The Role of Health Profession Regulation in Health Services Improvement

<p>This research investigates the role of health practitioner regulation in health service improvement. Over the last 25 years, service improvement has included management reforms, quality and redesign programmes, multidisciplinary teamwork, the integration of clinical information systems, and new roles for health professionals. Yet despite sustained effort, improvements tend to be localised rather than organisation or system-wide. Remedies have included attention to leadership, change management and service culture. Through the same period, there have been changes to expand and strengthen health practitioner regulation, but scant attention to whether this regulation could contribute to difficulties with health service improvement. A critical realist methodology was used to build an explanation of how regulatory policies could condition health professionals and health service organisations in ways that limit the progress of service improvement. A multilevel approach was used to discover the mechanisms that could operate among policy-makers and the health workforce, generating effects in health service organisations. The study concluded that this explanation contributes new insights to explain persistent difficulties in health service improvement. The research began with the 19th century to understand the social conditions in the construction of the health workforce and health service organisations. Next, it identified the network of modern regulatory stakeholders in healthcare, along with the potential for their policies to operate in conflict or concert depending on the circumstances. Deficiencies were identified in the traditional accounts of health practitioner regulation, which assumes a single profession and sole practice. ‘Regulatory privilege’ was developed as an alternative theory that describes the operation of nine historically constructed regulatory levers among the multiple health professions employed in health service organisations. This theory linked the regulatory and practice levels, to observe the interactions between health practitioner regulation and policies for health service improvement. Drawing on the recent history of health reforms, eight elements were identified that characterise directions for service improvement in healthcare. Investigation of interactions between these nine levers and eight elements identified sources for policy interactions through six sector levels. Interactive effects were identified in: policy design influenced by health practitioner regulation; the leadership and management capability in health service organisations, the design options for delivery of services, the means available to coordinate services, the role opportunities and practice arrangements for health professionals, and the experience of service fragmentation by consumers. This multilevel explanation shows how health practitioner regulation could contribute to difficulties with service improvement, even when health services have adopted best practice in their implementations. It shows how poor alignment between the regulatory and practice levels makes it unlikely that health service organisations could address certain difficulties in the ways suggested by some scholars. Given the sustained directions for health service improvement, these findings could contribute to policy thinking around how to better align the regulatory and practice levels to realise organisation or systemwide improvements in the delivery of healthcare.</p>

The Role of Health Profession Regulation in Health Services Improvement

<p>This research investigates the role of health practitioner regulation in health service improvement. Over the last 25 years, service improvement has included management reforms, quality and redesign programmes, multidisciplinary teamwork, the integration of clinical information systems, and new roles for health professionals. Yet despite sustained effort, improvements tend to be localised rather than organisation or system-wide. Remedies have included attention to leadership, change management and service culture. Through the same period, there have been changes to expand and strengthen health practitioner regulation, but scant attention to whether this regulation could contribute to difficulties with health service improvement. A critical realist methodology was used to build an explanation of how regulatory policies could condition health professionals and health service organisations in ways that limit the progress of service improvement. A multilevel approach was used to discover the mechanisms that could operate among policy-makers and the health workforce, generating effects in health service organisations. The study concluded that this explanation contributes new insights to explain persistent difficulties in health service improvement. The research began with the 19th century to understand the social conditions in the construction of the health workforce and health service organisations. Next, it identified the network of modern regulatory stakeholders in healthcare, along with the potential for their policies to operate in conflict or concert depending on the circumstances. Deficiencies were identified in the traditional accounts of health practitioner regulation, which assumes a single profession and sole practice. ‘Regulatory privilege’ was developed as an alternative theory that describes the operation of nine historically constructed regulatory levers among the multiple health professions employed in health service organisations. This theory linked the regulatory and practice levels, to observe the interactions between health practitioner regulation and policies for health service improvement. Drawing on the recent history of health reforms, eight elements were identified that characterise directions for service improvement in healthcare. Investigation of interactions between these nine levers and eight elements identified sources for policy interactions through six sector levels. Interactive effects were identified in: policy design influenced by health practitioner regulation; the leadership and management capability in health service organisations, the design options for delivery of services, the means available to coordinate services, the role opportunities and practice arrangements for health professionals, and the experience of service fragmentation by consumers. This multilevel explanation shows how health practitioner regulation could contribute to difficulties with service improvement, even when health services have adopted best practice in their implementations. It shows how poor alignment between the regulatory and practice levels makes it unlikely that health service organisations could address certain difficulties in the ways suggested by some scholars. Given the sustained directions for health service improvement, these findings could contribute to policy thinking around how to better align the regulatory and practice levels to realise organisation or systemwide improvements in the delivery of healthcare.</p>

