Search

The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acute care hospitals as a means to improve the quality of end-of-life care. If policy is to be effective, health care professionals who provide hospital care will need to respond to its patient-centered purpose. Health services will also be called upon to train health care professionals to work with dying people in a more participatory way and to assist them to develop the clinical processes that support shared decision making. Health professionals who manage clinical workplaces become central in reshaping this practice environment by promoting patient-centered care policy objectives and restructuring health service systems to routinely incorporate patient and family preferences about care at key points in the patient's care episode. (Contains 1 table.)

Analysis of 150 years of accident news writing in the Sydney (Australia) Morning Herald is presented, with the aim of uncovering the genesis of the "hard" news story and locating the practice of news writing in a historical context. Parallels are suggested between the nature of accident stories and the role and concerns of print media in modern industrial society. (Author/MSE)

Background: Health organisations are increasingly implementing 'embedded researcher' models to translate research into practice. This paper examines the impact of an embedded researcher model known as the embedded Economist (eE) Program that was implemented in an Australian Primary Health Network (PHN) located in regional New South Wales, Australia. The site, participants, program aims and design are described. Insights into the facilitators, challenges and barriers to the integration of economic evaluation perspectives into the work of the PHN are provided.Methods: The eE Program consisted of embedding a lead health economist on site, supported by offsite economists, part-time, for fifteen weeks to collaborate with PHN staff. Evaluation of the eE at the PHN included qualitative data collection via semi-structured interviews (N= 34), observations (N=8) and a field diary kept by the embedded economists. A thematic analysis was undertaken through the triangulation of this data.Results: The eE Program successfully met its aims of increasing PHN staff awareness of the value of economic evaluation principles in decision-making and their capacity to access and apply these principles. There was also evidence that the program resulted in PHN staff applying economic evaluations when commissioning service providers. Evaluation of the eE identified two key facilitators for achieving these results. First, a highly receptive organisational context characterised by a work ethic, and site processes and procedures that were dedicated to improvement. Second was the development of trusted relationships between the embedded economist and PHN staff that was enabled through: the commitment of the economist to bi-directional learning; facilitating access to economic tools and techniques; personality traits (likeable and enthusiastic); and because the eE provided ongoing support for PHN projects beyond the fifteen-week embedding period.Conclusions: This study provides the first detailed case description of an embedded health economics program. The results demonstrate how the process, context and relational factors of engaging and embedding the support of a health economist works and why. The findings reinforce international evidence in this area and are of practical utility to the future deployment of such programs. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to explore the service and policy structures that impact open disclosure (OD) practices in New South Wales (NSW), Australia. Participants and methods: An explorative study using semi-structured interviews was undertaken with 12 individuals closely involved in the implementation of OD in hospitals at policy or practice levels within the state of NSW, Australia. Interviews explored the service and policy structures surrounding OD and the perceived impact of these on the implementation of the OD policy. These data were thematically analyzed to understand the factors facilitating and creating barriers to openness after adverse events. Results: The data identified three key areas in which greater alignment between OD policy and the wider service and policy structures may enhance the implementation of OD practice: 1) alignment between OD and root cause analysis processes, 2) holistic training that links to other relevant processes such as communicating bad news, risk management, and professional regulation and insurance, and 3) policy clarification regarding the disclosure of incidents that result in no or low-level harm. Conclusion : Evidence from this study indicates that formal OD processes are not routinely applied after adverse events in NSW, despite clear guidelines for OD. The reasons for this are unclear as the service-level and policy-level phenomena that support or hinder OD are understudied. This knowledge is critical to addressing the policy-practice gap. Our paper provides insights regarding the influence of current service-level and policy-level phenomena on the delivery of OD and how policy clarification may contribute to addressing some of the challenges for implementing OD policy. The principles of virtue ethics – specifically, openness and the involvement of service users – may contribute to progressing in this area. [ABSTRACT FROM AUTHOR]

This article seeks to establish the educational and social significance of narrative and affect in anaesthetic training. Data were obtained from focus group discussions involving three groups of eight (total 24) young anaesthetists from around Australia held at an Australian and New Zealand College of Anaesthetists (ANZCA) residential conference. Analysis applied to transcripts of the discussions revealed the prominence of narratives used among trainees and supervisors as a medium for explaining and nurturing anaesthetic expertise. Nurturing expertise was accomplished by sharing narratives about extreme circumstances that highlighted a need for constant vigilance directed towards not just clinical circumstances but also colleagues. The article suggests that the narrative emphasis on remaining vigilant and maintaining personal resourcefulness may explain graduands' tendency towards social exclusivity (avoidance of non-colleague others), and contribute to a better understanding of medicine's professional inclusivity (strong in-group bonding). [ABSTRACT FROM AUTHOR]

Background Understanding a patient's hospital experience is fundamental to improving health services and policy, yet, little is known about their experiences of adverse events (AEs). This study redresses this deficit by investigating the experiences of patients in New South Wales hospitals who suffered an AE. Methods Data linkage was used to identify a random sample of 20 000 participants in the 45 and Up Cohort Study, out of 267 153 adults aged 45 years and over, who had been hospitalised in the prior 6 months. A crosssectional survey was administered to these patients to capture their experiences, including whether they had an AE and received honest communication about it. Results Of the 18 993 eligible participants, 7661 completed surveys were received (40% response rate) and 474 (7%) reported having an AE. Most AEs related to clinical processes and procedures (33%), or medications and intravenous fluids (21%). Country of birth and admission through emergency were significant predictors of the occurrence of an event. An earlier admission in the prior 6 months or a transfer to another healthcare facility was also associated with more AEs. Of those who suffered an AE, 58% reported serious or moderate effects. Conclusions Given the exclusions in our sample population (under 45 years), the AE rate reported by patients of 7% is similar to the approximately 10% rate reported in the general population by retrospective medical record reviews. AE data that include patient experience may provide contextual information currently missing. Capturing and using patient experience data more effectively is critical; there may be opportunities for applying co-design methodology to improve the management of AEs and be more responsive to patients' concerns. [ABSTRACT FROM AUTHOR]

