Before you measure ....

Fitness-to-work tests to be reformed after criticism

- you check your tools:

You calibrate, validate and balance ...

strengths - weaknesses

functional - diagnostic

humanistic - mechanistic
individual - group
purpose - policy
practice - process

physical - emotional

person centred - policy centered
sad (?) - (you will be -) happy

Additional links:
How to assess happiness? A tale of three measures
WWF: Manifesto - The Politics of Happiness
Frank Furedi: Why the ‘politics of happiness’ makes me mad

Care Logistics: have model will travel ...

From: NHS Logistics - supplies, v4m, corporate, orders, consultancy, catalogue, process, delivery, stock, just in time, service, quality, priority, efficiency, customers, finance, contracts ...
	To: Care Logistics - access, choice, attitude, empathy, communication, values, outcomes, human rights, dignity and respect, quality care, professionalism, purpose, roles, holistic competency, standards, personal, measures, equity ...

Book: "Outcome Measurement in Mental Health" Cambridge University Press

Outcome Measurement in Mental Health
Theory and Practice
Edited by Tom Trauer
Hardback
Published June 2010

In order to operate in an evidence-based fashion, mental health services rely on accurate, relevant, and systematic information. One important type of information is the nature of the problems experienced by recipients of mental health care, and how these problems change over the course of time. Outcome measurement involves the systematic, repeated assessment of aspects of health and illness, either by service providers, service recipients, or both. From outcome measurement clinicians and service recipients achieve a common language whereby they can plan treatment and track progress, team leaders and managers secure a basis to compare their services with others and to promote quality, while policy makers and funders derive evidence of effectiveness. This book will be an essential and practical resource for all members of the mental health clinical team as well as those responsible for establishing or managing services, and directing policy.

• Presents a global perspective on outcome measurement enabling readers to compare and contrast practices around the world
• Enables readers to identify the specific challenges presented in different groups and settings, the instruments to use, and how to use the results
• Emphasizes the relevance and use of outcome data to clinicians, to help them improve their effectiveness

Contents

Preface; 1. Introduction Tom Trauer; Part I. Outcome Measurement Around the World: 2. Mental health outcome measurement in Australia Jane Pirkis and Tom Callaly; 3. Outcome measures in New Zealand Graham Mellsop and Mark Smith; 4. Outcome measurement in England Mike Slade; 5. Outcome measurement in Ohio and the United States James Healy and Dee Roth; 6. The outcome questionnaire system: a practical application for mental health care settings Michael J. Lambert; 7. Outcome measurement in Italy Mirella Ruggeri; 8. Outcome measurement in Germany Sylke Andreas, Thomas Becker, Holger Schulz and Bernd Puschner; 9. Outcome measurement in mental health services in Norway Torleif Ruud; 10. Outcome measurement in Canada: one province's experience with implementation in community mental health David Smith; Part II. Outcome Measurement in Specific Groups and Settings: 11. Routine outcome measurement in child and adolescent mental health Peter Brann; 12. Outcome measurement in adult mental health services Tom Trauer; 13. Outcome measurement in older persons Rod McKay and Regina McDonald; 14. Outcome measurement with indigenous consumers Tricia Nagel and Tom Trauer; 15. Routine measurement of outcomes by Australian private hospital-based psychiatric services Allen Morris-Yates and Andrew Page; 16. Mental health outcome measurement in Non-Governmental Organizations (NGOs) Glen Tobias; 17. Outcome measurement in drug and alcohol services Maree Teesson and Mark Deady; Part III. Current Issues in Outcome Measurement: 18. Outcome measurement - applications and utility Tom Trauer; 19. Stakeholder perspectives in outcome measurement Tom Trauer; 20. Assessment of change in outcome measurement Tom Trauer; 21. Routine outcome measurement: perspectives on skills and training Tom Trauer and Tim Coombs; 22. A review of instruments in outcome measurement Tom Trauer; 23. Some economic and policy considerations for outcome measurement Rowena Jacobs; 24. Future directions Tom Trauer; Index.

http://www.cambridge.org/uk/catalogue/catalogue.asp?isbn=9780521118347

My source:
UK Routine Clinical Outcomes Network Forum

The cost of anholistic care

Being 'holistic' in care delivery can seem anachronistic, paying homage to new age thinking and practices. Paradoxically, being holistic in nursing can also mimic an admin exercise that amounts to ticking the boxes. So for Hodges' model - have you visited all the care domains?

• INTERPERSONAL care ✓
• POLITICAL care ✓
• PHYSICAL care ✓
• SOCIAL care ✓

Advanced discharge planning is many things:

• idealised care;
• standardised care;
  
• evidence of policy, targets;
• sign posting for the care pathway;
• an essential care aspiration that emphasizes the individual's strengths and resources.

As Wimbledon once again reaches its climax we observe that a fast serve needs to be prepared for a fast return of serve.

