Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

Adherence to treatment in children and adolescents with cystic fibrosis:a cross-sectional, multi-method study investigating the influence of beliefs about treatment and parental depressive symptoms

Background: Adherence to treatment is often reported to be low in children with cystic fibrosis. Adherence in cystic fibrosis is an important research area and more research is needed to better understand family barriers to adherence in order for clinicians to provide appropriate intervention. The aim of this study was to evaluate adherence to enzyme supplements, vitamins and chest physiotherapy in children with cystic fibrosis and to determine if any modifiable risk factors are associated with adherence. Methods: A sample of 100 children (≤18 years) with cystic fibrosis (44 male; median [range] 10.1 [0.2-18.6] years) and their parents were recruited to the study from the Northern Ireland Paediatric Cystic Fibrosis Centre. Adherence to enzyme supplements, vitamins and chest physiotherapy was assessed using a multi-method approach including; Medication Adherence Report Scale, pharmacy prescription refill data and general practitioner prescription issue data. Beliefs about treatments were assessed using refined versions of the Beliefs about Medicines Questionnaire-specific. Parental depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. Results: Using the multi-method approach 72% of children were classified as low-adherers to enzyme supplements, 59% low-adherers to vitamins and 49% low-adherers to chest physiotherapy. Variations in adherence were observed between measurement methods, treatments and respondents. Parental necessity beliefs and child age were significant independent predictors of child adherence to enzyme supplements and chest physiotherapy, but parental depressive symptoms were not found to be predictive of adherence. Conclusions: Child age and parental beliefs about treatments should be taken into account by clinicians when addressing adherence at routine clinic appointments. Low adherence is more likely to occur in older children, whereas, better adherence to cystic fibrosis therapies is more likely in children whose parents strongly believe the treatments are necessary. The necessity of treatments should be reinforced regularly to both parents and children.

A multi-method approach for the assessment of composite indices and rankings

There is growing popularity in the use of composite indices and rankings for cross-organizational benchmarking. However, little attention has been paid to alternative methods and procedures for the computation of these indices and how the use of such methods may impact the resulting indices and rankings. This dissertation developed an approach for assessing composite indices and rankings based on the integration of a number of methods for aggregation, data transformation and attribute weighting involved in their computation. The integrated model developed is based on the simulation of composite indices using methods and procedures proposed in the area of multi-criteria decision making (MCDM) and knowledge discovery in databases (KDD). The approach developed in this dissertation was automated through an IT artifact that was designed, developed and evaluated based on the framework and guidelines of the design science paradigm of information systems research. This artifact dynamically generates multiple versions of indices and rankings by considering different methodological scenarios according to user specified parameters. The computerized implementation was done in Visual Basic for Excel 2007. Using different performance measures, the artifact produces a number of excel outputs for the comparison and assessment of the indices and rankings. In order to evaluate the efficacy of the artifact and its underlying approach, a full empirical analysis was conducted using the World Bank's Doing Business database for the year 2010, which includes ten sub-indices (each corresponding to different areas of the business environment and regulation) for 183 countries. The output results, which were obtained using 115 methodological scenarios for the assessment of this index and its ten sub-indices, indicated that the variability of the component indicators considered in each case influenced the sensitivity of the rankings to the methodological choices. Overall, the results of our multi-method assessment were consistent with the World Bank rankings except in cases where the indices involved cost indicators measured in per capita income which yielded more sensitive results. Low income level countries exhibited more sensitivity in their rankings and less agreement between the benchmark rankings and our multi-method based rankings than higher income country groups.

A multi-method study of the transformation of the carbonaceous skeleton of a polymer-based nanoporous carbon along the activation pathway

