Business Process Modelling is an Essential Part of a Requirements Analysis. Contribution of EFMI Primary Care Working Group.

OBJECTIVES: To perform a requirements analysis of the barriers to conducting research linking of primary care, genetic and cancer data. METHODS: We extended our initial data-centric approach to include socio-cultural and business requirements. We created reference models of core data requirements common to most studies using unified modelling language (UML), dataflow diagrams (DFD) and business process modelling notation (BPMN). We conducted a stakeholder analysis and constructed DFD and UML diagrams for use cases based on simulated research studies. We used research output as a sensitivity analysis. RESULTS: Differences between the reference model and use cases identified study specific data requirements. The stakeholder analysis identified: tensions, changes in specification, some indifference from data providers and enthusiastic informaticians urging inclusion of socio-cultural context. We identified requirements to collect information at three levels: micro- data items, which need to be semantically interoperable, meso- the medical record and data extraction, and macro- the health system and socio-cultural issues. BPMN clarified complex business requirements among data providers and vendors; and additional geographical requirements for patients to be represented in both linked datasets. High quality research output was the norm for most repositories. CONCLUSIONS: Reference models provide high-level schemata of the core data requirements. However, business requirements' modelling identifies stakeholder issues and identifies what needs to be addressed to enable participation.

Evaluating tools to support a new practical classification of diabetes: excellent control may represent misdiagnosis and omission from disease registers is associated with worse control.

AIMS: To conduct a service evaluation of usability and utility on-line clinical audit tools developed as part of a UK Classification of Diabetes project to improve the categorisation and ultimately management of diabetes. METHOD: We conducted the evaluation in eight volunteer computerised practices all achieving maximum pay-for-performance (P4P) indicators for diabetes; two allowed direct observation and videotaping of the process of running the on-line audit. We also reported the utility of the searches and the national levels of uptake. RESULTS: Once launched 4235 unique visitors accessed the download pages in the first 3 months. We had feedback about problems from 10 practices, 7 were human error. Clinical audit naive staff ran the audits satisfactorily. However, they would prefer more explanation and more user-familiar tools built into their practice computerised medical record system. They wanted the people misdiagnosed and misclassified flagged and to be convinced miscoding mattered. People with T2DM misclassified as T1DM tended to be older (mean 62 vs. 47 years old). People misdiagnosed as having T2DM have apparently 'excellent' glycaemic control mean HbA1c 5.3% (34 mmol/mol) vs. 7.2% (55 mmol/mol) (p<0.001). People with vague codes not included in the P4P register (miscoded) have worse glycaemic control [HbA1c 8.1% (65 mmol/mol) SEM=0.42 vs.7.0% (53mmol/mol) SEM=0.11, p=0.006]. CONCLUSIONS: There was scope to improve diabetes management in practice achieving quality targets. Apparently 'excellent' glycaemic control may imply misdiagnosis, while miscoding is associated with worse control. On-line clinical audit toolkits provide a rapid method of dissemination and should be added to the armamentarium of quality improvement interventions.

RCGP Quality Team Development programme: an illuminative evaluation.

BACKGROUND: There is increasing interest in quality initiatives that are locally owned and delivered, team based, multiprofessional, and formative. The Royal College of General Practitioners' Quality Team Development (QTD) programme is one such initiative aimed at developing primary healthcare teams and their services. AIMS: To evaluate QTD from the perspective of participants and assessors. SETTING: UK primary health care. DESIGN AND METHOD: Twelve of 14 practices and all four primary care organisations (PCOs) approached agreed to participate. Thirty four semi-structured interviews were conducted with key stakeholders. The interviews were taped, transcribed, and analysed using the constant comparative method. RESULTS: The QTD programme appears to be highly valued by participating organisations. Practice based respondents perceived it as acceptable and feasible, and reported positive changes in teamwork and patient services. They valued its formative, participative, and multiprofessional nature, especially the peer review element. PCOs saw QTD as a method of delivering on prevailing national policies on clinical quality and modernization agendas as well as promoting interorganizational collaboration. The main concerns raised were the workload, particularly for assessors, and maintaining the quality of the assessments and the programme. CONCLUSION: This qualitative study suggests positive benefits for participants in the QTD programme. However, such practices are a self-selecting innovative minority. Further research is needed on more typical practices to identify barriers to their participation in QTD or other formative, team based quality improvement programmes.

Teamwork in health care. Lessons from the literature and from good practice around the world.

It is becoming more difficult to provide health care that meets the needs of patients within tight budget constraints. This article suggests that one way forward is to channel the energies of people more constructively to work as teams. Some definitions are shown for teams and teamwork, and four benefits suggested of effective teamwork: learning and development, resource management, task performance and communications. In each of these four areas, examples are given from the international world of health care of how teamwork can be achieved. Finally, it is concluded that teamwork can be difficult, but that it is worth pursuing.

An analysis of catering options within NHS acute hospitals.

Reforms of the NHS's healthcare structure have placed additional pressure on all aspects of hospital management. Evaluation of the effects of these reforms is difficult without more information on current conditions. Hospital catering in acute care trusts has little contemporary background research available. With this in mind, a survey of all the acute care NHS trusts within the eight regions in England was undertaken to investigate the hospital meal service process. A mailed questionnaire asked for the meal production system, food service method and food delivery personnel used by each trust, and a copy of a weekly menu. Results, from an 80.7 per cent response rate, indicate that most trusts use batch cooking to prepare their meals, and plated meal service to deliver the food to the wards. Almost 75 per cent of the trusts use nurses, at least in part, to serve food. English foodstuffs dominate the menus. Most of the trusts have moved towards meeting the goals set by the Patients' Charter and other NHS recommendations.

The changing context of employment in the NHS: some legal implications of changes to employment contracts.

The NHS has undergone and continues to undergo rapid change. As a result of this, the duties and responsibilities of employees will also change. Managers within the NHS have a responsibility to ensure that appropriate contracts of employment are held by employees and that, where required, variations in these contracts are documented. This paper uses the example of the changing role of the Executive Nurse Director to highlight the importance of this need. It concludes by warning that failure to consider both the legal duties placed on employers when implementing contractual variations and the legal implications of adopting an unlawful method of variation, might lead to large legal bills and a demand on managerial time dealing with any legal claim against the employer.

Improving service quality in NHS Trust hospitals: lessons from the hotel sector.

This article looks to review recent practice undertaken within the UK hotel sector to improve customer service, and suggests ideals that could be implemented within National Health (NHS) Trust hospitals. At a time of increasing competition, hotel firms are using service enhancement as a means to gain competitive advantage, and therefore developing a range of techniques to measure levels of service quality improvement. With continued change in the health service, where greater focus now lies with patient satisfaction, so there is a requirement for managers to adapt techniques presently being offered in other service industries to improve levels of customer service and ensure patients are targeted to define their levels of satisfaction.

Training needs analysis within the community.

A project was undertaken to provide a description of the training needs of agencies who are partners in the provision of care in the community. In developing the research strategy a service design approach was adopted which complied with the design control requirement of the Quality Standard EN ISO 9001: 1994. A questionnaire for self-completion was sent to 25 individuals involved in delivering community care. The findings enabled priorities of joint training to be identified. The findings also enabled training to be suggested for both manager and direct care staff. Demonstrates the need for skill acquisition in a variety of areas. Generally it was indicated by respondents that planning training arising from the project should be multidisciplinary. Enthusiasm for such training was also a feature of the respondents' responses.