Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department.

Increasing demand and changing case-mix have resulted in bottlenecks and longer waiting times in emergency departments (ED). However, many process improvement efforts addressing the bottlenecks have limitations, as they lack accurate models of the real system as input accounting for operational complexities. To understand the limitations, this research modelled granular procedural information, to analyse processes in a Level-1 ED of a 1200-bed teaching hospital in the UK. Semi-structured interviews with 21 clinicians and direct observations provided the necessary information. Results identified Majors as the most crowded area, hence, a systems modelling technique, role activity diagram, was used to derive highly granular process maps illustrating care in Majors which were further validated by 6 additional clinicians. Bottlenecks observed in Majors included awaiting specialist input, tests outside the ED, awaiting transportation, bed search, and inpatient handover. Process mapping revealed opportunities for using precedence information to reduce repeat tests; informed alerting; and provisioning for operational complexity into ED processes as steps to potentially alleviate bottlenecks. Another result is that this is the first study to map care processes in Majors, the area within the ED that treats complex patients whose care journeys are susceptible to variations. Findings have implications on the development of improvement approaches for managing bottlenecks.

Bridging the Gap between Theory, Practice, and Policy: A Decision-Making Process Based on Public Health Evidence Feasible in Multi-Stage Research on Biological Risk Factors in Poland.

Stakeholder input into the decision-making process when developing public health programs and policies is crucial. This article presents an innovative approach, involving online participation with a wide group of stakeholders located in different geographic locations for policy consensus. The results of the project have been used to propose assumptions regarding a strategy for preventing blood-borne diseases in Poland. The research was conducted iteratively using a multi-stage qualitative methodology to explore risk assessment involving blood-borne infections. The final output of the study is a list of key problems/challenges and potential solutions associated with medical and nonmedical services that are connected to the breakage of tissue continuity. Qualitative research is rare in risk assessment, as priority is generally given to statistical data and endpoints. In addition to policy preparation for blood-borne illnesses, the methodology employed in the study can also be used to successfully explore other areas of public health.

General practitioners providing non-urgent care in emergency department: a natural experiment.

OBJECTIVE: To examine whether care provided by general practitioners (GPs) to non-urgent patients in the emergency department differs significantly from care provided by usual accident and emergency (A&E) staff in terms of process outcomes and A&E clinical quality indicators. DESIGN: Propensity score matched cohort study. SETTING: GPs in A&E colocated within the University Hospitals Coventry and Warwickshire NHS Trust between May 2015 and March 2016. PARTICIPANTS: Non-urgent attendances visits to the A&E department. MAIN OUTCOMES: Process outcomes (any investigation, any blood investigation, any radiological investigation, any intervention, admission and referrals) and A&E clinical indicators (spent 4 hours plus, left without being seen and 7-day reattendance). RESULTS: A total of 5426 patients seen by GPs in A&E were matched with 10 852 patients seen by emergency physicians (ratio 1:2). Compared with standard care in A&E, GPs in A&E significantly: admitted fewer patients (risk ratio (RR) 0.28, 95% CI 0.25 to 0.31), referred fewer patients to other specialists (RR 0.31, 95% CI 0.24 to 0.40), ordered fewer radiological investigations (RR 0.38, 95% CI 0.34 to 0.42), ordered fewer blood tests (0.57, 95% CI 0.52 to 0.61) and ordered fewer investigations (0.93, 95% CI 0.90 to 0.96). However, they intervened more, offered more primary care follow-up (RR 1.78, 95% CI 1.67 to 1.89) and referred more patients to outpatient and other A&E clinics (RR 2.29, 95% CI 2.10 to 2.49). Patients seen by GPs in A&E were on average less likely to spend 4 hours plus in A&E (RR 0.37, 95% CI 0.30 to 0.45) compared with standard care in A&E. There was no difference in reattendance after 7 days (RR 0.96, 95% CI 0.84 to 1.09). CONCLUSION: GPs in A&E tended to manage self-reporting minor cases with fewer resources than standard care in A&E, without increasing reattendance rates.

Targeting Parents for Childhood Weight Management: Development of a Theory-Driven and User-Centered Healthy Eating App.

BACKGROUND: The proliferation of health promotion apps along with mobile phones' array of features supporting health behavior change offers a new and innovative approach to childhood weight management. However, despite the critical role parents play in children's weight related behaviors, few industry-led apps aimed at childhood weight management target parents. Furthermore, industry-led apps have been shown to lack a basis in behavior change theory and evidence. Equally important remains the issue of how to maximize users' engagement with mobile health (mHealth) interventions where there is growing consensus that inputs from the commercial app industry and the target population should be an integral part of the development process. OBJECTIVE: The aim of this study is to systematically design and develop a theory and evidence-driven, user-centered healthy eating app targeting parents for childhood weight management, and clearly document this for the research and app development community. METHODS: The Behavior Change Wheel (BCW) framework, a theoretically-based approach for intervention development, along with a user-centered design (UCD) philosophy and collaboration with the commercial app industry, guided the development process. Current evidence, along with a series of 9 focus groups (total of 46 participants) comprised of family weight management case workers, parents with overweight and healthy weight children aged 5-11 years, and consultation with experts, provided data to inform the app development. Thematic analysis of focus groups helped to extract information related to relevant theoretical, user-centered, and technological components to underpin the design and development of the app. RESULTS: Inputs from parents and experts working in the area of childhood weight management helped to identify the main target behavior: to help parents provide appropriate food portion sizes for their children. To achieve this target behavior, the behavioral diagnosis revealed the need for eliciting change in parents' capability, motivation, and opportunity in 10-associated Theoretical Domains Framework (TDF) domains. Of the 9 possible intervention functions, 6 were selected to bring about this change which guided the selection of 21 behavior change techniques. Parents' preferences for healthy eating app features revolved around four main themes (app features, time saving and convenience, aesthetics, and gamification) whereupon a criterion was applied to guide the selection on which preferences should be integrated into the design of the app. Collaboration with the app company helped to build on users' preferences for elements of gamification such as points, quizzes, and levels to optimize user engagement. Feedback from parents on interactive mock-ups helped to inform the final development of the prototype app. CONCLUSIONS: Here, we fully explicate a systematic approach applied in the development of a family-oriented, healthy eating health promotion app grounded in theory and evidence, and balanced with users' preferences to help maximize its engagement with the target population.