Public and private hospital services reform:an investigation in Iranian hospitals

This research aimed to present a model of efficiency for selected public and private hospitals of East Azerbaijani province of Iran by making use of DEA approach in order to recognize and suggest the best practice standards. In other words, its aim was to suggest a suitable context to develop efficient hospital systems while maintaining the quality of care at minimum expenditures. It is recommended for inefficient hospitals to make use of the followings: transferring, selling, or renting idle/unused beds; transferring excess doctors and nurses to the efficient hospitals or other health centers; pensioning off, early retirement clinic officers, technicians/technologists, and other technical staff. The saving obtained from the above approaches could be used to improve remuneration for remaining staff and quality of health care services of hospitals, rural and urban health centers, support communities to start or sustain systematic risk and resource pooling and cost sharing mechanisms for protecting beneficiaries against unexpected health care costs, compensate the capital depreciation, increasing investments, and improve diseases prevention services and facilities in the provincial and national levels.

Senior management leadership, social support, job design and stressor-to-strain relationships in hospital practice

Purpose: The purpose of this paper is to examine the effect of the quality of senior management leadership on social support and job design, whose main effects on strains, and moderating effects on work stressors-to-strains relationships were assessed. Design/methodology/approach: A survey involving distribution of questionnaires was carried out on a random sample of health care employees in acute hospital practice in the UK. The sample comprised 65,142 respondents. The work stressors tested were quantitative overload and hostile environment, whereas strains were measured through job satisfaction and turnover intentions. Structural equation modelling and moderated regression analyses were used in the analysis. Findings: Quality of senior management leadership explained 75 per cent and 94 per cent of the variance of social support and job design respectively, whereas work stressors explained 51 per cent of the variance of strains. Social support and job design predicted job satisfaction and turnover intentions, as well as moderated significantly the relationships between quantitative workload/hostility and job satisfaction/turnover intentions. Research limitations/implications: The findings are useful to management and to health employees working in acute/specialist hospitals. Further research could be done in other counties to take into account cultural differences and variations in health systems. The limitations included self-reported data and percept-percept bias due to same source data collection. Practical implications: The quality of senior management leaders in hospitals has an impact on the social environment, the support given to health employees, their job design, as well as work stressors and strains perceived. Originality/value: The study argues in favour of effective senior management leadership of hospitals, as well as ensuring adequate support structures and job design. The findings may be useful to health policy makers and human resources managers. © Emerald Group Publishing Limited.

A KM perspective on implementing an electronic patient record within an NHS hospital

The Electronic Patient Record (EPR) is being developed by many hospitals in the UK and across the globe. We class an EPR system as a type of Knowledge Management System (KMS), in that it is a technological tool developed to support the process of knowledge management (KM). Healthcare organisations aim to use these systems to provide a vehicle for more informed and improved clinical decision making thereby delivering reduced errors and risks, enhanced quality and consequently offering enhanced patient safety. Finding an effective way for a healthcare organisation to practically implement these systems is essential. In this study we use the concept of the business process approach to KM as a theoretical lens to analyse and explore how a large NHS teaching hospital developed, executed and practically implemented an EPR system. This theory advocates the importance of taking into account all organizational activities - the business processes - in considering any KM initiatives. Approaching KM through business processes allows for a more holistic view of the requirements across a process: emphasis is placed on how particular activities are performed, how they are structured and what knowledge demanded and not just supplied across each process. This falls in line with the increased emphasis in healthcare on patient-centred approaches to care delivery. We have found in previous research that hospitals are happy with the delivery of patient care being referred to as their 'business'. A qualitative study was conducted over a two and half 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 documentary data. We believe that the inclusion of patients within the study may well be the first time this has been done in examining the implementation of a KMS. The theoretical propositions strategy was used as the overarching approach for data analysis. Here Initial theoretical research themes and propositions were used to help shape and organise the case study analysis. This paper will present preliminary findings about the hospital's business strategy and its links to the KMS strategy and process.

Severe visual impairment due to diabetes mellitus:can this be influenced by community & hospital retinal screening and formal hospital diabetic annual review?

