Understanding the impetus for major systems change: A multiple case study of decisions and non-decisions to reconfigure emergency and urgent care services.

OBJECTIVE: The optimal organisation of emergency and urgent care services (EUCS) is a perennial problem internationally. Similar to other countries, the Health Service Executive in Ireland pursued EUCS reconfiguration in response to quality and safety concerns, unsustainable costs and workforce issues. However, the implementation of reconfiguration has been inconsistent at a regional level. Our aim was to identify the factors that led to this inconsistency. METHODS: Using a multiple case study design, six case study regions represented full, partial and little/no reconfiguration at emergency departments (EDs). Data from documents and key stakeholder interviews were analysed using a framework approach with cross-case analysis. RESULTS: The impetus to reconfigure ED services was triggered by patient safety events, and to a lesser extent by having a region-specific plan and an obvious starting point for changes. However, the complexity of the next steps and political influence impeded reconfiguration in several regions. Implementation was more strategic in regions that reconfigured later, facilitated by clinical leadership and "lead-in time" to plan and sell changes. CONCLUSION: While the global shift towards centralisation of EUCS is driven by universal challenges, decisions about when, where and how much to implement are influenced by local drivers including context, people and politics. This can contribute to a public perception of inequity and distrust in proposals for major systems change.

The impact of behavioural skills training on the knowledge, skills and well-being of front line staff in the intellectual disability sector: a clustered randomised control trial.

BACKGROUND: Staff with varying backgrounds and educational qualifications can be effectively trained to implement procedures in line with evidence-based practice. Behavioural skills training (BST) is a competency-based training model used to effectively educate a broad selection of professionals, including front line staff, in a range of work-related skills. However, BST has yet to be evaluated in a large group-based experiment. METHODS: This study involved a parallel cluster randomised control trial. Six service sites, with a total of 54 participants, were randomised to the intervention condition using the 'coin toss' method. The intervention condition used BST to coach intellectual disability staff in reinforcement, systematic prompting, functional communication training and task analysis. Six service sites, with a total of 50 participants, were also randomised to a control condition in which generalised training in behavioural interventions was restricted. Recruited service sites were randomly assigned to the intervention condition (N = 6, n = 54) or the control condition (N = 6, n = 50) at one point in time, immediately after recruitment and before baseline testing took place. Allocations were stratified by service type (residential or day) and geographical region. One member of the research team allocated service sites using the 'coin toss' method, and another member, blind to the allocations, decided which experimental arm would receive the intervention and which would be designated as control. It was not possible to mask the intervention from participants, but they were recruited prior to randomisation. RESULTS: Participants in the intervention condition demonstrated statistically significant improvements in their knowledge scores over the study period. Participants in the control condition showed no change or a statistically significant decrease in their knowledge scores. No statistically significant changes to well-being were observed for either group. There was clear evidence of knowledge maintenance, as well as skill acquisition and subsequent generalisation to the workplace environment, among participants in the intervention condition. Participants also evaluated the BST intervention positively. CONCLUSIONS: Results support BST as a method for disseminating evidence-based practice to front line staff working with adults with intellectual and developmental disabilities.

Perspectives on the underlying drivers of urgent and emergency care reconfiguration in Ireland.

BACKGROUND: There is an increasing tendency to reconfigure acute hospital care towards a more centralised and specialised model, particularly for complex care conditions. Although centralisation is presented as "evidence-based", the relevant studies are often challenged by groups which hold perspectives and values beyond those implicit in the literature. This study investigated stakeholder perspectives on the rationale for the reconfiguration of urgent and emergency care in Ireland. Specifically, it considered the hypothesis that individuals from different stakeholder groups would endorse different positions in relation to the motivation for, and goals of, reconfiguration. METHODS: Documentary analysis of policy documents was used to identify official justifications for change. Semi-structured interviews with 175 purposively sampled stakeholders explored their perspectives on the rationale for reconfiguration. RESULTS: While there was some within-group variation, internal and external stakeholders generally vocalised different lines of argument. Clinicians and management in the internal stakeholder group proposed arguments in favour of reconfiguration based on efficiency and safety claims. External stakeholders, including hospital campaigners and local political representatives expressed arguments that focused on access to care. A "voter" argument, focused on the role of local politicians in determining the outcome of reconfiguration planning, was mentioned by both internal and external stakeholders, often in a critical fashion. CONCLUSION: Our study adds to an emerging literature on the interaction between a technocratic approach to health system planning advocated by clinicians and health service managers, and the experiential "non-expert" claims of the public and patients.