Aims and objectives To examine user acceptance with a new format of charts for recording observations and as a prompt for responding to episodes of clinical deterioration in adult medical-surgical patients. Background Improving recognition and response to clinical deterioration remains a challenge for acute healthcare institutions globally. Five chart templates were developed in Australia, combining human factors design principles with a track and trigger system for escalation of care. Two chart templates were previously tested in simulations, but none had been evaluated in clinical practice. Design Prospective multisite survey of user acceptance of the charts in practice. Methods New observation and response charts were trialled in parallel with existing charts for 24 hours across 36 adult acute medical-surgical wards, covering 108 shifts, in five Australian states. Surveys were completed by 477 staff respondents, with open-ended comments and narrative from short informal feedback groups providing elaboration and context of user experiences. Results Respondents were broadly supportive of the chart format and content for monitoring patients, and as a prompt for escalating care. Some concerns were noted for chart size and style, use of ranges to graph vital signs and with specific human factors design features. Information and training issues were identified to improve usability and adherence to chart guidelines and to support improved detection and response for patients with clinical deterioration. Conclusions This initial evaluation demonstrated that the charts were perceived as appropriate for documenting observations and as a prompt to detect clinical deterioration. Further evaluation after some minor modifications to the chart is recommended. Relevance to clinical practice Explicit training on the principles and rationale of human factors chart design, use of embedded change management strategies and addressing practical issues will improve authentic engagement, staff acceptance and adoption by all clinical users when implementing a similar observation and response chart into practice. [ABSTRACT FROM AUTHOR]

Copyright of International Journal for Quality in Health Care is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This paper considers the ways in which clinicians enact 'being a team', by analysing how they inform one another about critical patient information. The process where this information exchange happens is known as 'clinical handover'. The study that informs this paper spanned ten months of data collection in four hospitals, involving 150 clinicians and five patients. The analysis presented here draws on data collected at one of the hospital sites: an emergency department at a regional tertiary teaching hospital. Our analysis reveals how central clinical handover is to 'being a team' in health care, and how deficiencies in handover weaken clinical teams' ability to provide continuous and safe care for their patients. We further discuss how clinical practitioners' own responses to the footage foregrounded different issues compared to those revealed by formal analysis; namely, issues centring on relationships, and on practical steps to ensure these relationships could be improved. We reflect on the differences between our own formal analysis of the footage, and practitioners' 'lived response' to the footage, and the implications of these differences for how we as analysts conceptualise 'teamness' in organisations. [ABSTRACT FROM AUTHOR]

Background: While ‘home’ is cited most frequently as being the preferred place of death, most people will die in institutions. Yet, the meaning and significance of home for people nearing the end of life has not been fully explored. Aim: The aim of this article is to critically examine the meaning of home for dying patients and their families. Design: The qualitative study used video-reflexive ethnography methods. Data were collected and analysed over an 18-month period. Setting/participants: Participants were recruited from two Australian sites: a palliative care day hospital and an acute hospital. Participants included patients with a prognosis of 6 months or less (n = 29), their nominated family member(s) (n = 5) and clinicians (n = 36) caring for them. Patients and families were ‘followed’ through care settings including the palliative care unit and into their own homes. Results: Whether or not participants deemed space(s) safe or unsafe was closely related to the notion of home. Six themes emerged concerning this relationship: ‘No place like home’; ‘Safety, home and the hospital’; ‘Hospital “becomes” home’; ‘Home “becomes” hospital’; ‘Hospital and “connections with home”’; and ‘The built environment’. Conclusion: Home is a dynamic concept for people nearing the end of life and is concerned with expression of social and cultural identity including symbolic and affective connections, as opposed to being merely a physical dwelling place or street address. Clinicians caring for people nearing the end of life can foster linkages with home by facilitating connections with loved ones and meaningful artefacts. [ABSTRACT FROM AUTHOR]

Aims and Objectives This paper explores patients' perspectives on infection prevention and control. Background Healthcare-associated infections are the most frequent adverse event experienced by patients. Reduction strategies have predominantly addressed front-line clinicians' practices; patients' roles have been less explored. Design Video-reflexive ethnography. Methods Fieldwork undertaken at a large metropolitan hospital in Australia involved 300 hours of ethnographic observations, including 11 hours of video footage. This paper focuses on eight occasions, where video footage was shown back to patients in one-on-one reflexive sessions. Findings Viewing and discussing video footage of clinical care enabled patients to become articulate about infection risks, and to identify their own roles in reducing transmission. Barriers to detailed understandings of preventative practices and their roles included lack of conversation between patients and clinicians about infection prevention and control, and being ignored or contradicted when challenging perceived suboptimal practice. It became evident that to compensate for clinicians' lack of engagement around infection control, participants had developed a range of strategies, of variable effectiveness, to protect themselves and others. Finally, the reflexive process engendered closer scrutiny and a more critical attitude to infection control that increased patients' sense of agency. Conclusion This study found that patients actively contribute to their own safety. Their success, however, depends on the quality of patient-provider relationships and conversations. Rather than treating patients as passive recipients of infection control practices, clinicians can support and engage with patients' contributions towards achieving safer care. Relevance to clinical practice This study suggests that if clinicians seek to reduce infection rates, they must start to consider patients as active contributors to infection control. Clinicians can engage patients in conversations about practices and pay attention to patient feedback about infection risk. This will broaden clinicians' understandings of infection control risks and behaviours, and assist them to support appropriate patient self-care behaviour. [ABSTRACT FROM AUTHOR]

Background Optimising clinical responses to deteriorating patients is an international indicator of acute healthcare quality. Observation charts incorporating track and trigger systems are an initiative to improve early identification and response to clinical deterioration. A suite of track and trigger 'Observation and Response Charts' were designed in Australia and initially tested in simulated environments. This paper reports initial clinical user experiences and views following implementation of these charts in adult general medical-surgical wards. Methods Across eight trial sites, 44 focus groups were conducted with 218 clinical ward staff, mostly nurses, who received training and had used the charts in routine clinical practice for the preceding 2-6 weeks. Transcripts of audio recordings were analysed for emergent themes using an inductive approach. Findings In this exploration of initial user experiences, key emergent themes were: tensions between vital sign 'ranges versus precision' to support decision making; using a standardised 'generalist chart in a range of specialist practice' areas; issues of 'clinical credibility', 'professional autonomy' and 'influences of doctors' when communicating abnormal signs; and 'permission and autonomy' when escalating care according to the protocol. Across themes, participants presented a range of positive, negative or mixed views. Benefits were identified despite charts not always being used up to their optimal design function. Participants reported tensions between chart objectives and clinical practices, revealing mismatches between design characteristics and human staff experiences. Overall, an initial view of 'increased activity/uncertain benefit' was uncovered. Conclusions Findings particularly reinforced the significant influences of organisational work-based cultures, disciplinary boundaries and interdisciplinary communication on implementation of this new practice chart. Optimal use of all chart design characteristics will be possible when these broader cultural issues are addressed. [ABSTRACT FROM AUTHOR]

