Development of a collaborative model to improve school health promotion in the Netherlands

In recent decades, school health promotion programs have been developing into whole-school health approaches. This has been accompanied by a greater understanding among health promoters of the core-business of schools, namely education, and how health promotion objectives can be integrated into this task. Evidence of the positive impact of school health promotion on health risk behavior of students is increasing. This article focuses on the processes and initial results of developing a collaborative model tailored for whole-school health in the Netherlands, named schoolBeat. The Dutch situation is characterized by fragmentation, a variety of health and welfare groups supporting schools, and a lack of sound integrated youth policies. A literature review, observations, and stakeholder consultation provided a clear picture of the current situation in school health promotion, and factors limiting a comprehensive and needs-based approach to school health. This revealed that a health promotion team within a school is fundamental to an effective approach to tailored school health promotion. A respected member of school staff should chair this team. To strengthen the link with the school care team, the school care coordinator should be a member of both teams. To provide coordinated support to all schools in a region, participating organizations decided to share advisory tasks. These tasks are included in the regular health promotion work of their staff. This means working with one advisor representing all school-health organizations per school, and using a comprehensive overview of possible support and projects promoting health. Empowering schools in needs assessments and comprehensive school health promotion is an important element of the developed approach. This article concludes with an examination of emerging issues in evaluating collaborative school health support during the first 18 months of development, and implementation and future perspectives regarding sustainable collaboration and quality improvement.

Checks and cheques : implementing a population health and recall system to improve coverage of patients with diabetes in a rural general practice

Identification of all diabetic patients in the population is essential if diabetic care is to be effective in achieving the targets of the St Vincent Declaration.¹ The challenge therefore is to establish population based monitoring and control systems by means of state of the art technology in order to achieve quality assurance in the provision of care for patients with diabetes. ^2,3 Disease management receives extensive international support as the most appropriate approach to organising and delivering healthcare for chronic conditions like diabetes.⁴ This approach is achieved through a combination of guidelines for practice, patient education, consultations and follow up using a planned team approach and a strong focus on continuous quality improvement using information technology. ^5,6 The current software (Medical Director) could not easily meet these requirements which led us to adopt a trial of Ferret. In designing this project we used change management⁷ and the plan, do, study, act cycle⁸ illustrated in Diagram 1.

Variable definitions: implications for the prediction of pulmonary complications after adult cardiac surgery

Aim: The aim of this paper was to review the implications that variable definitions have for the prediction of post-operative pulmonary complications after cardiac surgery.

Method: A review of the literature from 1980 to 2002. Selected studies demonstrated an original attempt to examine multivariate associations between pre, intra or post-operative antecedents and pulmonary outcomes in patients undergoing coronary artery bypass grafting (CABG). Reports that described the validation of established clinical prediction rules, testing interventions or research conducted in non-human cohorts were excluded from this review.

Results: Consistently, variable factor and outcome definitions are combined for the development of multivariate prediction models that subsequently have limited clinical value. Despite being prevalent there are very few attempts to examine post-operative pulmonary complications (PPC) as endpoints in isolation. The trajectory of pulmonary dysfunction that precedes complications in the post-operative context is not clear. As such there is little knowledge of post-operative antecedents to PPC that are invariably excluded from model development.

Conclusion: Multivariate clinical prediction rules that incorporate antecedent patient and process factors from the continuum of cardiovascular care for specific pulmonary outcomes are recommended. Models such as these would be useful for practice, policy and quality improvement.

Challenges in health services and health systems research

The relationship between emerging trends in healthcare systems and the consequent research priorities will be explored.

Governments and policy makers in developed countries are increasingly focused on the management of chronic disease, reflecting demographic changes and shifts in the burden of disease. Systems of quality improvement and reward are increasingly based on performance in chronic disease management. There is some evidence that countries with well-developed systems of primary care, such as Australia, achieve better health outcomes at less cost. In the past 15 years, almost all developed countries have undergone some type of health care reform. There has been a major focus on reducing costs; often involving shifting services from secondary to primary care. While there are few international comparisons, most suggest a complex relationship between the strength of primary care within the overall health services system and good performance, particularly with regard to lower costs of care and particularly relevant measures of health.