Health workforce planning and service expansion during an economic crisis: A case study of the national breast screening programme in Ireland.

This article aims to estimate the workforce and resource implications of the proposed age extension of the national breast screening programme, under the economic constraints of reduced health budgets and staffing levels in the Irish health system. Using a mixed method design, a purposive sample of 20 participants were interviewed and data were analysed thematically (June-September 2012). Quantitative data (programme-level activity data, screening activity, staffing levels and screening plans) were used to model potential workload and resource requirements. The analysis indicates that over 90% operational efficiency was achieved throughout the first six months of 2012. Accounting for maternity leave (10%) and sick leave (3.5%), 16.1 additional radiographers (whole time equivalent) would be required for the workload created by the age extension of the screening programme, at 90% operational efficiency. The results suggest that service expansion is possible with relatively minimal additional radiography resources if the efficiency of the skill mix and the use of equipment are improved. Investing in the appropriate skill mix should not be limited to clinical groups but should also include administrative staff to manage and support the service. Workload modelling may contribute to improved health workforce planning and service efficiency.

Methods of recording theatre activity across publicly funded hospitals in Ireland.

BACKGROUND: A review of theatre activity in all Health Service Executive (HSE) hospitals in Cork and Kerry in 2008 required a manual extraction of theatre activity data from largely paper-based log books. A key data management recommendation suggested that "a standardised computerised theatre log book system be developed in all hospitals in the region". HSE (2010) Reconfiguration of health services for Cork and Kerry­theatre utilisation review. ISBN 978-1-906218-54-6. MATERIALS AND METHODS: In 2010, a computerised minimum dataset project group conducted a telephone survey of theatre managers nationally to determine the methods of recording theatre activity across publicly funded hospital theatres in Ireland. RESULTS: Sixty-one percent of acute hospitals nationally did not have a computerised theatre register. Of those who did, 15 % had a fully electronic system, 13 % had a dual paper-based and electronic system and 7 % had a single surgical specialty system. The HSE South region was significantly deprived of an electronic operating system in comparison to other HSE regions. While the total number of fully computerised hospital theatres remained small,they still dealt with the greater number of hospital discharges nationally. CONCLUSIONS: The roll-out of the productive operating theatre programme is facilitating the implementation of operating room management systems on a phased basis nationally. This will greatly facilitate audit, research,patient care and theatre efficiencies.

Derived relational responding as generalized operant behavior.

The major aim of the present study was to demonstrate that derived relational responding may be viewed as a form of generalized operant behavior. In Experiment 1, 4 subjects were divided into two conditions (2 in each condition). Using a two-comparison matching-to-sample procedure, all subjects were trained and tested for the formation of two combinatorially entailed relations. Subjects were trained and tested across multiple stimulus sets. Each set was composed of novel stimuli. Both Conditions 1 and 2 involved explicit performance-contingent feedback presented at the end of each block of test trials (i.e., delayed feedback). In Condition 1, feedback was accurate (consistent with the experimenter-designated relations) following exposure to the initial stimulus sets. When subjects' responding reached a predefined mastery criterion, the feedback then switched to inaccurate (not consistent with the experimenter-designated relations) until responding once again reached a predefined criterion. Condition 2 was similar to Condition 1, except that exposure to the initial stimulus sets was followed by inaccurate feedback and once the criterion was reached feedback switched to accurate. Once relational responding emerged and stabilized, response patterns on novel stimulus sets were controlled by the feedback delivered for previous stimulus sets. Experiment 2 replicated Experiment 1, except that during Conditions 3 and 4 four comparison stimuli were employed during training and testing. Experiment 3 was similar to Condition 1 of Experiment 1, except that after the mastery criterion was reached for class-consistent responding, feedback alternated from accurate to inaccurate across each successive stimulus set. Experiment 4 involved two types of feedback, one type following tests for mutual entailment and the other type following tests for combinatorial entailment. Results from this experiment demonstrated that mutual and combinatorial entailment may be controlled independently by accurate and inaccurate feedback. Overall, the data support the suggestion, made by relational frame theory, that derived relational responding is a form of generalized operant behavior.