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(2012)Journal ArticleSince the 1991 enactment of mandatory helmet legislation (MHL) for cyclists in New South Wales (NSW), Australia, there has been extensive debate as to its effect on head injury rates at a population level. Many previous studies have focused on the impact of MHL around the time of enactment, while little has been done to examine the ongoing effects. We aimed to extend prior work by investigating long-term trends in cyclist head and arm injuries over the period 1991–2010. The counts of cyclists hospitalised with head or arm injuries were jointly modelled with log-linear regression. The simultaneous modelling of related injury mechanisms avoids the need for actual exposure data and accounts for the effects of changes in the cycling environment, cycling behaviour and general safety improvements. Models were run separately with population counts, bicycle imports, the average weekday counts of cyclists in Sydney CBD and cycling estimates from survey data as proxy exposures. Overall, arm injuries were higher than head injuries throughout the study period, consistent with previous post-MHL observations. The trends in the two injury groups also significantly diverged, such that the gap between rates increased with time. The results suggest that the initial observed benefit of MHL has been maintained over the ensuing decades. There is a notable additional safety benefit after 2006 that is associated with an increase in cycling infrastructure spending. This implies that the effect of MHL is ongoing and progress in cycling safety in NSW has and will continue to benefit from focusing on broader issues such as increasing cycling infrastructure.
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(2012)ReportThis project aimed to assess the impact of electronic ordering systems, on the quality use of pathology services across six hospital sites and different pathology departments, for the following areas:- the legibility and completeness of laboratory test orders and the impact on Central Specimen Reception work processes (Quality of test orders). - the volume and mix of tests ordered examined by such factors as Diagnosis-related Groups (DRGs), adjusted for clinical activity where appropriate, and the prevalence of add-on and repeat testing (Effectiveness). - the timeliness of the pathology laboratory process (Turnaround time). - the impact of pathology performance (e.g., laboratory test turnaround times) on the duration of patient stay in the emergency department (Patient outcome).The project also produced a benefits realisation framework, made up of performance indicators, that can be used to guide the assessment of electronic ordering in a pathology service and to monitor what works (or doesn’t work), where, and in what circumstances. The project was funded by an Australian Government Department of Health and Ageing, Quality Use of Pathology Program grant.
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(2013)Journal ArticleThis article responds to criticisms made in a rejoinder (Accident Analysis and Prevention 2012, 45: 107–109) questioning the validity of a study on the impact of mandatory helmet legislation (MHL) for cyclists in New South Wales, Australia. We systematically address the criticisms through clarification of our methods, extension of the original analysis and discussion of new evidence on the population-level effects of MHL. Extensions of our analysis confirm the original conclusions that MHL had a beneficial effect on head injury rates over and above background trends and changes in cycling participation. The ongoing debate around MHL draws attention away from important ways in which both safety and participation can be improved through investment in well-connected cycling infrastructure, fostering consideration between road users, and adequate legal protection for vulnerable road users. These are the essential elements for providing a cycling environment that encourages participation, with all its health, economic and environmental benefits, while maximising safety.
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(2012)ThesisThis thesis examines the role of medical clinician surveyors (MC surveyors) working in the hospital-based health care accreditation arena. The thesis examines their motivations for participating in accreditation, the issues that influence them during the survey process, and the ways in which they deal with the influences to facilitate a reliable and credible survey outcome. The study is an evidence-based examination of MC surveyors working for the Australian Council on Healthcare Standards (ACHS), the dominant accreditation agency for public and private hospitals in Australia. There is limited research and empirical evidence as to the benefits of accreditation and improved service quality, despite the significance of accreditation for hospitals and the resources expended on it. The research consisted of three distinct stages: a questionnaire which examined the motivations for MC surveyors participating in accreditation; interviews which looked at the scale and scope of influences on MC surveyors during the accreditation survey process; and a case study approach which assessed how MCs and other surveyors dealt with the influences. The large amount of data generated was analysed utilising a range of social science methods. The findings corroborate and augment past research into the motivations for MC surveyors participating in accreditation, and extend existing knowledge considerably. These motivations included participants perceptions that accreditation facilitated improvement of quality in the health system and within their own organisation, and provided an external perspective and the opportunity to benchmark and share ideas. Furthermore, participants considered accreditation assisted in their professional development, supported professional networking, augmented their prestige, and increased their influence and respect whilst being an enjoyable experience. The research identified fourteen interrelated factors that influence the survey process and potentially, the accreditation outcome. It found that MC surveyors were acutely aware of the need to be objective in their surveying and furthermore were conscious of the difficulty in attaining objectivity. It also provided evidence supporting MC involvement in the accreditation process and reported a positive view of accreditation. In addition, it highlighted the characteristics of the accreditation process that MC surveyors consider benefits health care as well as leading to a more reliable and credible accreditation outcome.
