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Introduction: Antibiotic use drives antibiotic resistance. The UK antimicrobial resistance (AMR) strategy aims to reduce antibiotic use. We aimed to quantify excess antibiotic use in a district general hospital in south-west England., Methods: Medical patients discharged in August 2020 who had received antibiotics were included. An audit tool of antibiotic prescribing appropriateness was used to collect relevant clinical information regarding each patient case. The appropriateness of antibiotic use was then determined by two infection specialists and excess days of therapy (DOTs) calculated., Results: 647 patients were discharged in August 2020. Of the 1658 antibiotic DOTs for the 184 patients reviewed, 403 (24%) were excess DOTs. The excess antibiotic DOTs were prescribed in 92 patients (50%); 112/403 (27.8%) excess DOTs originated at the initiation of antibiotic therapy (time point A); 184/403 (45.7%) of excess DOTs occurred at the antibiotic review pre-72 hours (time point B); and 107/403 (26.6%) of excess DOTs were due to protracted antibiotic courses (time point C)., Conclusion: 24% of antibiotic DOTs were deemed unnecessary. The greatest opportunity to reduce antibiotic use safely was the pre-72 hours antibiotic review, which may provide a target for reducing excess antimicrobial therapy in line with the national AMR strategy., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To describe clinic management and referral pathways among adults with type 1 diabetes (T1D) aged > 25 years attending a public outpatient diabetes service. Methods: Retrospective cohort study of people with T1D aged > 25 years seen by endocrinologists in one Australian urban public outpatient in 2017. Electronic and paper medical records were reviewed using a dataset adapted from the UK National Institute for Health and Care Excellence 2015 guidelines. Results: Among the 111 people with T1D (mean age 41 ± 13 years, 55% men, mean body mass index 27.1 ± 5.6 kg/m2), mean HbA1c was 8.1 ± 1.9% (66 ± 19 mmol/mol) (lower than the Australian National Diabetes Audit: 8.5%/69 mmol/mol) with 25.5% meeting the guideline target of < 53 mmol/mol (7.0%). Most people had seen a diabetes educator (80.2%) or dietitian (73.0%) and had complication screening. Complication rates were high (nephropathy 20.4%, retinopathy 27.4%, peripheral neuropathy 30.1%, ischaemic heart disease/acute infarction 10.5%). Overall, 27% of referrals occurred following an acute inpatient admission or emergency department presentation and 13% for management of diabetes in pregnancy. Conclusions: A high proportion of people with T1D accessed public specialist care either during pregnancy or after a largely avoidable acute glycaemia-related hospital presentation. Subsequent care was in line with national specialist standards. This area has a "wait for acute event" rather than "complication prevention" model of care, associated with under-referral to the local multidisciplinary specialist service. Understanding how widespread this model of care is, and ways to reduce its prevalence, are urgently required. [ABSTRACT FROM AUTHOR]

The article focuses on a study that was undertaken to consider changing perceptions of audit quality in Great Britain during a period of environmental change. The views of three audit stakeholder groups of auditors, auditees, and investors were considered. The implication of study for IS audit practitioners is that they need to be better prepared to conduct IT management audits and to contribute value to their organization as part of IT governance endeavors. The study also aims at identifying change factors within the various elements of the IS audit universe.

This paper investigates the effect of non-audit services on audit quality. Following the announcement of the requirement to disclose non-audit fees, approximately one-third of UK quoted companies disclosed before the requirement became effective. Whilst distressed companies were more likely to disclose early, auditor size, directors' shareholdings and non-audit fees were not significantly correlated with early disclosure. These results cast doubt on the view that voluntary disclosure of non-audit fees was used to signal audit quality. The evidence also indicates a positive weakly significant relationship between disclosed non-audit fees and audit qualifications. This suggests that when non-audit fees are disclosed, the provision of non-audit services does not reduce audit quality. [ABSTRACT FROM AUTHOR]

Within discussions of the "new public management" (NPM) it is suggested that professionals increasingly face managerial initiatives that are designed to reduce their autonomy and monitor their work. This paper draws on study data from the local aut hority children's homes sector to assess Power's predictions regarding the "colonisation" and "decoupling" of management audits within professional state agencies. The findings suggest that the introduction of a managerial audit in children's residential social work has involved a complex, negotiated and uneven process in which older patterns of autonomy have proved to be resilient. A key outcome has been the sometimes ritualistic and partial implementation of the audit process. [ABSTRACT FROM AUTHOR]

Examines the efficacy of audit system in the medical practice. Adequacy of data collection; Benefits in linking the audit system to the patient administration system; Measurement of the management of the firm through auditing.