The change in the carbonaceous skeleton of nanoporous carbons during their activation has received limited attention, unlike its counterpart process in the presence of an inert atmosphere. Here we adopt a multi-method approach to elucidate this change in a poly(furfuryl alcohol)-derived carbon activated using cyclic application of oxygen saturation at 250 °C before its removal (with carbon) at 800 °C in argon. The methods used include helium pycnometry, synchrotron-based X-ray diffraction (XRD) and associated radial distribution function (RDF) analysis, transmission electron microscopy (TEM) and, uniquely, electron energy-loss spectroscopy spectrum-imaging (EELS-SI), electron nanodiffraction and fluctuation electron microscopy (FEM). Helium pycnometry indicates the solid skeleton of the carbon densifies during activation from 78% to 93% of graphite. RDF analysis, EELS-SI, and FEM all suggest this densification comes through an in-plane growth of sp2 carbon out to the medium range without commensurate increase in order normal to the plane. This process could be termed ‘graphenization’. The exact way in which this process occurs is not clear, but TEM images of the carbon before and after activation suggest it may come through removal of the more reactive carbon, breaking constraining cross-links and creating space that allows the remaining carbon material to migrate in an annealing-like process.

Multi-criteria evaluation of wave energy projects on the south-east Australian coast

In the last decade, multiple studies focusing on national-scale assessments of the ocean wave energy resource in Australia identified the Southern Margin to be one of the most energetic areas worldwide suitable for the extraction of wave energy for electricity production. While several companies have deployed single unit devices, the next phase of development will most likely be the deployment of parks with dozens of units, introducing the risk of conflicts within the marine space. This paper presents a geo-spatial multi-criteria evaluation approach to identify optimal locations to deploy a wave energy farm while minimizing potential conflicts with other coastal and offshore users. The methodology presented is based around five major criteria: ocean wave climatology, nature of the seabed, distance to key infrastructure, environmental factors and potential conflict with other users such as shipping and fisheries. A case study is presented for an area off the south-east Australian coast using a total of 18 physical, environmental and socio-economic parameters. The spatial restrictions associated with environmental factors, wave climate, as well as conflict of use, resulted in an overall exclusion of 20% of the study area. Highly suitable areas identified ranged between 11 and 34% of the study area based on scenarios with varying criteria weighting. By spatially comparing different scenarios we identified persistence of a highly suitable area of 700 km2 off the coast of Portland across all model domains investigated. We demonstrate the value of incorporation spatial information at the scale relevant to resource exploitation when examining multiple criteria for optimal site selection of Wave Energy Converters over broad geographic regions.

Swedish-speaking Finns: a multi-method qualitative study of belonging and identification

The Swedish-speaking minority in Finland, often described as an ‘elite minority’, holds a special position in the country. With linguistic rights protected by the constitution of Finland, Swedish-speakers, as a minority of only 5.3%, are often described in public discourse and in academic and statistical studies as happier, healthier and more well off economically than the Finnish-speaking majority. As such, the minority is a unique example of language minorities in Europe. Knowledge derived from qualitatively grounded studies on the topic is however lacking, meaning that there is a gap in understanding of the nature and complexity of the minority. Drawing on ethnographic research conducted in four different locations in Finland over a period of 12 months, this thesis provides a theoretically grounded and empirically informed rich account of the identifications and sites of belonging of this diverse minority. The thesis makes a contribution to theoretical, methodological and empirical research on the Swedish-speaking minority, debates around identity and belonging, and ethnographic methodological approaches. Making use of novel methodology in studying Swedish-speaking Finns, this thesis moves beyond generalisations and simplifications on its nature and character. Drawing on rich ethnographic empirical material, the thesis interrogates various aspects of the lived experience of Swedish-speaking Finns by combining the concepts of belonging and identification. Some of the issues explored are the way in which belonging can be regionally specific, how Swedish-speakers create Swedish-spaces, how language use is situational and variable and acts as a marker of identity, and finally how identifications and sites of belonging among the minority are extremely varied and complex. The thesis concludes that there are various sites of belonging and identification available to Swedish-speakers, and these need to be studied and considered in order to gain an accurate picture of the lived experience of the minority. It also argues that while identifications are based on collective imagery, this imagery can vary among Swedish-speakers and identifications are multiple and situational. Finally, while language is a key commonality for the minority, the meanings attached to it are not only concerned with ‘Finland Swedishness’, but connected to various other factors, such as the context a person grew up in and the region one lives in. The complex issues affecting the lived experience of Swedish-speaking Finns cannot be understood without the contribution of findings from qualitative research. This thesis therefore points towards a new kind of understanding of Swedish-speaking Finns, moving away from stereotypes and simplifications, shifting our gaze towards a richer perception of the minority.