Purpose: Diabetes is a leading cause of visual impairment in working age population in the UK. This study looked at the causes of Severe Visual Impairment(SVI) in the patients attending diabetic eye clinic and influence on the rate of SVI, over a 12 year period, after introducing retinal screening programmes in the hospital and the community in 1993 (review in 1992, 1998 & 2004). Methods: Medical records of all the patients attending the diabetic eye clinic over a period of 5months(April to August) in 1992, 1998 and 2004 were reviewed. The data collected for each patient included age, sex, ethnic origin, diabetes (type,duration &treatment), the best corrected visual acuity (present and at time of presentation), type and duration of retinopathy and attendance record to both diabetic clinic and diabetic eye clinic. In this study, SVI is defined as a visual acuity of 6/36 or worse in at least one eye. Results: In 1992, of a total 245 patients, 58patients(23.6%) had SVI {38 (15.5% of total) due to diabetic retinopathy [31(12.6%) maculopathy, 2(0.8%) vitreous haemorrhage and 5(2%) retinal detachment] and 20(8.1%) due to non–diabetic retinopathy causes}. In 1998, of a total 297, 77patients(25.9%) had SVI {33(11.1% of total) due to diabetic retinopathy [19(6.4%) maculopathy, 9(3%) proliferative retinopathy, 8(2.7%) vitreous haemorrhage and 3(1%) retinal detachment]and 44(14.8%)due to non–diabetic retinopathy}. In 2004, of a total 471, 72patients(15.2%) had SVI{46(9.7%of total) due to diabetic retinopathy [37(7.8%) maculopathy, 1(0.2%) proliferative retinopathy, 6(1.8%) vitreous haemorrhage and 2(0.4%) retinal detachment]and 26(5.5%) due to non– diabetic retinopathy causes}. Conclusions: Introduction of formalised annual diabetic review including retinal screening and a community retinal screening programme has reduced the rate of severe visual impairment due to diabetic retinopathy, in patients attending diabetic eye clinic, from 15.5% in1992 to 9.7% in2004. Keywords: diabetic retinopathy

Developing an intervention to equip nurses for acute life threatening events (ALTEs) in hospital:a phenomenological approach to healthcare research

Objectives: To understand staff's experiences of acute life threatening events (ALTEs) in a pediatric hospital setting. These data will inform an intervention to equip nurses with clinical and emotional skills for dealing with ALTEs. Method: A mixed design was used in the broader research program; this paper focuses on phenomenon-focused interviews analyzed using interpretative phenomenological analysis (IPA). Results: Emerging themes included staff's relationships with patients and the impact of personhood on their ability to perform competently in an emergency. More experienced nurses described "automatic" competence generated through increased exposure to ALTEs and were able to recognize "fumbling and shaking" as a normal stress response. Designating a role was significant to staff experience of effectiveness. Key to nurses' learning experience was reflection and identifying experiences as "teachable moments." Findings were considered alongside existing theories of self-efficacy, reflective thought, and advocacy inquiry to create an experiential learning intervention involving a series of clinical and role-related scenarios. Conclusion: The phenomenological work facilitated an in-depth reading of experience. It accentuated the importance of exposure to ALTEs giving nurses experiential knowledge to prepare them for the impact of these events. Challenges included bracketing the personhood of child patients, shifting focus to clinical tasks during the pressured demands of managing an ALTE, normalizing the physiological stress response, and the need for a forum and structure for reflection and learning. An intervention will be designed to provide experiential learning and encourage nurses to realize and benefit from their embodied knowledge.

Support for paediatric prescribers:what is discussed at hospital board level?

Prescribing support tools range from traditional printed texts to state-of-the-art computerised decision support systems. Comparison between available literature is difficult due to country-specific resources often being the focus of the research. In the UK, it is widely accepted that hospitals take their own individualised approaches to reducing prescribing errors. Objective - This study focused on specialist paediatric hospitals. It aimed to identify the localised approaches taken by paediatric hospitals to reduce prescribing errors. Method - Applied thematic analysis was used to explore the publically published board meeting minutes from the four specialist stand-alone paediatric hospitals in England. Three years of data was collected from each hospital. Codes were collected into groups to identify themes from the data. Results - The main themes identified were clinician involvement in prescribing support is important; credit card-sized reminder tools are used to provide prescribing guidance; electronic prescribing is considered important for reducing prescribing errors; feedback from clinical pharmacists on prescribing errors is widely used; junior doctors require extra support when prescribing; medical records may be incomplete and specific prescribing support (eg, antibiotic prescribing support) is widely in use. Conclusions - There is no single collaborative approach taken to paediatric prescribing support in English paediatric hospitals. Success of electronic prescribing in English paediatric hospitals is considerably behind leaders such as the USA. Use of clinical pharmacists to support prescribers is important as supported by previous studies in Spain and the USA.