Last month 23 June, 2010 The Guardian, Society Guardian featured The high cost of return:

Hospitals could lose up to £1.5bn of NHS funding a year because of the government's decision to penalise those where patients return within 30 days of being treated. That is the conclusion of research conducted by health analysts Dr Foster into the potential impact of the tough new policy. It warns that NHS trusts face large potential losses, the biggest could reach £28.7m, as a result of the new approach. In all, 146 acute, specialist and mental health trusts could lose out. Denis Campbell, p.3.

Apparently -

Andrew Lansley wants to force the NHS to provide better care in hospitals and mental health establishments, to keep treating patients there until they are fit to leave and to work more closely with community-based healthcare professionals, such as GPs and district nurses, to ensure sick people receive more help with their convalescence after discharge and so are less likely to return to hospital. "Making hospitals responsible for a patient's ongoing care after discharge will create more joined-up working between hospitals and community services and may be supported by the developments in re-ablement and post-discharge support," he says.

I hope in reading the above you have a sense of my frustration in that the health career model can encourage and support timely reflection that can help achieve holistic, integrated - coherent care.

If the model was shared
- a common resource -
across disciplines and available to patients and carers
then the potential benefits (and savings?) are even greater.

Carer's support evidence / measures and end of life care

The following e-mail was received this week from (Prof.) George Kernohan and includes correspondence with Mary A. Waldron, Research Assistant, University of Ulster (thanks to Mary for confirming the reference).

My responses to George's points are right justified, italicised.

<->

Peter,

I am beginning to find examples of Hodges’ model every day now.

Once you adopt the model as a framework George it does tend to frame everything,
so I am not surprised at your finding. Maybe there is a paper there too...

Today we had a second research meeting to consider a (more) rigorous attempt to evaluate the provision of ‘support’ to carers of people undergoing palliative or End-of-Life Care (EOLC). An area of care with a dearth of evidence. So we looked at one review from Grande et al. (2009). They say that:

There has already been considerable research identifying carers’ needs in EOLC. These include psychological support, information, help with personal, nursing and medical care of the patient, out of hours and night support, respite, domestic and financial help.^9,10,16–21 There is also a large body of research into adverse effects of care-giving, such as anxiety, depression, stress, strain, fatigue and mortality.^22–24
Given this strong evidence base, any further investigation into the prevalence of needs and adverse effects should mainly focus on under-researched groups to ensure that future interventions are sensitive to their specific concerns. This includes carers of patients with conditions other than cancer, including neurodegenerative disorders,²⁵ respiratory²⁶ and cardiovascular diseases,²⁷ to help us understand how differences in disease trajectories, awareness of the terminal nature of the disease and available support²⁸ translate into different carer experiences. Although carers of patients with dementia have been extensively researched, little is known about their needs during patients’ final phase of life.⁹ p.340.

(The numbers refer to references by Grande et al., I have extended the quote used here).

Thanks for this paper George (and Mary) which I will read in full.
I extended your quote to encompass some additional interesting ideas.

To move toward a plan for a more rigorous evaluation, I would like to use a simple framework: here we go!

I think I will be suggesting Hodges’ Health Career as a possible model.

:-) ! If I can support you in this George I am pleased to help.

This could provide a framework for all carer-focused interventions in a broad way. As always, it would imply that carers need to have their needs addressed in terms of science, sociology, politics and interpersonal needs. As I see it, the first step would be to ‘map’ the carers’ needs onto that framework (from publications, if necessary from carers themselves). The basic idea (I think) is that care should address the four quadrants:

• Science: (carer’s physical needs, information, instruction)
• Political: (policy that enables care for carer, finance, allowance)
• Sociology: (recognising that people need people, networks and “sharing” groups, story telling/hearing)
• Interpersonal: (psychological support, prevention of anxiety & depression)

Have you any thoughts or guidance on this “mapping exercise”?

Goodness, that's quite a question!

Plenty of thoughts George but not sure how meaningful ....
Basically, since a community mental health project in 1990s
I have always considered (as per standard approach of course) that a toolkit of measures are needed. Even when we start from that most basic of distinctions between demand and supply.

As per your approach if h2cm is considered as a circle, a spectrum -
(sometimes we must circle the square)
then (if holstic) the adopted measures should cover all the domains:

Political: (outcomes, carer, patient satisfaction, financial assessment (means testing), respite care frequencies, reviews)
Interpersonal: (mood, coping ability, anxiety, depression, sleep, HoNOS)
Sciences: (pain, general health scales, care complexity (measures?))
Sociology: (dedicated carer assessment tools, sociability - social network size, psychosocial measures... there are many out there)

George, I realise the above is a ragbag collection but - like yours - these are dimensions which can (must) be reduced. Now there is also emphasis on this area post Darzi and the 'new' quality agenda.

This will serve (and is serving) to emphasize the distinctions between measures:

Objective - Subjective
Quantity - Quality
Staff administered - Self (Patient, Carer) administered
Global/general - condition specific
Service centered: Primary care - Secondary care

While it is easy to spin dichotomies,
the NHS must (constantly) focus on this area whatever the policy emphasis:

NHS Information Centre: Measuring for Quality Improvement

NHS Information Center: What is happening on indicators for...?

