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Biomedical subjects

H T Davies

Publications and source records attributed to H T Davies.

At least 19 recordsLinked to original sources
PubMed2001

Exploring the pathology of quality failings: measuring quality is not the problem--changing it is.

The USA can boast a long history of investigation into quality failings in health care. From Ernest Codman and Abraham Flexner in the opening decades of this century through to the intense activity of the 1980s and 1990s, much careful study has exposed extraordinary and at times scandalous deficiencies in the quality of care (Millenson 1997; Chassin & Galvin 1998; Schuster et al. 1998). Yet we are still far from developing 'industrial strength' quality in health care: in all but a few isolated areas, such as general anaesthesia, 'six sigma quality' (i.e. a handful of errors per million) seems wishful thinking (Chassin 1998). Pockets of excellence and innovation notwithstanding, the dominant experience of the past two decades has been an increasing ability to document quality failings and a seeming inability to mobilize effective action (Coye & Detmer 1998). The rich literature on health-care quality that has sprung up over the past few decades has largely failed to provide a clear direction for quality improvement activity. This paper analyses some of the reasons why this might be so. Contrasting the relative absence of progress on health-care quality with the relative success of disease epidemiology provides some illuminating parallels. In essence, study of the quality of care has focused largely on providing a 'descriptive epidemiology'. Much more work is needed yet to unravel the underlying pathology of quality failings, in order to empower development of an 'aetiological epidemiology' of quality in health care. Such understanding is essential as a precursor to targeted and effective preventative and remedial action.

Epidemiology↗
PubMed2001

Developing organizational learning in the NHS.

Learning has been identified as a central concern for a modernized NHS. Continuing professional development has an important role to play in improving learning but there is also a need to pay more attention to collective (organizational) learning. Such learning is concerned with the way organizations build and organize knowledge. Recent emphasis within the NHS has been on the codification of individual and collective knowledge - for example, guidelines and National Service Frameworks. This needs to be balanced by more personalized knowledge management strategies, especially when dealing with innovative services that rely on tacit knowledge to solve problems. Having robust systems for storing and communicating knowledge is only one part of the challenge. It is also important to consider how such knowledge gets used, and how routines become established within organizations that structure the way in which knowledge is deployed. In many organizations these routines favour the adaptive use of knowledge, which helps organizations to achieve incremental improvements to existing practices. However, the development of organizational learning in the NHS needs to move beyond adaptive (single loop) learning, to foster skills in generative (double loop) learning and meta-learning. Such learning leads to a redefinition of the organization's goals, norms, policies, procedures or even structures. This paper argues that moving the NHS in this direction will require attention to the cultural values and structural mechanisms that facilitate organizational learning.

Education, Medical↗
PubMed2001

A rapidly expanding lesion in the neck: unusual presentation of Castleman's disease.

We report a painless but rapidly enlarging 9 cm x 4 cm lobulated hard neck mass. CT scanning suggested lymphoid tissue that was not confirmed by cytopathology. Histopathological analysis of the excision specimen detected Castleman's disease, extending to the resection margin. Postoperative radiotherapy was administered. The patient remains disease-free after 44 months.

Adult↗
PubMed2001

Public release of performance data and quality improvement: internal responses to external data by US health care providers.

Health policy in many countries emphasises the public release of comparative data on clinical performance as one way of improving the quality of health care. Evidence to date is that it is health care providers (hospitals and the staff within them) that are most likely to respond to such data, yet little is known about how health care providers view and use these data. Case studies of six US hospitals were studied (two academic medical centres, two private not-for-profit medical centres, a group model health maintenance organisation hospital, and an inner city public provider "safety net" hospital) using semi-structured interviews followed by a broad thematic analysis located within an interpretive paradigm. Within these settings, 35 interviews were held with 31 individuals (chief executive officer, chief of staff, chief of cardiology, senior nurse, senior quality managers, and front line staff). The results showed that key stakeholders in these providers were often (but not always) antipathetic towards publicly released comparative data. Such data were seen as lacking in legitimacy and their meanings were disputed. Nonetheless, the public nature of these data did lead to some actions in response, more so when the data showed that local performance was poor. There was little integration between internal and external data systems. These findings suggest that the public release of comparative data may help to ensure that greater attention is paid to the quality agenda within health care providers, but greater efforts are needed both to develop internal systems of quality improvement and to integrate these more effectively with external data systems.

Attitude of Health Personnel↗
PubMed2001

How to present the findings of research.

Providing an account of research involves telling a story during which four key questions are answered: why did you start, what did you do, what did you find out and what does it mean? It is the third of these--what did you find out--that is at the heart of any research paper. Ensuring that the key messages emerge from the data is the duty of the author and requires considerable skill and craft.

Humans↗
PubMed2001

Understanding screening: requirements for a successful programme.

Screening has generally been successful in identifying those at risk from disease. This success has led to the belief that screening in the general population is always a good thing. However, there are pitfalls which must be avoided if screening programmes are to achieve what is intended for them.