Assessing the queuing process using data envelopment analysis:an application in health centres

Queuing is one of the very important criteria for assessing the performance and efficiency of any service industry, including healthcare. Data Envelopment Analysis (DEA) is one of the most widely-used techniques for performance measurement in healthcare. However, no queue management application has been reported in the health-related DEA literature. Most of the studies regarding patient flow systems had the objective of improving an already existing Appointment System. The current study presents a novel application of DEA for assessing the queuing process at an Outpatients’ department of a large public hospital in a developing country where appointment systems do not exist. The main aim of the current study is to demonstrate the usefulness of DEA modelling in the evaluation of a queue system. The patient flow pathway considered for this study consists of two stages; consultation with a doctor and pharmacy. The DEA results indicated that waiting times and other related queuing variables included need considerable minimisation at both stages.

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.

Bagging model with cost sensitive analysis on diabetes data

Diabetes patients might suffer from an unhealthy life, long-term treatment and chronic complicated diseases. The decreasing hospitalization rate is a crucial problem for health care centers. This study combines the bagging method with base classifier decision tree and costs-sensitive analysis for diabetes patients' classification purpose. Real patients' data collected from a regional hospital in Thailand were analyzed. The relevance factors were selected and used to construct base classifier decision tree models to classify diabetes and non-diabetes patients. The bagging method was then applied to improve accuracy. Finally, asymmetric classification cost matrices were used to give more alternative models for diabetes data analysis.

Pregnancy complications in hyperemesis-affected pregnancy:a large hospital database study

Objective: Vomiting in pregnancy is a common condition affecting 80% of pregnant women. Hyperemesis is at one end of the spectrum, seen in 0.5–2% of the pregnant population. Known factors such as nulliparity, younger age and high body mass indexare associated with an increased risk of this condition in the first trimester. Late pregnancy complications attributable to hyperemesis, the pathogenesis of which is poorly understood, have not been studied in large population-based studies in the United Kingdom. The objective of this study was to determine a plausible association between hyperemesis and pregnancy complications,such as pregnancy-related hypertension, gestational diabetes and liver problems in pregnancy, and the rates of elective (ElCS) and emergency caesarean section (EmCS). Methods: Using a database based on ICD-10 classification, anonymised data of admissions to a large multi-ethnic hospital in Manchester, UK between 2000 and 2012 were examined.Notwithstanding the obvious limitations with hospital database-based research, this large volume of datasets allows powerful studies of disease trends and complications.Results Between 2000 and 2012, 156 507 women aged 45 or under were admitted to hospital. Of these, 1111 women were coded for hyperemesis (0.4%). A greater proportion of women with hyperemesis than without hyperemesis were coded forhypertensive disorders in pregnancy such as pregnancy-induced hypertension, pre-eclampsia and eclampsia (2.7% vs 1.5%;P=0.001). The proportion of gestational diabetes and liver disorders in pregnancy was similar for both groups (diabetes:0.5% vs. 0.4%; P=0.945, liver disorders: 0.2% vs. 0.1%;P=0.662). Hyperemesis patients had a higher proportion of elective and emergency caesarean sections compared with the non-hyperemesis group (ElCS: 3.3% vs. 2%; P=0.002, EmCS: 5% vs.3%; P=0.00). Conclusions: There was a higher rate of emergency and elective caesarean section in women with hyperemesis, which could reflect the higher prevalence of pregnancy-related hypertensive disorders(but not diabetes or liver disorders) in this group. The factors contributing to the higher prevalence of hypertensive disorders arenot known, but these findings lead us to question whether there is a similar pathogenesis in the development of both the conditions and hence whether further study in this area is warranted.