Objective To analyse rural patients' and their families' experiences of open disclosure and offer recommendations to improve disclosure in rural areas. Design Retrospective qualitative study based on a subset of 13 semistructured, in-depth interviews with rural patients from a larger dataset. The larger data set form a nationwide, multisite, retrospective-qualitative study that included 100 semistructured, in-depth interviews with 119 patients and family members who were involved in high-severity health care incidents and incident disclosure. The larger study is known as the '100 Patient Stories' study. Interviews were transcribed verbatim and analysed by one analyst ( D.P.) for recurrent experiences and concerns. Setting Acute care. Participants A sub-set of 13 of the 100 participants from the '100 Patient Stories' study who identified as experiencing an adverse incident in a rural or regional area. Main outcome measures Patients' and family members' perceptions and experiences of health care incident disclosure, as expressed in interviews. Results Rural patients and clinicians experience additional challenges to metropolitan patients and clinicians in their experiences of health care incidents. These additional barriers include: a lack of resources at small hospitals; delays in diagnosis and transfer; distance between services; and a lack of communication between providers. These challenges impact not only upon how patients and their families experience incidents, but also how open disclosure is implemented. Conclusions This analysis of 13 of the 100 Patient Stories interviews provides guidance to rural health services on how to conduct open disclosure. [ABSTRACT FROM AUTHOR]

To elicit patients' views on whether they could contribute to improvements in their care by carrying their own health information to clinician encounters; and to consider the implications for the development of a patient-held health file (PHF). Increasing rates of chronic disease lead to health care being delivered by multiple care providers often at distributed geographic locations. As a way of increasing the availability of patient information to care providers our project will trial a PHF. Patients carry these files to doctors' appointments where clinicians record data for other doctors or the patient. Increasing the availability of patient information is anticipated to enhance the safety and quality of care delivery and improve health outcomes. Qualitative semi-structured interviews were conducted with 10 patients. Participants were evenly distributed in terms of gender, aged 60 years or greater and visited at least two specialists and one general practitioner. In this exploratory study, patients who were currently active in decision making about their own health already recorded some health information. They were receptive to carrying their information and thought they should take some responsibility for their health. Patients who were more passive in making decisions about their health did not perceive a need to carry their own information and felt that their doctors communicated adequately. Patient-held health files provide an opportunity for patients to access their health information. Such files have the potential to improve health outcomes for patients who adopt both active and passive roles in relation to their own health and engaging with their health information. [ABSTRACT FROM AUTHOR]

The article discusses a cross-sectional survey of 51 health care professionals engaged in open disclosure (OD) conducted in Australia in 2009. The aim of the study is to assess the attitudes of OD practitioners toward the legal risks and protections that surround this activity. Respondents of the survey showed concerns about both the medicolegal implications of OD and the skills needed to conduct it effectively. They also perceive current laws to protect against use of this information in legal proceedings as inadequate.

The aim of this study was to understand the environment of health care, and how clinicians and managers respond in terms of performance accountability. A qualitative method was used in a tertiary metropolitan teaching intensive care unit (ICU) in Sydney, Australia, including interviews with 15 clinical managers and focus groups with 29 nurses of differing experience. The study found that a managerial focus on abstract goals, such as budgets detracted from managing the core business of clinical work. Fractures were evident within clinical units, between clinical units and between clinical and managerial domains. These fractures reinforced the status quo where seemingly unconnected patient care activities were undertaken by loosely connected individual clinicians with personalized concepts of accountability. Managers must conceptualize health services as an interconnected entity within which self-directed teams negotiate and agree objectives, collect and review performance data and define collective practice. Organically developing regimens of care within and across specialist clinical units, such as in ICUs, directly impact upon health service performance and accountability. [ABSTRACT FROM AUTHOR]

Abstract: This paper analyses talk produced by twenty-four newly qualified anaesthetists. Data were collected from round table discussions at the Young Fellows Conference of the Australia and New Zealand College of Anaesthetists 2006. The talk consisted to an important extent of narratives about experiences of horror. The paper isolates three themes: the normalization of horror, the functionalisation of horror for pedagogic purposes, and the problematization of horror. The last theme provides a springboard into our argument that confronting the affect invested in coping with medical–clinical failure is central to enabling young doctors, and clinicians generally, to address and resolve such adverse events. We conclude that the negotiation of affect through shared or ‘dialogic’ narrative is central to enabling doctors to deal with adverse events on a personal level, and to enabling them at a collective level to become attentive to threats to patients'' safety. [Copyright &y& Elsevier]

Objectives: To understand the views of doctors, nurses, allied health professionals and health managers of open disclosure of medical errors. Methods: Semi-structured interviews were conducted with 131 health professionals to understand their experiences of implementing open disclosure in 21 providers in Australia. Results: Health professionals are positive about open disclosure and are applying the model to patient-clinician communication encounters more generally. Workforce and systems competencies enable clinicians and health service managers to implement open disclosure principles and practices, although a propensity to hide errors, wavering commitment and to exacerbate the problem inhibits implementation as policy intends. The gap between policy objectives and their implementation limits the benefits to health professionals. Conclusion: Health services must develop organizing capabilities if open disclosure is to be implemented as intended. Activities should identify and address factors that impede implementation and enable workforce and system competencies to develop. These activities will allow health services to adapt central open disclosure policy to local conditions and to embed its principles and practices organization-wide. [ABSTRACT FROM AUTHOR]

Abstract: Background: Clinicians worldwide are being called upon to reconcile accountability for patient outcomes with the resources they consume. In the case of intensive care, contradictory pressures can arise in decisions about continuing treatment where benefit is diminishing. As concern grows about the cost effectiveness of treatment at end-of-life, nursing expertise and advocacy become significant factors in decision making. Objectives: To explore the potential for a nursing advocacy role within a specific regime of nursing practice: end-of-life care; specifically to examine the concept of nursing advocacy from the literature, to consider its application in the workplace and to assess the capacity for nurses to advocate for people who die in institutions such as intensive care units. Design: Open-ended interviews with nurse managers and educators (4), palliative care specialists (2), chaplain (1), medical managers (2), intensives (7); focus groups with nurses (4 focus groups and 29 participants); patient case studies (13); observation of family conferences (6 conferences and 15 participants); observation of ward rounds (3 ward rounds and 11 participants). Total number of participants: 84. Setting: A large ICU in a principal referral and teaching hospital in Sydney, Australia. Participants: Clinical staff within, and clinical and non-clinical caregivers external to the unit. Method: Qualitative, ethnographic study. Results: Spurious economic imperatives, primacy given to medical intervention, conflict between medical and nursing clinicians about patient management and absence of nursing operational autonomy and organizational authority, impede the opportunity for nurses to define and enact an advocacy role. Conclusions: If nurses are to be effective patient advocates at end-of-life, they will need to develop clear criteria within which nursing assessments of patient status can be framed, the specialized skills to manage the non-medical needs of dying people and the organizational and political skills to negotiate changing clinical practice and workplace relations. [Copyright &y& Elsevier]