NHS Inst. for Innovation and Improvement: Quality and Service Improvement Tools

Earlier this year I contacted the NHS-IC [enquiries at ic.nhs.uk] regards additional measures of quality suggesting that the health career model bears due consideration (research).

Mental health services (and others?) have recognised how the measures they use can be a chaotic, personally selected, preferred, legacy-mix of assessment tools. Dictated by Senior Nurses, Consultants, Senior Management and not the evidence base. Now these are assured (are they?) with purposed selection (a task worthy of an 'away day') and then supported with regular in-house training.

Last month Anne-Marie Osbourne-Fitzgerald, Clinical Development Nurse, with (her) Clinical Manager, Denise Banks (Cygnet Hospitals), met Michael Doyle (Univ. of Manchester & Edenfield Unit, Prestwich Hospital) and I one evening at the Trafford Center in Manchester. Our two hour+ discussion covered the health career model, documentation, approaches to formal assessment and future plans (aspirations!). In the time available we obviously only scratched the surface, but Mike and Anne-Marie brought along examples of their paperwork.

Mike demonstrated how the health career model can be used implicitly or explicitly. At the Edenfield Unit the domains are being used individually to make up what is a standard A4 portrait form. The model informs their existing documentation; rather than the explicit form of the h2cm with the 2 x 2 matrix.
(I have a MS Word version of the latter and must update this to other formats).

Legally, as we know if it is not written down, recorded then it did not happen.
Educationally however, the objective is also to get students - practitioners - to think - before they do.

Anne Marie's documentation example at Cygnet Hospital included The Recovery Star:

http://www.mhpf.org.uk/recoveryStarApproach.asp

As you consider the star's points against the domains of the health career model - where in the model are you?

Can this provide another means to define 'care pathway'? A way that is not masked, hiding behind political, policy rhetoric (and really service-centered)? There are without question some excellent tools available, so care needs to be taken not to re-invent the wheel - hence your literature search. In some tools the effort and engagement of patients, carers and the public is exemplary. It seems what is needed is a hybrid solution. There is no single measure.

It may not sound scientific, but the complexities of care mean that academics, clinicians and managers must resort to a pick'n'mix approach. There is a battery of evidenced tools each with their history, application context and issues log (Why not? Lack of the latter might denote that such tools are no longer in development / review). As a clinician also involved in training, managers need to listen and make some tough operational decisions. The comms 'traffic' between clinicians, their managers, and senior managers needs to improve even more. Since, just using the above as an example, the STAR approach may find us on a ramble in the humanistic domains, the constraints of the mechanistic domain prompts the clinician's to ask:

"If you want me to use this assessment tool, what other thing do you want me to put down?"

As we are all aware: There is only so much time in a day, week, month, quarter. ...

In follow up emails I directed Anne-Marie to -

http://www.p-jones.demon.co.uk/contexts.htm

If you scroll down there is some discussion and graphics I did quite a while ago. This deserves revision as per the rest of the website, but the ideas are there I believe which can inform your project George?

Back then - and here on W2tQ I have been trying to demonstrate the wide range of contexts to which the health career model can be applied. In our meeting that evening the well established Tidal Model was also noted. This has of course benefitted from specific development, as per research that has produced audit and evaluation tools (Stevenson, et al. 2002).

It might make a useful reflective article – or at least a conference presentation. Ideally it would lead us to a measurement or observation approach ...

I would relish the prospect of a paper George, or a conference presentation. Not just contributing as a co-author/presenter, but supporting and enthusing new authors. The 21st century belongs to our students. Hodges' model can act as 'stellar' nursery not just here in the UK and EU, but globally. And not just in our respective disciplines (mental health, palliative - end of life care, forensic nursing care), but in informatics - conjoining and championing the need for socio-technical perspectives.

In addition to the above and thinking before they do, all health and social care practitioners must be able to reflect after.

As one of the original purposes for the model in my initial interview with Brian Hodges, research work addressing these are much needed.

This conceptual framework can offer much in case formulation, evaluation, clinical supervision, patient, carer and public (health) engagement.

[In short -] Can we measure Hodges' model?

George K. (Prof.)

You started with a big question George and similarly here at the end.
We have to be able to do this. In the first instance taking apart your question - there are clearly several questions here:

PRACTICE:

Above you noted that:

This could provide a framework for all carer-focused interventions in a broad way. As always, it would imply that carers need to have their needs addressed in terms of science, sociology, politics and interpersonal needs. As I see it, the first step would be to ‘map’ the carers’ needs onto that framework (from publications, if necessary from carers themselves).

It would be interesting to consider the formal process and practice of dementia care mapping against Hodges' model. Perhaps the approach you seek is something similar? If carer's make use of self-assessments these e-documents might act as an input for text analysis tools? If appropriate you could also weight certain items according to the priorities of carers? This would build on other carer research adding validity to your 'final' objectives.

