Pre-conception care : current practice and methods of provision

This thesis examines the present provisions for pre-conception care and the views of the providers of services. Pre-conception care is seen by some clinicians and health educators as a means of making any necessary changes in life style, corrections to imbalances in the nutritional status of the prospective mother (and father) and the assessment of any medical problems, thus maximizing the likelihood of the normal development of the baby. Pre-conception care may be described as a service to bridge the gap between the family planning clinic and the first ante-natal booking appointment. There were three separate foci for the empirical research - the Foresight organisation (a charity which has pioneered pre-conception care in Britain); the pre-conception care clinic at the West London Hospital, Hammersmith; and the West Midlands Regional Health Authority. The six main sources of data were: twenty five clinicians operating Foresight pre-conception clinics, couples attending pre-conception clinics, committee members of the Foresight organisation, staff of the West London Hospital pre-conception clinic, Hammersmith, District Health Education Officers working in the West Midlands Regional Health Authority and the members of the Ante-Natal Care Action Group, a sub-group of the Regional Health Advisory Group on Health Promotion and Preventive Medicine. A range of research methods were adopted. These were as follows: questionnaires and report forms used in co-operation with the Foresight clinicians, interviews, participant observation discussions and informal meetings and, finally, literature and official documentation. The research findings illustrated that pre-conception care services provided at the predominantly private Foresight clinics were of a rather `ad hoc' nature. The type of provision varied considerably and clearly reflected the views held by its providers. The protocol which had been developed to assist in the standardization of results was not followed by the clinicians. The pre-conception service provided at the West London Hospital shared some similarities in its approach with the Foresight provision; a major difference was that it did not advocate the use of routine hair trace metal analysis. Interviews with District Health Education Officers and with members of the Ante Natal Care Action Group revealed a tentative and cautious approach to pre-conception care generally and to the Foresight approach in particular. The thesis concludes with a consideration of the future of pre-conception care and the prospects for the establishment of a comprehensive pre-conception care service.

Combined quality function deployment and logical framework analysis to improve quality of emergency care in Malta

Purpose – The purpose of this paper is to develop an integrated patient-focused analytical framework to improve quality of care in accident and emergency (A&E) unit of a Maltese hospital. Design/methodology/approach – The study adopts a case study approach. First, a thorough literature review has been undertaken to study the various methods of healthcare quality management. Second, a healthcare quality management framework is developed using combined quality function deployment (QFD) and logical framework approach (LFA). Third, the proposed framework is applied to a Maltese hospital to demonstrate its effectiveness. The proposed framework has six steps, commencing with identifying patients’ requirements and concluding with implementing improvement projects. All the steps have been undertaken with the involvement of the concerned stakeholders in the A&E unit of the hospital. Findings – The major and related problems being faced by the hospital under study were overcrowding at A&E and shortage of beds, respectively. The combined framework ensures better A&E services and patient flow. QFD identifies and analyses the issues and challenges of A&E and LFA helps develop project plans for healthcare quality improvement. The important outcomes of implementing the proposed quality improvement programme are fewer hospital admissions, faster patient flow, expert triage and shorter waiting times at the A&E unit. Increased emergency consultant cover and faster first significant medical encounter were required to start addressing the problems effectively. Overall, the combined QFD and LFA method is effective to address quality of care in A&E unit. Practical/implications – The proposed framework can be easily integrated within any healthcare unit, as well as within entire healthcare systems, due to its flexible and user-friendly approach. It could be part of Six Sigma and other quality initiatives. Originality/value – Although QFD has been extensively deployed in healthcare setup to improve quality of care, very little has been researched on combining QFD and LFA in order to identify issues, prioritise them, derive improvement measures and implement improvement projects. Additionally, there is no research on QFD application in A&E. This paper bridges these gaps. Moreover, very little has been written on the Maltese health care system. Therefore, this study contributes demonstration of quality of emergency care in Malta.

Psychotic symptoms are associated with physical health problems independently of a mental disorder diagnosis:results from the WHO World Health Survey

This study explored whether physical health problems are related to psychotic symptoms independently of a mental disorder diagnosis. A total of 224,254 subjects recruited for the World Health Organization World Health Survey were subdivided into those with both a lifetime diagnosis of psychosis and at least one psychotic symptom in the 12 months prior to the evaluation, those with at least one psychotic symptom in the past 12 months but no lifetime diagnosis of psychosis, and those without psychotic symptoms in the past 12 months and without a lifetime diagnosis of psychosis. The three groups were compared for the presence of medical conditions, health problems, and access to health care. Medical conditions and health problems (angina, asthma, arthritis, tuberculosis, vision or hearing problems, mouth/teeth problems, alcohol consumption, smoking, and accidents), medication consumption, and hospital admissions (but not regular health care visits) were more frequent in individuals with psychotic symptoms but no psychosis diagnosis, compared to those with no symptoms and no diagnosis. The number of medical conditions increased with the number of psychotic symptoms. Given the sample analyzed, this trend seems to be independent from the socio-economic development of the country or the specific health care system.