Reports the acceptability of audit in Great Britain. Determinant of acceptability; Definition of the audit objectives; Comparison of cost and effectiveness between British internal audit and Federal Government in the United States.

In 1981 the Ministry of Defence brought together the capabilities of staff inspection, internal audit and central management services under a Director General of Management Audit (DGMA) with the objectives of achieving greater co-ordination of these functions and of developing the concept of management audit, i.e. the bringing to bear of a ‘total audit’ approach on selected departmental organizations or activities. This article comments on the progress made so far in developing this concept and describes changes which have taken place in the conduct of the individual disciplines which have had the effect of concentrating their attention on wider questions of efficiency, economy and effectiveness. The article goes on to describe the parallel development in the Ministry of Defence of new resource management machinery — responsibility budgets, a new management information system for ministers and top management (MINIS), management principles and, most recently, a re-organization of the Ministry itself — and the place which the management audit capability occupies within this. [ABSTRACT FROM AUTHOR]

The Department of Social Security's Operational Strategy — the biggest computerisation project in Europe — is beginning to be successfully implemented. A few years ago, this would have seemed an unlikely outcome. What made the difference? [ABSTRACT FROM AUTHOR]

While financial management in the Civil Service has improved in the past few years, the management of human resources has lagged behind The National Audit Office intends to develop human resources management audit in order to give a boost to this activity, but what are the issues to be covered? [ABSTRACT FROM AUTHOR]

This article investigates the role of human resource management (HRM) in mergers and acquisitions in Great Britain during the 1980s. The involvement of the HRM function is a matter of a humanitarian concern for absorbing grief among personnel that were acquired. Some financial reasons for HRM assistance in the integration process and transference of the acquired personnel's commitment to the new owners of the firm are examined. Several conditions for effective communication in successful acquisitions are discussed.

Objective: To standardize the discharge policy for outpatient appointments and reduce the burden of service provision placed on trainee surgeons., Design: Retrospective audit of practice followed by a prospective audit following our intervention., Setting: Cardiac surgery outpatient clinic at Liverpool Heart and Chest Hospital, a large tertiary cardiothoracic center in the United Kingdom., Participants: All patients (total 1002) attending postcardiac surgery follow-up appointments in the periods January to March 2015 (n = 428), February to March 2016 (n = 250), and February to March 2017 (n = 324)., Results: Introduction of departmentally agreed guidelines on discharge from follow-up reduced the number of inappropriate recalls among patients attending their first postoperative appointment (4.6% vs 17.6%; p < 0.001), which was maintained at 1 year (4.5% vs 17.6%; p < 0.001). In the initial cohort, a significantly higher proportion of patients were inappropriately recalled if they were seen by registrars who were not from the operating consultant's team (11.7% vs 24.1%; p = 0.007); this was not apparent after the guidelines were introduced (5.4% vs 3.8%; p = 0.62). There was no increase in the number of patients referred back to the cardiac surgical department after introduction of the guidelines (0.71% vs 2.8%; p = 0.078). We calculated an annual cost saving of £3841 ($5377). There was a significant increase in the number of new patients seen by trainees in each clinic (0.15 vs 0.38, p = 0.04)., Conclusion: Implementation of a discharge guideline decreased the number of unnecessary attendances at the outpatient clinic without an increase in subsequent re-referrals and was cost neutral. Trainees were able to assess more new referrals, increasing the educational value of the clinics., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

We report the findings of the first national lung cancer organisational audit. The results demonstrate marked variation in service provision and workload of some lung cancer specialists. For example, over half of the clinical nurse specialists report case volumes over recommended numbers. Some trusts have no access to key treatments such as video assisted thoracoscopy (VAT) lobectomy and stereotactic radiotherapy. Multivariate regression analysis demonstrated an association between higher surgical resection rates and the on-site availability of advanced staging and therapeutic modalities, for example, PET scan and VAT lobectomy. We conclude by making a number of recommendations to address the variation in lung cancer care., (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.)