Carers and clients (patients, service users) can with due explanation, appreciate the health career model. The model has a role to play in health education. I can well imagine a proforma similar to the Recovery Star example above, but purposed for carers and underpinned with the health career model. We also need to remember the spiritual domain, which is collective.

Ultimately George, your question concerns our ability to measure holistic, integrated, person-centred, multidisciplinary care and to state the obvious: there is no single measure to do this. Several tools and approaches gathered within a conceptual framework might however provide an environment favourable for a hybrid measure to emerge - literally a cycle?

THEORY:

In the paper you referred to George - Grande. et al. (2009) state:

In parallel with the lack of empirical evidence, there has been a lack of theoretical and conceptual models for when and how support provision in EOLC should improve carer outcomes. To guide further research, palliative care may here benefit from drawing on models within other fields, such as gerontology, sociology or psychology. p.341.

I am biased, but reading the paper the potential of the health career model as a high level tool is convincing just from a 'disciplinary cross-match'. Intra-, interdisciplinary, metadisciplinary and transdisciplinary perspectives could be a focus. This in addition to the specific knowledge and practical domains of sociology and psychology and as the authors note models therein. I forget the reference at the moment (and will check), but I recall carers / family units being framed in terms of strengths and weaknesses. That is, events, characteristics and relationships impact on a family with either additive, subtractive or neutral effects. This would seem applicable here?

While Grande et al. (2009) note that the (informal) carer's role is hidden (and is routinely described in this way) I wonder if in palliative care there are other dimensions that accentuate this 'hidden, covert' role?

The politics of potential death and actual dying may be another factor the health career model can help illuminate in a constructive, enabling way? Health care, patiency, sick roles, caring are always mediated by 'politics'. Hence the need for a political domain in any conceptual framework that Grande, et al. may consider. On a negative front, the model might also illustrate alienation and related concepts?

In conclusion!

Thank you so much George and Mary for my being able to share your initial thoughts here and respond with some of my own. I hope this helps you take your work further? There may be a few points to follow, which I will add and as you have noted above there is much that could be done to take this further.

Peter J.

From: Waldron Mary [mailto:MA.Waldron at ulster.ac.uk]
Sent: 06 June 2010 17:49
To: wg.kernohan at ulster.ac.uk
Subject: Carers Support Evidence

George,

Jury's still out on the effectiveness of support interventions and programmes which support carers in palliative care. Not enough research. Lack of evaluation, lack of rigour, no conclusive research, but lots of policy advocacy of carers support and addressing of needs. Sample of lit attached.

Mary A Waldron,
Research Assistant,
School of Nursing,
University of Ulster.

Many thanks George and Mary for your ongoing interest, and to Anne-Marie, Denise and Mike.

Reference:

Grande, G. et al. (2009) Supporting lay carers in end of life care: current gaps and future priorities, Palliative Medicine, 23: pp. 339-344. DOI: 10.1177/0269216309104875

Stevenson C, Barker P and Fletcher E (2002) Judgement days: developing an evaluation for an innovative nursing model. J Psychiatric and Mental Health Nursing, 9(3), 271-276.

Stellar nursery image
My source: http://media-2.web.britannica.com/eb-media/60/21260-004-3C62CA58.jpg

EHR Software Market Share Analysis & UK residential care / nursing home sector musings

Last month (20th May 2010) Chris Thorman, who blogs about EMR systems at Software Advice, e-mailed me (copied below). Could I mention his recent EHR post on my blog?

Well thanks Chris! It is very encouraging to learn that W2tQ is seen by others as an infocare centre and valuable media avenue. It is very difficult for me to comment on this USA based analysis which is detailed at:

EHR Software Market Share Analysis

- but here are some thoughts. ... This is a great piece of work-in-progress which acknowledges the problem of being 100% comprehensive and coherent given the task, plus the market's spread and dynamics.

My perspective is UK and my full-time work as a nurse gives me a limited outlook on health IT markets as a whole. Nonetheless I value efforts to capture such data in order to better understand the health informatics industry and grasp the bigger picture. As Chris notes this project is challenging, the post is also an appeal for help. While a great proportion of surveys are commercial in motivation, the e-community and e-media can now add value by pointing out the gaps and other data sources. The comments that conclude Chris's post ably demonstrate this.

I would very much like to read something similar for the UK, including the use of information systems in the residential and nursing home sector (any suggestions welcome). It still amazes me how many care homes - including those that are part of large business groups - do not use a 'resident' information system.

Perhaps the new - post-election - health ICT market in England will see new opportunities?
(See post re. 1 July 2010 NW England BCS - British Computer Society meeting).

In ICT terms the care / nursing home sector to me seems passive; it is content to be waited-upon by primary care and the hospital based systems. If they are not engaged on this level can they (and others, e.g. commissioners) argue that they are integrated? I think not.