This paper considers the nonmedical status of patients in end-of-life decisions. Considering nonmedical factors is not yet routine, particularly in decisions to withhold or withdraw treatment. The paper advocates that non-medical factors—the capacity and willingness to withstand continuing treatment—are essential to ensure that decisions taken are in the patient's best interest. We argue that including this dimension of patient care not commonly considered gives balance to decisions about continuing treatment where its benefit is diminishing. Drawing on a qualitative study of intensive care nursing in a large public hospital in Sydney, Australia, the paper exemplifies and interprets the tendency of some clinicians to not disclose the medical and nonmedical status to conscious patients, and the environment of mistrust and conflict that can result. We propose a process of ‘conferencing’—a regular, inclusive, ongoing, and dynamic process of communication begun early in the patient's admission—to allow multidisciplinary clinicians to manage their differences, agree on patient-care goals, and prepare the patient and their family for the experience of dying. By integrating both medical and nonmedical factors, conferencing becomes the means of enacting and embedding a multidisciplinary, multidimensional approach to end-of-life care. [ABSTRACT FROM AUTHOR]

Hospitals are being restructured more frequently. Increased cost efficiency is the usual justification given for such changes. All 20 major teaching hospitals in Australia's two most populous states were investigated by classifying each over a 5–6 year period in terms of their cost efficiency (average cost per case weighted by Australian diagnosis-related group [AN-DRG] data and adjusted for inflation) and structure, categorized as traditional–professional (TP), clinical–divisional (CD), or clinical–institute (CI). In all, 12 hospitals changed structure during the study period. There was slight evidence that CD structures were more efficient than TP structures but this was not supported by other evidence. There were no significant differences in efficiency in the first or second years following changes from either TP to CD or TP to CI structures. All four hospitals changing from CD to CI structure became significantly less efficient. This may be due to frequency rather than type of change as they were the only hospitals that implemented two structural changes. Hospitals that changed or did not change structure were similar in efficiency at the beginning and at the end of the study period, in overall efficiency during the period, and in trends toward efficiency over time. The findings challenge those who advocate restructuring hospitals on the grounds of improving cost efficiency. [ABSTRACT FROM AUTHOR]

Background: Accreditation has become ubiquitous across the international health care landscape. Award of full accreditation status in health care is viewed, as it is in other sectors, as a valid indicator of high quality organisational performance. However, few studies have empirically demonstrated this assertion. The value of accreditation, therefore, remains uncertain, and this persists as a central legitimacy problem for accreditation providers, policymakers and researchers. The question arises as to how best to research the validity, impact and value of accreditation processes in health care. Most health care organisations participate in some sort of accreditation process and thus it is not possible to study its merits using a randomised controlled strategy. Further, tools and processes for accreditation and organisational performance are multifaceted. Methods/design: To understand the relationship between them a multi-method research approach is required which incorporates both quantitative and qualitative data. The generic nature of accreditation standard development and inspection within different sectors enhances the extent to which the findings of in-depth study of accreditation process in one industry can be generalised to other industries. This paper presents a research design which comprises a prospective, multi-method, multilevel, multi-disciplinary approach to assess the validity, impact and value of accreditation. Discussion: The accreditation program which assesses over 1,000 health services in Australia is used as an exemplar for testing this design. The paper proposes this design as a framework suitable for application to future international research into accreditation. Our aim is to stimulate debate on the role of accreditation and how to research it. [ABSTRACT FROM AUTHOR]

This article addresses how professionals working in an intensive care unit in Australia speak about dying, with particular reference to the contradictions and complexities that characterize their work in this setting. The article reflects on the incommensurabilities in these clinicians' talk, and the consequences of this for how different professionals work together and care for extremely ill patients. Examples are drawn from talk recorded during ward rounds and focus groups. The article argues that intensive care units are settings where being reflexive about one's work and assumptions is especially difficult because it involves negotiating decisions and taking moral responsibility for decisions affecting very sick patients. These decisions and responsibilities put into sharp relief the 'wicked problems and tragic choices' of end-of-life existence and of intensive care in specific. This article shows some of the complex ways in which specific clinicians' discourse absorbs and manifests these tensions and responsibilities. The article concludes that these kinds of complexities are unlikely to be resolved with reference to formal knowledge or in-principle conviction, and that a new interactive basis needs to be found where clinicians can rehearse alternative ways of speaking with which to approach each other, the dying, and their families. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The purpose of this study was to identify the key implications of the implementation of a computerized physician order entry (CPOE) system on pathology laboratory services. Methods: An in-depth qualitative study using observation, focus groups and interviews with pathology staff, managers, clinicians and information systems staff during implementation of a CPOE system in 2004 at a major Australian teaching hospital. Results: Pathology laboratories experienced a shift in their work roles resulting in altered work practices, responsibilities and procedures. These changes were marked by terminological and procedural changes in the test order process from when clinicians issued a request for a test, to the new system that established clinical orders at the point of care. This change was accompanied by some organizational dysfunctions including the emergence of a new category of “frustrated” orders without specimens; problems with the procedure of adding tests to previously existing specimens; the appearance of discrepancies in the recorded time of specimen collection. In response to these changes, hospital and pathology staff adopted a variety of means to cope with their changed circumstances. These ranged from efforts to increase clinical awareness to compensatory laboratory workarounds and enforced rule changes. Conclusions: CPOE systems can have a major impact on the nature of the work of pathology laboratories. Understanding how and why these changes occur can be enhanced through considering the organizational and social contexts involved. The effectiveness of CPOE systems will rely on how administrators and staff approach and deal with these challenges. [Copyright &y& Elsevier]

