This study examined inter-departmental relationships as a threat to patient safety in an operating department through 18 months of ethnographic research including observations and 80 staff interviews. Observations mapped organizational networks, processes, and relationships within the operating department and identified recurrent issues like bottlenecks, crisis points, and breakdowns. Interviews explored how organizational issues affected routines and work patterns in operating theatres. The findings revealed how poor relationships between departments introduced risks to patient safety in the operating department.

1. 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

2. 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.

3. 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.

4. 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,

5. 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.

6. 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.

7. 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:

8. 1. “All in all, I am satisfied with my job”;
2. “In general, I don't like my job”; and
3. “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.

9. 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.

10. 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

11. 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.

12. 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.

13. 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.

14. 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”,

15. 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.

16. 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; and
3. 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.

17. 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.