Stress, burnout and coping strategies in the emergency and intensive care hospital departments

Doctors and nurses working at the accident and emergency (A&E), and intensive care departments are at risk of burnout. They often spend substantial time in intense interactions with other people, centered on patients? health problems (physical, psychological and social) that may lead to feelings of anger, anxiety and frustration, and eventually to burnout. Burnout is a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment (Maslach & Jackson, 1981) The purpose of this chapter is to assess work stressors, burnout and stress-coping mechanisms among doctors and nurses at the A&E and intensive care departments. A quantitative design using the survey approach was used to collect data from a sample of 200 participants with a response rate of 71% (n=154) Work stressors were associated with burnout in both doctors and nurses. Workload was the most salient work stressor in the sample. Nurses experienced more stress (M=1.5, SD=0.4) than doctors (M=1.2, SD=0.4) in all the work stressor variables examined. The A&E department was reported as more stressful than the intensive care department. Avoidance-oriented and task-oriented coping were the most and the least frequently reported coping strategies respectively. Additionally, only emotion-oriented coping strategy was significantly different between doctors and nurses, and this strategy was also significantly positively correlated with all the variables in the adapted nursing stress scale, and the three burnout variables. Death and dying was most strongly correlated with emotion-oriented coping. This chapter provides an assessment of stress, burnout and coping experienced by both doctors and nurses within the A&E and intensive care departments. Methods that may mitigate stress in these environments may be adequate staffing, supportive management, stress management programs, as well as improvement in communication strategies between doctors and nurses.

Potential causes of ethnic group disparities in infertility:a hospital database study

Introduction - Lower success rates of in vitro fertilisation (IVF) in South East Asian countries compared to Western countries in informal studies and surveys was considered a reflection of variations in methodology and expertise. However, recent studies on the effects of ethnicity on success rates of infertility procedures in western countries have suggested other inherent contributing factors to the ethnic disparity but the evidence evaluating these is lacking. In our study we aim to investigate some of the comorbidities that might cause ethnic disparity to infertility and related procedures from hospital admissions data. Methods - Anonymous hospital admissions data on patients of various ethnic groups with infertility, comorbidities and infertility procedures from multiple hospitals in Birmingham andManchester, UK between 2000 and 2013 were obtained from the local health authority computerised hospital activity analysis register using ICD-10 and OPCS coding systems. Statistical analysis was performed using SPSS version 20.Results Of 522 223 female patients aged 18 and over, there were44 758 (8.4%) patients from South Asian (SA) community. 1156(13.4%) of the 8653 patients coded for infertility were SA, whichis a considerably higher proportion of the background SA population. For IVF procedures, the percentage of SA increased to15.4% (233 of the total 1479 patients). The mean age of SA codedfor infertility (30.6 ± 4.7 SD years versus 32.8 ± 4.9 SD years)and IVF (30.4 ± 4.3 SD years versus 32.7 ± 4.4 SD years) was significantly lower than caucasian patien ts (P < 0.001). A multivariate logistic regression model looking at patients with infertility, accounting for variations in age, showed that SA have significantly higher prevalence of hypothyroidism, obesity andiron-deficiency anaemia compared to caucasians but lower prevalence of endometriosis. Interestingly, psychiatric and psychological conditions diagnoses were seldom registered in infertility patients. Conclusion - Other studies suggest that various cultural, lifestyles, psychosocial and socio-economic factors may explain the disparities in IVF success rates between South Asians and caucasians. The fact that SA infertility and IVF patients, in ou rstudy, were significantly younger than caucasians and that their proportion is considerably higher than the background South Asian population suggests the influence of these factors. A significant psychiatric disease burden in other conditions and low numbers in our data suggest under diagnosis in this group.Despite the limitations of the coding data, from our study, we propose that hypothyroidism, obesity and/or iron-deficiency anaemia should be considered for the ethnic disparity. Further research in this topic is essential to fully investigate the reasons for such ethnic disparities.

