Search results

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

The topic of offender rehabilitation has been subject to much research over the past decade. Numerous meta‐analytic reviews of offender treatment, particularly group treatment based on cognitive behavioural principles, have been reported. Together with the ‘triad of principles’ — risk, need and responsivity — they have formed the foundation upon which most offending behaviour interventions have developed. However, outcome data from existing programmes provides mixed evidence, and evidence for interventions for those in forensic mental health settings are still in their infancy. This paper critically considers the current evidence for the treatment of offending behaviour, and its application in forensic mental health settings, in order to inform development of such treatments in low secure mental health care. Most of the research focuses on non‐mental health settings, and is largely what will be considered here. The paper concludes that low secure interventions need to capitalise on the evidence of ‘what works’ while revisiting key concepts such as ‘dose’ and responsivity in order to design appropriate treatments. Individual outcome evaluation needs to form part of development in this area.

This paper aims to improve community care for people with intellectual disabilities (ID) and/or autism. Lack of coordination between agencies leads to children and young people with the most complex needs falling between services. The North West Operational Delivery Network (ODN) for learning disability and autism set out to develop a model of care for mental health services for children and young people with ID and/or autism in North West England that would improve coordination between services and lead to better community care.

The ODN held a series of good practice events and consultations with stakeholders in North West England to look at gaps in service provision, national guidelines and agree on a pathway for services.

The ODN decided to use the THRIVE framework as the basis for a specific model of care. Interventions were mapped against the THRIVE groupings, including pathways and team specifications for assessment and support for children with autism, and models for child and adolescent mental health service support for ID and/or autism, for keeping children and young people with behaviour that challenges in the community and transition.

This model aims to provide the North West England region with a clear multi-agency approach for supporting the needs of this population and supports multi-agency commissioning, gap analysis, earlier intervention and improving health outcomes for this population.

The purpose of this paper is to use a descriptive case study to establish how collaboration, innovation and knowledge‐management strategies have scaled‐up learning and development in rural, remote and other resource‐constrained Canadian delivery settings.

Intervention design was realized through a one‐time, collaborative, national capacity‐building project. A project portfolio of 72 sub‐projects, initiatives and strategic activities was used to improve access, enhance quality and create capacity for palliative and end‐of‐life care services. Evaluation was multifaceted, including participatory action research, variance analysis and impact analysis. This has been supplemented by post‐intervention critical reflection and integration of relevant literature.

The purposeful use of collaboration, innovation and knowledge‐management strategies have been successfully used to support a rapid scaling‐up of learning and development interventions. This has enabled enhanced and new pan‐Canadian health delivery capacity implemented at the local service delivery catchment‐level.

The intervention is bounded by a Canada‐specific socio‐cultural/political context. Design variables and antecedent conditions may not be present and/or readily replicated in other nation‐state contexts. The findings suggest opportunities for future integrative and applied health services and policy research, including collaborative inquiry that weaves together concepts from adult learning, social science and industrial engineering.

Scaling‐up for new capacity is ideally approached as a holistic, multi‐faceted process which considers the total assets within delivery systems, service catchments and communities as potentially being engaged and deployed.

The Pallium Integrated Capacity‐building Initiative offers model elements useful to others seeking theory‐informed practices to rapidly and effectively scale‐up learning and development efforts.

Housing First (HF) is an evidence-based practice effective in reducing homelessness among those who experience chronic homelessness. However, a strong synthesis evaluating the effectiveness of this intervention is lacking for people who use drugs. The purpose of this study is to explore international literature databases to identify the effectiveness of the HF programme among people who use drugs.

A modified framework from Arksey and O’Malley (2005) was used, namely: identifying the research question; developing inclusion and exclusion criteria; identifying relevant studies for study selection; charting the data; and collating, summarising and reporting the results.

Three main themes were identified: substance use related outcomes, housing-related outcomes and social outcomes. There is strong evidence that HF increases housing retention and reduces homelessness among chronically homeless people who use drugs. However, literature relating to substance use and social outcomes for this population report mixed and inconclusive findings.

This scoping review concludes that additional research is required to conclusively determine whether HF is an effective intervention for homeless substance users. Future researchers must use formal assessments of substance use and ensure clear reporting of the HF intervention is accomplished. It is recommended for researchers and policymakers to consider the specific needs of the people who use drugs before implementation of HF for this population.