Objective: The aim of the study was to determine from patient-reported data the relationships between patients' experiences of adverse events (AEs), the disclosure of the events, and patients propensity for complaints or legal action., Methods: A cross-sectional survey was administered to 20,000 participants randomly chosen from the 45 and Up Study. The surveyed participants were older than 45 years and hospitalized in New South Wales, Australia, between January and June 2014. They were identified using data linkage to capture experiences of AEs., Results: Of the 7661 respondents, 474 participants (7%) reported experiencing an AE. Those who did not receive an apology or expression of regret in the incident disclosure process were significantly more likely to make a complaint (P < 0.05). Those who found out about the event from hospital staff but did not receive a formal open disclosure process were found to be significantly more likely to seek legal advice (P < 0.05). Patients who made a complaint generally perceived that they experienced more problems in their hospital care, with significant differences identified between those who did and did not make a complaint on 13 of the 15-item Picker Patient Experience Questionnaire., Conclusions: Although incident disclosure was not associated with whether a complaint was made or legal action pursued, significant associations between key aspects of the disclosure process and these outcomes were noted. Significant differences between those who did and did not make a complaint were noted in relation to the timing and apology components of open disclosure. The critical role of overall patient experience in the context of optimal AE management was evident from these data., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: We draw on institutional theory to explore the roles and actions of innovation teams and how this influences their behaviour and capabilities as 'institutional entrepreneurs (IEs)', in particular the extent to which they are both 'willing' and 'able' to facilitate transformational change in healthcare through service redesign., Design: A longitudinal qualitative study that applied a 'researcher in residence' as an ethnographic approach., Setting: The development and implementation of two innovation projects within a single public hospital setting in an Australian state jurisdiction., Participants: Two innovation teams, with members including senior research fellows, PhD scholars and front-line clinicians (19 participants and 47 interviews)., Results: Despite being from the same hospital, the two innovation teams occupied contrasting subject positions with one facilitating transformational improvements in service delivery, while the other sought more conservative improvements. Cast as 'IEs' we show how one team took steps to build legitimacy for their interventions enabling spread and scale in improvements and how, in the other case, failure to build legitimacy resulted in unintended consequences which undermined the sustainability of the improvements achieved., Conclusions: Adopting an institutional approach provided insight into the 'willingness' and 'ability' to facilitate transformational change in healthcare through service redesign. The manner in which innovation teams operate from different subject positions influences the structural and normative legitimacy afforded to their activities. Specifically, we observed that those with the most power (organisational or professional) to bring about transformational change can be the least willing to do so in ways which challenge current practice. Those most willing to challenge the status quo (more peripheral organisation members or professionals) can be least able to deliver transformation. Better understanding of these insights can inform healthcare leaders in supporting innovation team efforts, considering their subject position., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist-the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an 'explanatory theoretical model of change' that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities-narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome. TRIAL REGISTRATION NUMBER: The Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results)., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective Since Australia initiated national open disclosure standards in 2002, open disclosure policies have been adopted in all Australian states and territories. Yet, research evidence regarding their adoption is limited. The aim of the present study was to determine the frequency with which patients who report an adverse event had information disclosed to them about the incident, including whether they participated in a formal open disclosure process, their experiences of the process and the extent to which these align with the current New South Wales (NSW) policy. Methods A cross-sectional survey about patient experiences of disclosure associated with an adverse event was administered to a random sample of 20000 participants in the 45 and Up Study who were hospitalised in NSW, Australia, between January and June 2014. Results Of the 18993 eligible potential participants, completed surveys were obtained from 7661 (40% response rate), with 474 (7%) patients reporting an adverse event. Of those who reported an adverse event, a significant majority reported an informal or bedside disclosure (91%; 430/474). Only 79 patients (17%) participated in a formal open disclosure meeting. Most informal disclosures were provided by nurses, with only 25% provided by medical practitioners. Conclusions Experiences of open disclosure may be enhanced by informing patients of their right to full disclosure in advance of or upon admission to hospital, and recognition of and support for informal or bedside disclosure for appropriate types of incidents. A review of the open disclosure guidelines in relation to the types of adverse events that require formal open disclosure and those more suitable to informal bedside disclosure is indicated. Guidelines for bedside disclosure should be drafted to assist medical practitioners and other health professionals facilitate and improve their communications about adverse events. Alignment of formal disclosure with policy requirements may also be enhanced by training multidisciplinary teams in the process. What is known about the topic? While open disclosure is required in all cases of serious adverse events, patients' experiences are variable, and lack of, or poor quality disclosures are all too common. What does this paper add? This paper presents experiences reported by patients across New South Wales in a large cross-sectional survey. Unlike previous studies of open disclosure, recently hospitalised patients were identified and invited using data linkage with medical records. Findings suggest that most patients receive informal disclosures rather than a process that aligns with the current policy guidance. What are the implications for practitioners? Experiences of open disclosure may be enhanced by informing patients of their right to full disclosure in advance of or upon admission to hospital, and recognition of and support for informal or bedside disclosure for appropriate types of incidents.

