Becoming frail: A more than human exploration.

'Frailty' is increasingly used as a clinical term to refer and respond to a particular bodily presentation, with numerous scores and measures to support its clinical determination. While these tools are typically quantitative in nature and based primarily on physical capacity, qualitative research has revealed that frailty is also associated with a range of social, economic and environmental factors. Here, we progress the understanding of frailty in older people via a new materialist synthesis of recent qualitative studies of frailty and ageing. We replace a conception of frailty as a bodily attribute with a relational understanding of a 'frailty assemblage'. Within this more-than-human assemblage, materialities establish the on-going 'becoming' of the frail body. What clinicians refer to as 'frailty' is one becoming among many, produced during the daily activities and interactions of older people. Acknowledging the complexity of these more-than-human becomings is essential to make sense of frailty, and how to support and enhance the lives of frail older people.

Transferring, translating and transforming knowledge: the role of brokering in healthcare networks.

PURPOSE: This research examines how knowledge and information are managed within two care networks. We develop a conceptual framework drawing on the notion of brokering and the 3T framework, which is used to describe the relative complexity of boundaries (referred to in the framework as syntactic, semantic and pragmatic) as well as capabilities and processes required to exchange information within the network. Previous research on brokering has focused on healthcare managers and professionals, but this research extends to patients and caregivers. Understanding knowledge exchange and brokering practices in healthcare is critical to the delivery of effective services. DESIGN/METHODOLOGY/APPROACH: For this case research, non-participant observation and experienced-based interviews were undertaken with healthcare professionals, patients and caregivers within two care networks. FINDINGS: The findings reveal brokering roles occupied by healthcare professionals, patients and caregivers support the transfer, translation and transformation of knowledge and information across functional and organisational boundaries. Enablers and disablers to brokering and the exchange of knowledge and information are also identified. RESEARCH LIMITATIONS/IMPLICATIONS: The study is limited to two care networks for long-term conditions within the UK. Further research opportunities exist to examine similar care networks that extend across professional and organisational boundaries. PRACTICAL IMPLICATIONS: This research informs healthcare professionals of the brokering capabilities that occur within networks and the enabling and disabling factors to managing knowledge across boundaries. ORIGINALITY/VALUE: This paper provides a conceptual framework that categorises how increased levels of knowledge and information exchange and brokering practices are managed within care networks.

Talking about frailty: The role of stigma and precarity in older peoples' constructions of frailty.

The clinical identification of frailty is increasingly thought to be important in countries with ageing populations. Understanding how older people labelled as frail make sense of this categorisation is therefore important. A number of recent studies have reported negative perceptions of the term among older people themselves. Building on this, we focus on how and why those assessed to be frail make sense of frailty as they do. We draw on 26a discourse analysis of situated interviews with 30 older people accessing emergency care in an English NHS hospital. Three interpretive repertoire pairs (Frailty is 26a bodily issue/frailty is about mind-set; Frailty is 26a negative experience/frailty is an inevitable experience; I'm not frail/I feel frail), identified across the participants' talk, are outlined and discussed in relation to discourses of the fourth age and precarity. We conclude that frailty is often seen in terms what others have referred to as 'real' old age and is linked to discourses of dependence and precarity.

Frailty as biographical disruption.

Biographical disruption positions the onset of chronic illness as a major life disruption in which changes to body, self and resources occur (Sociology of Health & Illness, 4, 1982, 167-182). The concept has been used widely in medical sociology. It has also been subject to critique and development by numerous scholars. In this paper, we build on recent developments of the concept, particularly those taking a phenomenological approach, to argue that it can also help in understanding other disruptive health-related experiences across the life course, in this case the onset of frailty. We draw on the findings of 30 situated interviews with frail older people, relating their experiences of frailty to the concept of biographical disruption. We show that frailty shares many similarities with the experience of chronic illness. Using the lens of biographical disruption to understand frailty also offers insights relevant to recent debates around both concepts, and on the continued relevance of the idea of biographical disruption given changing experiences of health and illness, including the circumstances in which biographical disruption is more and less likely to be experienced. Finally, we reflect on the potentials and limitations of applying the concept to a health-related condition that cannot be categorised as a disease.

An integrative approach to improving patient care pathways.

PURPOSE: Globally, healthcare managers continue to struggle with increasing demands for their services being delivered with limited or shrinking resources. It is, therefore, clear that systems, processes and practices need to change to meet these challenges. The purpose of this paper is to assess how integrating two improvement technologies, Lean and integrated care pathways (ICP) might help. DESIGN/METHODOLOGY/APPROACH: Lean and ICP in healthcare provide a platform to develop conceptual frameworks for integrating two approaches. FINDINGS: A conceptual integrated framework is provided to assist care pathway designers and implementers to consider the synergistic benefits of combining approaches to improvement. RESEARCH LIMITATIONS/IMPLICATIONS: The authors provide a conceptual framework that requires empirically testing. PRACTICAL IMPLICATIONS: This research provides a conceptual framework to aid practitioners to improve healthcare design and delivery. ORIGINALITY/VALUE: For the first time, the authors bring together two approaches to improving patient care pathway design and consider how these are linked in relation to improving healthcare delivery.

