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 reducethe risk of its complications. It is a major cause of coronary artery disease, one of the leadingcauses 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 aggressivescreening strategies allow earlier detection and management of these complications. Diabetes iscostly both to the affected person and to society. The World Health Organization estimates thatas of November 2009, more than 220 million people have diabetes worldwide and that themortality from diabetes in 2005 was over 1.1 million people. Saudi Arabia has an alarmingprevalence 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 experiencingviolence and aggressive behavior compared to other occupational groups. Authors suggest thathealth professional, particularly those who work in hospitals, are at risk because they are dealingdirectly with patients and their caretakers, many of whom are emotionally disturbed. One of themost difficult situations that health care providers face is being threatened or physically harmedby 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 therelationships that patients form with their doctors. The concept has been studied by a widerange of researchers including medical professionals, health care economists, socialpsychologists, medical sociologists, rhetoricians, and healthcare communication experts.
Determinants of length of stay in an inpatient stroke rehabilitation unit in Saudi Arabia ABSTRACTObjectives: To determine and analyze the influence of age, gender, and ethnicity in thelength of stay (LoS) of inpatient rehabilitation unit patients after stroke.Methods: All patients who completed the stroke rehabilitation program at Sultan BinAbdulaziz Humanitarian City, Riyadh, Kingdom of Saudi Arabia from 1st January 2005 to15th 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 wereexcluded due to small sample size. Age, gender, and ethnic differences of LoS wereanalyzed.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 maleswere longer than females in all age groups, and statistically significant results wereobserved in the 51-60 (p=0.0084), 61-70 (p=0.0042), and 71-80 (p=0.037) age groups ascompared with females. The study also found that the LoS of Saudi patients were higherwhen compared with non-Saudis (p=0.0009).Conclusions: The results of the study suggest that gender, age, and ethnic differences wererisk factors of LoS of stroke patients.Stroke is the most common cause of disability and a leading cause of mortalityworldwide,
Knowledge, perceptions, attitude and educational needs of physicians to evidence based medicine in South-Western Saudi Arabia ABSTRACTObjectives: To define the knowledge, perception, attitude, educational needs, and barriersin practicing Evidence Based Medicine (EBM) among physicians in Abha city, Kingdom ofSaudi Arabia.Methods: This is a cross-sectional study using a self-administered validated questionnairedistributed to 290 physicians between 1st July to 30th July 2008. This study took place inthe Family and Community Medicine Department, King Khalid University, College ofMedicine, Abha, Kingdom of Saudi Arabia.Results: Completed questionnaires were received from 210 (72.4%) of 290 physicians. Mostphysicians had a positive attitude towards EBM (median score=8/10). Half of them supportthe shift from daily based practice to evidence based decision. They showed acceptablelevel of knowledge on the terminologies used in EBM and critical appraisal. The consultantsand specialists had a better knowledge toward EBM compared with residents. The mainbarriers facing the respondents in practicing EBM as indicated by the physicians were lackof resources and time.Conclusions: The physicians showed acceptable level of knowledge on EBM. There was agap between their knowledge and practice. This gap could be attributed to what wasaddressed by the physicians, namely, inadequacy of time and unavailability of access tointernet in their working place. The better knowledge of the trained than the untrainedphysicians could draw the attention towards the importance of training courses relevant toEBM.Evidence Based Medicine (EBM) define as a new philosophy of clinical practice and aprocess of long life learning, which emphasized a systematic and rigorous assessmentof evidence for decision making in healthcare. It involves integrating evidence withthe expertise of decision makers and the expectation and value of patient.
