Effect of an intervention to improve the management of patients

with diabetes in primary care practice  

ABSTRACT 

Objectives: To assess the effect of an intervention targeted at primary care physicians (PCPs) in order to improve their management of diabetic patients. Methods: Diabetic patients seen by PCPs in King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from January 2008 to July 2009 were included in this prospective cohort study. The PCPs were divided into intervention and control groups. The intervention group with the help of an assistant, utilized a customized designed computer program generating a checklist for the PCPs. The list included clinical and biochemical screening tests needed for the patients current visit, according to evidence-based diabetes guidelines. For the control group, no assistant was used. At the end of one year, an independent reviewer evaluated the patients files in both groups to assess the adherence to diabetes guidelines. Results: We enrolled 162 patients in the control group and 517 patients in the intervention group. The intervention significantly improved the percentage of patients being screened for diabetic complications; retinopathy from 24.7-98.5%, neuropathy from 25.9-92%, and nephropathy from 37.8-73.7%. There was no improvement in glycemic control in both groups and glycosylated hemoglobin level (HbA1c) values were still above the 7% target.  Conclusions: Management of diabetic patients in the primary care clinics is below standard. The intervention applied was effective in promoting better adherence to evidence-based diabetes guidelines.

Diabetes mellitus is a common chronic disease that requires continuous medical care to reduce the risk of its complications. It is a major cause of coronary artery disease, one of the leading causes of death, and a leading cause of new cases of blindness and kidney disease in adults. Intensive treatment of diabetes reduces the risk of its complications, and more aggressive screening strategies allow earlier detection and management of these complications. Diabetes is costly both to the affected person and to society. The World Health Organization estimates that as of November 2009, more than 220 million people have diabetes worldwide and that the mortality from diabetes in 2005 was over 1.1 million people. Saudi Arabia has an alarming prevalence of diabetes according to a national epidemiologic survey carried out in 2004

Violence exposure among health care professionals in Saudi public hospitals. A preliminary investigation

  

ABSTRACT 

Objectives: To identify the prevalence, causes, types, and sources of workplace violence among health professionals in public hospitals in the Kingdom of Saudi Arabia. Methods: This exploratory cross-sectional survey employed self-administered questionnaires to collect data on aspects of workplace violence against physicians and nurses in Saudi hospitals. The questionnaires were distributed randomly to 600 physicians and nurses, of which 383 (63.8%) completed the questionnaires at 2 public hospitals in Riyadh city between May and July 2011. Results: More than two-thirds (67.4%) of respondents reported they were victims of violence in the previous 12 months. Nurses were more likely to be exposed to violent incidents than physicians (p<0.001). Males, less experienced, and younger respondents were more likely to encounter violent episodes than their counterparts. Respondents reported that excessive waiting time, shortage of staff, and unmet patients’ demands were the most common reasons for violence. Verbal abuse was the most common type encountered. The assailants were mostly the patients’ relatives or friends, followed by the patients themselves. Reasons for not reporting violent events included: feel it is a part of the job, previous experience of no action, and fear of consequences. Conclusions: Physicians and nurses are at high risk of violent incidents. Health decision makers need to be aware of the potential consequences of such events. Appropriate preventive measures are needed to make hospitals safer environments.

Health care professionals are ranked as one of the most vulnerable groups experiencing violence and aggressive behavior compared to other occupational groups. Authors suggest that health professional, particularly those who work in hospitals, are at risk because they are dealing directly with patients and their caretakers, many of whom are emotionally disturbed. One of the most difficult situations that health care providers face is being threatened or physically harmed by their patients, or by patients’ relatives, or even by their colleagues.

