Exploring the relationship between senior management team culture and hospital performance.

The purpose of this study was to explore relationships between senior management team culture and organizational performance in English hospital organizations (NHS trusts [National Health Service]). We used an established culture-rating instrument, the Competing Values Framework, to assess senior management team culture. Organizational performance was assessed using a wide variety of routinely collected measures. Data were gathered from all English NHS acute hospital trusts, a total of 197 organizations. Multivariate econometric analyses were used to explore the associations between measures of culture and measures of performance using regressions, ANOVA, multinomial logit, and ordered probit. Organizational culture varied across hospital organizations, and at least some of this variation was associated in consistent and predictable ways with a variety of organizational characteristics and measures of performance. The findings provide particular support for a contingent relationship between culture and performance.

Cultural characteristics of "high" and "low" performing hospitals.

PURPOSE: To compare and contrast the cultural characteristics of "high" and "low" performing hospitals in the UK National Health Service (NHS). DESIGN/METHODOLOGY/APPROACH: A multiple case study design incorporating a purposeful sample of "low" and "high" performing acute hospital Trusts, as assessed by the star performance rating system. FINDINGS: These case studies suggest that "high" and "low" performing acute hospital organisations may be very different environments in which to work. Although each case possessed its own unique character, significant patternings were observed within cases grouped by performance to suggest considerable cultural divergence. The key points of divergence can be grouped under four main headings: leadership and management orientation; accountability and information systems; human resources policies; and relationships within the local health economy. PRACTICAL IMPLICATIONS: As with any study, interpretation of findings should be tempered with a degree of caution because of methodological considerations. First, there are the limitations of case study which proceeds on the basis of theoretical rather than quantitative generalisation. Second, organisational culture was assessed by exploring the views of middle and senior managers. While one should in no way suggest that such an approach can capture all important cultural characteristics of organisations, it is believed that it may be at least partially justified, given the agenda-setting powers and influence of the senior management team. Finally "star" performance measures are far from a perfect measure of organisational performance. Despite such reservations, the findings indicate that organisational culture is associated in a variety of non-trivial ways with the measured performance of hospital organisations. ORIGINALITY/VALUE: Highlights considerable cultural divergence within UK NHS hospitals.

Assessing the quality of care of multiple conditions in general practice: practical and methodological problems.

OBJECTIVE: To investigate practical and methodological problems in assessing the quality of care of multiple conditions in general practice. SETTING: Sixteen general practices from two socioeconomically diverse regions in the UK. METHOD: Quality of care was assessed in 100 randomly selected patient records in each practice using an established set of quality indicators covering 23 conditions commonly seen in primary care. Inter-rater reliability assessment was carried out for five of the conditions. RESULTS: Conducting simultaneous quality assessment across multiple conditions is highly resource intensive. Poor data quality and the low prevalence of some items of care defined by the indicators are significant problems. Scores for individual indicators require very large samples for reliable assessment. Quality scores are more reliable when reported at a higher unit of analysis. This is particularly true for indicators and conditions with low prevalence where data may need to be aggregated to the level of groups of conditions or organisational providers. There is no single ideal way of aggregating quality scores. CONCLUSION: The study identified some of the practical and methodological difficulties in assessing quality of care across multiple conditions. For improved quality assessment, advances in information technology and improvements in data quality are required for more efficient and reliable data extraction from medical records, together with the development of methods for combining scores across indicators, conditions, and practices. However, electronic data extraction methods will still be based on the assumption that the care recorded reflects the care provided.

Evaluation of PCR primers for denaturing gradient gel electrophoresis analysis of fungal communities in compost.

AIMS: Three previously published fungal specific PCR primer sets, referred to as the NS, EF and NL primer sets, were evaluated for use in compost microbial community analysis by PCR and denaturing gradient gel electrophoresis (DGGE). METHODS AND RESULTS: Primers were first evaluated based on their tolerance to PCR inhibitors. Due to its sensitivity to inhibitors, the NS primer set was determined to require a 10-fold smaller volume addition of compost DNA to PCR than the EF and NL primer sets, based on a logistic regression model for a 75% PCR success rate. Further evaluation of the EF and NL primer sets involved testing the resolution of PCR products from pure fungal cultures on DGGE. The NL primer set, which targets the more variable 28S rDNA, resulted in multiple bands for each pure culture. Thus, the EF primer set was used to monitor the microbial community during compost colonization studies, where three fungi were inoculated onto autoclaved grape pomace and rice straw compost. CONCLUSIONS: Of the three primer sets evaluated, the EF primer set was determined to be the best for PCR-DGGE of compost fungal populations; however, concerns with the EF primer set included the lack of sequence divergence in the targeted region of 18S rDNA and PCR artifacts which interfered with detection of inoculated fungi in the colonization studies. SIGNIFICANCE AND IMPACT OF THE STUDY: There are many factors related to PCR primers that need to be assessed prior to applying PCR-DGGE to fungal communities in complex environments such as compost.