Differential effectiveness of HF through diagnostic subgroups such as alcohol use and drug use is varied with alcohol use being found to decrease due to the HF programme, but findings relating to other drug use outcomes are varied. As most previous studies used the Addiction Severity Index (ASI) to measure substance use among participants, however, the ASI, a self-reporting measure has unstable criterion validity and can cause under or over reporting of substance use. Structured toxicology or diagnostic assessments of substance use must be used for research instead to assist researchers in making firm conclusions about the reported rates.

The slightly poorer housing outcomes among people who use substances indicate that this group may need more intensive approaches to finding and maintaining housing. Additional services for the group that address comorbid problems and consequences relating to substance use are required. It is suggested that housing should be provided within an integrated model that offers additional support services such as case management as when well matched to clients, case management appears to be an effective intervention among homeless sub-populations, as it reduces substance use, improves quality of life and health outcomes, improves social connectedness and increases housing tenure and satisfaction.

This scoping review concludes that additional research is required to conclusively determine whether HF is an effective intervention for homeless substance users. Future researchers must use formal assessments of substance use and ensure clear reporting of the HF intervention is accomplished. It is recommended for researchers and policymakers to consider the specific needs of the people who use drugs before HF implementation for this population.

A region’s transforming care partnership identified that autistic adults without an intellectual disability (ID) may be falling through gaps in services when presenting with a significant emotional and/or behavioural need in the absence of a mental health diagnosis. The region’s intensive support teams (ISTs) for adults with ID therefore piloted a short-term “behavioural support service” for this population. The purpose of this paper is to evaluate this pilot.

This study represents a mixed-methods service evaluation over a four year pilot period. The quantitative component examined referral rates and demographic data of accepted and declined referrals; and length of referral episodes and Health of The Nation Outcomes Scores (HoNOS) for accepted referrals. The qualitative component used thematic analysis to identify key themes relating to reasons for referral, clinical/therapeutic needs, and the models of support that most informed assessments and interventions at individual and systems levels.

The ISTs accepted 30 referrals and declined 53. Most accepted referrals were male (83%), and under 24 years old (57%). Average HoNOS scores were above the thresholds generally associated with hospital admission. Key qualitative themes were: transitional support; sexual risks/vulnerabilities; physical aggression; domestic violence; and attachment, trauma and personality difficulties. Support mostly followed psychotherapeutic modalities couched in trauma, attachment and second- and third-wave cognitive behavioural therapies. Positive Behaviour Support (PBS) did not emerge as a model of preference for service users or professionals.

This project represents one of the first of this type for autistic adults without an ID in the UK. It provides recommendations for future service development and research, with implications for Transforming Care policy and guidance.

People with a borderline personality disorder (BPD) diagnosis can require support from mental health services for managing risk behaviour. Current routine inpatient and community treatment can be unhelpful for this group. Positive risk taking has been developed to help community teams manage risk with people with a BPD. This study aims to explore experiences of risk management in an NHS Trust where positive risk taking is being implemented with people with a BPD.

Interpretative phenomenological analysis is the methodology of transcripts from semi-structured interviews. Nine adults with a diagnosis of BPD and current or previous experiences of risk management approaches were sampled from one NHS Trust.

Limited resources and interpersonal barriers had a negative impact on experiences of Positive risk taking. Participants experienced one-off risk assessments and short-term interventions such as medication which they described as “meaningless”. Traumatic experiences could make it difficult to establish therapeutic relationships and elicit unhelpful responses from professionals. Participants could only feel “taken seriously” when in crisis which contributed towards an increase in risky behaviour. Positive risk taking was contingent upon collaborative and consistent professional relationships which created a “safety net”, enabling open communication and responsibility taking which challenged recovery-relapse patterns of service use.

Positive risk taking approaches to risk management may benefit people with a BPD. Findings complement those from other studies emphasising the importance of compassion and empathy when working with personality disorder. Training and increased resources are required to implement effective risk management with this group.

Findings expand upon the sparse existing research in the area of risk management using the Positive risk taking approach with people with a BPD diagnosis, and provide idiographic understanding which is clinically meaningful. Participants’ experiences suggest Positive risk taking may provide a framework for improving quality of life and decreasing service use for people diagnosed with BPD engaging in risk management with Community Mental Health Teams, which facilitates recovery and other benefits.