Cost-Benefit Analysis↗
PubMed2001

Understanding sampling: representativeness matters.

Sampling, or selecting a group of people to represent a whole population, lies at the heart of almost all research designs. There are many ways of going about this, each of which presents its own problems. The trick is to obtain a good-sized sample that is truly representative of the population as a whole.

Humans↗
PubMed2001

Reading and assessing qualitative research.

What makes doctors burn out? What is it like to have epilepsy? Why do smokers not give up? Qualitative research makes it possible to look behind the statistics and to study health and health care from the inside: to find out what it is really like for the health professionals who provide the care and for the patients on the receiving end.

Data Collection↗
PubMed2000

Decision analysis in evidence-based decision making.

Many real world decisions have to be made on a limited evidence base, and clinical decisions are at best problematic. We explored some of the reasons why decision making in health care is so complex, and examined how decision analytic techniques might contribute to problem structuring and to implementation of evidence-based practice. We argued that decision analysis could, to some extent, overcome complexity of decision making by a clear structuring of the problem and a formal analysis of the implications of different decisions. Decision-analytic techniques can guide the management of individual patients or can be used to address policy questions about the use of treatment for groups of patients. However, decision analysis is not without its criticisms, e.g. problems are narrowly defined, replacing judgement and dehumanizing care, neglect of process utility and lack of primary data to develop decision analytic models. The development of evidence-based guidelines is a key component of the UK Government's quality strategy led by the National Institute for Clinical Excellence (NICE). However, the guidelines approach may lead to conflict when assessments of the effectiveness of interventions for individuals (whether or not supported by a formal decision analysis) conflict with the recommendations made by NICE for cost and clinical effectiveness for aggregate groups of patients. Decision analysis may or may not help with this but if guidelines are derived from a decision analysis, then the implications of patient preferences should be made clearer. However, decision analysis-derived guidelines will make general recommendations that may not be appropriate for all individuals. Nonetheless, decision analysis does make such implications explicit and propose that the guidelines should be supported by some mechanism for determining individual patient preferences. It will now need to consider whether some of NICE resources should be directed beyond evidence-based guidelines into decision analysis-derived guidelines and into decision analytical techniques to provide support for clinical and cost effective decision making within the patient-clinician encounter.

Decision Making↗
PubMed2000

Ultracision: the harmonic scalpel and its possible uses in maxillofacial surgery.

We report on the potential uses and benefits of a new development in incisive technology. The harmonic scalpel uses high-frequency mechanical energy to offer the surgeon controlled and precise incision and haemostasis. Vessels up to 2 mm in diameter may be sealed by coaptation with the blade before division. No special training or precautions are required before using this self-cleaning device. It produces considerably less smoke or smell than either diathermy or laser, which reduces the need for instrument exchanges and smoke evacuation. We think that it will be useful for tongue resections and possibly for neck dissections.

Equipment Design↗
PubMed2000

Managing patient trust in managed care.

Patient trust has been identified as an important element in the patient-physician relationship. However, common features of managed care, such as risk-sharing, utilization review, and limitations on benefits, may erode the traditionally high trust that patients have in their physicians. High trust is not always justified; rather, an optimal level of trust arises from the level of interdependence between patients and physicians. This analysis of the interrelationship between patient-physician trust and some of the key facets of managed care has important implications for managed care. A return to high levels of trust may be impracticable, and new strategies for balancing trust-building efforts by caregivers with checking mechanisms accessible to patients are recommended.

Confidentiality↗
PubMed2000

Reviewing audit: barriers and facilitating factors for effective clinical audit.

OBJECTIVE: To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process. DESIGN: A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of "audit", "audit of audits", and "evaluation of audits" and a handsearch of the indexes of relevant journals for key papers. RESULTS: Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation. The main barriers to clinical audit can be classified under five main headings. These are lack of resources, lack of expertise or advice in project design and analysis, problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, effective training, dedicated staff, protected time, structured programmes, and a shared dialogue between purchasers and providers. CONCLUSIONS: Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing effective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise.

Attitude of Health Personnel↗
PubMed2000

What stops effective clinical audit? Reports from the front line.

Semi-structured interview were conducted with 145 clinicians from a variety of clinical backgrounds in twelve Trusts across three Scottish health boards. Questions examined barriers to the audit process and obstacles that impeded the implementation of changes in response to the audit findings as well as the need for resources to facilitate the audit activity. The most difficult part of the audit process was reported as data collection (32%) but almost half of respondents would have changed the way the audit was done with hindsight. The biggest barrier to doing the audit was perceived as lack of time (33%). Colleagues' attitudes posed the biggest obstacles to making changes as a result of the audit (26%). Few perceived the need for more resources but preferred focused and proactive support from managers and audit support staff. Trusts need to work harder at creating cultures where clinical audit is supported and actively encouraged.

Data Collection↗