Care homes need to realize that a dedicated information system could pay dividends in terms of assessment; continuity of care (transfer of care); quality of care; client, family and staff engagement, reporting to inform commissioning, inspection and marketing. When we talk of a patient's viability, there is also the question of the future viability of this market sector amid competition, economics, standards and costs ... ?

Buyer sought for Loyd’s Nursing Homes Group’s 64 care homes
Catherine Boyle, Times Online, 21 May 2010.

Chris' focus is the EHR market, very much concentrated upon physician, medical and medical billing coding  applications. This is reflected in the search facility on the Software Advice website. The search is constrained and directed, driven of course by the underlying database of companies, their applications and reviews. Markets are, however, defined by their boundaries and the way they change over time. Anticipation of that change is a gift indeed.

The personal health record (PHR) lies outside the scope of this Software Advice post, since as per WikiPedia:

It is important to note that PHRs are not the same as EHRs (electronic health records). The latter are software systems designed for use by health care providers. Like the data recorded in paper-based medical records, the data in EHRs are legally mandated notes on the care provided by clinicians to patients. There is no legal mandate that compels a consumer or patient to store her personal health information in a PHR.

This work by Chris and respondents helps to establish and define the boundaries. The EHRs in question are not purely institutional (e.g. hospital-based), the vendors cater for varying numbers of users, in different care settings as you can see on the site's 3-stage search. So while I cannot add anything as such, I wonder if there could (should) be scope for residential care in there?

Or perhaps the EHR market is not viable when it comes to older adult* residential care?

Heaven forbid that the transatlantic (and global) EHR market is ageist!

Thanks again Chris.

*Residential care is also needed for younger adults too.

From: Chris Thorman
To: " Peter,"
Sent: Thu, 20 May, 2010 18:57:41
Subject: Blog post idea for your blog

Hello Peter,

I hope you've had a good week. I just finished a blog post about market share in the EMR industry and I wanted to give you a heads up about it. Here is the link:

http://www.softwareadvice.com/articles/medical/ehr-software-market-share-analysis-1051410/

In the article, I broke down:

• The size of the outpatient EMR market;
• What EMR vendors have the most physicians using their system; and,
• What EMR vendors have the most practices using their system.

As I'm sure you can imagine, it was a tough project to get accurate numbers on. I was hoping you could mention my article on your blog to get more eyes on it so we can clear up any discrepancies. Sort of a "crowd sourcing" project if you will. I'd also be interested to read your thoughts on our findings.

Would you mind mentioning my post?

------------------------------------------------------------
Chris Thorman
Senior Marketing Manager
Software Advice
www.softwareadvice.com
chris at softwareadvice.com

As one chapter closes another opens ...

Even if that chapter number is 15, 20 or even the penultimate - when it comes to older adults entering or residing in residential and nursing care facilities this is not just an excuse for a euphemism roll call:

'the end of the road',
'Club Medicated',
'Eldergarten',
'the final chapter', ...

Residents and their families all too frequently find that care needs are not static. The book is far from complete and ready for review. Their health (and we had better add well-being) status changes constantly. A care home's ability to cope and meet an individual resident's care needs adequately in safety without comprising other residents and staff must be continually evaluated. A person's condition may improve psychologically and yet their physical health calls for more nursing care that is physically driven; or vice versa. Trying to anticipate care needs what can be several years in advance is very difficult.

It is one of those intangible questions - as to how many care homes carry dual nursing registrations and so will be able to provide not only the current level of care, but future elderly mentally infirm care needs if required. The reasoning being that an internal move is far less traumatic than finding a new home? So, what is the state of care moves?

If we have no information about this
then we know nothing.

What might this tell us about an individual's health career and the health career - likely care trajectory - of conditions such as dementia?

Of course our assessments are, and can only be determined (a keyword if there ever was one) in the here and now. This is the priority, while also trying to anticipate the future if we possibly can.

There is undoubtedly a great need for research here. Research that spans the many care dimensions which residents, their families, care home staff and other multidisciplinary team members must balance. These include quality of life, physical, mental and spiritual care, economics, demand and supply and our very notions of care quality and holistic care.

Only then - for all unique individuals - can we write an epilogue that befits each of those preceding chapters.

Image: M.C. Escher crystal ball

What's good for art students ....

Never take the stylus or brush
in your hand if you have not first
constituted in your mind all that you have to do.

Leon Battista Alberti, On Painting, 1435-36

My source: 16 May 2010, Visit to The British Museum, Italian Renaissance drawings.

Is this my excuse for taking so long with a new website?

