Ruth Boaden

Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data

Objectives To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people. Design Practice level before and after analysis of hospital admissions data with control group. Setting Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission. Main outcome measures Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out). Results The intervention had no significant effect on rates of emergency admission (increase 16.5%, (95% confidence interval −5.7% to 38.7%), emergency bed days (increase 19.0%, −5.3% to 43.2%), and mortality (increase 34.4%, −1.7% to 70.3%) for a high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged ≥65 effects on the rates of emergency admission (increase 2.5%, −2.1% to 7.0%), emergency bed days (decrease −4.9%, −10.8% to 1.0%), and mortality (increase 5.5%, −3.5% to 14.5%) were also non-significant. Conclusions Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions.

Reduced Mortality with Hospital Pay for Performance in England

BACKGROUND Pay-for-performance programs are being adopted internationally despite little evidence that they improve patient outcomes. In 2008, a program called Advancing Quality, based on the Hospital Quality Incentive Demonstration in the United States, was introduced in all National Health Service (NHS) hospitals in the northwest region of England (population, 6.8 million). METHODS We analyzed 30-day in-hospital mortality among 134,435 patients admitted for pneumonia, heart failure, or acute myocardial infarction to 24 hospitals covered by the pay-for-performance program. We used difference-in-differences regression analysis to compare mortality 18 months before and 18 months after the introduction of the program with mortality in two comparators: 722,139 patients admitted for the same three conditions to the 132 other hospitals in England and 241,009 patients admitted for six other conditions to both groups of hospitals. RESULTS Risk-adjusted, absolute mortality for the conditions included in the pay-for-performance program decreased significantly, with an absolute reduction of 1.3 percentage points (95% confidence interval [CI], 0.4 to 2.1; P=0.006) and a relative reduction of 6%, equivalent to 890 fewer deaths (95% CI, 260 to 1500) during the 18-month period. The largest reduction, for pneumonia, was significant (1.9 percentage points; 95% CI, 0.9 to 3.0; P<0.001), with nonsignificant reductions for acute myocardial infarction (0.6 percentage points; 95% CI, -0.4 to 1.7; P=0.23) and heart failure (0.6 percentage points; 95% CI, -0.6 to 1.8; P=0.30). CONCLUSIONS The introduction of pay for performance in all NHS hospitals in one region of England was associated with a clinically significant reduction in mortality. As compared with a similar U.S. program, the U.K. program had larger bonuses and a greater investment by hospitals in quality-improvement activities. Further research is needed on how implementation of pay-for-performance programs influences their effects. (Funded by the NHS National Institute for Health Research.).

Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors’ and nurses’ views

Background: The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules. Methods: Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews. Results: Doctors’ views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines. Conclusions: While the creation of a “safety culture” requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.

Lessons for Lean in Healthcare from Using Six Sigma in the NHS

In the UK the National Health Service (NHS) has applied a number of quality improvement approaches from manufacturing, often in a piecemeal fashion; most notably Six Sigma and, more recently, Lean. This article reports on an evaluation of a programme used in the NHS to consider what can be learned about the application of such approaches—including what themes also apply to Lean, and its implementation, particularly in the healthcare context.

Can good bed management solve the overcrowding in accident and emergency departments

The NHS Plan1 makes the commitments that a patient’s total time in accident and emergency (A&E) will be no more than four hours. Many trusts are currently struggling to reduce four hour trolley waits (the time from the decision to admit (DTA) to leaving A&E). A recent survey conducted by the BMA and the British Association for Accident and Emergency Medicine2 suggests that official figures give an over-optimistic picture of the current pressures in A&E departments, and long patient waits are still common. The ability to move patients with a DTA out of A&E depends on the ability of the hospital to accommodate them (or to accommodate patients from the MAU, etc, to make room available). This movement is normally the responsibility of the bed management (BM) function, according to the National Audit Office (NAO),3 and this is the case in all trusts with which we are familiar. BM forms an important part of operational capacity planning and control, a wider activity concerned with the efficient use of resources. Outside the health context, the production/operations function of an organisation is concerned with activities such as scheduling and work flow to enable throughput to meet demand, and minimise work in progress and maximise resource utilisation. Despite the obvious analogies, very few acute hospitals have an operations management function. The objective of this paper is to demonstrate the part that operational capacity planning and control, in particular BM, plays, and could play, in improving service delivery. It starts by describing the typical function and structure of BM in acute hospitals, patterns of hospital activity, and their effects, particularly on A&E. Developments in operational capacity planning are then considered. These aim to improve planning and management of supply and demand, and moving towards and maintaining lower bed occupancy in medicine. …

Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis

Objective To investigate whether centralisation of acute stroke services in two metropolitan areas of England was associated with changes in mortality and length of hospital stay. Design Analysis of difference-in-differences between regions with patient level data from the hospital episode statistics database linked to mortality data supplied by the Office for National Statistics. Setting Acute stroke services in Greater Manchester and London, England. Participants 258 915 patients with stroke living in urban areas and admitted to hospital in January 2008 to March 2012. Interventions “Hub and spoke” model for acute stroke care. In London hyperacute care was provided to all patients with stroke. In Greater Manchester hyperacute care was provided to patients presenting within four hours of developing symptoms of stroke. Main outcome measures Mortality from any cause and at any place at 3, 30, and 90 days after hospital admission; length of hospital stay. Results In London there was a significant decline in risk adjusted mortality at 3, 30, and 90 days after admission. At 90 days the absolute reduction was −1.1% (95% confidence interval −2.1 to −0.1; relative reduction 5%), indicating 168 fewer deaths (95% confidence interval 19 to 316) during the 21 month period after reconfiguration in London. In both areas there was a significant decline in risk adjusted length of hospital stay: −2.0 days in Greater Manchester (95% confidence interval −2.8 to −1.2; 9%) and −1.4 days in London (−2.3 to −0.5; 7%). Reductions in mortality and length of hospital stay were largely seen among patients with ischaemic stroke. Conclusions A centralised model of acute stroke care, in which hyperacute care is provided to all patients with stroke across an entire metropolitan area, can reduce mortality and length of hospital stay.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

The impact of performance measurement in the voluntary sector: Identification of contextual and processual factors.

Purpose – The purpose of this research paper is to identify the impact of contextual and processual factors on the development, use and impact of performance measurement systems in voluntary and community organisations.Design/methodology/approach – The paper reviews the applicability of business and public sector performance measurement frameworks to voluntary organisations. It presents the findings of a study through four case studies and draws conclusions on the impact of measurement systems in the voluntary sector.Findings – The research identifies a low utilisation of performance measurement frameworks and discusses what systems are currently used, how such systems are administered and the impact of measurement on performance.Research limitations/implications – The evidence is based on four micro‐voluntary organisations that receive public sector funding. The findings are based on the perceptions of the organisations delivering the services and illustrate the relationship between the public and volunt...

Sustaining total quality management: what are the key issues?

From both fieldwork and the academic literature a number of issues have been identified which impact negatively on the sustaining of TQM in manufacturing organizations. The issues reflect a variety of business operations perspectives including continuous improvement, organizational behaviour, human resources management, industrial relations and the labour process. They have been grouped into a five‐part categorization of internal/external environment, management style, policies, organization structure, and the process of change and configured into a TQM sustaining audit tool. Describes, in brief, these categories and issues and presents some of the findings from their examination, using the audit tool, at six manufacturing sites.

Developing an understanding of corporate anorexia

“Lean working”, “leanness” or “lean” are terms that can be used to describe “doing more with less” i.e. improved utilisation of an organisations resources. This paper outlines the concept of leanness before developing thinking to describe a state of “corporate anorexia” – the inability to utilise or balance effectively the facets/resources of the organisation. There may be a variety of causes of this state of anorexia; this paper will not however consider all of them in detail, since its main focus is around identifying the characteristics of an anorexic organisation. The case study analysis presented focuses on the process of change undergone by an organisation when becoming lean and the extent to which this may result in corporate anorexia. A review of literature is used to develop a set of questions that can be used to consider the impact of the process of change to a state of leanness on various facets of the organisation, and in particular the way in which they balance with each other. These questions are then applied to some case studies in order to assess how lean an organisation is, and conclusions drawn about what the cases show in relation to both leanness and anorexia.