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    Quality improvement interpreted as a complex adaptive system : implications and opportunities : a thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy at Massey University, Palmerston North, New Zealand
    (Massey University, 2024-11-01) Wilson, William
    The effectiveness of quality improvement (QI) methods in healthcare has been challenged, especially under circumstances of high complexity. This thesis examines the implications for quality improvement if complex socio-technical systems such as healthcare are interpreted as complex adaptive systems (CAS). The research followed a mixed-method design. Informed by the complex systems and quality management literature, a conceptual model for quality improvement within CAS was developed — the complex quality improvement network (CQIN). An agent-based simulation model was then used to establish the plausibility and face validity of the model constructs and their interaction. Thematic analysis and crisp-set qualitative comparative analysis (QCA) were then used to examine the evidence for CQIN constructs within published quality improvement case studies. One applied case study was also conducted for deeper insight into the practical difficulties of interpreting a real-world quality improvement project as a CAS. Finally, the findings of the simulation modelling and the secondary data analysis were integrated into a Bayesian network model. Empirical evidence, in the form of consistency across cases and coverage within cases, was found for eleven of the twelve CQIN constructs. Multiple sets of sufficient conditions for reported improvement success were identified across cases. These sets were minimised to four strategies for successful quality improvement; i) strengthening agent network communication paths; ii) building shared understanding of problem and context amongst networked agents; iii) increasing problem-solving effectiveness; and iv) improved system signal integration. If the evolutionary foundations for CAS are in some way inhibited, the likelihood of quality improvement success is reduced. Healthcare quality improvement can be plausibly simulated using fundamental CAS principles. The first contribution to quality improvement discourse is the CQIN model, a CAS model of change applied specifically to quality improvement. A second contribution of this research is a complex quality improvement risk assessment model, the CQIN Bayesian Network. Practitioners can use this model to examine and test identified CAS-informed improvement strategies. The individual CQIN constructs make a third contribution by providing new categories of causal factors for the comparison of disparate quality improvement case studies.
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    The key factors driving successful improvement in primary care : a mixed methods investigation of the determinants of quality improvement success in Aotearoa New Zealand : a thesis with publication presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Palmerston North, Aotearoa New Zealand
    (Massey University, 2023-11-30) Cullen, Jane
    Primary care is where the population receives most of their health care and where successful quality improvement (QI) can have the biggest impact on health, wellbeing, equity, and health system performance. A better understanding of the factors that influence QI in primary care is urgently needed to support a high-performing primary healthcare system. Most prior studies into the determinants of effective QI have focused on secondary care organisations and large-scale collaborative efforts. Primary care services such as general practice present a different set of challenges. Various key contextual factors have been identified in the literature, but few studies explain how they relate to each other and QI success. This study sought to answer the following questions: 1. What are the contextual factors influencing primary care improvement interventions? 2. How do the contextual factors, improvement content (topic and planned changes) and the implementation process influence each other and the improvement outcomes in primary care? 3. How applicable for primary care assessment is the Model for Understanding Success in Quality (MUSIQ), a tool for assessing modifiable contextual factors developed in secondary care? This research was an explanatory sequential mixed methods study based in the Aotearoa, New Zealand (NZ) primary care setting of general practice and Primary Health Organisations (PHOs). Amulti-case mixed methods approach was followed in the first stage. Mainly qualitative data were collected from primary care interviews guided by the Consolidated Framework for Implementation Research (CFIR). This was compared with quantitative data from the MUSIQ survey. The second stage consisted of a national survey where emerging theory was tested by partial least squares structural equation modelling (PLS-SEM). The findings revealed that most teams did not use formal QI methods, instead relying on their people-centred relationship skills and networks to drive QI via distributed leadership. Teams were intrinsically motivated by community and patient need and drew on strengths developed within the complexity and uncertainty of the primary care settings to drive QI. The collaborative skills which are increasingly required in the modern primary care setting support the shared social processes of sensemaking for enacting change. The key success factors driving QI in primary care are identified and how they relate to each other explained. A primary care adaptation of MUSIQ has been proposed that may aid improvement practitioners and researchers to assess primary care contexts. The key strengths should be developed and supported across primary care services and capability, capacity and resources supported centrally to increase the ability of primary care to improve services more easily and effectively.