Can health care quality indicators be transferred between countries?

OBJECTIVE: To evaluate the transferability of primary care quality indicators by comparing indicators for common clinical problems developed using the same method in the UK and the USA. METHOD: Quality indicators developed in the USA for a range of common conditions using the RAND-UCLA appropriateness method were applied to 19 common primary care conditions in the UK. The US indicators for the selected conditions were used as a starting point, but the literature reviews were updated and panels of UK primary care practitioners were convened to develop quality indicators applicable to British general practice. RESULTS: Of 174 indicators covering 18 conditions in the US set for which a direct comparison could be made, 98 (56.3%) had indicators in the UK set which were exactly or nearly equivalent. Some of the differences may have related to differences in the process of developing the indicators, but many appeared to relate to differences in clinical practice or norms of professional behaviour in the two countries. There was a small but non-significant relationship between the strength of evidence for an indicator and the probability of it appearing in both sets of indicators. CONCLUSION: There are considerable benefits in using work from other settings in developing measures of quality of care. However, indicators cannot simply be transferred directly between countries without an intermediate process to allow for variation in professional culture or clinical practice.

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance.

OBJECTIVES: To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care. DESIGN: Qualitative case studies using semi-structured interviews and documentation review. SETTING: Twelve purposively sampled PCG/Ts in England. PARTICIPANTS: Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members. MAIN OUTCOME MEASURES: Participants' perceptions of the role of clinical governance in PCG/Ts. RESULTS: PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment). CONCLUSION: PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand.

OBJECTIVES: Little is known about the quality of clinical care provided outside the hospital sector, despite the increasingly important role of clinical generalists working in primary care. In this study we aimed to summarise published evaluations of the quality of clinical care provided in general practice in the UK, Australia, and New Zealand. DESIGN: A systematic review of published studies assessing the quality of clinical care in general practice for the period 1995-9. SETTING: General practice based care in the UK, Australia, and New Zealand. Main outcome measures-Study design, sampling strategy and size, clinical conditions studied, quality of care attained for each condition (compared with explicit or implicit standards for the process of care), and country of origin for each study. RESULTS: Ninety papers fulfilled the entry criteria for the review, 80 from the UK, six from Australia, and four from New Zealand. Two thirds of the studies assessed care in self-selected practices and 20% of the studies were based in single practices. The majority (85.5%) examined the quality of care provided for chronic conditions including cardiovascular disease (22%), hypertension (14%), diabetes (14%), and asthma (13%). A further 12% and 2% examined preventive care and acute conditions, respectively. In almost all studies the processes of care did not attain the standards set out in national guidelines or those set by the researchers themselves. For example, in the highest achieving practices 49% of diabetic patients had had their fundii examined in the previous year and 47% of eligible patients had been prescribed beta blockers after an acute myocardial infarction. CONCLUSIONS: This study adopts an overview of the magnitude and the nature of clinical quality problems in general practice in three countries. Most of the studies in the systematic review come from the UK and the small number of papers from Australia and New Zealand make it more difficult to draw conclusions about the quality of care in these two countries. The review helps to identify deficiencies in the research, clinical and policy agendas in a part of the health care system where quality of care has been largely ignored to date. Further work is required to evaluate the quality of clinical care in a representative sample of the population, to identify the reasons for substandard care, and to test strategies to improve the clinical care provided in general practice.

Characterizing the production of a wild-type and benomyl-resistant Fusarium lateritium for biocontrol of Eutypa lata on grapevine.

Benomyl-resistant (BR) and wild-type (WT) strains of Fusarium lateritium were examined for their tolerance to benomyl on potato dextrose agar (PDA) containing benomyl and control of the Eutypa lata in grapevine bioassays. The WT strain grew on PDA containing 1 microg/ml benomyl at 13, 26 and 29 degrees C. The BR strain grew on PDA containing 10 microg/ml benomyl at 4 degrees C, on PDA containing 100 microg/ml benomyl at 29 degrees C, and on PDA containing 1,000 microg/ml benomyl at 13 degrees C and 26 degrees C. The BR strain was also able to colonize grapevine segments and control E. lata in the presence of 1,000 microg/ml benomyl. Both strains were amenable to production via liquid fermentation and both achieved 100% control of E. lata in grapevine bioassays. Neither the duration of fermentation nor incubation temperature during grapevine bioassays influenced the efficacy of either strain against E. lata. The results suggest that application of BR F. lateritium alone or in combination with benomyl may provide good control of E. lata.

How do general practices manage requests from patients for 'same-day' appointments? A questionnaire survey.