Recurrent visits and admissions of children with asthma in central Saudi Arabia ABSTRACTObjectives: To identify the pediatric age group and most affected gender by asthma, andto determine the significant predictors of severity of asthma, and assess theappropriateness of asthma medication administration.Methods: This cross-sectional study was carried out at Emergency Department (ED) ofchildren’s Hospital at King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia fromJanuary to March 2009. Interviews were carried out with the parents of 185 children, whopresented 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 administrationtechnique.Results: Most patients were males 71.9%, aged 1-6 years (58.9%), and 8.1% of thempresented to the ED because of asthma exacerbation more than once over the last 6months. Approximately two-thirds (65.9%) of the parents explained the way of meter doseinhaler 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 associatedwith severity. However, this may not be considered a valid predictor of severity, as parentsof children with recurrent attacks may have a better chance of being taught how to usemedications.
High performance work systems: the gap between policy and practice in health care reformMethod..The studies used a combination of quantitative and qualitativemethodologies. For the quantitative data collection two organizational level surveys and a system levelsurvey were completed. The organizational level questionnaire was provided with thepay slips to all 240 staff within a rural hospital (30 per cent response rate) and 1700staff of a regional hospital (32 per cent response rate) to measure High performancework 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 outcomeswithin the organizations from the perspective of the three types of managers. We also completed interviews with senior managers and focus groups with the middleand line managers of two rural hospitals and one regional hospital to examine theenactment of the HRM policies and practices within the organizations.Measures.. Two separate questionnaires were constructed from existing validatedscales. The organizational-level questionnaire was used to explore the relationship ofHPWS with the attitudes of staff and their perceptions of the quality of patientdelivered.This questionnaire included measures of four variables.The first was high-performance work systems; the 42-item scale was used to measureHPWS.The second variable was psychological empowerment,12-item scale comprising fourcomponents:autonomy; competence; impact; and meaning.third variable, job satisfaction, was measured using the thee- comprising the followingthree items:
1. “All in all, I am satisfied with my job”; 2. “In general, I dont like my job”; and 3. “In general, I like working here”.Staff perception of the quality of patient care was the fourth variableThe system-level questionnaire was used to explore the state of HPWS and humanresource 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 strategicplanning, and human resource management priorities and functions.This study also explored HRM outcome variables such as staff turnover, absenteeismand grievance rates.
The impact of network and environmental factors on service innovativenessDesign/methodology/approach – Utilizing data from 1,428 acute healthcare hospitals inthe USA OLS regression was used to examine the antecedents to serviceinnovativeness.Method.. Data and sampleAll non-state and non-federal, acute care hospitals in the United States were selectedfor study. The data were compiled from two existing data sets. Hospital variables weremeasured 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 UnitedStates to determine their service offerings, administration, and performance.Environmental variables were measured with Area Resource File (ARF) data. The ARFcomes from various sources such as American Medical Association, AmericanHospital Association, Centers of Medicare and Medicated Services, Bureau of LaborStatistics, and National Center for Health Statistics. We procured the ARF used inthis study from the National Center for Workforce Analysis.Our sample consisted of 1,428 hospitals, after deletion of cases with significant missingdata. 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 tenstates with community benefit laws or guidelines. Ninety percent were participants inan alliance, joint venture, network or multi-hospital system.Findings – The results reveal that organizations in large networks (alliances) limitproviders service innovation. Whereas competition increased service innovativeness,regulatory forces (formal institutional pressure) and informal regulatory forces stifledit.