Continuously meeting, and exceeding, the needs of our customers is one of the core requirements for any successful organization. This is no different for hospital trusts when providing secondary health services within the UK, they are continually in the spotlight to save costs and are bring urged to take on the role of 'small businesses' and have an independent view of their business and their stakeholders.

The article offers news briefs concerning best practices issued by the Supreme Audit Institutions. The Australian National Audit Office published a guide which aims to demonstrate and explain best practices that organizations should use in combating fraud. The New Zealand Office of the Auditor-General issued a guide entitled "Principles to Underpin Management by Public Entities of Funding to Non-Government Organizations." The British National Audit Office has unveiled its Efficiency Toolkit.

Objective: A specialist balance clinic to effectively deal with dizzy patients is recommended by ENT-UK. We audit the patient pathway before and following the introduction of a consultant-led dedicated balance clinic., Design: Process evaluation and audit., Setting: ENT outpatients department of a district general hospital., Main Outcome Measures: The journey of dizzy patients seen in the general ENT clinic was mapped from case notes and recorded retrospectively. A consultant-led, multidisciplinary balance clinic involving an otologist, a senior audiologist and a neurophysiotherapist was then set up, and the journey was prospectively recorded and compared with that before the change., Results: Of the 44 dizzy patients seen in the general clinic, 41% had further follow-up consultations; 64% were given definitive or provisional diagnoses; 75% were discharged without a management plan. Oculomotor examination was not systematically performed. The mean interval between Visits 1 and 2 was 8.4 weeks and the mean number of visits was 3. In the consultant-led dedicated balance clinic, following Visit 1, only 8% of patients required follow-up; 97% received definitive diagnoses, which guided management; all patients left with definitive management plans in place. In all patients, oculomotor assessment was systematically performed and all patients received consultant and, where necessary, allied healthcare professional input., Conclusions: By standardising the management experience for dizzy patients, appropriate and timely treatment can be achieved, allowing for a more seamless and efficient patient journey from referral to treatment. A multidisciplinary balance clinic led by a consultant otologist is the ideal way to achieve this., (© 2014 John Wiley & Sons Ltd.)

Objectives: To report our experience in providing cardiac technician led paediatric echocardiography services in a district general hospital in the United Kingdom., Methods: We have collected prospectively the numbers of referrals, and the proportion of abnormal echocardiograms, since inception of the service in 2000. In additional, for a period of 12 months, we have audited in detail the patterns of referral to the service, and outcomes, assessing the effect of the service on the outreach clinic run by a visiting paediatric cardiologist., Results: Use of the system resulted in detection of a wide range of abnormalities, with our audit showing that the patients received appropriate management. The total referrals to the service increased 10 fold over the 4 year period of the study. The proportion of abnormal hearts detected by echocardiography, however, dropped from 90 per cent to 16 per cent over the same period. The numbers of patients seen in the outreach cardiology clinic remained unaltered., Conclusions: Having been proved to be an effective model for the triage of children with suspected congenital cardiac disease, adoption of a cardiac technician led echocardiographic service has seen a dramatic increase in the numbers of echocardiograms requested, without decreasing the workload of the visiting paediatric cardiologist.

Performance reviews for trust boards are rare, despite their strategic importance. Cohesion between executives and non-executives, and willingness for board members to challenge one another, are critical. Too much challenge and too little trust can suppress innovation.

This paper seeks to gain an insight into the behavior of a large NHS trust, in its attempt to meet a 90 percent patient access target, in a week long national audit in March 2003. Why did individuals act in dramatically different ways to their norm over this period. The work of Michel Foucault is used to explore these issues. The discourses of power, knowledge, discipline and governmentality are identified as key foucaudian themes that offer an alternative interpretation of how individuals behave in their place of work. The importance of the historical context of discourse within the NHS cannot be underestimated in shaping the behavior of individuals and groups today. Power and knowledge permeate NHS organizations through disciplinary practices and dressage. Governmentality seeks to maintain the status quo through disciplinary processes such as national healthcare targets. The natural response of NHS organizations is therefore, to seek order and conformity rather than disorder and conflict.