HoNOS, checklists and semi-structured interviews

Mental health services not routinely (and formally) using HoNOS (Health of the Nation Outcome Scales) are gearing up with a push to implement the scale across services by April. HoNOS has been around for a long time almost 20 years so it is time it earned its keep. Perhaps high quality tools take time to emerge from the noise and chatter of the care marketplace? ;-)

Although they are available, I've been putting a presentation together to help get to grips with HoNOS in the role of a trainer. The evidence for the validity and benefits of using HoNOS is well established, with the HoNOS family of scales boasting global usage and development:

• HoNOS for working age adults
• HoNOS65+ for older people
• HoNOSCA for children and adolescents
• HoNOS-Secure for use in health and social care settings secure psychiatric, prison health care and related forensic services, including those based in the community)
• HoNOS-LD for learning disabilities
• HoNOS-ABI for acquired brain injury (ref.)
  

The number of assessment, intervention and evaluation tools available to clinicians AND managers begs the question (ironically): is there 'space' in the toolkit for yet another tool? If HoNOS can help establish a coherent currency for mental health commissioning beyond the block contract then this is most welcome. Mental health services need to move forward on several fronts. There is a timeline running with completion of this difficult task in its sights.

One set of guidance for HoNOS points out that:

The scales are not used as a checklist or semi-structured interview, but form a brief record of severity.

There is some succor there then, since Hodges' model is a checklist and a quad-structured interview there is still a role for a global conceptual framework.

There's nothing like a full and tidy set of tools!

Ref. http://www.gpsa.org.au/media/docs/mentalhealth/honos_information.pdf

DoH: Honos health of the nation outcome scales report on research and development July 1993 - December 1995

Additional links:

The UK Routine Clinical Outcomes in Mental Health Group

The NHS Information Centre: Mental Health Minimum Dataset

RCP references

Currencies and travel in health and social care

Before the advent of the euro, holidays in Europe were that bit more exotic. Having to buy and adjust to another currency - and not just one - was part of the novelty and fascination of travel.

Health and social care have their own currencies (and yes, read that as there being integration here too!). Most of the currencies are national given the efforts to standardise, with examples such as, length of stay, referral to treatment and more recently in residential care and elsewhere continuing care and its occasionally truculent neighbour 1-to-1. Unfortunately, like land masses, these currencies can also suffer from continental drift.

Dissemination (use in the wild) lack of review and ongoing attention to standards, benchmarks and definitions can see a currency drift in its application and subsequent reporting (affecting perceived utility, value and impact). The value of a currency can be diminished over time as it no longer acts as a unit of difference.

So enjoy your travels, but beware the risks while you vive la difference, especially in your work!

Image source: http://www.artlebedev.com/mandership/77/

BBC R4 Friday 8th Jan: NHS Punters Speak Out

This programme (episode 1) is on BBC Radio 4 on Friday 11.00:

With the help of dissatisfied NHS patients, Liz Barclay asks if the growing popularity of online feedback can really make a difference to standards of health care and treatment.

The culture of customers offering brickbats and bouquets to service providers has now extended beyond hotels and coffee chains to the NHS. Hospital rating websites invite patients to grade their hospital stay out of five stars, and to leave comments about the care they received.

Liz invites NHS patients who have used one of these patient rating websites to discuss their experiences and puts their points to the hospitals where they were treated.

She asks if the idea of online feedback can be really be applied to our health service and if it can genuinely improve standards of care. Critics suggest the sites are merely window-dressing and that NHS patients are not 'consumers'. Some health professionals claim that the sites can easily just become places where personal scores are settled against NHS staff.

<->

Introductions to Hodges' model for different audiences -

"Patiency" (person-centred care)	Health, Social Care professionals (inc. all in a student capacity)
The Public, Citizens	Managers, Policy Makers

These introductions will be re-written for the new website and represent possible projects for volunteers / students...?

(many) Care Transitions and The Little '-' That Could

Some people looking at Hodges' model may believe that the model perpetuates the dichotomies of old:

Human --- Machine
Individual --- Group
Sick --- Healthy
Supply --- Demand
Home --- Hospital
Self care --- Nursing care

In the 1990s as a community mental health nurse I was involved with a group of general nurses looking at ways of improving:

• discharge planning
• continuity of care

These issues remain and with the dichotomies of care above we can see how Hodges' model can assist our thinking and planning about transition. Not just one transition, but several.

This past week I was fortunate to attend one of a series of workshops -
Delivering High Quality Health Care for All: Bringing the social and technical together for a joined-up approach to deliver supporting systems and technologies
10th/11th December 2009, Leeds, UK

Organised by the UK Faculty of Health Informatics and the BCS Socio-Technical Group

The event was very good, stimulating and challenging. In the closing debate the appeal of 'socio-technical' and how to market a much needed joined-up approach in health IT came down at one point to the difference between:

'socio-technical' and 'sociotechnical'

In trying to find an alternative title, the hyphen was lost, and whilst it is not a crucial issue - for me that hyphen represents the axes of Hodges' model. Hodges' model acts as a high level aide-mémoire and that little hyphen can perform the same trick. The hyphen reminds us of the differences. The dichotomies that need to be navigated and negotiated in our dialogues about care AND caring. These are most evident in transfers and transitions (after all - "getting out of bed is a risk").