Same-day appointment requests are common and can be problematic for general practices that run appointment systems. In a questionnaire survey sent to 90 general practices in one health authority area (response rate 88%), a variety of management systems existed for dealing with same-day appointment requests. Managing the requests was found to be a significant cause of stress for many general practitioners. Registrars, locums, and practice nurses play only a small part in meeting patient demands and few practices operate telephone triage to help manage these requests.

Head lice infestation: bug busting vs. traditional treatment.

The two main methods of managing head lice infestation in the UK are head lice lotions and bug busting; there is no conclusive evidence as to which of these methods is most effective. The aim of this study was to compare the effectiveness of the bug busting method with lotion. A pilot study in the form of a randomized controlled trial involving two semi-rural general practices was used. Thirty children aged 4-16 years were randomly assigned to two intervention groups. After initial dry combing to detect the presence of head lice, one group was treated with phenothrin lotion. The bug busting group received combing using special combs provided in the bug busting pack and hair conditioner. The main outcome measure was the number of adult live lice and nymphs at day 14. On day 14 in the bug busting group, total eradication of head lice had occurred in eight children; in the lotion group, total eradication had occurred in two children (P=0.052); number needed to treat 2.5 (95% CI: 2.19-2.81). These results suggest that bug busting performed by nurses in a controlled situation is an effective method of managing head lice infestation.

The public release of performance data: what do we expect to gain? A review of the evidence.

CONTEXT: Information about the performance of hospitals, health professionals, and health care organizations has been made public in the United States for more than a decade. The expected gains of public disclosure have not been made clear, and both the benefits and potential risks have received minimal empirical investigation. OBJECTIVE: To summarize the empirical evidence concerning public disclosure of performance data, relate the results to the potential gains, and identify areas requiring further research. DATA SOURCES: A literature search was conducted on MEDLINE and EMBASE databases for articles published between January 1986 and October 1999 in peer-reviewed journals. Review of citations, public documents, and expert advice was conducted to identify studies not found in the electronic databases. STUDY SELECTION: Descriptive, observational, or experimental evaluations of US reporting systems were selected for inclusion. DATA EXTRACTION: Included studies were organized based on use of public data by consumers, purchasers, physicians, and hospitals; impact on quality of care outcomes; and costs. DATA SYNTHESIS: Seven US reporting systems have been the subject of published empirical evaluations. Descriptive and observational methods predominate. Consumers and purchasers rarely search out the information and do not understand or trust it; it has a small, although increasing, impact on their decision making. Physicians are skeptical about such data and only a small proportion makes use of it. Hospitals appear to be most responsive to the data. In a limited number of studies, the publication of performance data has been associated with an improvement in health outcomes. CONCLUSIONS: There are several potential gains from the public disclosure of performance data, but use of the information by provider organizations for quality improvement may be the most productive area for further research.

Improving quality in general practice: qualitative case study of barriers faced by health authorities.

OBJECTIVES: To identify and assess the barriers that health authorities face as they manage quality improvements in general practice in the context of the NHS reforms. DESIGN: Qualitative case study. SETTING: Three UK health authorities: a rural health authority in the south west, a deprived inner city health authority in the north east, and an affluent suburban health authority in the south east. PARTICIPANTS: Senior and junior managers. MAIN OUTCOME MEASURES: Structure of strategic and organisational management, and barriers to the leadership and management of quality improvement in general practice. RESULTS: Seven barriers were identified: absence of an explicit strategic plan for general practice, competing priorities for attention of the health authority, sensitivity of health professionals, lack of information due to poor quality of clinical data, lack of authority to implement change, unclear roles and responsibilities of managers within the organisations, and isolation from other authorities or organisations facing similar challenges. CONCLUSIONS: The health authorities faced significant barriers that would impede their ability to fulfil their responsibilities in the new NHS and that would reduce their capacity to contribute to quality improvements in general practice.

How well do GPs and hospital consultants work together? A survey of the professional relationship.

BACKGROUND: The professional relationship between GPs and hospital consultants (sometimes referred to as 'specialists') is important in a healthcare system based upon the generalist as the first point of contact for patients and the gate-keeper for hospital services. This relationship has been the subject of considerable interest over the years, but little empirical research. OBJECTIVES: We aimed to compare the attitudes of GPs and specialists to key issues, and to produce a validated objective measure of their ability to work together. METHODS: We conducted a Likert-style survey based upon statements made in qualitative interviews with GPs and specialists working in the South and West of England. The questionnaire was modified and validated during a multi-stage pilot and was distributed to a stratified random sample of 800 clinicians. RESULTS: GPs and specialists demonstrate a good level of agreement, mutual understanding and respect, though there are significant differences between the two branches of the profession in terms of attitude towards financial parity and direct access to special investigations. CONCLUSIONS: A measure of the ability of GPs and specialists to work together has been developed, with acceptable internal consistency and validity. It may be used in other geographical areas to assess a relationship which is central to the efficient and effective operation of the National Health Service.