Aims for 21st century health systems
What, then, are the issues which are shaping contemporary general practice in developed countries? There are several imperatives: Safety, effectiveness, patient-centredness, timeliness, efficiency and equity. A study by the Nuffield Trust (Dargie, 1999) projected the shape of healthcare for the first fifteen years of this century. The study identified six issues that need to be addressed in the process of formulating health systems policies:

• Peoples’ expectations and financial sustainability
• Demography and ageing
• Information and knowledge management
• Scientific advance and new technology
• Workforce education and training
• Systems performance and quality (efficiency, effectiveness, economy
and equity)

Each of these six issues requires innovative thinking and priority setting on the part of the health sector, such as the delivery of health services in new and creative ways. Furthermore, there is a clear need for a finely tuned research, development and evaluation strategies to match these goals.

Power and passion:remoulded teamwork in a plastics factory

Purpose: – The purpose of this paper is to document the progress made in a specified period and the experience of managers and staff in sustaining the high performance team approach in a plastics factory.

Design/methodology/approach: – Single-case analysis was conducted on data collected through semi-structured interviews and site observations made with two managers and one team of six in a multinational plastics manufacturer (Visy) headquartered in Australia.

Findings: – Based on the authors' experiences and literature review a successful high performance team requires clear targets and efficiency standards, communication, rules of behaviour, continual input of facts and feedback, and last but not least – recognition of successes.

Research limitations/implications: – The findings are based on observations and interviews conducted in one part of a multinational organization in Australia. No follow-up interviews could be undertaken to track the progress.

Originality/value: – No other similar study had been undertaken in this organisation documenting the experiences of a quality improvement team and its interactions with managers. The findings have practical implications for industrial and other kinds of organisations engaged in implementing quality improvements through enhanced teamwork.

Mapping the information resources available to patients with colorectal cancer

The objectives of this study were to identify gaps in information provision along the colorectal cancer (CRC) treatment pathway as provided by health services within the North Eastern Metropolitan Integrated Cancer Service in Victoria Australia; to evaluate the information and recommend consistent, high quality health information resources; and to recommend strategies to improve delivery of patient information. A random sample of health professionals (n= 47) from various disciplines at eight health service sites participated in semi-structured interviews regarding the types of information they provided to CRC patients. Information items were mapped against a published CRC patient management framework and evaluated. A total of 193 information items were collected with 24 items specific to CRC. Gaps in information provision were evident in the community, at diagnosis, in clinics, when treatment was determined and when completed. The quality of information delivery to CRC patients across the public health sites was variable. Resources were often unavailable, out of date and inaccessible in other languages. Results indicate a need to improve health information availability and resource delivery to all CRC patients across different health services particularly at diagnosis and after treatment. Further research is required to determine patient preferences for information about CRC.

Capacity building for integrated health care at the local level

Aims & Rationale/Objectives
Taking a capacity building approach to research and evaluation within the context of a federally funded national program challenges the traditional paradigms of both research and evaluation. The objective of this approach was to foster attitudes and behaviours of reflection, critical inquiry and collaborative action amongst participants responsible for health care integration activities.

Methods
A series of workshops focusing on different elements of health care integration was conducted. Each workshop offered skill development in research and evaluation methods relevant to the participants' clinical practise. The workshops were multidisciplinary and cross-sectoral in order to promote discussion about shared patient care issues.

Principal Findings
Participatory action research facilitated by external agents can build the capacity of participants to identify and make changes that improve health care integration at local levels. A capacity building approach to research and evaluation can mediate tensions between top-down initiatives and on-the-ground practitioners.

Discussion
A capacity building approach was crucial to the success of this project particularly as the project proposal was developed at the corporate level. The workshops played an important role in engaging the participants and fostering the development of solutions for locally identified clinical issues. The opportunities for discussion with other health care service providers were both readily embraced and appreciated by the participants. The networks formed during the workshops are likely to be vital in sustaining integration efforts.