Patient opinion of the doctor-patient relationship in a public

hospital in Qatar 

ABSTRACT 

Objectives: To analyze the factors associated with the level of satisfaction of outpatients in their relationship with their doctor at the largest public hospital in Qatar. Methods: This study was a cross-sectional survey of attitudes. Researchers surveyed 626 outpatients at Hamad General Hospital in Doha, Qatar from September 2009 to January 2010 using a novel questionnaire assessing satisfaction with patients’ interaction(s) with their doctor (spent time with patient, took case seriously, maintained confidentiality, and the overall quality of visit). Results:  Mean responses on 4 Likert scale items (one to 5) were as follows: "spent enough time with patient" = 4.39; "doctor took case seriously" = 4.57; "satisfaction with doctor-patient confidentiality" = 4.71; "overall quality of visit" = 4.46. Age, gender, citizenship, level of education, and number of visits did not significantly impact the level of satisfaction. For 73.1% of patients, the physician’s qualification was the most important factor in choosing a doctor. Of those surveyed, 40.7% of men and 28.1% of women preferred to see a doctor of their own gender. A positive correlation between perceived communication and satisfaction with the doctor-patient encounter was established. Conclusions: This study found that patients in the Out-Patient Department at Hamad Hospital were highly satisfied with their relationships with their doctors, and physician qualification was the most significant factor in choosing a doctor. A significant number of males and females preferred a physician of their own gender. Communication difficulty correlated with lower satisfaction.

The doctor-patient relationship is a difficult concept to define due to the individual nature of the relationships that patients form with their doctors. The concept has been studied by a wide range of researchers including medical professionals, health care economists, social psychologists, medical sociologists, rhetoricians, and healthcare communication experts.

 Determinants of length of stay in an inpatient stroke

rehabilitation unit in Saudi Arabia 

ABSTRACT 

Objectives: To determine and analyze the influence of age, gender, and ethnicity in the length of stay (LoS) of inpatient rehabilitation unit patients after stroke. Methods: All patients who completed the stroke rehabilitation program at Sultan Bin Abdulaziz Humanitarian City, Riyadh, Kingdom of Saudi Arabia from 1st January 2005 to 15th October 2008 were selected for the study. Admission records of 823 (male; 551, female; 272) patients with a mean age of 62.87 +/- 0.54 years were included in this study. Patients aged less than or equal to 19 and more than than or equal to 91 years were excluded due to small sample size. Age, gender, and ethnic differences of LoS were analyzed. Results: The mean LoS on the stroke rehabilitation program of the study population was 45 +/- 1.56 days. Results showed that the frequency of the stroke was higher in the 51-60, 61-70, and 71-80 age groups, and lower in the 20-30 and 31-40 age groups. The LoS of males were longer than females in all age groups, and statistically significant results were observed in the 51-60 (p=0.0084), 61-70 (p=0.0042), and 71-80 (p=0.037) age groups as compared with females. The study also found that the LoS of Saudi patients were higher when compared with non-Saudis (p=0.0009). Conclusions: The results of the study suggest that gender, age, and ethnic differences were risk factors of LoS of stroke patients.

Stroke is the most common cause of disability and a leading cause of mortality worldwide,

 Knowledge, perceptions, attitude and educational needs of

physicians to evidence based medicine in South-Western Saudi Arabia

 ABSTRACT

 Objectives: To define the knowledge, perception, attitude, educational needs, and barriers in practicing Evidence Based Medicine (EBM) among physicians in Abha city, Kingdom of Saudi Arabia.  Methods: This is a cross-sectional study using a self-administered validated questionnaire distributed to 290 physicians between 1st July to 30th July 2008. This study took place in the Family and Community Medicine Department, King Khalid University, College of Medicine, Abha, Kingdom of Saudi Arabia.  Results: Completed questionnaires were received from 210 (72.4%) of 290 physicians. Most physicians had a positive attitude towards EBM (median score=8/10). Half of them support the shift from daily based practice to evidence based decision. They showed acceptable level of knowledge on the terminologies used in EBM and critical appraisal. The consultants and specialists had a better knowledge toward EBM compared with residents. The main barriers facing the respondents in practicing EBM as indicated by the physicians were lack of resources and time.  Conclusions: The physicians showed acceptable level of knowledge on EBM. There was a gap between their knowledge and practice. This gap could be attributed to what was addressed by the physicians, namely, inadequacy of time and unavailability of access to internet in their working place. The better knowledge of the trained than the untrained physicians could draw the attention towards the importance of training courses relevant to EBM. Evidence Based Medicine (EBM) define as a new philosophy of clinical practice and a process of long life learning, which emphasized a systematic and rigorous assessment of evidence for decision making in healthcare. It involves integrating evidence with the expertise of decision makers and the expectation and value of patient.