Developing a tool to support communication of parental concerns when a child is in hospital

The involvement of parents in their child’s hospital care has been strongly advocated in paediatric healthcare policy and practice. However, incorporating parental worries about their child’s condition into clinical care can be difficult for both parents and healthcare professionals. Through our “Listening To You” quality improvement project we developed and piloted an innovative approach to listening, incorporating and responding to parental concerns regarding their child’s condition when in hospital. Here we describe the phases of work undertaken to develop our “Listening To You” communications bundle, including a survey, literature review and consultation with parents and staff, before findings from the project evaluation are presented and discussed.

The evaluation of information systems in the organisational context of the National Health Service. Available in 2 volumes.

This thesis describes a project which has investigated the evaluation of information systems. The work took place in, and is related to, a specific organisational context, that of the National Health Service (NHS). It aims to increase understanding of the evaluation which takes place in the service and the way in which this is affected by the NHS environment. It also investigates the issues which surround some important types of evaluation and their use in this context. The first stage of the project was a postal survey in which respondents were asked to describe the evaluation which took place in their authorities and to give their opinions about it. This was used to give an overview of the practice of IS evaluation in the NHS and to identify its uses and the problems experienced. Three important types of evaluation were then examined in more detail by means of action research studies. One of these dealt with the selection and purchase of a large hospital information system. The study took the form of an evaluation of the procurement process, and examined the methods used and the influence of organisational factors. The other studies are concerned with post-implementation evaluation, and examine the choice of an evaluation approach as well as its application. One was an evaluation of a community health system which had been operational for some time but was of doubtful value, and suffered from a number of problems. The situation was explored by means of a study of the costs and benefits of the system. The remaining study was the initial review of a system which was used in the administration of a Breast Screening Service. The service itself was also newly operational and the relationship between the service and the system was of interest.

Experiences of patients with age-related macular degeneration receiving anti-vascular endothelial growth factor therapy:a qualitative study

The societal cost for the average health authority in the United Kingdom for the care of wet age-related macular degeneration (AMD) has been suggested to be around £7.4 million. It is vital that the best possible care based on the best available evidence is provided to reduce the impact of AMD on patients' lives and the financial cost to the health-care system. This study explored the experiences of AMD patients treated with intravitreal ranibizumab injections. Three semistructured interviews were conducted with seven participants over the course of 18 months. Transcripts were analysed using interpretative phenomenological analysis. Analysis identified four themes: preparing for treatment, the treatment process, patient-provider communication, and results of treatment. Patient experiences highlighted the need to move away from the reliance on letters for information provision, and the need for clearer guidelines about when to cease AMD treatment. Interviews highlighted the need for the inclusion of rigorous qualitative evidence with experiential data in future good clinical practice guideline development for AMD. © The Author(s) 2013.

Clinical decision support system for point of care use: ontology driven design and software implementation

OBJECTIVES: The objective of this research was to design a clinical decision support system (CDSS) that supports heterogeneous clinical decision problems and runs on multiple computing platforms. Meeting this objective required a novel design to create an extendable and easy to maintain clinical CDSS for point of care support. The proposed solution was evaluated in a proof of concept implementation. METHODS: Based on our earlier research with the design of a mobile CDSS for emergency triage we used ontology-driven design to represent essential components of a CDSS. Models of clinical decision problems were derived from the ontology and they were processed into executable applications during runtime. This allowed scaling applications' functionality to the capabilities of computing platforms. A prototype of the system was implemented using the extended client-server architecture and Web services to distribute the functions of the system and to make it operational in limited connectivity conditions. RESULTS: The proposed design provided a common framework that facilitated development of diversified clinical applications running seamlessly on a variety of computing platforms. It was prototyped for two clinical decision problems and settings (triage of acute pain in the emergency department and postoperative management of radical prostatectomy on the hospital ward) and implemented on two computing platforms-desktop and handheld computers. CONCLUSIONS: The requirement of the CDSS heterogeneity was satisfied with ontology-driven design. Processing of application models described with the help of ontological models allowed having a complex system running on multiple computing platforms with different capabilities. Finally, separation of models and runtime components contributed to improved extensibility and maintainability of the system.