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(2012)ThesisThis study explored Junior Medical Officers' (JMOs), particularly international medical graduates' (IMGs) understanding of interprofessional practice (IPP) and its links to patient safety. It investigated their willingness to practise interprofessionally and identified factors inhibiting collaborative IPP. The links between IPP and patient safety are established. Evidence supports the benefits of health professionals working collaboratively for enhanced patient outcomes. Hospital environments are complex with proliferating professional and departmental cultures. Patients are managed by a multiplicity of health professionals. We know that to practise interprofessionally challenges the territorial traditions of health professionals. An understanding of IPP and a preparedness to put patient interests before professional self interests are fundamental to realising improved patient safety. There are difficulties associated with transformation to a collaborative approach to patient care. Paradoxically, overcoming cultural boundaries between interdependent health professionals is one prerequisite for practising interprofessionally. This thesis contributes to our knowledge about junior doctors' perceptions of IPP in teaching hospitals and organisational factors challenging their interprofessional functioning. It reveals compromised intraprofessional practice linked to the hierarchical culture of hospital doctors. A triangulated method comprising semi-structured interviews, a survey questionnaire and ethnographic observations was employed for the research. Thirty two international and Australian medical graduates (IMGs and AMGs) from three Australian teaching hospitals participated. Four themes framed the study: culture, communication, collaboration and competency. The findings highlight diversity in the cultures and medical training of JMOs. Participants' experience of shared learning was minimal, limiting their proclivity to IPP in postgraduate training. JMOs' willingness to embrace IPP is overshadowed by the challenges of adapting to different cultures within hospitals, understanding other health professionals' roles, and working with inadequate support and supervision. Mutual respect and communication are lacking, both intraprofessionally and interprofessionally. Excessive demands, bounded professional cultures and uncompromising hospital organisational cultures impede IPP. The findings can be applied to other comparable settings and individual issues such as supervision, explored in further research.
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(2013)ThesisMotor neurone disease (MND), also known as amyotrophic lateral sclerosis, presents many challenges to patient and carer engagement in decision-making. A progressive and terminal multisystem disorder without a cure, MND care focuses on symptom management and quality of life, as patients and families attempt to come to terms with the diagnosis. In addition to physical deterioration, the cognitive, communication and behavioural abilities of many patients are affected. Care is delivered in specialised multidisciplinary clinic settings, creating decision-rich environments in which to test normative models of patient-centric decision-making. As patients continually face care decisions, few options are available to slow disease progression or extend survival time. Family carers are extensively involved in patient care, yet the decision-making relationships between MND health professionals, patients and their carers are undefined. Models of decision-making used in cancer and chronic disease care have limited applicability to MND care. Patients use a cyclic process of adaptation to their rapidly changing needs. The available treatment choices are often ethically and culturally complex, and may be time-constrained. While patient choices are well documented, little is known about the underlying factors influencing their decisions. This study addresses two research questions. The first asks: what are the influences on patient decision-making in MND multidisciplinary care? The second question is: how is patient-centred decision-making is delivered in MND multidisciplinary care? The thesis contributes insight into the underlying aspects of decision-making, and their implications for delivering patient-centred, collaborative and evidence-based care. Qualitative methods were used to examine factors influencing patient-centred decision-making. Fifty-four respondents from two specialised