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    The application of complexity theory to contracting out public health interventions : a thesis presented in fulfilment of the requirements for the degree of Master of Philosophy, School of Health at Massey University, Wellington, New Zealand
    (Massey University, 2019) Oakden, Judith Penelope
    The New Zealand government has used a policy approach called New Public Management since the 1980s to contract out public health services. Under this approach contracting out works well for public health services that are predictable, stable and controllable. However, the approach does not always work so well for hard to specify, complex to deliver services, where it is challenging to measure whether the right people benefit. Complexity theorists suggest that public services are complex adaptive systems and therefore do not respond in linear, predictable ways. Complexity theorists also suggest New Public Management framing of contracting out is too simplistic and overlooks the needs of some important population groups, in its quest for efficiency. The overall objective of the research was to explore contracting out of public health services using a general complexity framing to see what insights it might add. The research considered: which ideas from within complexity theory might provide a possible frame to examine contracting out practices; how complexity theory might inform contracting out practice for public health services; and how public sector managers might understand the processes and dynamics of contracting out if informed by complexity theory. A review of complexity and public management literature identified four complexity concepts used to frame interview questions and analyse results for this research: path dependence, emergence, self-organisation and feedback. A small-scale qualitative study used a theory-based approach to test the complexity concepts with public sector managers experienced in contracting out for public health and social services. This research argues that a framing informed by complexity theory resonated with public sector managers in understanding and working in the messy ‘realities’ of contracting out. This research observes that contracting out is often not tidy, linear and controllable as suggested by New Public Management practices. Public sector managers seeking to try new contracting out approaches, can find the underlying New Public Management ethos found in many administrative arms of government hampers them. This research provides insights about why change is hard to achieve, as well as offering public sector managers some alternative ways to think about how they contract out public health services.
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    Inter-district flow transfers : health and economic impacts : a thesis presented in partial fulfilment of the requirements for the degree of Master of Business Studies in Economics at Massey University, Albany, New Zealand
    (Massey University, 2018) Bruce-Brand, Bronwyn
    As part of the introduction of the New Zealand Public Health and Disabilities Act in 2000, the introduction of the Population Based Funding Formula led to a change in the flow of funds for transfer patients. Prior to the PBFF, for the years 2000-2003, healthcare events were contracted on a fee-for-service basis and thus were borne by the DHB of treatment. From 2003 onwards, the cost of transfer patients followed the transfer back to their DHB of domicile. This study replicates and extends work done by Shin (2013) in assessing the impacts of this change in funding flows on the level of transfer and patient health outcomes. I use OLS and logistic modelling to empirically assess these effects and draw conclusions as to the effectiveness of the policy change and any potential efficiencies that are gained. I find evidence of a focus in the probability of transfers after the change in funding, where the overall probability of transfer decreases and the probability of transfer to tertiary DHBs increases. Additionally, patient outcomes demonstrate a concentration effect whereby after the policy is implemented, the pool of transfers is less diluted by low severity patient transfers and thus displays poorer health outcomes on average for the transfer group. The concentration of health outcomes suggests that the transfer decision is being considered more carefully now that costs are aligned to the DHB of domicile. A novel addition to this research is the analysis of regional DHB pairs. The analysis of five secondary-to-tertiary transfer flows provides insight into the necessity of a decentralised healthcare system in New Zealand and is mostly consistent with the analysis at the national level. Overall, the introduction of Inter-District Flow transfer funding has increased the efficiency of the transfer mechanism and enabled a more streamlined redistribution of funds to tertiary providers. This is an important finding because it reinforces the necessity of the transfer mechanism, specialist providers and local provision in a healthcare system such as New Zealand’s.
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    Community participation in policy development : a case study of the National Cervical Screening Programme : a thesis presented in partial fulfilment of the requirements for the degree of Master of Educational Administration at Massey University
    (Massey University, 1992) Grew, Gillain Dorothy Anne
    This thesis is a case study of the development of the National Cervical Screening Programme policy. The aim of the study was to identify and describe the political, social and ideological factors which may have influenced the National Cervical Screening Programme policy. The policy-makers included community or consumer participants as well as professionals. This relatively unique feature of community involvement was also a focus of study. The study involved a literature search and review as well as interviews with key informants. Cervical screening on a population basis was trialled as far back as the 1960s at the same time that Professor Green was questioning the efficacy of early treatment of cervical abnormalities. Green's controversial research resulted in a Royal Commission of Inquiry which recommended the establishment of a population based national cervical screening programme. The political, social and ideological context in which the National Cervical Screening programme policy was developed is described and interpreted. It is concluded that the National Cervical Screening Programme policy was adopted by the Government as a means to ameliorate the crisis of legitimation which was evident during the 1980s. It is further concluded that community or consumer participation in policy development is a highly complex issue requiring further study. Consumer representation is particularly problematic as consumer policy-makers require considerable skills, the acquisition of which may cause them to become less representative of the public whose voice they are intended to be.
