The ebbs and flows of changing acute bed capacity delays.

OBJECTIVE: This case study provides a summary of changes in acute hospital bed delays that have occurred over a 4-year period as identified through a Capacity Audit process. BACKGROUND: Royal Adelaide Hospital (RAH) designed a Capacity Audit process and tool that provides a systematic method to evaluate factors limiting access to inpatient bed capacity. The aim of the audit is to improve understanding of bed capacity by identifying key causes of delay for hospital inpatients and quantify the most frequent causes of blocked bed capacity. This can then be used to underpin targeted improvement work. The Capacity Audit has been undertaken at the RAH over three cycles. METHOD: The Capacity Audit involves a survey of every open and staffed bed, identifying how the bed is being used: for acute care or treatment, if there was a delay to the patient for discharge, or if the bed was unavailable. The first and second cycle of the audit (2007-2008) involved a twice-daily survey over a 2-week period and the third audit cycle in 2010 occurred once daily for 1 week. RESULTS: On average, 620 beds were surveyed daily with an audit compliance rate ranging from 85-97%. This process has revealed almost 75% of beds are used positively for care. Of the remaining 25% of hidden capacity identified, non-clinical discharge delays account for 10% of total beds surveyed. Waiting for post-acute beds has consistently remained the main cause of acute bed delay. CONCLUSION: The Capacity Audit process and tool has been used to track progress, trends and change resulting from service improvement efforts, and to provide the evidence to commence strategies to reduce the hidden capacity issues. This case study has shown that whilst overall bed stock usage for positive care has not changed significantly there are various ebbs and flows over time in relation to the reasons for bed delays.

Building capacity for change: evaluation of an organisation-wide leadership development program.

Objective This study evaluated Leading 4 Change, a change leadership development program designed to support healthcare middle managers through a period of significant organisational change and enhance workplace resilience. Methods A mixed methods evaluation was conducted within the program's framework of a quality improvement activity. Quantitative measures were participant responses (n=160) to online questionnaires, which were compared before and after the program, using an uncontrolled pre-post study design. Four questionnaires were used: Resilience @ Work, General Self-Efficacy, the 11-item Learning Organization Survey and organisational climate. Differences between the pre- and post-program periods were compared using linear mixed-effects models, incorporating repeated measures between 'pre' and 'post' periods. Qualitative data were obtained by interviewing four participants on three occasions during the program, and through text responses provided by participants during a presentation session after the program finished. Both interview data and textual data were subjected to thematic analysis. Results Integration of data from quantitative and qualitative analyses generated three main findings: (1) participants were satisfied and engaged with the program, which met their learning objectives; (2) the program led to increased workplace resilience, in particular the ability to manage stress and self-efficacy for individuals; and (3) organisational learning perceptions were unchanged. Conclusion Although conducted during a period of intense internal and external pressure, Leading 4 Change led to demonstrable effects. It effectively engaged middle managers across a health system. However, there was no evidence that the effect of the program extended beyond individual participants to their perceptions of their work environment as a learning organisation. What is known about the topic? Although much has been written about change management and change leadership within healthcare, the failure to manage the 'people' element and engage employees hampers the success of that change. However, how to engage employees and enhance their resilience and self-efficacy (self-belief to proactively manage) during change has been little explored. Further, the concept of a learning organisation has been developed in private, non-healthcare fields and there is little known about it in other areas, such as healthcare, particularly during change. What does this paper add? The paper describes the evaluation of a 16-week change leadership development program (Leading 4 Change) for middle managers of a public health system undergoing significant reform. It assesses how the program engaged employees, and how and to what extent their workplace resilience, self-efficacy and perceptions of their workplace as a learning organisation changed after the program. Based on the present study, individual development of staff does not necessarily translate directly to better staff perceptions of organisational outcomes. What are the implications for practitioners? Despite being clearly engaged with Leading 4 Change, quantitative and qualitative measures suggested mixed effects of the program on participants. Participants' self-rated workplace resilience, ability to manage stress and self-efficacy increased after the program. However, there was no evidence that the effect of the program improved staff perceptions of their work as a learning organisation. For complex public sector healthcare organisations to become learning organisations, other organisational factors, in addition to staff development and training, require consideration.

Risk of death among cases attending South Australian major trauma services after severe trauma: the first 4 years of operation of a state trauma system.

BACKGROUND: Factors predictive of death at South Australian major trauma services were investigated among 8,654 patients who had experienced severe trauma from 1997 to 2000. METHOD: Univariate and multivariate analyses of age, sex, injury severity, presence of comorbid conditions, and calendar year of presentation were performed. RESULTS: Multiple logistic regression indicated that factors predictive of death were older age; higher injury severity as indicated by the New Injury Severity Score and the Revised Trauma Score; and accompanying chronic liver disease, ischemic heart disease, and chronic renal failure. A decrease in risk of death by calendar year was statistically significant (p = 0.001). Using 1997 as the reference, the relative odds of death were 0.86 (95% confidence limits) (0.53, 1.39) for 1998, 0.60 (0.36, 0.99) for 1999, and 0.45 (0.27, 0.76) for 2000. CONCLUSION: Results show a decrease in risk of death of patients attending South Australian major trauma services, from injuries of equivalent severity, during the first 4 years of operation of the State Trauma System.