Introduction: User engagement in mental health service design is heralded as integral to health systems quality and performance, but does engagement improve health outcomes? This article describes the CORE study protocol, a novel stepped wedge cluster randomised controlled trial (SWCRCT) to improve psychosocial recovery outcomes for people with severe mental illness., Methods: An SWCRCT with a nested process evaluation will be conducted over nearly 4 years in Victoria, Australia. 11 teams from four mental health service providers will be randomly allocated to one of three dates 9 months apart to start the intervention. The intervention, a modified version of Mental Health Experience Co-Design (MH ECO), will be delivered to 30 service users, 30 carers and 10 staff in each cluster. Outcome data will be collected at baseline (6 months) and at completion of each intervention wave. The primary outcome is improvement in recovery score using the 24-item Revised Recovery Assessment Scale for service users. Secondary outcomes are improvements to user and carer mental health and well-being using the shortened 8-item version of the WHOQOL Quality of Life scale (EUROHIS), changes to staff attitudes using the 19-item Staff Attitudes to Recovery Scale and recovery orientation of services using the 36-item Recovery Self Assessment Scale (provider version). Intervention and usual care periods will be compared using a linear mixed effects model for continuous outcomes and a generalised linear mixed effects model for binary outcomes. Participants will be analysed in the group that the cluster was assigned to at each time point., Ethics and Dissemination: The University of Melbourne, Human Research Ethics Committee (1340299.3) and the Federal and State Departments of Health Committees (Project 20/2014) granted ethics approval. Baseline data results will be reported in 2015 and outcomes data in 2017., Trial Registration Number: Australian and New Zealand Clinical Trials Registry ACTRN12614000457640., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Evidence of patients' experiences is fundamental to creating effective health policy and service responses, yet is missing from our knowledge of adverse events. This protocol describes explorative research redressing this significant deficit; investigating the experiences of a large cohort of recently hospitalised patients aged 45 years and above in hospitals in New South Wales (NSW), Australia., Methods and Analysis: The 45 and Up Study is a cohort of 265,000 adults aged 45 years and above in NSW. Patients who were hospitalised between 1 January and 30 June 2014 will be identified from this cohort using data linkage and a random sample of 20,000 invited to participate. A cross-sectional survey (including qualitative and quantitative components) will capture patients' experiences in hospital and specifically of adverse events. Approximately 25% of respondents are likely to report experiencing an adverse event. Quantitative components will capture the nature and type of events as well as common features of patients' experiences. Qualitative data provide contextual knowledge of their condition and care and the impact of the event on individuals. Respondents who do not report an adverse event will report their experience in hospital and be the control group. Statistical and thematic analysis will be used to present a patient perspective of their experiences in hospital; the characteristics of patients experiencing an adverse event; experiences of information sharing after an event (open disclosure) and the other avenues of redress pursued. Interviews with key policymakers and a document analysis will be used to create a map of the current practice., Ethics and Dissemination: Dissemination via a one-day workshop, peer-reviewed publications and conference presentations will enable effective clinical responses and service provision and policy responses to adverse events to be developed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Poor prognosis is difficult to impart, particularly across a cultural divide. This study compared prognostic communication with immigrants (with and without interpreters) versus native-born patients in audio-taped oncology consultations., Methods: Ten oncologists, 78 patients (31 Australian-born, 47 immigrants) and 115 family members participated. The first two consultations after diagnosis of incurable disease were audiotaped, transcribed and coded. 142 consultations were included in the analysis., Results: Fifty percent of doctor and 59% of patient prognostic speech units were not interpreted or interpreted non-equivalently when an interpreter was present. Immigrant status predicted few prognostic facts, and oncologist characteristics no prognostic facts, disclosed. Oncologists were significantly less likely to convey hope to immigrants (p=0.0004), and more likely to use medical jargon (p=0.009) than with Australian-born patients. Incurable disease status and a limited life span were commonly acknowledged, generally with no timeframe provided. Physical issues were discussed more commonly than emotional aspects., Conclusions: While culture did not appear to influence doctor speech, interpreters filtered or blocked much prognostic communication., Practice Implications: Initiatives to empower all patients to attain needed information, optimise communication when an interpreter is present and train cancer health professionals in culturally appropriate care, are urgently required., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Purpose: Harnessing the advantage of mobile information technology (IT) solutions at the point of care and contributing to patients' safety by involving them., Design/methodology/approach: International collaboration between specialists in health communication processes and information management and systems., Methods Used: Case studies, design science., Findings: User-friendly portable IT applications going beyond documentation of patient records and administration require an understanding of complex communication processes between patients and the different caregivers. Home care increasingly faces structural deficits to be mitigated by integration of IT solutions. Platforms chosen in combination with services should be well established. How to implement this must be scrutinized by comprehensive research as initiated here. Preliminary results indicate potentials for novel mobile applications., Practical Implications: Contribution to increasing patients' safety by developing mobile solutions to support health care. Those may also contribute to cost savings in health care., Social Implications: Health care experiences an increasing significance for Western industrialized countries because of demographic developments. Care generally shifts from inpatient to outpatient settings; the global shortage of qualified nurses becomes even more prevailing. More support, among others by IT and enhanced interprofessional communication, is demanded for an improved quality and efficiency of care processes., Originality/value: Mutual approach benefits from the partner's understanding of complex interactions among clinicians, health services, and patients: the ability to design, monitor, and evaluate research strategies integrating care (information) needs is invaluable when applying creative technology solutions within health care domain.

Background: Adverse-event incident disclosure is gaining international attention as being central to incident management, practice improvement, and public engagement, but those charged with its execution are experiencing barriers. Findings have emerged from two large studies: an evaluation of the 2006-2008 Australian Open Disclosure Pilot, and a 2009-2010 study of patients' and relatives' views on actual disclosures. Clinicians and patients interviewed in depth suggest that open disclosure communication has been prevented by a range of uncertainties, fears, and doubts., Methods: Across Australia, 147 clinical staff were interviewed (mostly over the phone), and 142 patients and relatives were interviewed in their homes or over the phone. Interviews were recorded, transcribed, and analysed by three independent investigators. Transcription analyses yielded thematic domains, each with a range of ancillary issues., Results: Analysis of interview transcripts revealed several important barriers to disclosure: uncertainty among clinicians about what patients and family members regard as requiring disclosure; clinicians' assumption that those harmed are intent on blaming individuals and not interested in or capable of understanding the full complexity of clinical failures; concerns on the part of clinicians about how to interact with (angry or distressed) patients and family members; uncertainties about how to guide colleagues through disclosure; and doubts surrounding how to manage disclosure in the context of suspected litigation risk, qualified-privilege constraints, and risk-averse approaches adopted by insurers., Conclusions: Disclosure practices appear to be inhibited by a wide range of barriers, only some of which have been previously reported. Strategies to overcome them are put forward for frontline clinicians, managerial staff, patient advocates, and policy agencies.

Objective: Immigrants report challenges communicating with their health team. This study compared oncology consultations of immigrants with and without interpreters vs Anglo-Australian patients., Methods: Patients with newly diagnosed incurable cancer who had immigrated from Arabic, Chinese or Greek speaking countries or were Anglo-Australian, and family members, were recruited from 10 medical oncologists in 9 hospitals. Two consultations from each patient were audio-taped, transcribed, translated into English and coded., Results: Seventy-eight patients (47 immigrant and 31 Anglo-Australian) and 115 family members (77 immigrant and 38 Anglo Australian) participated in 141 audio-taped consultations. Doctors spoke less to immigrants with interpreters than to Anglo-Australians (1443 vs. 2246 words, p=0.0001), spent proportionally less time on cancer related issues (p=0.005) and summarising and informing (p≤0.003) and more time on other medical issues (p=0.0008) and directly advising (p=0.0008). Immigrants with interpreters gave more high intensity cues (10.4 vs 7.4). Twenty percent of cues were not interpreted. Doctors tended to delay responses to or ignore more immigrant than Anglo-Australian cues (13% vs 5%, p=0.06)., Conclusions: Immigrant cancer patients with interpreters experience different interactions with their doctors than Anglo-Australians, which may compromise their well-being and decisions., Practice Implications: Guidelines and proven training programmes are needed to improve communication with immigrant patients, particularly those with interpreters., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To investigate patients' and family members' perceptions and experiences of disclosure of healthcare incidents and to derive principles of effective disclosure., Design: Retrospective qualitative study based on 100 semi-structured, in depth interviews with patients and family members., Setting: Nationwide multisite survey across Australia., Participants: 39 patients and 80 family members who were involved in high severity healthcare incidents (leading to death, permanent disability, or long term harm) and incident disclosure. Recruitment was via national newspapers (43%), health services where the incidents occurred (28%), two internet marketing companies (27%), and consumer organisations (2%)., Main Outcome Measures: Participants' recurrent experiences and concerns expressed in interviews., Results: Most patients and family members felt that the health service incident disclosure rarely met their needs and expectations. They expected better preparation for incident disclosure, more shared dialogue about what went wrong, more follow-up support, input into when the time was ripe for closure, and more information about subsequent improvement in process. This analysis provided the basis for the formulation of a set of principles of effective incident disclosure., Conclusions: Despite growing prominence of open disclosure, discussion about healthcare incidents still falls short of patient and family member expectations. Healthcare organisations and providers should strengthen their efforts to meet patients' (and family members') needs and expectations.