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    The development and testing of a contextual model for healthcare quality improvement using Lean and the Model for Understanding Success in Quality (MUSIQ) : a thesis presented in partial fulfilment of the requirements for the degree of Master of Quality Systems at Massey University, Palmerston North, New Zealand
    (Massey University, 2017) Wilson, William James
    This study developed a new theoretical model of quality improvement (QI) contextual factors, for QI activity undertaken at the healthcare microsystem level. The Model for Understanding Success in Quality (MUSIQ) (Kaplan, Provost, Froehle, & Margolis, 2012), was aligned with Lean improvement activity using the Toyota Way framework. The aim of the research was to improve the effectiveness of healthcare quality improvement initiatives by providing more understanding of the associations, relative importance and precise functioning of critical contextual factors. A new survey instrument, based on the literature, was developed to collect data and the hypothesised theoretical relationships were tested using the partial least squares path modelling (PLSPM) technique. QI practitioners at a large New Zealand District Health Board were surveyed on a range of contextual factors hypothesised to influence improvement outcomes. All survey participants had recently completed a small-scale improvement project using Lean, or were participants in training programmes that introduced them to Lean thinking and methods. Some participants worked autonomously on improvements of their own selection; others were part of a wider training programme derived from the National Health Service’s (UK) ‘productive ward’ programme. In the healthcare organisational context, the majority of these improvement initiatives were carried out at the microsystem level – initiated and delivered by the teams responsible for the work processes being modified. Survey responses were first analysed via principal components analysis (to examine the dimensionality of the scales) and then PLSPM. The defined contextual factors for ‘Teamwork’, ‘Respect for People’, ‘Lean Actions’ and the influence of negatively motivating factors all reached significance. Defined contextual factors for ‘Previous Experience’ and the influence of positive motivating factors did not reach significance at 5% level. The final model showed a statistically significant, moderate predictive strength, with an overall adjusted R2 of 0.58. This result was an encouraging validation of the microsystem-level layer of the MUSIQ model using Lean as the QI method (context). The relative influence of ‘Teamwork’, ‘Respect for People’, Motivation’, and a mediating mechanism for making process changes (in this instance, Lean) were measured and found to be consistent with the MUSIQ model. Identifying more detailed causal mechanisms (the present model was intentionally parsimonious due to the time frame allowed and the resources available for the research), refining the operational definitions, and developing and testing predictive models for the defined contextual factors are the proposed next steps in the research.
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    An evaluation of the impact of the "MAISS" needs assessment concept in influencing the empowerment of people with disabilities : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Rehabilitation at Massey University
    (Massey University, 1999) Sullivan, Lorna
    MAISS, (Managed Access to Integrated Support Services) as defined within Midland Health's service requirement definition, will be the single means of access to all support services for people with disabilities living within the Midland Health region. It must, therefore be considered, if not as the single most significant service purchased for people with disabilities then as one of the major disability service initiatives to have developed from the 1992 health reforms. For people with disabilities, the manner in which the MAISS services are delivered, the level of skill of the people delivering the services, and the subsequent availability of flexible, responsive service provision, will be the test of the Governments ability to achieve stated health reform outcomes. These outcomes were clearly articulated by people with disabilities themselves within the Self Help and Empowerment document, developed from the Consensus Development Conferences of the Core Services Committee. This research took the form of an evaluation of the impact which MAISS has had on the expressed feelings of self help and empowerment for one group of significant services users. The MAISS concept as delivered by one of three contracted providers, is examined to determine whether or not MAISS services are perceived by people with disabilities as having resulted in an enhancement of their perceived empowerment or mastery over the decisions which impact upon their lives. Judgments are made on the extent to which the MAISS concept and its implementation is seen to be supporting the enablement of people with disabilities. The research identifies those aspects of service delivery which most significantly contribute to expressed feelings of empowerment. Investigation was undertaken through the development of a structured questionnaire. This questionnaire was used as the single means of data collection. The questionnaire was developed from a conceptual framework based upon the New Zealand Standards for Needs Assessment developed and promoted by the Ministry of Health. The key recommendations made within this study relate to the need for assessment services to utilize assessment practices which foster the integrity and internal validity of the assessment process. The study also recommends that there needs to be a greater sharing of knowledge and accuracy of information in interactions between providers and consumers of services. Finally the research notes the need for continued investigation into the concept and implementation of services as defined within MAISS as such services continue to act as the major gatekeeper for people with disabilities seeking access to essential support services.