Recurrent visits and admissions of children with asthma in central Saudi Arabia

 ABSTRACT

 Objectives: To identify the pediatric age group and most affected gender by asthma, and to determine the significant predictors of severity of asthma, and assess the appropriateness of asthma medication administration. Methods: This cross-sectional study was carried out at Emergency Department (ED) of children’s Hospital at King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia from January to March 2009. Interviews were carried out with the parents of 185 children, who presented to the Hospital with asthma exacerbation more than once over the last 6 months, to collect data of possible risk factors, and appropriateness of medication administration technique.  Results: Most patients were males 71.9%, aged 1-6 years (58.9%), and 8.1% of them presented to the ED because of asthma exacerbation more than once over the last 6 months. Approximately two-thirds (65.9%) of the parents explained the way of meter dose inhaler administration correctly. Infants were significantly the least affected group (p=0.02). Severity was significantly higher among appropriate users of medications (p=0.046).  Conclusions: Appropriateness of medications administration was significantly associated with severity. However, this may not be considered a valid predictor of severity, as parents of children with recurrent attacks may have a better chance of being taught how to use medications.

 

High performance work systems: the gap between policy and practice in health care reform

Method..The studies used a combination of quantitative and qualitative methodologies.

For the quantitative data collection two organizational level surveys and a system level survey were completed. The organizational level questionnaire was provided with the pay slips to all 240 staff within a rural hospital (30 per cent response rate) and 1700 staff of a regional hospital (32 per cent response rate) to measure High performance work systems HPWS, selected HRM outcomes (such as job satisfaction, empowerment, staff turnover) and perceived quality of patient care.

The questionnaire was sent to all levels of management and staff including medical, nursing, allied health, clerical and administrative, and support staff.

This questionnaire was designed to measure HRM policy, practice and outcomes within the organizations from the perspective of the three types of managers.

We also completed interviews with senior managers and focus groups with the middle and line managers of two rural hospitals and one regional hospital to examine the enactment of the HRM policies and practices within the organizations.

Measures.. Two separate questionnaires were constructed from existing validated scales. The organizational-level questionnaire was used to explore the relationship of HPWS with the attitudes of staff and their perceptions of the quality of patient delivered.

This questionnaire included measures of four variables.

The first was high-performance work systems; the 42-item scale was used to measure HPWS.

The second variable was psychological empowerment,12-item scale comprising four components:

autonomy; competence; impact; and meaning.

third variable, job satisfaction, was measured using the thee- comprising the following three items:

1. “All in all, I am satisfied with my job”;2. “In general, I don't like my job”; and3. “In general, I like working here”.

Staff perception of the quality of patient care was the fourth variable

The system-level questionnaire was used to explore the state of HPWS and human resource management practices throughout the Victorian health care sector.

This questionnaire focused on the three constructs of the extent of strategic HRM, defined as the extent to which management strategically integrated HR strategic planning, and human resource management priorities and functions.

This study also explored HRM outcome variables such as staff turnover, absenteeism and grievance rates.

The impact of network and environmental factors on service innovativeness

Design/methodology/approach – Utilizing data from 1,428 acute healthcare hospitals in the USA OLS regression was used to examine the antecedents to service innovativeness.

Method.. Data and sample

All non-state and non-federal, acute care hospitals in the United States were selected for study. The data were compiled from two existing data sets. Hospital variables were measured with American Hospital Association Annual Survey data for the year 2000. The American Hospital Association serves all types of hospitals, heath care networks, and their patients and communities. AHA conducts surveys of hospitals in the United States to determine their service offerings, administration, and performance. Environmental variables were measured with Area Resource File (ARF) data. The ARF comes from various sources such as American Medical Association, American Hospital Association, Centers of Medicare and Medicated Services, Bureau of Labor Statistics, and National Center for Health Statistics. We procured the ARF used in this study from the National Center for Workforce Analysis.

Our sample consisted of 1,428 hospitals, after deletion of cases with significant missing data. Within this sample, 15 percent were investor owned, 61 percent were not-for-profit, and 24 percent were local public hospitals. Thirty three percent were in the ten states with community benefit laws or guidelines. Ninety percent were participants in an alliance, joint venture, network or multi-hospital system.

Findings – The results reveal that organizations in large networks (alliances) limit providers' service innovation. Whereas competition increased service innovativeness, regulatory forces (formal institutional pressure) and informal regulatory forces stifled it.

Inter-departmental relationships as a threat to patient safety in the operating department

Design/methodology/approach – Ethnographic research methods were used, with observations of the operating department setting for 18 month and interviews

with 80 members of hospital staff. The setting for the study was the Operating Department of a large teaching hospital in the North-West of England.