Purpose: Immigrants with cancer often have professional and/or family interpreters to overcome challenges communicating with their health team. This study explored the rate and consequences of nonequivalent interpretation in medical oncology consultations., Patients and Methods: Consecutive immigrant patients with newly diagnosed with incurable cancer, who spoke Arabic, Cantonese, Mandarin, or Greek, were recruited from the practices of 10 medical oncologists in nine hospitals. Their first two consultations were audio taped, transcribed, translated into English and coded., Results: Thirty-two of 78 participants had an interpreter at 49 consultations; 43% of interpreters were family, 35% professional, 18% both a professional and family, and 4% a health professional. Sixty-five percent of professional interpretations were equivalent to the original speech versus 50% for family interpreters (P= .02). Seventy percent of nonequivalent interpretations were inconsequential or positive; however, 10% could result in misunderstanding, in 5% the tone was more authoritarian than originally intended, and in 3% more certainty was conveyed. There were no significant differences in interpreter type for equivalency of interpretations., Conclusion: Nonequivalent interpretation is common, and not always innocuous. Our study suggests that there may remain a role for family or telephone versus face-to-face professional interpreters., Practice Implications: careful communication between oncologists and interpreters is required to ensure optimal communication with the patient.

Objectives: To understand patients' and health professionals' experience of Open Disclosure and how practice can inform policy., Background: Open Disclosure procedures are being implemented in health services worldwide yet empirical evidence on which to base models of patient-clinician communication and policy development is scant., Design, Setting and Participants: A qualitative method was employed using semi-structured open-ended interviews with 154 respondents (20 nursing, 49 medical, 59 clinical/administrative managerial, 3 policy coordinators, 15 patients and 8 family members) in 21 hospitals and health services in four Australian states., Results: Both patients and health professionals were positive about Open Disclosure, although each differed in their assessments of practice effectiveness. We found that five major elements influenced patients' and professionals' experience of openly disclosing adverse events namely: initiating the disclosure, apologizing for the adverse event, taking the patient's perspective, communicating the adverse event and being culturally aware., Conclusions: Evaluating the impact of Open Disclosure refines policy implementation because it provides an evidence base to inform policy. Health services can use specific properties relating to each of the five Open Disclosure elements identified in this study as training standards and to assess the progress of policy implementation. However, health services must surmount their sensitivity to revealing the extent of error so that research into patient experiences can inform practice and policy development.

Clinical handover is an area of critical concern, because deficiencies in handover pose a patient safety risk. Redesign of handover must allow for input from frontline staff to ensure that designs fit into existing practices and settings. The HELiCS (Handover--Enabling Learning in Communication for Safety) tool uses a "video-reflexive" technique: handover encounters are videotaped and played back to the practitioners involved for analysis and discussion. Using the video-reflexive process, staff of an emergency department and an intensive care unit at two different tertiary hospitals redesigned their handover processes. The HELiCS study gave staff greater insight into previously unrecognised clinical and operational problems, enhanced coordination and efficiency of care, and strengthened junior-senior communication and teaching. Our study showed that reflexive and "bottom-up" handover redesign can produce outcomes that harbour local fit, practitioner ownership and (to date) sustainability.

This article explores the way that professionals are being inducted into articulating apologies to consumers of their services, in this case clinicians apologising to patients. The article focuses on the policy of Open Disclosure that is being adopted by health care organisations in the US, Canada, the UK and Australia and other nations. Open Disclosure policy mandates 'open discussion of clinical incidents' with patient victims. In Australia, Open Disclosure policy implementation is currently being complemented by intensive staff training, involving simulation of apology scenarios with actor-patients. The article presents an analysis of data collected from such training sessions. The analysis shows how simulated apologising engages frontline staff in evaluating the efficacy of their disclosures, and how staff may thereby be inducted into reconciling their affective and reflexive sensibilities with their organisational and professional responsibilities, and thereby produce the required organisational apology. The article concludes that Open Disclosure, besides potentially relaxing tensions between clinicians and consumers, may also affect how staff experience and enact their role in the overall system of health care organisation.

Purpose: This paper aims to understand the impact of emotional labour in specific health care settings and its potential effect on patient care., Design/methodology/approach: Multi-method qualitative ethnographic study undertaken in a large ICU in Sydney, Australia using observations from patient case studies, ward rounds and family conferences, open ended interviews with medical and nursing clinicians and managers and focus groups with nurses., Findings: Clinician attitudes to death and dying and clinicians' capacity to engage with the human needs of patients influenced how emotional labour was experienced. Negative effects were not formally acknowledged in clinical workplaces and institutional mechanisms to support clinicians did not exist., Research Limitations/implications: The potential effects of clinician attitudes on performance are hypothesised from clinician-reported data; no evaluation was undertaken of patient care., Practical Implications: Health service providers must openly acknowledge the effect of emotional labour on the care of dying people. By sharing their experiences, multidisciplinary clinicians become aware of the personal, professional and organisational impact of emotional labour as a core element of health care so as to explicitly and practically respond to it., Originality/value: The effect of care on clinicians, particularly care of dying people, not only affects the wellbeing of clinicians themselves, but also the quality of care that patients receive. The affective aspect of clinical work must be factored in as an essential element of quality and quality improvement.