Objective: The aim of this study was to examine the speed of response of human resources departments to requests for job application forms for posts advertised in the British Medical Journal (BMJ). Of particular interest was the closing date for applications, postage cost, and the period to reply., Design: Twenty posts were randomly selected and application forms requested by telephone and then 20 by letter on two separate dates from the BMJ Classified (issues of 21 July 2001 and 28 July 2001). During the first week the forms were requested by telephone on receipt of the BMJ (Friday afternoon). During the second week the forms were requested by first class post. All letters were sent out on Saturday morning., Outcome Measures: The date of receipt of the application form/information pack, the cost of postage, and the closing date for application were recorded for each position., Results: Fifteen forms were received after the telephone application and 18 forms after the letter applications. One trust sent two replies spaced one week apart for the same job and two replies contained job application forms for the wrong job. The response rates to telephone requests varied from four to 10 days and by letter from three to 12 days. The minimum time between the reply being received and the closing date was one day, and the maximum 21 days. The time between the closing date for applications and the start date of the job varied from minus one week (closing date before advertisement) to three months. Thirteen replies gave no indication of the start date of the job. The cost of postage varied from 27p to pound 1.90. Thirty one trusts used first class postage., Conclusion: There is very limited scope to return job application forms on time, and significant delays in sending out application forms and information packs compound this problem. It is recommended that trust human resources departments place advertisements early and respond promptly to requests for application forms.

Objective: To examine the effect of the fourteen-day rule on the colorectal service of a district general hospital., Methods: Prospective audit of all patients referred by general practitioners to the colorectal service of a district general hospital serving a population of approximately 300,000 people. The main outcome measures were: (i) mean interval in days from referral to first clinic appointment; (ii) first clinic appointment to diagnosis; and (iii) overall interval from referral to diagnosis., Results: There was a change in the referral pattern with greater numbers of 'fourteen-day rule' and urgent referrals than expected (P < 0.001). The mean time interval from referral to diagnosis was reduced (P < 0.01). This was due to a reduction in the wait for a first clinic appointment (P < 0.01). The wait between first appointment and diagnosis was unchanged (P < 0.05). Waiting times for patients referred as 'routine' or whose GPs did not specify a priority also improved., Conclusions: The 'fourteen-day rule' with respect to colorectal cancer has reduced waiting times for a first appointment to see a specialist. Further improvements will require additional resources to reduce the delay for investigations. The effect on long-term survival remains to be seen.

In its latest attempt to improve performance, the British National Health Service (NHS) has turned to the business models of performance management. A range of managerial instruments has been deployed, signaling national priorities to local managers and seeking to offer the information, incentives, and capacity they need to respond appropriately. The arrangements are intellectually coherent and offer the prospect of major improvements in the quality of British health care. However, implementation is at an early stage, and some key issues have to be addressed. The various performance management instruments have not yet been properly aligned, and greater conceptual clarity in implementation is required. Performance management will not be fully effective unless adequate capacity--in information, leadership, and managerial resources--is made available.

Describes a process to assess facilities management (FM) process capabilities: the structured process improvement for construction environments--facilities management (SPICE FM) approach. The SPICE FM framework is a method that FM organizations can use to monitor continuously and subsequently improve their performance. The SPICE FM framework is being tested in a series of case studies to ensure that its outputs are appropriate to the FM sector and of value in the real world. Documents the outcomes of a study undertaken at a facilities directorate of a healthcare NHS trust, in searching its applicability within the NHS. Further describes the study methodology and the key activities undertaken and reviews the key communication and management processes that are in place to support the implementation of the strategic FM objectives within the specific NHS facilities directorate.

The NHS in the UK has recently adopted a new Performance Assessment Framework (PAF), aiming to provide a broader view of performance within the NHS The PAF is not only a multi-stakeholder approach reflecting various stakeholders' interests across six dimensions, but is also used by the Government as a strategic management tool to ink national strategies with local operation activities. The Government claims that the PAF is a "balanced scorecard" approach This study discusses the concepts of the BSC underlying the NHS PAF.