There are mini and macro transitions. Care pathways are not yellow-bricked unbroken splines from cottage to cottage hospital. They should be tortured if they do reflect person-centered experiences and needs.

Some transitions are process laden and repetitive, such as drug administration and must be protected - free from interruption. Although grounded in a social exchange of (correct) identities: a registered nurse, the right patient, right drug, right dose, right duration and right time these can be framed within the SCIENCE domain. That is where (for me) the conventional 'drug round' can be found. Counselling is another transition (if effective it also moves people on). Counselling can be found in the INTRAPERSONAL domain - close to the border with SOCIOLOGY.

Other transitions and transfers are more involved:

• person's home to attend day care (for the first time!)
• person's home to residential home
• hospital ward to home
• home encounter with the crisis team
• telecare consultation
  
• ...

Care is constantly passed hence the need to write and record. Passed from -

person-to-person
team-to-team
team-to-carer
time-to-time
discipline-to-discipline
self-care

This is the outcome that is sought. Ultimately passing responsibility back to the individual and when applicable their family. Having formal integrated care pathways is one thing, but they are never truly continuous, clear and true. And as they say crossing bridges you may have to break step and surely different disciplines march to different tunes? Today though the most audible tune must be socio-technical. ...

Additional link: The Little Engine That Could

Image source:
Drug round tabard http://internet-workwear.co.uk/acatalog/Drug_Round_Tabard.html

'cogeographic' or 'cogneographic' - concepts situated and abstract

The term 'cogeographic' materialised while writing a short article for the nursing press on Hodges' model.

Searching SCIENCE DIRECT and similar academic resources I thought I had found the word relating to geography, borders, ethnic groups and geopolitics, but now it seems to have disappeared....?

So I am not 100% sure whether cogeographic is a neologism. In some ways cogneographic better suits my purpose. That Matrix associated addition is a rather bizarre coincidence given the word's status and so with that I should explain how my lexical arrival here came about. ...

I was focusing on two fundamental claims in Hodges' model. Namely:

• The model is situated;
• The model assumes that concepts can be located within its knowledge domains.

For me, cogeographic (cogneographic) conjoins the cognitive (cognition) involved in defining, representing and using concepts in conceptual spaces; AND the finding that knowledge is invariably situated - that is knowledge has a geography.

Philo and Pickstone (2009) highlight the work of Haraway:

No knowledge, however ‘scientific’ or prestigious, can ever truly come from nowhere; it can not but originate somewhere, being thoroughly situated, in Donna Haraway’s (1991) valuable terminology; and it commonly bears marks of that origin - situation wherever it might then travel. p.651.

This combination of physical and mental (abstract) location then supports the use of a metric or measure. I suppose what I am thinking about is GIS for concepts - which in turn is the semantic web?

Should I locate any sources I will update this post, or if you can direct me to any please let me know: h2cmng at yahoo.co.uk

Reference:

Philo, C., Pickstone, J. (2009). Unpromising configurations: Towards local historical geographies of psychiatry, Health & Place, 15, 3, 649-656.

Open for applications: USA based Quality Improvement Fellowships

Dear NHS W2tQ readers,

Do you know of a clinically qualified NHS leader with a proven track record in quality improvement?
Do they have the potential to drive change and promote quality at a high level?

The Health Foundation's Quality Improvement Fellowships are now open for applications. Fellows will have an opportunity to spend a year in the USA working with the Institute for Healthcare Improvement (IHI) based in Cambridge, Massachusetts, studying the best international practice in quality improvement.

The fellowship includes:

• participation in the clinical effectiveness programme at the Harvard School of Public Health
• a personalised programme of taught and interactive learning at IHI
• active participation in the leadership teams for key IHI initiatives
• significant involvement in authorship and publication of research and improvement work
• strategic planning sessions to enable effective integration of a fellow's learning to better meet the needs of their home organisation

The Health Foundation will provide fellows with an allowance to support relocation, travel, visa and and USA healthcare costs, as well as replacement staff costs for their employing organisations.

Who can apply?
We are looking for senior NHS leaders who are clinically qualified and have a strong track record of achievement in the field of quality improvement.

Applicants must have the enthusiasm and potential to promote quality improvement nationally and to build organisational capability to drive quality improvement to higher levels of performance.

Please pass this information on to individuals who may be interested in applying.
The deadline for applications is 16 October 2009.

Visit Quality Improvement Fellowships or email awards@health. org.uk to find out more.

My source: Mental Health Informatics - SIG RCPsych via Stephen Thornton, The Health Foundation.

Congratulations to Paul Streets new Patient Voice Lead

Staying with the HSJ, this week (21 May) an 'in brief' item announces the appointment of the new Patient Voice Lead, Paul Streets - to whom I extend many congratulations! I note that:

His role includes developing methods of collecting near time patient feedback. p.8

Mr Streets could do worse than look (and listen) over here....

Hodges' model provides a person-centred, situated and multicontextual framework (across health and social care) that can be employed explicitly or implicitly. The model would also greatly benefit from and needs research and development.