Implications
Education sessions such as the workshops held within this project ensure that health care integration remains on the agenda of the relevant organisations. These workshops fostered a continuous quality improvement approach whilst focusing on the skills required and the systemic barriers to achieving health care integration. The success of these workshops is evidence that the need and desire for shared education opportunities exists and the interdisciplinary focus is a powerful tool for developing an appreciation of the cultures within disciplines as well as linkages.

Using project evaluation to build capacity for integrated health care at local levels

Capacity-building evaluation featuring multidisciplinary cross-agency workshops fostered continuous quality improvement, while focusing on skills required and systemic barriers to health care integration between GPs and a regional hospital.

Implementing a journal club in a palliative care setting : a link in the chain of evidence-based practice

This paper describes the implementation and evaluation of a journal club in a privately funded palliative care unit. Journal club meetings were initiated as part of a quality improvement process to foster the uptake of evidence-based practice. Nurses were presented with research articles each month and discussions were conducted focussing on methodological considerations of the research and implications of the research for patient care. The maximum number of attendees at any one meeting was nine and the minimum number was four. Overall, evaluations were positive about all aspects of the meetings. Attendees found that the selected articles were relevant, providing new information, stimulated discussion and reflection on clinical practice and encouraged further reading. One of the positive aspects of the meetings identified by participants was the facilitation style that enabled discussion in a safe and supportive environment. An important outcome of the meetings is the potential to explore evidence-based practices relevant to palliative care and to implement new practices or revise existing ones. As part of this process practice changes and clinical guidelines have been implemented. A dedicated facilitator with university links and a supportive organisational culture promoted club meetings as a practical way to provide clinical nurses with the opportunity to explore evidence-based research in the area of palliative care.

Moving beyond resistance to restraint minimization : a case study of change management in aged care

Aim: This case study describes a quality initiative to minimize restraint in an Australian residential aged care facility.

Approach: The process of improving practice is examined with reference to the literature on implementation of research into practice and change management. The differences between planned and emergent approaches to change management are discussed. The concepts of resistance and attractors are explored in relation to our experiences of managing the change process in this initiative. The importance of the interpersonal interactions that were involved in facilitating the change process is highlighted.

Implications: Recommendations are offered for dealing with change management processes in clinical environments, particularly the need to move beyond an individual mind-set to a systems-based approach for quality initiatives in residential aged care.

Integration and coordination of care

The health care systems in Australia are under pressure from workforce shortages, increasing costs and an ageing population with a high prevalence of chronic disease. There is a well-established description of inequity in health outcomes among rural and remote populations. Most of the inequity appears to be due to poorer access to services than higher levels of health risk factors, such as cholesterol, blood pressure or obesity. Over the last 15 years, the science of improvement has led to quality improvement techniques, such as collaboratives, managed clinical networks and collaborative care, all of which have been tried successfully in Australia. Each of these offers ways to reduce the inequity in health outcomes attributed to rurality or remoteness.

Investigation of overweight and obesity management in a rural primary health care setting

Background : The rural region of interest has one main central medical clinic and several smaller outlying clinics. The services available for weight management include dietetic services, community-based groups and bariatric surgery. At present, no formal area specific referral pathway exists for the treatment of overweight and obesity.
Aims & rationale/Objectives : To investigate general practitioners':
- assessment practices and experiences with overweight and obese clients
- experience of different treatment options for overweight and obesity
- perceived barriers to overweight and obesity management.
Methods : A self-administered survey will be sent to general practitioners within the region of interest. The survey was designed to investigate current methods of assessing overweight and obesity; treatment options; and perceived barriers to successful weight management. Participants will also be offered a brief interview to discuss the following topics; Usefulness of NHMRC's Overweight and Obesity Guidelines; barriers and frustrations of weight management, GP's and dietitian's roles in overweight and obesity treatment.
Principal findings : It is expected the principal findings will include details about methods used to determine overweight and obesity; factors considered when selecting patients for treatment; favoured treatment options of GPs; perceived barriers and frustrations of managing overweight and obese patients.
Discussion : Overweight and obesity are significant health issues in Australia, with recent data indicating more than 60% of Australian adults are affected (NHMRC, 2003). Studies have also suggested that the prevalence of overweight and obesity is higher in rural populations (Coulson, 2005). GPs have been recognised as an important contributor in the treatment of overweight and obesity (Campbell, 2000). There have been guidelines produced to assist GPs, however the extent to which guidelines are utilised or their perceived effectiveness have not yet been investigated.
Implications : It is thought that an investigation into current methods of assessing overweight and obesity; treatment options; and perceived barriers to successful weight management will provide valuable information to inform primary health care service provision and future quality improvement directions.
Presentation type : Poster
Session theme : Primary health care delivery