Performance measurement is playing an increasingly important role in health care systems around the world, and many countries are designing and implementing measurement systems to achieve a range of objectives. Yet, the production of research evidence to inform practice has not kept pace with this policy development. In this paper we employ a simple model of performance measurement that focuses on issues related to the measurement of performance; the analysis and interpretation of performance information; and the action, which occurs as a consequence. The framework is used to analyse the key elements of the performance measurement process, drawing on experience and evidence from the United Kingdom. By drawing on the cross-national experience, individual health systems can learn from examples of good practice and avoid implementation errors made elsewhere.

The UK breast screening programme (UK BSP) is organised into a large number of individual screening units. Decision makers need to ensure these units are producing efficiently, particularly as the programme is anticipated to expand. Data envelopment analysis (DEA) was applied to investigate: the relative efficiency of screening units; the impact of screening unit size on efficiency; and how individual units could improve. Sixty-four screening units were categorised into 33 large and 31 small. Data were collected using a national survey and routinely collected data. The overall median efficiency score was 91%, 39 units were inefficient. Variation in efficiency scores was wide. Large units had a median efficiency score of 100% and 12 units were inefficient. Smaller units had a median efficiency score of 95% and 19 were inefficient. This difference was not statistically significant (Mann-Whitney, P=0.076). Forty-two percent of large units and 21% of small units were operating at constant returns to scale (mean difference 0.20, 95% CI: 0.15-0.43). Although there is no systematic difference in efficiency by size of screening unit there are inefficiencies in both large and small units and there is scope for many individual units to improve their use of current resources. It will be necessary for decision-makers to examine the practices of individual screening units before considering options for how best to improve their resource use. DEA can help to identify feasible options.

The rhetoric of user involvement has featured in health policy documents for over a decade. However, there is mixed evidence as to the extent to which it is being achieved. This paper explores what is meant by user involvement, proposing that it exists at a series of levels ranging from information giving to true empowerment. Examples are presented from two practice development projects. The first sought to develop multidisciplinary audit in primary care, attempting to involve users in defining health needs and determining services. Although the project co-ordinators were highly committed to user involvement this was only achieved to a limited extent. It was concluded that there was a resistance to user involvement grounded in the fear that such involvement would increase user expectations and add to the pressures of overworked primary care teams. The second project used interviews with service users to assess the effectiveness of a team building initiative. Users were found to be knowledgeable about practitioner roles and how to access the care they required. The overall conclusion is that there needs to be a shift from rhetoric to reality at governmental and practitioner level if true user involvement is to be achieved.

Problem: A need to improve service to patients by reducing the time wasted by reception staff so that the 48 hour target for processing repeat prescription requests for patient collection could be achieved., Design: An interprofessional team was established within the practice to tackle the area of repeat prescribing which had been identified as a priority by practice reception staff. The team met four times in three months and used continuous quality improvement (CQI) methodology (including the Plan-Do-Study-Act cycle) with the assistance of an external facilitator., Background and Setting: A seven partner practice serving the 14,000 patients on the northern outskirts of Bournemouth including a large council estate and a substantial student population from Bournemouth University. The repeat prescribing process is computerised., Key Measures for Improvement: Reducing turn around times for repeat prescription requests. Reducing numbers of requests which need medical records to be checked to issue the script. Feedback to staff about the working of the process., Strategies for Change: Using a Plan-Do-Study-Act cycle for guidance, the team decided to (a) coincide repeat medications and to record on the computer drugs prescribed during visits; (b) give signing of prescriptions a higher priority and bring them to doctors' desks at an agreed time; and (c) move the site for printing prescriptions to the reception desk so as to facilitate face to face queries., Effects of Change: Prescription turnaround within 48 hours increased from 95% to 99% with reduced variability case to case and at a reduced cost. The number of prescriptions needing records to be looked at was reduced from 18% to 8.6%. This saved at least one working day of receptionist time each month. Feedback from all staff within the practice indicated greatly increased satisfaction with the newly designed process., Lessons Learnt: The team's experience suggests that a combination of audit and improvement methodology offers a powerful way to learn about, and improve, practice. The interventions used by the team not only produced measurable and sustainable improvements but also helped the team to learn about the cost of achieving the results and provided them with tools to accomplish the aims. The importance of feedback to all staff about CQI measures was also recognised.

