Coercion in mental health care gives rise to many ethical challenges. Many countries have recently implemented state policy programs or development projects aiming to reduce coercive practices and improve their quality. Few studies have explored the possible role of ethics (i.e., ethical theory, moral deliberation and clinical ethics support) in such initiatives. This study adds to this subject by exploring health professionals' descriptions of their ethical challenges and strategies in everyday life to ensure morally justified coercion and best practices. Seven semi-structured telephone interviews were carried out in 2012 with key informants in charge of central development projects and quality-assurance work in mental health services in Norway. No facilities used formal clinical ethics support. However, the informants described five areas in which ethics was of importance: moral concerns as implicit parts of local quality improvement initiatives; moral uneasiness and idealism as a motivational source of change; creating a normative basis for development work; value-based leadership; and increased staff reflexivity on coercive practices. The study shows that coercion entails both individual and institutional ethical aspects. Thus, various kinds of moral deliberation and ethics support could contribute to addressing coercion challenges by offering more systematic ways of dealing with moral concerns. However, more strategic use of implicit and institutional ethics is also needed.
External inspections are widely used in health care as a means of improving the quality of care. However, the way external inspections affect the involved organization is poorly understood. A better understanding of these processes is important to improve our understanding of the varying effects of external inspections in different organizations. In turn, this can contribute to the development of more effective ways of conducting inspections. The way the inspecting organization states their grounds for noncompliant behavior and subsequently follows up to enforce the necessary changes can have implications for the inspected organization's change process. We explore how inspecting organizations express and state their grounds for noncompliant behavior and how they follow up to enforce improvements.
We conducted a retrospective review, in which we performed a content analysis of the documents from 36 external inspections in Norway. Our analysis was guided by Donabedian's structure, process, and outcome model.
Deficiencies in the management system in combination with clinical work processes was considered as nonconformity by the inspecting organizations. Two characteristic patterns were identified in the way observations led to a statement of nonconformity: one in which it was clearly demonstrated how deficiencies in the management system could affect clinical processes, and one in which this connection was not demonstrated. Two characteristic patterns were also identified in the way the inspecting organization followed up and finalized their inspection: one in which the inspection was finalized solely based on the documented changes in structural deficiencies addressed in the nonconformity statement, and one based on the documented changes in structural and process deficiencies addressed in the nonconformity statement.
External inspections are performed to improve the quality of care. To accomplish this aim, we suggest that nonconformities should be grounded by observations that clearly demonstrate how deficiencies in the management system might affect the clinical processes, and that the inspection should be finalized based on documented changes in both structural and process deficiencies addressed in the nonconformity statement.
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To develop and validate an instrument for guidance and evaluation of quality and safety improvement efforts in health care.
The instrument is based on the Plan-Do-Study-Act cycle and the 3 fundamental improvement questions regarding aims, measurement, and change-making.
An interdisciplinary team of improvement experts developed the Change Process and Outcome (CPO) scale. After studying the improvement literature, the scale was tested and refined on a sample of 5 projects. The CPO evaluation process and classification system was developed when evaluating 189 of the quality improvement projects of the Norwegian Medical Association by their final reports. The scale was validated by applying statistical testing to the evaluation results.
The final CPO scale consists of 13 process items and 7 outcome items. Interrater reliability ranged from 0.53 to 0.79, and test-retest reliability was 0.82. Factor analyses with Varimax rotation identified 2 significant process domains: Aims/change-making and Measurement/reporting, with Cronbach a values 0.88 and 0.95, respectively. The classification system produced 3 performance levels: successful, promising, and uncertain.
The CPO scale shows good internal consistency, reliability, and validity for evaluating the success of quality improvement initiatives.
Since 1996, the Swedish National Diabetes Register (NDR) enabled health care providers to monitor their clinical performance over time and compare it with the national average. All health systems of Swedish county councils report data. By 2014, the NDR included data from 360 000 patients. Comparisons among county councils show significant variations in clinical outcomes and in adherence to evidence-based national guidelines. The purpose of this study was to evaluate whether and how a quality improvement collaborative could influence clinical practice and outcomes.
Twenty-three diabetes teams from all over Sweden, both primary care units and internal medicine departments, joined a quality improvement collaborative. The project was inspired by the Breakthrough Collaborative Model and lasted for 20 months. Evaluation data were collected from the teams' final reports and the NDR throughout the study period.
The teams reported improved patient outcomes significantly compared with the national average for systolic blood pressure and low-density lipoprotein levels. In contrast, glycated hemoglobin A1c levels deteriorated in the whole NDR population. Five themes of changes in practice were tested and implemented. Success factors included improved teamwork, with active use of register data, and testing new ideas and learning from others.
The aim of this study was to explore students' experiences during their clinical placements in five nursing homes after implementing measures to improve the learning environment. It is vital to stimulate more future nurses to consider a career within geriatric wards and nursing homes. One way to achieve this, is to enhance nursing students' learning experiences during clinical placements in these settings. Measures to improve the learning environment were implemented as a result of a joint effort between a university college and five nursing homes. An explorative design was developed to collect empirical data concerning the students' experiences expressed through questionnaires and logs. The results generally conveyed more positive than negative experiences. Students expressed most satisfaction with peer collaboration, the placement's contribution to awareness of future nursing role and described the learning arena as exciting and interesting. They expressed less satisfaction with supervision from preceptor and how the practice site was prepared for and organized students' placements. Clinical placement arenas and educational institutions should collaborate closely to explore and develop models of supervision appropriate for the nursing home context, to build on existing potentials and resolve the issues that represent barriers for creating interesting and effective learning environments.
Purpose - The purpose of this study is to evaluate how LEAN thinking is used as a management and development tool in the Finnish public healthcare system and what kind of outcomes have been achieved or expected by using it. The main focus is in managing and developing patient and treatment processes. Design/methodology/approach - A mixed-method approach incorporating the Webropol survey was used. Findings - LEAN is quite a new concept in Finnish public healthcare. It is mainly used as a development tool to seek financial savings and to improve the efficiency of patient processes, but has not yet been deeply implemented. However, the experiences from LEAN initiatives have been positive, and the methodology is already quite well-known. It can be concluded that, because of positive experiences from LEAN, the environment in Finnish healthcare is ready for the deeper implementation of LEAN. Originality/value - This paper evaluates the usage of LEAN thinking for the first time in the public healthcare system of Finland as a development tool and a management system. It highlights the implementation and achieved results of LEAN thinking when used in the healthcare environment. It also highlights the expectations for LEAN thinking in Finnish public healthcare.
The Cancer Quality Council of Ontario has undertaken 3 programmatic reviews, in partnership with Cancer Care Ontario, to evaluate an emerging or existing program and to provide future directions. The reviews are a quality improvement tool consisting of an assessment of the program's current state, a critical appraisal, and an environmental scan in advance of an event where attendees hear best practices from jurisdictions and participate in a discussion leading to a set of recommendations for the program.