Objective: To explore patients' and family members' perceptions of Open Disclosure of adverse events that occurred during their health care., Design: We interviewed 23 people involved in adverse events and incident disclosure using a semi-structured, open-ended guide. We analyzed transcripts using thematic discourse analysis., Setting: Four States in Australia: New South Wales, Victoria, Queensland and South Australia., Study Participants: Twenty-three participants were recruited as part of an evaluation of the Australian Open Disclosure pilot commissioned by the Australian Commission on Safety and Quality in Health Care., Results: All participants (except one) appreciated the opportunity to meet with staff and have the adverse event explained to them. Their accounts also reveal a number of concerns about how Open Disclosure is enacted: disclosure not occurring promptly or too informally; disclosure not being adequately followed up with tangible support or change in practice; staff not offering an apology, and disclosure not providing opportunities for consumers to meet with the staff originally involved in the adverse event., Analysis: of participants' accounts suggests that a combination of formal Open Disclosure, a full apology, and an offer of tangible support has a higher chance of gaining consumer satisfaction than if one or more of these components is absent., Conclusions: Staff need to become more attuned in their disclosure communication to the victim s perceptions and experience of adverse events, to offer an appropriate apology, to support victims long-term as well as short-term, and to consider using consumers' insights into adverse events for the purpose of service improvement.

Aim: This paper is a report of a study to identify how nurse clinicians learn with and from each other in the workplace., Background: Clinicians' everyday practices and interactions with each other have recently been targeted as areas of research, because it is there that quality of care and patient safety are achieved. Orientation of new nurses and doctors into a specialty unit often results in stress., Method: An ethnographic approach was used, including a 12-month period of fieldwork observations involving participation and in-depth interviews with nurse, doctor and allied health clinicians in their workplace. The data were collected in 2005-2006 in a paediatric teaching hospital in Australia., Findings: The findings were grouped into four dimensions: orientation of nurses, orientation of medical registrars, preceptoring and decision-making. The orientation of new staff (nursing and medical) is a complex and multi-layered process which accommodates multiple kinds of learning, in addition to formal learning. Workplace learning also can be informal, incidental, interpersonal and interactive. Interactive and interpersonal learning and the transfer of knowledge include codified and tacit knowledge as well as intuitive understandings of 'how we do things here'., Conclusion: Research into how nurses learn is crucial for illuminating learning that is non-formal and less recognized than more formal kinds. To provide a safe practice environment built on a foundation of knowledge and best practice, there needs to be an allocation of time in the busy workday for learning and reflection.

Objective: To determine which aspects of open disclosure "work" for patients and health care staff, based on an evaluation of the National Open Disclosure Pilot., Design, Setting and Participants: Qualitative analysis of semi-structured and open-ended interviews conducted between March and October 2007 with 131 clinical staff and 23 patients and family members who had participated in one or more open disclosure meetings. 21 of 40 pilot hospital sites, in New South Wales, South Australia, Victoria and Queensland, were included in the evaluation. Participating health care staff comprised 49 doctors, 20 nurses, and 62 managerial and support staff. In-depth qualitative data analysis involved mapping of discursive themes and subthemes across the interview transcripts., Results: Interviewees broadly supported open disclosure; they expressed uncertainty about its deployment and consequences, and made detailed suggestions of ways to optimise the experience, including careful pre-planning, participation by senior medical staff, and attentiveness to consumers' experience of the adverse event., Conclusion: Despite some uncertainties, the national evaluation indicates strong support for open disclosure from both health care staff and consumers, as well as a need to resource this new practice.

Conflict in health service delivery is common. It is often attributed to disputes between clinicians and patients or their families about treatment decisions and is particularly common in intensive care units (ICUs), in the form of ;futility disputes' between families and medical clinicians about decisions to terminate the active treatment of a dying family member. More common, but less prominent in the literature, is conflict within the medical profession about patient care goals and treatment. We contend that managing the plurality of medical interests is essential in achieving a more managed and positive experience for patients and families of the care they receive, and for achieving standards of quality and resource use. From an ethnographic study undertaken in a large ICU in Sydney, Australia, we found that the knowledge and practice differences of multiple medical decision-makers generated conflict, inconsistency of practice and subjectivity of decision-making that impeded coherent clinical decision-making and integrated patient care planning, coordination and care review. Improving patients' and families' experience of care requires medical clinicians and medical managers to accept responsibility for institutionalizing effective communication and decision-making processes within clinical networks and between clinical and managerial domains. Thus, strategies to improve patient care will need to extend beyond the medical profession to incorporate administrative management. We conclude that restructuring communication and decision-making processes is imperative to achieve clinical accountability in the workplace and systems accountability in the organization.

How public health is managed in various settings is an important but under-examined issue. We examine themes in the management literature, contextualize issues facing public health managers and investigate the relative importance placed on their various work pursuits using a 14-activity management model empirically derived from studies of clinician-managers in hospitals. Ethnographic case studies of 10 managers in nine diverse public health settings were conducted. The case study accounts of managers' activities were content analysed, and substantive words encapsulating their work were categorized using the model. Managerial activities of the nine public health managers were ranked according to the number of words describing each activity. Kendall's coefficient of concordance yielded W = 0.710, P < 0.000, revealing significant similarity between the activity patterns of the public health managers. A rank order correlation between the activity patterns of the average ranks for the public health sample and for the hospital clinician-managers (n = 52) was R = 0.420, P = 0.131, indicating no significant relationship between relative activity priorities of the two groups. Public health managers put less emphasis on pursuits associated with structure, hierarchy and education, and more on external relations and decision-making. The model of hospital clinician-managers' managerial activities is applicable to public health managers while identifying differences in the way the two groups manage. The findings suggest that public health management work is more managerialist than previously thought.

Clinical directorate service structures (CDs) have been widely implemented in acute settings in the belief that they will enhance efficiency and patient care by bringing teams together and involving clinicians in management. We argue that the achievement of such goals depends not only on changing its formalized structural arrangements but also the culture of the organisation concerned. We conducted comparative observational studies and questionnaire surveys of two large Australian teaching hospitals similar in size, role and CD structure. Martin's conceptualization of culture in terms of integration, differentiation and fragmentation was applied in the analysis of the data. The ethnographic work revealed that compared to Metropolitan Hospital, Royal Hospital was better supported and more favourably viewed by its staff across six categories identified in both settings: leadership, structure, communication, change, finance and human resource management. Royal staff were more optimistic about their organisation's ability to meet future challenges. The surveys revealed that both staff groups preferred CD to traditional structures and shared some favourable and critical views of them. However Royal staff were significantly more positive, reporting many more benefits from CDs e.g. improved working relations, greater accountability and efficiency, better cost management, more devolvement of management to clinicians and a hospital more strategically placed and patient focused. Metropolitan staff were more likely to claim that CDs failed to solve problems and created a range of others including disunity and poor working relationships. There was greater consensus of views among Royal staff and more fragmentation at Metropolitan where both intensely held and uncertain attitudes were more common. The outcomes of implementing CDs in these two similar organisations differed considerably indicating the need to address cultural issues when introducing structural change. Martin's framework provides a useful antidote to researchers' tendency to focus at only one level of culture.