The paper shows how small firms perceive the pathways through which access to and adoption of superfast broadband-enabled resources strengthen business performance. Improvements to broadband infrastructure do not automatically lead to adoption of opportunities made available through the broadband resource. Then, interventions can be used to alert small firms to new opportunities. However, the quality of interventions in terms of education and digital audits can be better targeted with information available on how small firms perceive the benefits from broadband access and whether these perceptions are reflected in business performance outcomes.

Data are used from the Digital Maturity Survey from Wales. The study uses principal component analysis and a dual stage cluster approach to show how SMEs believe they are benefitting from broadband access. These belief-based perceptions of broadband inferred business benefits are tested against business performance variables.

The analysis shows variation in SME perceptions of the benefits of broadband-enabled services. This study reveals a cluster of firms which perceived routes to business value in terms of variables linked to security and risk management, and then more commonly held notions linked to communication, competition enhancement and productivity.

While the research literature points to Information and Communication Technology (ICT) resources (ICT investment and skills) and use (digital applications), leading to new to business value improvements, this study suggests less work has sought to identify the critical themes identified by business owners in explaining how ICT resources and use tie to observed business performance. The study identifies these critical themes. The analysis suggests that these critical themes in terms of business value benefits as perceived by business owners can be summarised in terms of communication and competition benefits, and security and risk related benefits. The findings have a series of implications for interventions in the space.

Hospitals worldwide are facing the same opportunities and threats: the demographics of an aging population; steady increases in chronic diseases and severe illnesses; and a steadily increasing demand for medical services with more intensive treatment for multi-morbid patients. Additionally, patients are becoming more demanding. They expect high quality medicine within a dignity-driven and painless healing environment.

The severe financial pressures that these developments entail oblige care providers to more and more cost-containment and to apply process reengineering, as well as continuous performance improvement measures, so as to achieve future financial sustainability. At the same time, regulators are calling for improved patient outcomes. Benchmarking and best practice management are successfully proven performance improvement tools for enabling hospitals to achieve a higher level of clinical output quality, enhanced patient satisfaction, and care delivery capability, while simultaneously containing and reducing costs.

This chapter aims to clarify what benchmarking is and what it is not. Furthermore, it is stated that benchmarking is a powerful managerial tool for improving decision-making processes that can contribute to the above-mentioned improvement measures in health care delivery. The benchmarking approach described in this chapter is oriented toward the philosophy of an input–output model and is explained based on practical international examples from different industries in various countries.

Benchmarking is not a project with a defined start and end point, but a continuous initiative of comparing key performance indicators, process structures, and best practices from best-in-class companies inside and outside industry.

Benchmarking is an ongoing process of measuring and searching for best-in-class performance:

• Measure yourself with yourself over time against key performance indicators

• Measure yourself against others

• Identify best practices

• Equal or exceed this best practice in your institution

• Focus on simple and effective ways to implement solutions

Measure yourself with yourself over time against key performance indicators

Measure yourself against others

Identify best practices

Equal or exceed this best practice in your institution

Focus on simple and effective ways to implement solutions

Comparing only figures, such as average length of stay, costs of procedures, infection rates, or out-of-stock rates, can lead easily to wrong conclusions and decision making with often-disastrous consequences. Just looking at figures and ratios is not the basis for detecting potential excellence. It is necessary to look beyond the numbers to understand how processes work and contribute to best-in-class results. Best practices from even quite different industries can enable hospitals to leapfrog results in patient orientation, clinical excellence, and cost-effectiveness.

Despite common benchmarking approaches, it is pointed out that a comparison without “looking behind the figures” (what it means to be familiar with the process structure, process dynamic and drivers, process institutions/rules and process-related incentive components) will be extremely limited referring to reliability and quality of findings.

In order to demonstrate transferability of benchmarking results between different industries practical examples from health care, automotive, and hotel service have been selected.

Additionally, it is depicted that international comparisons between hospitals providing medical services in different health care systems do have a great potential for achieving leapfrog results in medical quality, organization of service provision, effective work structures, purchasing and logistics processes, or management, etc.