Methods..This paper is based upon an ethnographic study carried out between 2003 and 2004 in the operating department of a single large teaching hospital in northern England. We used standard ethnographic research methods to investigate social, cultural and organizational issues related to patient safety within this setting, including observations, informal and formal interviewing and documentary analysis .ethical approval was obtained in advance of the study through the Local Research Ethics Committee and participants were informed of the study's objectives.

We carried out non-participatory observations within the operating department on a daily basis for 18 months. These observations took place in various locations, such as staff rooms, management meetings, corridors, reception areas and various clinical settings, including ten operating theatres with adjoining anesthetic rooms and two recovery areas. From these findings we also made observations of other hospital settings related to the work of the operating department, including outpatient clinics, surgical wards and laboratory services. From these observations we were able to “map” the organizational networks, processes and relationships that contributed to the work of the operating department, including a record of recurrent “bottlenecks” “crisis points” and “breakdowns” in the planned or designated working arrangements as perceived by staff members. A further period of observations was undertaken to better understand how these organizational issues affected the routines and patterns of work within the operating theatre. Our observations were recorded in field journals together with reflective notebooks.

Alongside our observations we interviewed those involved in the work of the operating department both formally and informally. Informal interviews were carried out in situ whilst making our observations and involved opportunistic chats and conversations with staff members. These were used to clarify and further understand work activities and were recorded alongside our observational records. We also interviewed 80 members of hospital staff more formally outside the immediate work setting, including 14 consultant-grade surgeons of mixed specialty, 12 consultant-grade anesthetists, 14 members of theatre nursing staff of mixed grade, four operating department managers, and a range of managers, administrators and professional representatives from other hospital departments, as well as senior hospital managers and executives. These participants were purposively selected on the basis of their occupational role and contribution to the working of the operating department. These semi-structured face-to-face interviews were recorded electronically with the consent of the participants and followed a topic guide that involved asking participants to describe their work environment and activities, with particular focus on what they saw as the threats to patient safety within their work context. This guide evolved throughout the research process to reflect emerging issues and topics that were of theoretical relevance.

The interview data, together with the observational records, were electronically transcribed and entered into the computer package Atlas ti for the purpose of data analysis, which followed the strategic principles of grounded theory. This was led by two of the authors who scrutinized the findings to develop a descriptive understanding of the operating department's structures, systems, process and group and individual activities. Through this process we were able to develop conceptual models of the operating department with reference to its interactive complexity and couplings in the form of inter-departmental relations. We further analyzed the data to identify and code the descriptions, attitudes, assumptions and viewpoints of individuals and professional groups involved in the work of the operating department to understand how organizational processes could impact upon the safety of practice. These coded findings were further compared and contrasted for their consistency and conceptual relationships, and with the observational records provided the basis of our analysis.

Findings – The work of the operating department is determined by inter-dependant, “tightly coupled” organizational relationships between hospital departments based upon the timely exchange of information, services and resources required for the delivery of care. Failures within these processes, manifest as “breakdowns” within inter-departmental relationships lead to situations of constraint, rapid change and uncertainty in the work of the operating department that require staff to break with established routines and work with increased time and emotional pressures. This means that staff focus on working quickly, as opposed to working safely.

Emotional labor: clinicians' attitudes to death and dying

Design/methodology/approach – Multi-method qualitative ethnographic study undertaken in a large ICU in Sydney, Australia using observations from patient case studies, ward rounds and family conferences, open ended interviews with medical and nursing clinicians and managers and focus groups with nurses.

Method..

We undertook a qualitative study to gauge the effect of clinician attitudes and practices on end-of-life care in a large intensive care unit (ICU) in an acute public tertiary hospital in Sydney, Australia. We chose a unit that fulfilled the requirements of aacknowledged in the field as progressive in intensive care practice and research, and likely to be representative of Australian tertiary hospital ICUs in general and those of other countries with similar health systems. Ethics approval was gained from the hospital in which the study was conducted, and data were collected between 2000 and June 2002.

Interviews and focus groups were conducted and tape recorded by a social scientist and transcribed by a professional service; case notes were taken of observations in family conferences, clinician interactions with patients and ward rounds. Over 240,000 words of transcript were produced. The data gathered were analyzed by a social scientist, a policy analyst and an organizational behaviorist using grounded theory techniques and categorized using open coding methods .Themes and patterns that emerged were analyzed using the constant comparative method from which tentative theories were generated that were further contextualized using specific literature reviews. Each of the participants of our study was asked in varying ways how their work with dying people affected them. We have selected statements from a small group of clinicians that are particularly emblematic and representative of the theme under scrutiny here.