81 Integrating A Front Door Frailty Service in the Emergency Department: Results of A Pilot Study

Introduction Increasing old age and frailty is putting pressure on health services with 5–10% of patients attending the emergency department (ED) and 30% of patients in acute medical units classified as older and frail. National Health Service improvement mandates that by 2020 hospital trusts with type one EDs provide at least 70 hours of acute frailty service each week. Methodology A two-week pilot (Monday–Friday 8 am-5 pm) was undertaken, with a “Front Door Frailty Team” comprising a consultant, junior doctor, specialist nurse and pharmacist, with therapy input from the existing ED team. They were based in the ED seeing patients on arrival, referrals from the ED team and patients in the ED observation ward—opposed to the usual pathway of referral from the ED team to medical team. Data was captured using “Cerner” electronic healthcare records. A plan, do, study, act methodology was used throughout with daily debrief and huddle sessions. Results 95 patients were seen over two weeks. In the over 65 s, average time to be seen was 50 minutes quicker than the ED team over the same period, with reduced admission rate (25.7% vs 46.5%). The wait between decision to admit and departure was shortened by 119 minutes. Overall, this led to patients spending on average 133 minutes less in the ED. 64 patients were discharged, of which 44 had community follow-up (including 37.5% of 64 referred to acute elderly clinic and 25% to rapid response). 47 medications were stopped across 25 patients. Conclusion The pilot shows that introduction of an early comprehensive geriatric assessment in the ED can lead to patients being seen sooner, with more timely decisions over their care and reduction in hospital admissions. It allowed for greater provision of acute clinics and community services as well as prompt medication review and real time medication changes.

‘I could have made those changes years earlier’: experiences and characteristics associated with receiving a prediabetes diagnosis among individuals recently diagnosed with type 2 diabetes

Background Prediabetes increases the risk of developing type 2 diabetes (T2D). Improving diet quality is key in preventing this progression, yet little is known about the characteristics of individuals with prediabetes or the nutrition care they receive. Objectives This study aims to identify characteristics and experiences associated with receiving a prediabetes diagnosis prior to developing T2D. Methods A mixed methods study encompassed a quantitative subanalysis of participants with newly diagnosed T2D from The 3D Study, and semi-structured telephone interviews with a subsample of participants who were previously diagnosed with prediabetes. Interviews were thematically analysed and survey data synthesized using SPSS statistical software. Results Of the 225 study participants, 100 individuals were previously diagnosed with prediabetes and 120 participants were not. Those with prediabetes were less likely to be smokers (P = 0.022) and more likely to be satisfied with seeing a dietitian (P = 0.031) than those without a previous prediabetes diagnosis. A total of 20 participants completed semi-structured interviews. Thematic analysis revealed three themes: (i) experiencing a prediabetes diagnosis; (ii) receiving nutrition care during prediabetes and (iii) reflecting on the experience of receiving care for prediabetes versus T2D. Conclusions There are gaps in the current management of prediabetes in Australia. Low rates of prediabetes diagnosis and an ambiguous experience of receiving this diagnosis suggest an area of health service improvement. With no difference in diet quality between individuals with and without a previous prediabetes diagnosis, the nutrition care during prediabetes may be more important than the diagnosis itself in delaying the onset of T2D.

An academic perspective of participation in healthcare redesign

Healthcare redesign, based on building collaborative capacity between academic and clinical partners, should create a method to facilitate flow between the key elements of health service improvement. However, utilising the skills and resources of an organisation outside of the health facility may not always have the desired effect. Accountability and mutually respectful relationships are fundamental for collaborative, sustainable and successful completion of clinical research projects. This paper provides an academic perspective of both the benefits of academic involvement in facilitating healthcare redesign processes as well as the potential pitfalls of involving external partner institutions in internal healthcare redesign projects.

Appreciating collaborative service improvement – a case study on using appreciative inquiry methodology in co-production in mental health

Purpose The purpose of this paper is to examine the value of appreciative inquiry (AI) methodology in enabling co-productive work within mental health service development. Design/methodology/approach The methodology of AI is described and observations on its use in mental health service improvement are considered. Findings AI is a really helpful tool in supporting service improvement and is particularly applicable in mental health discussions involving service users and carers. Many service users and carers engaging with service development discussions have had adverse past experiences which can inhibit their successful contribution to planning discussions. AI allows a more positive reflection on how services can be improved which can help achieve positive results. Research limitations/implications AI methodology is a really useful tool in supporting improvement discussions across health, and other public, services, and is particularly valuable in engaging mental health service users and carers in such activity. Practical implications The method is useful across service development needs and could be developed to support mental health service improvement locally, regionally and nationally. Developing the use of this method could make a real contribution to improving relations between service users, carers and health staff and support meaningful and positive change in the delivery of mental health services. Social implications Helping to overcome dissonance between service users and carers, and health staff and commissioners; and developing the use of appreciative enquiry could enhance the value of co-production as a key driver for service improvement. Originality/value The author is aware of little discussion of the value of appreciative enquiry in the growing literature around co-production in mental health.

Appreciative enquiry peer review improving quality of services

Purpose Mental health service improvement initiatives often involve the setting of targets and monitoring of performance. The purpose of this paper is to describe the application of appreciative enquiry (AE), a radically different but complementary approach to quality assurance and improvement, to specialist mental health services across a health region. Design/methodology/approach This case study describes a regional quality improvement (QI) project involving 12 early intervention in psychosis (EIP) services in South West England. In total, 40 people were trained in AE interviewing skills and in non-reciprocal peer review visits 59 interviews were conducted involving 103 interviewees including service users, carers, clinicians, managers and commissioners. Immediate verbal feedback was provided and main themes summarised in individual reports to host teams using the following headings: team values, strengths, dreams and development plans. A thematic analysis was conducted on team reports and a project report produced which summarised the stages and results of this regional initiative. Findings All participants rated the experience as positive; it enhanced staff motivation and led to service development and improvement. Research limitations/implications The experiences of these 12 EIP teams may not necessarily be generalisable to other services/regions but this positive approach to service improvement could be widely applied. Practical implications AE is applicable in large-scale QI initiatives. Originality/value To the authors knowledge this is the first time that AE has been applied to large-scale mental health service improvement and innovation.