Using the hidden Markov model to capture quality of care in Lombardy geriatric wards

Quality of care is an important aspect of healthcare monitoring, which is used to ensure that the healthcare system is delivering care of the highest standard. With populations growing older there is an increased urgency in making sure that the healthcare delivered is of the highest standard. Healthcare providers are under increased pressure to ensure that this is the case with public and government demand expecting a healthcare system of the highest quality. Modelling quality of care is difficult to measure due to the many ways of defining it. This paper introduces a potential model which could be used to take quality of care into account when modelling length of stay. The Coxian phase-type distribution is used to model length of stay and the associated quality of care incorporated into the Coxian using a Hidden Markov model. Covariates are also introduced to determine their impact on the hidden level to find out what potentially can affect quality of care. This model is applied to geriatic patient data from the Lombardy region of Italy. The results obtained highlighted that bed numbers and the type of hospital (public or private) can have an effect on the quality of care delivered.

Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians

Importance: Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers.

Objective: To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process.

Design, Setting, and Participants: Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces.

Main Outcomes and Measures: Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important).

Results: Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7% (512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach.

Conclusions and Relevance: Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.

Two Views of ‘Subordination’: the Personal Scope of Employment Discrimination Law in Jivraj v Hashwani

In Jivraj v Hashwani, the Supreme Court considered what requirements are necessary for a relationship to be considered as an employment relationship for the purposes of determining the scope of domestic employment discrimination law. The Court held that an element of subordination was necessary for the relationship to be considered employment under a contract personally to do work. This article discusses what the Court in Jivraj meant by this requirement, contrasting two differing views of subordination. It examines some implications of the decision for the relationship between employment law and anti-discrimination law, and for recent debates on the scope of employment law more generally.

Bearing Witness to the 'Pain of Others': Researching Power, Violence and Resistance in a Women's Prison

Addressing the dynamics of interpersonal violence, institutionalised abuses and prisoner isolation, this article consolidates critical analyses as challenges to the essentially liberal constructions and interpretations of prisoner agency and penal reformism. Grounded in long-term research with women in prison in the North of Ireland, it connects embedded, punitive responses that undermine women prisoners’ self-esteem and mental health to the brutalising manifestations of formal and informal punishments, including lockdowns and isolation. It argues that critical social research into penal policy and prison regimes has a moral duty, an ethical obligation and a political responsibility to investigate abuses of power, seek out the ‘view from below’. Challenging the revisionism implicit within the ‘healthy prison’ discourse, it argues for alternatives to prison as the foundation of decarceration and abolition.

Avoiding Negligence and Profusion: The failure of the Joint-Stock form in the Anglo-Indian Tea Trade, 1840-1870

In the 19th century, firms operating in the Anglo-Indian tea trade were organised using a variety ownership forms including the partnership, joint-stock and a combination of the two known as the Managing agency. Faced with both an increasing need for fixed capital and high agency costs caused by the distance between owners and managers, the firms adapted and increasingly adopted the hybrid managing agency model to overcome these problems. Using new data from Calcutta and Bengal Commercial Registers and detailed case studies of the Assam Company and Gillanders, Arbuthnot and Co, this paper demonstrates that British entrepreneurs did not see the choice of ownership as a dichotomy or firm boundaries as fixed, but instead innovatively drew on the strengths of different forms of ownership to compete and grow successfully.