Project management and action research: two sides of the same coin?

PURPOSE: To put forward the, to date, unidentified viewpoint that organisational action research and project management have many shared properties--making it a useful exercise to compare and contrast them in relation to organisational management structures and strategies. DESIGN/METHODOLOGY/APPROACH: A conceptual exploration, drawing on a wide range of supporting literature, is used here. FINDINGS: Project management represents a mainstay strategy for much of the organisational research seen in health care management--and has done for many years. More recently, the exploratory literature on project management has identified many limitations--especially when matched against "traditional" examples. Many health services have witnessed a more recent organisational management drive to seek out alternative strategies that incorporate less hierarchical and more participatory research methods. Action research certainly fits this bill and, on further examination, can be incorporated into a project management ethos and vice versa. RESEARCH LIMITATIONS/IMPLICATIONS: The views expressed here are of a theoretical construct and have not been implemented, as they are presented in this paper, in practice. The intention, however, is to do so in some of the author's future studies. PRACTICAL IMPLICATIONS: If the management of health service organisations are to evolve to incorporate desirable structures that promote consumer-oriented empowerment and participation (where the consumers also include the workforce), then having a wider array of research tools at one's disposal is one way of facilitating this. Incorporating action research principles into project management approaches, or the other way round, or marrying them both to form a "hybrid" research strategy--it is argued here--represents an appropriate and representative way forward for future organisational management studies. ORIGINALITY/VALUE: In terms of originality, this represents a conceptual piece of work that puts forward constructs that have, to date, not featured in the health care literature. Its value lies in suggesting further options for organisational-oriented health care research.     

Public release of information on quality of care: how are health services and the public expected to respond?

Public disclosure of the comparative performance of health care providers has been proposed as one mechanism of improving the quality of care. Performance data have been made public in the USA for over a decade and the provision of comparative information about quality of care is a central feature of current UK government health policy. The balance between the advantages and risks of pursuing such a policy in publicly funded health service is largely unknown. Advocates of public disclosure cite the role that comparative data can play in ensuring accountability, shifting the ownership of information (and therefore power) from professionals to service users and encouraging improvements in the processes and outcomes of care. However, these expectations are not necessarily realistic. There is some evidence that the public make little use of comparative data and there is a risk that public release may result in a loss of confidence in the health system and demoralisation of health service staff. In addition, there is a legitimate doubt that any early impact of disclosure will not be sustained and that the outcomes will not justify the necessary expenditure. In conclusion, we suggest that the theoretical benefits of promoting public disclosure as voiced by advocates of the policy may not be realised in practice.     

Help with your research? Sources of information and support

High quality research is essential to the provision of excellent health care in both primary and hospital settings. Midwives, health visitors, other community practitioners and allied health professionals should be encouraged to initiate and participate in research. No one should undertake research in isolation. Those who are novices should make sure that they are part of a team of more experienced researchers from whom they can learn and develop their own research skills. The National Institute for Health Research provides research training programmes, research funding and infrastructure to support researchers. The latter includes RDInfo, a free resource for all health and social care researchers in the UK. It provides comprehensive information on available research funding and training as well as individualised referrals for research advice.     

Improving the recognition and management of depression: is there a role for physician education?

BACKGROUND: Many patients who visit primary care physicians suffer from depression, but physicians may miss the diagnosis or undertreat these patients. Improving physicians' communication skills pertaining to diagnosing and managing depression may lead to better outcomes. METHODS: We performed a randomized controlled trial involving 49 primary care physicians to determine the effect of the Depression Education Program on their knowledge of depression and their behavior toward depressed patients. After randomization, physicians in the intervention group completed the Depression Education Program, which consists of 2 4-hour interactive workshops that combine lectures, discussion, audiotape review, and role-playing. Between sessions, physicians audiotaped an interview with one of their patients. Two to 6 weeks following the intervention program, physicians completed a knowledge test and received office visits from 2 unannounced people acting as standardized patients with major depression. These "patients" completed a checklist and scales. Logistic and linear regression were used to control for sex, specialty, and suspicion that the patient was a standardized patient. RESULTS: For both standardized patients, more intervention physicians than control physicians asked about stresses at home, and they also scored higher on the Participatory Decision-Making scale. During the office visits of one of the standardized patients, more intervention physicians asked about at least 5 criteria for major depression (82% and 38%, P = .006), discussed the possibility of depression (96% and 65%, P = .049), scheduled a return visit within 2 weeks (67% and 33%, P = .004), and scored higher than control physicians on the Patient Satisfaction scale (40.3 and 35.5, P = .014). CONCLUSIONS: The Depression Education Program changed physicians' behavior and may be an important component in the efforts to improve the care of depressed patients.     