MND multidisciplinary clinics participated in semi-structured interviews. These were 32 health professionals, 14 patients and eight carers. The views of each group were analysed separately, and then combined to provide a comprehensive picture of MND patient-centred decision-making. Thematic analysis revealed broad agreement between the groups on key factors influencing patient-centred decision-making. These were: the decision-making process; patient-centred focus; timing and planning; information sources; engagement with specialised ALS services; and access to non-specialised services. Specialised MND multidisciplinary clinics offered an optimal setting for decision-making. The roles and expectations of stakeholders influenced the decision-making process, while psychosocial factors and continually changing symptoms impacted on patients capacity to participate. Issues of timing of evidence-based care delivery and the role of carers were contentious. Patient-centred decision-making is a complex and cyclical process, with health professionals, patients and carers collaborating to form a decision-making triad. A four-stage triadic model, embedded in the specialised MND multidisciplinary clinic environment, was derived from the data. The first stage, Patient Engagement , identifies the participants and establishes their values, preferences and expectations. In stage two, Option Information , information and guidelines on the available management options are determined, including the optimal timing for implementation of each choice. During the third stage, Deliberation , patients weigh up the risks and benefits, and decide between proceeding with an option, deferring their decision, or choosing to do nothing. The final stage, Implementation , results once an option is chosen. The model captures the complexities of MND patient-centred decision-making and offers a framework for health professionals, researchers and policy makers in this challenging environment.
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(2013)ThesisHow does Human Resource Management (HRM) contribute to organisations and their functioning? What is the relationship between HRM, teamwork and clinical performance? We know that organisations deploy Human Resources (HR) departments and initiate HRM with the express purpose of improving performance, yet little is known about their associations, especially in the healthcare setting. HRM is essentially a black box which needs to be understood, thereby informing organisations on how to maximise the benefits of the HR function. This thesis contributes to this deficit in knowledge, examining team characteristics, job satisfaction and clinical performance and how these relate to HRM policy and practice. Specifically, it investigates the links between aspects of HRM with teamwork and performance. A mixed method cross sectional study was conducted focusing on full service category rehabilitation services from public hospitals in Australia. This setting was selected for investigation because of the strong teamwork orientation and the lack of research comprehensively evaluating the contribution of HRM in this medical field. A total of 163 participants, comprising 152 rehabilitation clinicians and 11 managerial staff from seven hospitals were enrolled. A semi-structured questionnaire was administered to clinicians to determine their individual and team characteristics. Two measures of team performance were employed, namely: self reported job satisfaction, and compliance with clinical indicators defined by the Australian Council of Healthcare Standards. Twenty four focus groups and 18 interviews were conducted with clinicians and HR managers to investigate HRM policy and practice. Quantitative input from survey and clinical indicator data were analysed using descriptive and inferential statistics while qualitative data from focus groups and interviews were thematically analysed. The results show that a holistic approach to HRM is related to teamwork and facets of performance. Influenced by local context, HRM has the potential to either positively or negatively affect teamwork, job satisfaction and clinical performance. HRM s links to teamwork and performance were found to be significantly mediated by elements of efficiency, effectiveness, change, structure, service constraints, leadership, staffing, specialisation and research. The tailoring of HRM approaches to take account of local organisational circumstances could contribute positively to desirable teamwork and performance outcomes.