While some of the comments in response to this on the HSJ site may reflect the current political-public pyrexia, perhaps they also demonstrate the need for a structured approach - an integrative and collaborative model?

Complex signatures

A signature is a very personal thing and has been since writing, power and authority were formalised in pre-printing times. Today with identity theft rampant, effective means of assuring, legitimating and protecting 'signatures' of various forms is a pressing concern.

Signatures matter in health and social care and not just because of individual budgets, but there again....



If an individual is suddenly vested with a budget for personalised care, then what about our expectations of them? What are the expectations of the councils counting pennies length and breadth of the land? The creative use of budgets depends upon self-knowledge, or reliance of the knowledge and experience of others. If things are to change - this requires in the first instance, personal reflection and insight that instils the confidence to take risks, a critical degree of self awareness with a piquant of realism. In the second instance an internet portal, other resources, perhaps a person is needed gifted (indeed) with holistic oversight and awareness of the individual's 4-5 fold unique care signature and local care economy.

Signatures are not new in health care. An effective relapse signature is a difficult and personally costly resource to identify, implement and refine. And yet this invaluable currency facilitates self-care management for many people with mental health problems and long term medical conditions.

Just as our written signatures change as we age, people had better get creative to ensure individuals are equipped and can be equipped with a care signature of their own.

Yours Truly,

Defining e-Health

E-Health is a compound and dynamic term for people, health (and social) care education and delivery, organisations, information and communications technologies (ICT), infrastructures, policies and means combined to facilitate, measure and improve the intentions, actions and outcomes of health (and social) care.

In a nursing context people refers to patients, carers, nurses and public; means refers to partnerships plus funding ranging from the macro level of the public sector to personal budgets; intentions, actions and outcomes covers education, the nursing process, records, quantitative and qualitative metrics.

To be holistic metrics must incorporate safety, access, personal outcomes, benefits, integrated informatics and economics.

1st draft: (c) Peter Jones

Intellect UK - Women in IT Scorecard: Ada Lovelace Day II

A definitive up-to-date evidence base for data and commentary on women in IT employment and education

Women in IT Scorecard (PDF 1MB) Published: March 2009
Type: Scorecard
Area: Transformational Business

Summary

Technology is central to the success of the UK economy and is becoming even more important the current economic situation. It is important to understand the trends in employment, education and any issues that could impact the future of the industry especially in such turbulent times.

British Computer Society (BCS), e-skills UK and Intellect., with support from Department for Business Enterprise and Regulatory Reform (BERR), have worked in partnership to produce a ‘Women in IT scorecard’ to understand and demonstrate the trends in our industry by gender from secondary education through into the IT workforce. The purpose of this document is to provide a robust evidence base for the facts behind the trends, to demonstrate differences in the participation rates between the genders and to present an analysis of these trends and the current situation to inform policy debate and future action by the partners and their communities.

The concern
While females represent 45% of the UK working population, they only make up 21% of the IT Industry workforce. For a profession that a few years ago was beginning to edge towards a ‘critical mass’ of 30% women - reaching 23% - we now find an alarming situation. In 2008 the make-up of the profession has changed:

* Males outnumber females in the IT industry by nearly 4:1.
* In the IT workforce, the number of males has fallen by 23,000 while the number of females has fallen by 63,000 since 2001.
* In IT occupations the number of males has increased by 77,000 while the number of females has fallen by 28,000 since 2001.
* Females account for around one in every five IT professionals.
* In Higher Education females account for 25% of all lecturers and 12% of professors in Computer Science / IT related subjects.
* In 2008 there were 17,455 male and just 1,581 female chartered IT professionals – 8% female.

Download
Women in IT Scorecard (PDF 1MB).

For more information contact:
Carrie Hartnell
Head of Industry Strategy
carrie.hartnell at intellectuk.org

See also - Ada Lovelace Day: Enid Mumford - Socio-technical perfume down the mine

BBC R4 Today - NHS productivity

Following the post yesterday - Don't waste energy - use a care plugin... - there was an item this morning on BBC R4 Today:

0815
A report published by the Office for National Statistics suggests that NHS productivity has been falling by 2% a year. Martin Weale of the National Institute of Social and Economic Research, and Shadow Health Secretary Andrew Lansley discuss the efficiency of the NHS.

There's no transcript of the interview so maybe I was (still) dreaming? At some stage though this a.m. a point was also made about the public (as tax payers and patients) either wanting to go into hospital to be treated and cured (quickly and efficiently) OR have a 'good' (positive) patient experience.

Why can't the two go hand-in-hand -
especially with all the emphasis on 'partnerships'?

Martin Weale highlighted how efficiency is not everything - people may have other requirements. If a patient is treated very efficiently and quickly - all evidence based, latest and greatest interventions - but their experience is at best neutral, or at worst negative, then how will that experience affect their recovery, staying well - relapse prevention - and any future care episodes and admissions? Complex indeed ...

- and Remembering...