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    The use of standards for information systems within New Zealand healthcare : a thesis presented in partial fulfilment of the degree of Master of Science in Information systems at Massey University
    (Massey University, 1999) Weston, Lisabeth Sarah Constance
    Standards are starting to gain prominence in a world that to some may seem to be being devoured by the advancements of technology. Healthcare is by no means void of the impact of technology, in fact some believe that technology could serve no better purpose than to advance healthcare. To be able to link these new (and what some may consider incredulous) technologies, from hospital to hospital, doctor to doctor, patient to doctor, or any of the permutations of these, appropriate information systems standards are required. Whilst people have begun to acknowledge that standards are important, few are willing to put forward what is exactly required from a standard, or indeed why one standard is considered to be more appropriate than another standard. Consequently this research aims to create and then investigate the framework to ascertain what the critical success factors are when selecting and utilising a standard. An associated goal of this study is to gain an understanding of which standards for information systems are being utilised within the New Zealand healthcare environment. A survey of New Zealand healthcare found that the 'Completeness' of the standard is considered to be the most important element for adopting health information systems standards. Organisations wish to adopt standards that meet the required need, and that provide the required functionality. A number of different standards are utilised within New Zealand healthcare, some of which differ between organisations. Information systems management standards were the least utilised standards by all organisations. It was found that organisation type and structure and the purpose of the standards both influenced the relative importance of different factors in the selection of standards.
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    The principles and practice of devolution : reform of health services in the Philippines : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Resource and Environmental Planning at Massey University
    (Massey University, 1996) Cailin, Elsa A
    1992 saw radical reform to local government in the Philippines through enactment of a new Local Government Code. This provided for the devolution of powers, resources and service functions from central government to local government. The process of devolution is now in its third year. This study has been undertaken as a preliminary assessment of the factors that influenced implementation of devolution in the health services, its impacts and its effectiveness. The study is based mainly on survey techniques. Face-to-face interviews were undertaken with policy makers to establish motivations underlying devolution, what they believe has been achieved, and what they think promote or impede implementation. Face-to-face interviews were also undertaken with key local officials to identify the health services and functions transferred from central to municipal governments, and to identify the degree of discretion these people now have in policy formulation, implementation, monitoring, and evaluation, and in fiscal and personnel matters. An opinion survey was administered to assess the perceptions of key players in the management of decentralised responsibility (elected officials, transferred health personnel, and advisory board members) to determine their views of the objectives, the factors that promoted or impeded devolution, and changes in the way things are done as a consequence. It was concluded that devolution is moving towards local autonomy as intended. The necessary structural changes have been met. Local government responsibilities, resources, and authority have increased, and public participation in local government has been institutionalised. Substantial benefits have been realised particularly in terms of local self-reliance, participation, and competence development. Devolution has also been effective in changing people's behaviour. The results indicate that the key to successful devolution and to decentralised responsibility is the nature of local leadership and local commitment.
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    A case study of a business process reengineering project, 'Straightening the path for patients', at Taranaki Healthcare, a New Zealand Crown Health Enterprise, 1995-1997 : a thesis presented in partial fulfillment of the requirements for the degree of Master of Business Studies (Health Management) at Massey University
    (Massey University, 1997) Pike, Pieter Wessel
    This case study describes and analyses the Change lmperative(Phase One); Visioning (Phase Two); Redesign (Phase Three) and Plan for Implementation (Phase Four) Phases of a Business Process Reengineering (BPR) project in the New Zealand Health sector at Taranaki Healthcare. The research strategy in the words of Yin (1994, p.1) was "an empirical inquiry that investigates a contemporary phenomenon in its real life context" when the boundaries between phenomena and context are not clearly evident and in which multiple sources of evidence are used. Michael Hammer, president of Hammer and Co., Cambridge, first coined the term Business Process Reengineering, in 1990. He described reengineering as fundamental and radical redesign of business processes to achieve dramatic improvements. The application of BPR methodology, as change strategy, is now widely applied. Numerous studies concentrate on the methodology but few discuss its actual application in a real time project. This case study addresses this issue. The empirical part of this study involved two surveys together with a qualitative analysis of debriefing sessions held at the end of each phase. The first survey was conducted in July 1996, after the completion of the Visioning Phase and the second during November 1996, after the Plan for implementation Phase. Both surveys included a cluster sampling of the reengineering project team and a stratified random sampling of Taranaki Healthcare employees. The data collection was based on a multi-method approach and included a review of project reports, surveys before the project, and quantitative analysis of patient numbers, case complexity, capacity, utilisation and other demand management factors.