A pilot study to evaluate the self-medication system for liver transplant patients at the Queen Elizabeth Hospital in Birmingham

Background and Objective: Medication non-compliance is a considerable obstacle in achievinga therapeutic goal, whichcan result in poorerhealthcare outcomes, increased expenditure, wastage and potential for medication resistance. The UK Government’s Audit Commission’s publication ‘A Spoonful of Sugar’1 addresses these issues and promotes self-medication systems as a possible solution. The self-medication system within the Liver Transplant Unit (LTU) was implemented to induct patients onto new post- transplantation medication regimes ready for discharge. The system involves initial consultations with both the Liver Transplant Pharmacist and Trans- plant Co-ordinator, supported with additional advice as and when necessary. Design: Following ethical approval, evaluation of the self-medication sys- tem for liver transplant patients was conducted between January and March 2004 via two methods: audit and structured post-transplantation interview. The audit enabled any discrepancies between current Hospital guidelines and Liver Transplant Unit (LTU) practices to be highlighted. Patient interviews generated a retrospective insight into patient acceptance of the self-medication system. Setting: LTU, Queen Elizabeth Hospital, Birmingham, England. Main Outcome Measures: LTU compliance with Hospital self-medication guidelines and patient insight into self-medication system. Results: A total of seven patients were audited. Findings illustrated that self- medication by transplant patients is a complex process which was not fully addressed by current Hospital self-medication guidelines. Twenty-three patients were interviewed, showing an overwhelming positive attitude to- wards participating in their own care and a high level of understanding towards their individual medication regimes. Following a drugs counselling session, 100% of patients understood why they were taking their medica- tion, and their doses, 95% understood how to take their medication and 85% were aware of potential side effects. Conclusions: From this pilot evaluation it can be stated that the LTU self-medication system is appreciated by patients and assists them in fully understanding their medication regimes. There appear to be no major defects in the system. However areas such as communication barriers and on-going internet education were illustrated as areas for possible future investigation. References: 1. Audit Commission. A spoonful of sugar – medicines management in NHS hospitals. London: Audit Commission; 2001.

Implementing a knowledge management system within an NHS hospital:a case study exploring the roll-out of an Electronic Patient Record (EPR)

This research aims to contribute to understanding the implementation of knowledge management systems (KMS) in the field of health through a case study, leading to theory building and theory extension. We use the concept of the business process approach to knowledge management as a theoretical lens to analyse and explore how a large teaching hospital developed, executed and practically implemented a KMS. A qualitative study was conducted over a 2.5 year period with data collected from semi-structured interviews with eight members of the strategic management team, 12 clinical users and 20 patients in addition to non-participant observation of meetings and documents. The theoretical propositions strategy was used as the overarching approach for data analysis. Our case study provides evidence that true patient centred approaches to supporting care delivery with a KMS benefit from process thinking at both the planning and implementation stages, and an emphasis on the knowledge demands resulting from: the activities along the care pathways; where cross-overs in care occur; and knowledge sharing for the integration of care. The findings also suggest that despite the theoretical awareness of KMS implementation methodologies, the actual execution of such systems requires practice and learning. Flexible, fluid approaches through rehearsal are important and communications strategies should focus heavily on transparency incorporating both structured and unstructured communication methods.

Better queue management in a busy public hospital of a developing country without appointment system::an application using data envelopment analysis

Queuing is a key efficiency criterion in any service industry, including Healthcare. Almost all queue management studies are dedicated to improving an existing Appointment System. In developing countries such as Pakistan, there are no Appointment Systems for outpatients, resulting in excessive wait times. Additionally, excessive overloading, limited resources and cumbersome procedures lead to over-whelming queues. Despite numerous Healthcare applications, Data Envelopment Analysis (DEA) has not been applied for queue assessment. The current study aims to extend DEA modelling and demonstrate its usefulness by evaluating the queue system of a busy public hospital in a developing country, Pakistan, where all outpatients are walk-in; along with construction of a dynamic framework dedicated towards the implementation of the model. The inadequate allocation of doctors/personnel was observed as the most critical issue for long queues. Hence, the Queuing-DEA model has been developed such that it determines the ‘required’ number of doctors/personnel. The results indicated that given extensive wait times or length of queue, or both, led to high target values for doctors/personnel. Hence, this crucial information allows the administrators to ensure optimal staff utilization and controlling the queue pre-emptively, minimizing wait times. The dynamic framework constructed, specifically targets practical implementation of the Queuing-DEA model in resource-poor public hospitals of developing countries such as Pakistan; to continuously monitor rapidly changing queue situation and display latest required personnel. Consequently, the wait times of subsequent patients can be minimized, along with dynamic staff scheduling in the absence of appointments. This dynamic framework has been designed in Excel, requiring minimal training and work for users and automatic update features, with complex technical aspects running in the background. The proposed model and the dynamic framework has the potential to be applied in similar public hospitals, even in other developing countries, where appointment systems for outpatients are non-existent.