changes in these river systems is adequate for comparative monitoring and evaluation purposes. While the implications of this analysis may be more tenable to small scale ?ashy systems, this represents an appropriate scale in terms of evaluating catchment mitigation strategies such as agri-environmental policies for managing diffuse P transfers in complex landscapes.

Does the UK Local Finance Improvement Trust (Lift) Initiative Improve Risk Management in Public-Private Procurement?

The UK government introduced the Private Finance Initiative (PFI) and, latterly, the Local Improvement Finance Trust (LIFT) in an attempt to improve public service provision. As a variant of PFI, LIFT seeks to create a framework for the effective provision of primary care facilities. Like conventional PFI procurement, LIFT projects involve long-term contracts, complex multi-party interactions and thus create various risks to public sector clients. This paper investigates the advantages and disadvantages of LIFT with a focus on how this approach facilitates or impedes risk management from the public sector client perspective. Our paper concludes that LIFT has a potential for creating additional problems, including the further reduction of public sector control, conflicts of interest, the inappropriate use of enabling funds, and higher than market rental costs affecting the uptake of space in the buildings by local health care providers. However, there is also evidence that LIFT has facilitated new investment and that Primary Care Trusts (PCTs) have themselves started addressing some of the weaknesses of this procurement format through the bundling of projects and other forms of regional co-operation.