Evaluating Lean in healthcare.

PURPOSE: The purpose of this paper is to present findings relating to how Lean is implemented in English hospitals. DESIGN/METHODOLOGY/APPROACH: Lean implementation snapshots in English hospitals were conducted by content analysing all annual reports and web sites over two time periods, giving a thorough analysis of Lean's status in English healthcare. FINDINGS: The article identifies divergent approaches to Lean implementation in English hospitals. These approaches are classified into a typology to facilitate an evaluation of how Lean is implemented. The findings suggest that implementation tends to be isolated rather than system-wide. A second dataset conveys Lean implementation trajectory across the time period. These data signal Lean's increasing use by English hospitals and shows progression towards an increasingly systemic approach. PRACTICAL IMPLICATIONS: Data were collected using content analysis methods, which relies on how "Lean" methods were articulated within the annual report and/or on the organisation's web site, which indicates approaches taken by hospital staff implementing Lean. ORIGINALITY/VALUE: This research is the first to examine more closely "how" Lean is implemented in English hospitals. The emergent typology could prove relevant to other public sector organizations and service organisations more generally. The research also presents a first step to understanding Lean thinking in the English NHS. This article empirically analyses Lean implementation in English hospitals. It identifies divergent approaches that allow inferences about how far Lean is implemented in an organisation. Data represent a baseline for further analysis so that Lean implementation can be tracked.

Lean in healthcare: the unfilled promise?

In an effort to improve operational efficiency, healthcare services around the world have adopted process improvement methodologies from the manufacturing sector, such as Lean Production. In this paper we report on four multi-level case studies of the implementation of Lean in the English NHS. Our results show that this generally involves the application of specific Lean 'tools', such as 'kaizen blitz' and 'rapid improvement events', which tend to produce small-scale and localised productivity gains. Although this suggests that Lean might not currently deliver the efficiency improvements desired in policy, the evolution of Lean in the manufacturing sector also reveals this initial focus on the 'tool level'. In moving to a more system-wide approach, however, we identify significant contextual differences between healthcare and manufacturing that result in two critical breaches of the assumptions behind Lean. First, the customer and commissioner in the private sector are the one and the same, which is essential in determining 'customer value' that drives process improvement activities. Second, healthcare is predominantly designed to be capacity-led, and hence there is limited ability to influence demand or make full use of freed-up resources. What is different about this research is that these breaches can be regarded as not being primarily 'professional' in origin but actually more 'organisational' and 'managerial' and, if not addressed could severely constrain Lean's impact on healthcare productivity at the systems level.

How healthy is the annual health check?

PURPOSE: This paper aims to provide an assessment of organisational implementation of the healthcare standards focusing on the annual health check (AHC) in the UK NHS. DESIGN/METHODOLOGY/APPROACH: Using a postal questionnaire a national survey of all acute and specialist NHS Trusts in England was undertaken. The survey yielded a total of 102 responses, which equates to a 59 per cent response rate. FINDINGS: The findings suggest considerable variation and diversity in the rate of progress individual Trusts made towards implementing the AHC in its first year. However, across many of the organisations surveyed, there was good evidence of some progress towards ensuring that basic operational and strategic components of the framework were in place. RESEARCH LIMITATIONS/IMPLICATIONS: The research appears to reflect the findings of earlier work on the implementation of clinical governance, suggesting that few lessons have been learnt from previous policy initiatives and raising important questions for the future of health care standards. PRACTICAL IMPLICATIONS: The findings could be used to support future national health care initiatives by giving an insight into how organisations respond to and manage the process of standards. ORIGINALITY/VALUE: This study makes a number of recommendations to facilitate smooth implementation of standards in health care. These include the introduction of a national IT solution; development of regional/national networks; more timely, relevant and consistent national guidance and, the definition of minimum information requirements needed for organisational assurance.

Success factors for implementation of the balanced scorecard in a NHS multi-agency setting.

Even though the balanced scorecard (BSC) has become a highly popular performance management tool, usage in local public sector National Health Service (NHS) organisations is still rare. This paper conditionally outlines some grounds in supporting such usage. In particular underlying conceptual concerns with the BSC system and its implementation pitfalls require full consideration. This paper then outlines some factors to be taken into account for "successful" BSC implementation in a NHS multi-agency setting. These findings emerged from a series of focus groups that took place with contributors drawn from all the key organisations within the Bradford Health Action Zone. Finally, this paper argues that if key criteria are met, successful implementation of the BSC may then proceed. However, "blind" BSC implementation without consideration of these factors may result in potential "failure".