Inter-departmental relationships as a threat to patient safety in the operating departmentDesign/methodology/approach – Ethnographic research methods were used, withobservations of the operating department setting for 18 month and interviews with 80members of hospital staff. The setting for the study was the Operating Department ofa large teaching hospital in the North-West of England.Methods..This paper is based upon an ethnographic study carried out between 2003and 2004 in the operating department of a single large teaching hospital in northernEngland. 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 ResearchEthics Committee and participants were informed of the studys objectives.We carried out non-participatory observations within the operating department on adaily basis for 18 months. These observations took place in various locations, such asstaff rooms, management meetings, corridors, reception areas and various clinicalsettings, including ten operating theatres with adjoining anesthetic rooms and tworecovery areas. From these findings we also made observations of other hospitalsettings 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 workof the operating department, including a record of recurrent “bottlenecks” “crisispoints” and “breakdowns” in the planned or designated working arrangements asperceived by staff members. A further period of observations was undertaken tobetter understand how these organizational issues affected the routines and patternsof work within the operating theatre. Our observations were recorded in field journalstogether with reflective notebooks.Alongside our observations we interviewed those involved in the work of the operatingdepartment both formally and informally. Informal interviews were carried out in situwhilst making our observations and involved opportunistic chats and conversationswith staff members. These were used to clarify and further understand work activitiesand were recorded alongside our observational records. We also interviewed 80members of hospital staff more formally outside the immediate work setting, including14 consultant-grade surgeons of mixed specialty, 12 consultant-grade anesthetists, 14
members of theatre nursing staff of mixed grade, four operating departmentmanagers, and a range of managers, administrators and professional representativesfrom other hospital departments, as well as senior hospital managers and executives.These participants were purposively selected on the basis of their occupational roleand contribution to the working of the operating department. These semi-structuredface-to-face interviews were recorded electronically with the consent of theparticipants and followed a topic guide that involved asking participants to describetheir work environment and activities, with particular focus on what they saw as thethreats to patient safety within their work context. This guide evolved throughoutthe research process to reflect emerging issues and topics that were of theoreticalrelevance.The interview data, together with the observational records, were electronicallytranscribed and entered into the computer package Atlas ti for the purpose of dataanalysis, which followed the strategic principles of grounded theory. This was led bytwo of the authors who scrutinized the findings to develop a descriptiveunderstanding of the operating departments structures, systems, process and groupand individual activities. Through this process we were able to develop conceptualmodels of the operating department with reference to its interactive complexity andcouplings in the form of inter-departmental relations. We further analyzed the data toidentify and code the descriptions, attitudes, assumptions and viewpoints ofindividuals and professional groups involved in the work of the operating departmentto understand how organizational processes could impact upon the safety of practice.These coded findings were further compared and contrasted for their consistencyand conceptual relationships, and with the observational records provided the basis ofour analysis.Findings – The work of the operating department is determined by inter-dependant,“tightly coupled” organizational relationships between hospital departments basedupon the timely exchange of information, services and resources required for thedelivery of care. Failures within these processes, manifest as “breakdowns” withininter-departmental relationships lead to situations of constraint, rapid change anduncertainty in the work of the operating department that require staff to break withestablished routines and work with increased time and emotional pressures. Thismeans that staff focus on working quickly, as opposed to working safely.
Emotional labor: clinicians attitudes to death and dyingDesign/methodology/approach – Multi-method qualitative ethnographicstudy undertaken in a large ICU in Sydney, Australia using observationsfrom patient case studies, ward rounds and family conferences, open endedinterviews with medical and nursing clinicians and managers and focusgroups with nurses.Method..We undertook a qualitative study to gauge the effect of clinician attitudesand practices on end-of-life care in a large intensive care unit (ICU) in anacute public tertiary hospital in Sydney, Australia. We chose a unit thatfulfilled the requirements of aacknowledged in the field as progressive inintensive care practice and research, and likely to be representative ofAustralian tertiary hospital ICUs in general and those of other countrieswith similar health systems. Ethics approval was gained from the hospital inwhich the study was conducted, and data were collected between 2000 andJune 2002.Interviews and focus groups were conducted and tape recorded by a socialscientist and transcribed by a professional service; case notes were taken ofobservations in family conferences, clinician interactions with patients andward rounds. Over 240,000 words of transcript were produced. The datagathered were analyzed by a social scientist, a policy analyst and anorganizational behaviorist using grounded theory techniques andcategorized using open coding methods .Themes and patterns that emergedwere analyzed using the constant comparative method from which tentativetheories were generated that were further contextualized using specificliterature reviews. Each of the participants of our study was asked invarying ways how their work with dying people affected them. We haveselected statements from a small group of clinicians that are particularlyemblematic and representative of the theme under scrutiny here.