This article examines the appropriateness of the Business Excellence Model in developing a strategy for Bolton Hospitals NHS Trust to measure organisational performance. The need for a strategy to measure organisational performance and to improve organisational performance was highlighted with the production of the Government White Paper, The New NHS: Modern and Dependable. At the heart of recommendations there is emphasis on improving quality and driving efficiency. Greater emphasis will be placed on organisations measuring their performance. By utilising the conceptual framework, which consisted of The European Foundation for Quality Management (EFQM) Model, it became evident that, although tools were in existence within Bolton Hospitals to measure organisational performance, several critical areas needed addressing. By addressing these key areas, the organisation could begin to work towards its goal of business excellence. The conclusions drawn from this project demonstrated that there was scope for Bolton Hospitals to improve on organisational performance. It was highlighted that the Trust was functioning well in some areas of the EFQM Model, but not in others. For Bolton Hospitals NHS Trust to improve organisational performance, the EFQM Model should be adopted.

Following a brief description of the inception of self-assessment and the European Foundation for Quality business excellence model, this article describes how one clinical directorate in an NHS Trust used the principles of both to secure a culture of continuous improvement. The journey from a mainly hierarchical, bureaucratic, individualist culture to one where the norms, values and beliefs reflected teamwork, involvement and empowerment is described. The highs, lows and learning points are all included, in an attempt to enlighten other healthcare organisations considering the benefits and pitfalls of using the business excellence model to improve the quality of their healthcare delivery.

Wakefield and Pontefract Community Health NHS Trust uses the European Business Excellence Model self-assessment for continuous improvement. An outline of the key aspects of the model, an approach to TQM, is presented. This article sets out the context that led to the adoption of the model in the Trust and describes the approach that has been taken to completing self-assessments. Use of the model to secure continuous improvement is reviewed against Bhopal and Thomson's Audit Cycle and consideration is given to lessons learned. The article concludes with a discussion on applicability of the model to health care organisations. It is concluded that, after an initial learning curve, the model has facilitated integration of a range of quality initiatives, and progress with continuous improvement. Critical to this was the linking of self-assessment to business planning and performance management systems.

The publication of the government white paper 'Working for Patients' (1989, HMSO) and implementation of subsequent NHS reforms has led to the development of a great number of initiatives designed to improve the quality of patient care and to make the provision of care more clinically and cost effective. Many of these initiatives, whilst laudable, have been developed in isolation and often without proper consideration of how they relate to one another or might practically be implemented throughout the NHS. It has commonly been the case that attempts to transfer the initiative from an environment of high enthusiasm and, often, high resource to the NHS in general has either failed or led to poor application. Strategies to improve clinical effectiveness have not become a feature of the everyday practice of many, let alone most or all, clinicians in the NHS. The result has been their failure significantly to raise standards of care across the NHS as a whole. It is suggested that many of the initiatives are closely related, and more effective implementation in the NHS as a whole may follow attempts to integrate them in a more practical approach to care management within an organization-wide clinical effectiveness strategy. It is further suggested that this is best achieved by a continuous quality improvement approach focusing on the care process as the centrepiece of the initiative, and that this method will lead to significant improvements not only in clinical effectiveness but also in cost effectiveness. This paper describes a proposed method of achieving these goals.

Parental and professional responses to questionnaires evaluating a paediatric disability service are reported and the viability of auditing structural, process, and outcome aspects of clinical practice are discussed. Expectations of waiting time to first appointment (met for only 52% of consumers) illustrate structural issues. Process issues are reflected in consumer reactions to outreach work (for example, 94% of parents and 84% of professionals found this supportive). Outcome measures such as consumer satisfaction with the service (76% of consumers reported being 'very satisfied' and 20% 'fairly satisfied') suggest that service aims are being met. Good concurrence of service aims with consumer needs is indicated by parental reasons for referral (for example, 75% for diagnostic help, 73% for a better understanding of the disorder, 88% for practical help), referrers' reasons (for example, 55% for a second diagnostic opinion, 45% due to lack of local expertise), and reports from most other professionals involved with the case that a similar service was not provided locally.