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(2013)ThesisThis research investigates the use of an online curriculum mapping system developed to support the design, delivery and review of undergraduate medical education. This is an advanced, web-enabled and database-driven system known as eMed Map that has been in use by educational staff since late 2003 and by students since early 2004. eMed Map forms part of an integrated curriculum management system which sits at the interface of education, technology and practice. This mixed-method research project uses a case-study approach and a triangulation of methods. It consists of a qualitative component based on observations and textual documentation, a quantitative component appraised via web log reports linked to staff data, and an attitude assessment through a predominantly quantitative self-reported survey questionnaire. The thesis addresses a deficit in the current knowledge base about curriculum map use and impacts. Using systems theory and systems thinking paradigms to synthesise and discuss the findings, the research uncovered a number of interrelated factors affecting map use pertaining to the individual user, the technology and the organisation. Map awareness and use varied considerably, chiefly by staff type and by school location, and distinct groups of users were identified. Knowledge about the Map varied substantially, while utilisation of its help sites was minimal. The system was generally being used for content management while its more advanced educational and organisational uses were not being realised. The need for further information and training for staff was evident, as was the need to review certain educational and organisational procedures and information technology features and functions. Hence, while the system was widely available, its diffusion amongst staff was not what was hoped by planners and advocates of the curriculum map. The thesis considers practical implications for improving the diffusion of eMed Map by reviewing the whole curriculum mapping system and its leverage points from a systems thinking and system dynamics perspective. The lessons learnt from this case-study and the suggestions and key recommendations derived from it can be applied not only to medical education but also to other higher education programs that use or plan to use advanced online curriculum mapping systems.
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(2013)ThesisThe patients implied by the term patient safety are most commonly lying on an operating table or in a hospital bed. They are cast as potential victims of harm resulting from their encounters with a health service, harm which is often attributed to malfunctioning systems or toxic cultures of care. Mental health patients and professionals, and the particularities of the illnesses and interventions which structure their encounters, have often been ignored in this discourse. This study is about what patient safety means from the perspective of professionals in a mental health context, where: risk type and severity are contested and unpredictable; patients are often viewed as a threat to their own safety; and the professional role in keeping patients safe extends to interest in their social and economic circumstances. Emphasis in patient safety research is often given to the causes and consequences of error and harm, but this research brings the day-to-day unfolding of professional work to the fore. This shift in perspective allows for a detailed examination of the strategies staff members use to enact safety, and a concomitant exploration of the degree to which policies and rules penetrate practice. This has been accomplished through the ethnographically-informed design of an inquiry into understandings and enactments of safe care among a multidisciplinary range of staff in a community mental health team and an acute inpatient psychiatric unit in New South Wales, Australia. In the course of daily work, these professionals are found to negotiate a tension between two versions of patient safety. In the fluidity of everyday practice, the safe patient is only ever a transient, fragile phenomenon anchored to a particular time, place, and relationship between clinician and patient. However, the expectation of policymakers, Coroners, and members of the public is that the mental health service should act as guarantor of safety. Theoretical frameworks of socio-material ontology are used to tease out the implications of these sometimes contradictory demands, and to explore the possibility of a patient safety which prioritises therapeutic impact on the patient rather than only the management of their risk.
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(2013)ThesisProfessional networks are being used increasingly in healthcare to overcome problems of working within a system fragmented by professional “tribes,” and organisational and geographic boundaries. Such networks are thought to encourage the bridging of these boundaries, leading to greater collaboration. Research about how this is achieved does not yet give a comprehensive picture of network processes and the role of key actors. This thesis used a combination of qualitative and quantitative methods, primarily social network analysis, to explore the network structure and the role of key players within a representative network. The network was a new translational research network (TRN) based in Sydney, Australia that sought to drive collaboration between university-based researchers and hospital-based clinicians to translate biomedical research into clinical practice. The thesis asked the following questions: what is the structure of collaborative ties within this network? Who are the key players in this network? Do the formal, mandated leaders of this network recognise the potential held in their network positions? TRN documentation, semi-structured interviews with the 14 governing body members, and a systematic review of brokerage roles in collaborative networks gave context, and informed the design of the social network survey. An on-line, whole network survey was used to collect demographic and relationship data from all 68 members in early 2012 as well as opinions on aspects of the network. Geographic location was a significant factor determining patterns of collaboration. Central actors identified by analysis of network data mostly matched members’ perceptions of powerful and influential players but identified brokers were not perceived as such. Mandated leaders were found to have key network positions and recognised their significance in terms of facilitative activities. The thesis shows empirically the influence of “silos” on collaboration and that the network may increase connectivity between them. Secondly it shows the hidden identity of brokers in the healthcare setting. This confirmed that network interventions based on role support for key players can only be realised if the brokers are accurately identified. Thirdly it shows that mandated leaders in the network understand their roles and activities in a way that reflects their network potential.