Clinical significance of medication reconciliation in children admitted to a UK pediatric hospital:observational study of neurosurgical patients

Background: In December 2007, the National Institute for Health and Clinical Excellence and the National Patient Safety Agency in the UK (NICE-NPSA) published guidance that recommends all adults admitted to hospital receive medication reconciliation, usually by pharmacy staff. A costing and report tool was provided indicating a resource requirement of d12.9 million for England per year. Pediatric patients are excluded from this guidance. Objective: To determine the clinical significance of medication reconciliation in children on admission to hospital. Methods: A prospective observational study included pediatric patients admitted to a neurosurgical ward at Birmingham Childrens Hospital, Birmingham, England, between September 2006 and March 2007. Medication reconciliation was conducted by a pharmacist after the admission of each of 100 consecutive eligible patients aged 4 months to 16 years. The clinical significance of prescribing disparities between pre-admission medications and initial admission medication orders was determined by an expert multidisciplinary panel and quantified using an analog scale. The main outcome measure was the clinical signficance of unintentional variations between hospital admission medication orders and physician-prescribed pre-admission medication for repeat (continuing) medications. Results: Initial admission medication orders for children differed from prescribed pre-admission medication in 39%of cases. Half of all resulting prescribing variations in this setting had the potential to cause moderate or severe discomfort or clinical deterioration. These results mirror findings for adults. Conclusions: The introduction of medication reconciliation in children on admission to hospital has the potential to reduce discomfort or clinical deterioration by reducing unintentional changes to repeat prescribed medication. Consequently, there is no justification for the omission of children from the NICENPSA guidance concerning medication reconciliation in hospitals, and costing tools should include pediatric patients. © 2010 Adis Data Information BV. All rights reserved.

Perceptions and experiences of the implementation, management, use and optimisation of electronic prescribing systems in hospital settings:protocol for a systematic review of qualitative studies

Introduction: There is increasing evidence that electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitative approaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support. Methods and analysis: Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library (CDSR, DARE and CENTRAL databases), Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest and SCOPUS. In addition, other sources will be searched for ongoing studies (ClinicalTrials.gov) and grey literature: Healthcare Management Information Consortium, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by 2 reviewers. Qualitative studies, either standalone or in the context of mixed-methods designs, reporting the perspectives of any actors involved in the implementation, management and use of ePrescribing/CPOE systems in hospital-based care settings will be included. Data extraction will be conducted by 2 reviewers using a piloted form. Quality appraisal will be based on criteria from the Critical Appraisal Skills Programme checklist and Standards for Reporting Qualitative Research. Studies will not be excluded based on quality assessment. A postsynthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method. Ethics and dissemination: The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.

Three essays on hospital efficiency

This dissertation analyzes hospital efficiency using various econometric techniques. The first essay provides additional and recent evidence to the presence of contract management behavior in the U.S. hospital industry. Unlike previous studies, which focus on either an input-demand equation or the cost function of the firm, this paper estimates the two jointly using a system of nonlinear equations. Moreover, it addresses the longitudinal problem of institutions adopting contract management in different years, by creating a matched control group of non-adopters with the same longitudinal distribution as the group under study. The estimation procedure then finds that labor, and not capital, is the preferred input in U.S. hospitals regardless of managerial contract status. With institutions that adopt contract management benefiting from lower labor inefficiencies than the simulated non-contract adopters. These results suggest that while there is a propensity for expense preference behavior towards the labor input, contract managed firms are able to introduce efficiencies over conventional, owner controlled, firms. Using data for the years 1998 through 2007, the second essay investigates the production technology and cost efficiency faced by Florida hospitals. A stochastic frontier multiproduct cost function is estimated in order to test for economies of scale, economies of scope, and relative cost efficiencies. The results suggest that small-sized hospitals experience economies of scale, while large and medium sized institutions do not. The empirical findings show that Florida hospitals enjoy significant scope economies, regardless of size. Lastly, the evidence suggests that there is a link between hospital size and relative cost efficiency. The results of the study imply that state policy makers should be focused on increasing hospital scale for smaller institutions while facilitating the expansion of multiproduct production for larger hospitals. The third and final essay employs a two staged approach in analyzing the efficiency of hospitals in the state of Florida. In the first stage, the Banker, Charnes, and Cooper model of Data Envelopment Analysis is employed in order to derive overall technical efficiency scores for each non-specialty hospital in the state. Additionally, input slacks are calculated and reported in order to identify the factors of production that each hospital may be over utilizing. In the second stage, we employ a Tobit regression model in order to analyze the effects a number of structural, managerial, and environmental factors may have on a hospital’s efficiency. The results indicated that most non-specialty hospitals in the state are operating away from the efficient production frontier. The results also indicate that the structural make up, managerial choices, and level of competition Florida hospitals face have an impact on their overall technical efficiency.