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Search Results: 1 - 10 of 6041 matches for " Roland Bal "
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Studying Design and Use of Healthcare Technologies in Interaction: The Social Learning Perspective in a Dutch Quality Improvement Collaborative Program  [PDF]
Esther van Loon, Nelly Oudshoorn, Roland Bal
Health (Health) , 2014, DOI: 10.4236/health.2014.615223
Abstract: Designing technologies is a process that relies on multiple interactions between design and use contexts. These interactions are essential to the development and establishment of technologies. This article seeks to understand the attempts of healthcare organisations to integrate use contexts into the design of healthcare technologies following insights of the theoretical approaches of social learning and user representations. We present a multiple case study of three healthcare technologies involved in improving elderly care practice. These cases were part of a Dutch quality improvement collaborative program, which urged that development of these technologies was not “just” development, but should occur in close collaboration with other parts of the collaborative program, which were more focused on implementation. These cases illustrate different ways to develop technologies in interaction with use contexts and users. Despite the infrastructure of the collaborative program, interactions were not without problems. We conclude by arguing that interactions between design and use are not naturally occurring phenomena, but must be actively organised in order to create effects.
Telemedicine in interdisciplinary work practices: On an IT system that met the criteria for success set out by its sponsors, yet failed to become part of every-day clinical routines
Antoinette de Bont, Roland Bal
BMC Medical Informatics and Decision Making , 2008, DOI: 10.1186/1472-6947-8-47
Abstract: We evaluated a telecare service set up to reduce the workload of ophthalmologists. In this project, optometrists in 10 optical shops made digital images to detect patients with glaucoma which were further assessed by trained technicians in the hospital. Over a period of three years, we conducted interviews with the project team and the users about the workability of the system and its integration in practice. Beside the interviews, we analyzed record data to measure the quality of the images. We compared the qualitative accounts with these measurements.According to our measurements, the quality of the images was at least satisfactory in 90% of the cases, i.e. the images could be used to screen the patients – reducing the workload of the ophthalmologist considerably. However, both the ophthalmologist and the optometrists became increasingly dissatisfied respectively with the perceived quality of the pictures and the perceived workload.Through a detailed analysis of how the professionals discussed the quality of the pictures, we re-constructed how the notion of quality of the images and being a good professional were constructed and linked. The IT system transformed into a quality system and, at the same time, transformed the notions of being a good professional. While a continuous dialogue about the quality of the pictures became an emblem for the quality of care, this dialogue was hindered by the system and the way the care process was structured.To conceptualize what telemedicine does in interdisciplinary work practices, a fine-tuned analysis is needed to assess how IT systems re-shape the social relations between professional groups. Such transformations should not be exclusively attributed to the technology itself or to the professionals working with it. Instead we need to assess these technologies through an empirically grounded study of the sociotechnical functioning of telemedicine.Information systems can play a key role in care innovations including task rede
Databases as policy instruments. About extending networks as evidence-based policy
Antoinette de Bont, Herman Stoevelaar, Roland Bal
BMC Health Services Research , 2007, DOI: 10.1186/1472-6963-7-200
Abstract: We conducted three case studies to reconstruct the development and use of databases as policy instruments. Each database was intended to be employed to control the use of one particular pharmaceutical in the Netherlands (growth hormone, antiretroviral drugs for HIV and Taxol, respectively). We studied the archives of the Dutch Health Insurance Board, conducted in-depth interviews with key informants and organized two focus groups, all focused on the use of databases both in policy circles and in clinical practice.Our results demonstrate that policy makers hardly used the databases, neither for cost control nor for quality assurance. Further analysis revealed that these databases facilitated self-regulation and quality assurance by (national) bodies of professionals, resulting in restrictive prescription behavior amongst physicians.The databases fulfill control functions that were formerly located within the policy realm. The databases facilitate collaboration between policy makers and physicians, since they enable quality assurance by professionals. Delegating regulatory authority