Findings – Clinician attitudes to death and dying and clinicians' capacity to engage with the human needs of patients influenced how emotional labor was experienced. Negative effects were not formally acknowledged in clinical workplaces and institutional mechanisms to support clinicians did not exist.

Motivation and retention of health workers in Ghana district hospitals: Addressing the critical issues

Design/methodology/approach – The study employed a purely quantitative design with a sample of 285 health workers from ten district hospitals in four regions of Ghana. A stepwise regression model was used in the analysis.

Method,, Sample

A total of ten district hospitals were selected from four regions (Upper East, Upper West, Northern, and Central Regions). In Ghana, these four regions are worst-served in terms of health sector distribution of human resources. This is evidenced in a survey by , which revealed that these regions have for long suffered significant deterioration of health worker-population ratio over the years. Northern region in particular has the

worse doctor-population ratio, 1:92,046 and a nurse-population ratio of 1:1,868 . Three hospitals each were selected from Upper East, Upper West and Central while one hospital was selected from Northern region. Within each hospital, a simple random sampling procedure was applied to select the different categories of health workers except doctors, ophthalmologist, and other specialist. Due to the inadequate numbers of these categories of health workers in the regions, applying convenient sampling technique was necessary since a random technique was likely to exclude them. The study excluded all categories of support staff that do not directly render care to patients. In all, a total of 400 respondents were chosen to participate in the study. To maximize representation, it was ensured that at least 20 health workers in each facility were interviewed.

Instruments and data collection

A questionnaire about the socio-demographics, the independent measures under analysis (salary supplement, benefit, leadership skill and supervision, continuing professional development, infrastructure and resources, recognition and appreciation) and the dependent measure (motivation and retention) constituted the primary source of data for the study. The questionnaire was coded on a five point-likert scale anchored at the numeral 1=“strongly disagree” to 5=“strongly agree”,

Findings – The study found that financial incentives significantly influence motivation and intention to remain in the district hospital. Further, of the four factor model of the non-financial incentives, only three (leadership skill and supervision, opportunities for continuing professional development and availability of infrastructure and resources) were predictors of motivation and retention.

Defining and measuring productivity in the public sector: managerial perceptions

Design/methodology/approach – The approach is both theoretical and empirical. The first part is a literature review of research concerning public sector productivity. The second part presents findings of empirical research that is based on interviews and workshops with municipal authorities representing: special healthcare services; basic healthcare and social services, and educational services. The research was carried out in the Päijät-Häme region, Finland.

5.1 Methods of the case study

This case study is based on empirical research concerning how to define and measure productivity in the public sector, especially in the municipal context. Findings are presented of research on how different actors approach the concept and meaning of productivity in the public sector. This case study concentrates on one specific Finnish region – Päijät-Häme, where municipal officials in managerial positions in three different spheres of authority were interviewed. The research themes looked into are how the municipal officials define productivity, and how productivity is measured and should be measured and improved, according to them. The Päijät-Häme region has faced many public sector reforms during the last few years – for example setting up of a social affairs and health district – following the principles of purchaser-provider-model.

The three different spheres of authority focused on are:

1. special healthcare services;

2. basic healthcare and social services; and3. Educational services.

In Finland, the municipalities need to take care of educational services, social care services and basic healthcare services, as well as fund hospitals providing special healthcare. Changes related to the ageing population, growth of service needs, diminishing labor force and increasing age dependency ratio affect especially these three spheres of authority. If the municipalities wish to maintain a large amount of public services, it is necessary to look into these three spheres.

All the eight interviewees worked at the managerial level in their municipality or organization. The interviews were semi-structured to explore interviewees' views on how they see that productivity is defined in their sphere of authority, how it should be defined, how productivity is measured and how it should be measured. The interviews lasted for about one hour, and they were recorded and transcribed. In this study, differences between the three spheres of authority are not focused on; on the contrary, we search for similarities that are common in each sphere of authority.

Findings – According to the results, there is a certain mismatch between perceptions concerning productivity and the potential that lies in this concept as a functional tool in the public sector's development efforts. Public sector productivity cannot be developed and discussed without taking into consideration the issue of effectiveness.