Findings – Clinician attitudes to death and dying and clinicians capacity toengage with the human needs of patients influenced how emotional laborwas experienced. Negative effects were not formally acknowledged inclinical workplaces and institutional mechanisms to support clinicians didnot exist.
Motivation and retention of health workers in Ghana district hospitals: Addressing the critical issuesDesign/methodology/approach – The study employed a purely quantitativedesign with a sample of 285 health workers from ten district hospitals infour regions of Ghana. A stepwise regression model was used in the analysis.Method,, SampleA total of ten district hospitals were selected from four regions (UpperEast, Upper West, Northern, and Central Regions). In Ghana, these fourregions are worst-served in terms of health sector distribution of humanresources. This is evidenced in a survey by , which revealed that theseregions have for long suffered significant deterioration of health worker-population ratio over the years. Northern region in particular has the worsedoctor-population ratio, 1:92,046 and a nurse-population ratio of 1:1,868 .Three hospitals each were selected from Upper East, Upper West andCentral while one hospital was selected from Northern region. Within eachhospital, a simple random sampling procedure was applied to select thedifferent categories of health workers except doctors, ophthalmologist,and other specialist. Due to the inadequate numbers of these categories ofhealth workers in the regions, applying convenient sampling technique wasnecessary since a random technique was likely to exclude them. The studyexcluded all categories of support staff that do not directly render care topatients. In all, a total of 400 respondents were chosen to participate in thestudy. To maximize representation, it was ensured that at least 20 healthworkers in each facility were interviewed.Instruments and data collectionA questionnaire about the socio-demographics, the independent measuresunder analysis (salary supplement, benefit, leadership skill and supervision,continuing professional development, infrastructure and resources,recognition and appreciation) and the dependent measure (motivation andretention) constituted the primary source of data for the study. Thequestionnaire was coded on a five point-likert scale anchored at thenumeral 1=“strongly disagree” to 5=“strongly agree”,
Findings – The study found that financial incentives significantly influencemotivation and intention to remain in the district hospital. Further, of thefour factor model of the non-financial incentives, only three (leadership skilland supervision, opportunities for continuing professional development andavailability of infrastructure and resources) were predictors of motivationand retention.
Defining and measuring productivity in the public sector: managerial perceptionsDesign/methodology/approach – The approach is both theoretical and empirical. Thefirst part is a literature review of research concerning public sector productivity. Thesecond part presents findings of empirical research that is based on interviews andworkshops with municipal authorities representing: special healthcare services; basichealthcare and social services, and educational services. The research was carried outin the Päijät-Häme region, Finland.5.1 Methods of the case studyThis case study is based on empirical research concerning how to define and measureproductivity in the public sector, especially in the municipal context. Findings arepresented of research on how different actors approach the concept and meaning ofproductivity in the public sector. This case study concentrates on one specific Finnishregion – Päijät-Häme, where municipal officials in managerial positions in threedifferent spheres of authority were interviewed. The research themes looked into arehow the municipal officials define productivity, and how productivity is measured andshould be measured and improved, according to them. The Päijät-Häme region hasfaced many public sector reforms during the last few years – for example setting up ofa 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; and 3. Educational services.In Finland, the municipalities need to take care of educational services, social careservices and basic healthcare services, as well as fund hospitals providing specialhealthcare. Changes related to the ageing population, growth of service needs,diminishing labor force and increasing age dependency ratio affect especially thesethree spheres of authority. If the municipalities wish to maintain a large amount ofpublic services, it is necessary to look into these three spheres.All the eight interviewees worked at the managerial level in their municipality ororganization. The interviews were semi-structured to explore interviewees views onhow they see that productivity is defined in their sphere of authority, how it should bedefined, how productivity is measured and how it should be measured. The interviewslasted 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 thecontrary, we search for similarities that are common in each sphere of authority.
Findings – According to the results, there is a certain mismatch between perceptionsconcerning productivity and the potential that lies in this concept as a functional toolin the public sectors development efforts. Public sector productivity cannot bedeveloped and discussed without taking into consideration the issue of effectiveness.