Rapeseed (canola) oil and other monounsaturated fatty acid-rich vegetable oils

Rapeseed (canola) and other monounsaturated fatty acid (MUFA)-rich oils are viewed as good candidates to replace, at least partially, the fish oil normally included in aquaculture feeds (aquafeeds). In fact, their utilization as a dietary lipid source for aquatic animals has some advantages over other readily available terrestrial alternative oils and fats; however, this is not without difficulties. MUFA are, indeed, easily digestible and a good source of available energy, and their deposition into fish flesh is considered to be less detrimental than other fatty acid classes, from a human nutritional viewpoint. This chapter attempts to review the principal information available regarding the utilization of MUFA-rich vegetable oil (VO) in aquaculture feed. Initially the chapter focuses on the rapeseed oil eRa) industry, agronomy, quality improvement, processing, and uses, and the main chemical and physical characteristics of rapeseed oil and other MUFA-rich va such as olive oil, peanut oil, and rice bran oil, amongst others. Following this, the potential advantages and challenges of using these alternative oils in the aquaculture feed industry are presented and discussed.

Addressing the basics : academics' views of the purpose of higher education

A number of changes have occurred in the higher education sector under the auspices of quality and quality improvement. Much of this change has resulted in a compliance-driven environment (more measures, more meetings, more form-filling and less time for the core activities of teaching and research). It is an environment that seeks to assure all and sundry of the quality of academic programs. Anecdotally, many academics are not convinced that the current systems do, indeed, assure quality. The reasons for this may be many and varied. One suggestion is that differences in perceptions about the purpose of higher education inevitably lead to differences in the definition of quality itself and consequently, differences in systems designed to assure that quality. Understanding what academics think about the purpose of higher education may provide some clues about how they consider quality should be defined.

In this research, the focus is on the views of academic accountants in Australia, defined as: academics whose main discipline area is accounting and who are involved in accounting education at an Australian university. The findings of this research show that the respondent group do, in fact, view the purpose of higher education currently promoted in their schools/departments differently from the purpose that they consider ought to be promoted. Such fundamental differences have the potential to influence the motivation and effectiveness of staff undertaking core activities in Australian universities. In addition, articulating the views of this important stakeholder group also has the potential to ensure that their views are considered in the discussions around purpose, quality and performance measures in higher education – all of which impact on the working lives of academic accountants in Australian universities.

Facilitating best practice : transferring the lessons of the Clinical Support Systems program

The Clinical Support Systems Program (CSSP) includes the management of clinical practice using clinical and consumer pathways, outcome and performance indicators, clinical measurement and review in a continuous improvement cycle using the best available extant evidence. The Royal Australasian College of Physicians is testing the CSSP model through four consortia around Australia. There are 17 project sites in three States. The funded projects address major clinical problems including congestive heart failure and acute coronary syndromes, acute stroke management, and colorectal cancer care. There is some early evidence of the CSSP influencing change in areas beyond the bounds of the project settings and the College has developed a plan to promote wider adoption of best practice. This approach recognises the College’s role in providing Fellows with the practical tools of quality improvement, the means to collect data and compare their practice to other clinicians, while traversing the appropriate educational framework.