Opening Pandora's box? Freedom of information and health services research

The introduction, or extension, of freedom of information legislation in Britain and other Western countries seems certain to influence the climate for health services research. However, researchers should be clear that, although such legislation may improve access to certain types of data, it will also create new problems and dilemmas. Statutory freedom of information regimes are likely to raise difficult issues of adaptation and compliance for health service bodies. Researchers may find that this translates into reluctance to agree access and accentuates difficulties in managing field relationships. They may, inter alia, face difficult dilemmas in deciding whether, or how, to report non-compliance, judging whether to extend research into areas where consent has not been obtained and weighing the benefits of using the official rules to insist on disclosure against the dis-benefits of jeopardising relationships. Health services researchers should regard freedom of information legislation, not simply as a resource, but a topic deserving study in its own right.     

International rescue? The dynamics and policy implications of the international recruitment of nurses to the UK

This paper focuses on one global aspect of the current health sector workforce policy agenda - the international recruitment and migration of health workers. It does so primarily by using a case study of the recruitment of nurses to the UK, as a means of exploring the policy challenges and associated research questions. The paper highlights the limitations in comparing national data on the nursing workforce, illustrating the extent to which currently collated national data can present a misleading picture of staff:population ratios in different countries. It then reports on the significant growth in the numbers of nurses entering the UK from other countries, using registration data. In 2001/02, more than 16 000 nurses entered the UK nursing register from non-UK sources. In this year, for the first time, the number exceeded the number of home-trained nurses. An analysis of postcode data highlights that these non-UK nurses have a younger age profile than home-based registered nurses and are more likely to report a postcode in London and south-east England. The paper also examines the push and pull factors that contribute to the international mobility of health workers. The paper concludes by examining the policy implications of this growing reliance on international recruitment, including the effect of the ethical guidelines on international recruitment introduced by the Department of Health in England.     

Integrity: the key to quality in community-based medical education? (Part two)

Relationships do matter! In fact, medicine cannot be learned without them, and community-based medical education (CBME) curricula that ignore them or take them for granted do so at their students peril! Could these assertions provide a key to quality in CBME curricula? In a previous paper, I provided evidence for a simple model of four key relationships, the four Rs, to act as a framework to analyse CBME. These four Rs are the relationships between (1) clinicians and patients, (2) health service and university research, (3) government and community, and (4) personal principles and professional expectations. In this paper I describe a key to discerning quality in this model. This key is integrity - that coalition of soundness and interdependence that enables the quality of the whole to be greater than the sum of the parts. I will also discuss the implications of this model for CBME with particular reference to reform of student selection, curricular goals, course structure, and assessment. Whilst further research based on this model is needed, as a result of this synthesis of the current medical education literature, I propose that it is its capacity to produce clinical, social, institutional and interpersonal integrity in its graduates that makes community-based medical education such an attractive alternative. Relationships do matter!     

Research and continuous improvement: the merging of two entities?

Hospital administrators are under pressure to provide a quality product at reasonable prices. As a result, all aspects of hospital structure and culture are under review, which places continuous improvement (CI) programs addressing quality and satisfaction in a more prominent role. Although the theory, data collection methods, and analysis techniques of continuous improvement have grown considerably since the days of quality assurance, clinical problems in healthcare organizations are also increasingly complex and difficult to solve. From this perspective, research has a great deal to offer our current continuous improvement efforts. This paper proposes that CI and research are similar problem-solving approaches, based on philosophies that provide direction for theorizing, collecting and analyzing data, and identifying solutions. A clinical problem elaborates on the similarities of each approach. Finally, common misconceptions are discussed.     

How should hospital reimbursement be refined to support concentration of complex care services?

The English National Health Service is promoting concentration of the treatment of patients with relatively rare and complex conditions into a limited number of specialist centres. If these patients are more costly to treat, the prospective payment system based on Healthcare Resource Groups (HRGs) may need refinement because these centres will be financially disadvantaged. To assess the funding implications of this concentration policy, we estimate the cost differentials associated with caring for patients that receive complex care and examine the extent to which complex care services are concentrated across hospitals and HRGs. We estimate random effects models using patient‐level activity and cost data for all patients admitted to English hospitals during the 2013/14 financial year and construct measures of the concentration of complex services. Payments for complex care services need to be adjusted if they have large cost differentials and if provision is concentrated within a few hospitals. Payments can be adjusted either by refining HRGs or making top‐up payments to HRG prices. HRG refinement is preferred to top‐payments the greater the concentration of services among HRGs.     

Care pathways: the road to better health services?

This paper describes the development and implementation of care pathways in two orthopaedic units in Scotland. Although originally developed as a tool of project management, care pathways have been promoted internationally as a response to concerns for patient safety, variability in care and increasing costs. Generally, care pathways can be seen as an example of clinician led rather than management led reform. However, it does reflect a wider shift towards process and away from hierarchical approaches to management. Within the UK care pathways have been promoted as a response to the modernization initiative of the Labour Government. While the initiative was a success in both units it was more difficult to implement care pathways in a trauma rather than an elective unit. In conclusion, it is questionable whether care pathways are a universal response to the requirement for modernization and service redesign in the NHS.