downwards into a network of physicians who control the use of pharmaceuticals seems to be a good alternative for centralized control on the basis of monitoring data.Several authors have stressed the need for improving evidence-based health policy [1-3]. One way of enabling truly evidence based policy is claimed to be the use of databases [4,5]. Where the results of clinical studies are lacking or are insufficient – for example in when there is uncertainty about the long-term effects of a specific technology – databases may be used to monitor the effectiveness and safety of using these technologies in clinical practice. In addition, monitoring can be used to produce data about the appropriateness of care and associated costs. In short, it is assumed that databases, particularly those linked to electronic medical records, would enable the long-term follow-up of patients, providing informatio
Cost-effectiveness of a pressure ulcer quality collaborative
Peter Makai, Marc Koopmanschap, Roland Bal, Anna P Nieboer
Cost Effectiveness and Resource Allocation , 2010, DOI: 10.1186/1478-7547-8-11
Abstract: We used a non-controlled pre-post design to establish the change in incidence and prevalence of PUs in 88 patients over the course of a year. Staff indexed data and prevention methods (activities, materials). Quality of life (Qol) weights were assigned to the PU states. We assessed the costs of activities and materials in the project. A Markov model was built based on effectiveness and cost data, complemented with a probabilistic sensitivity analysis. To illustrate the results of longer term, three scenarios were created in which change in incidence and prevalence measures were (1) not sustained, (2) partially sustained, and (3) completely sustained.Incidence of PUs decreased from 15% to 4.5% for the 88 patients. Prevalence decreased from 38.6% to 22.7%. Average Quality of Life (Qol) of patients increased by 0.02 Quality Adjusted Life Years (QALY)s in two years; healthcare costs increased by €2000 per patient; the Incremental Cost-effectiveness Ratio (ICER) was between 78,500 and 131,000 depending on whether the changes in incidence and prevalence of PU were sustained.During the QIC PU incidence and prevalence significantly declined. When compared to standard PU care, the QIC was probably more costly and more effective in the short run, but its long-term cost-effectiveness is questionable. The QIC can only be cost-effective if the changes in incidence and prevalence of PU are sustained.A pressure ulcer (PU) is a preventable condition that affects patients with impaired mobility, especially the elderly [1]. PUs are classified from grades 1 to 4, or least to most severe. The average prevalence of PUs in the Netherlands is 7.9% in assisted living homes and 18.3% in nursing homes [2]. Incidence varies between 2.9% and 4.5% in intensive care [3]. No incidence data are available for the Dutch long-term care sector. The probability of healing within 90 days varies with severity: 67% (grade 2), 44% (grade 3) and 32% (grade 4) [4]. PUs can interfere with recovery, cause pain
Opening the black box of quality improvement collaboratives: an Actor-Network theory approach
Tineke Broer, Anna P Nieboer, Roland A Bal
BMC Health Services Research , 2010, DOI: 10.1186/1472-6963-10-265
Abstract: In an ethnographic design we probed two projects within a larger quality improvement collaborative on long term mental health care and care for the intellectually disabled. Ethnographic observations were made at nine national conferences. Furthermore we conducted six case studies involving participating teams. Additionally, we interviewed the two program leaders of the overall projects.In one project the problematisation seemed to undergo a shift of focus away from the one suggested by the project leaders. In the other we observed multiple roles of the measurement instrument used. The instrument did not only measure effects of the improvement actions but also changed these actions and affected the actors involved.Effectiveness statistics ideally should be complemented with an analysis of the construction of the collaborative and the improvement practices. Effect studies of collaboratives could benefit from a mixed methods research design that combines quantitative and qualitative methods.Ever since the US Institute of Medicine described the so-called "quality chasm" in health care [1], quality improvement has become an important policy issue. A proposed solution for bridging the chasm is setting quality improvement collaboratives (QIC's) to work. A nice example is the Breakthrough Series model that brings together teams from different hospitals or clinics with the aim to attain improvements on a certain theme [2]. The QIC model in general and BTS in particular are widely adopted in Western countries [3]. So far, there is little evidence, however, on the effectiveness of QIC's [3,4].Despite the lack of evidence concerning effectiveness of QIC's, most studies evaluating QIC's are investigating their effectiveness rather than follow the collaborative as it gets formed. Bate and Robert argue that many evaluation studies take up an approach they describe as "summative, noninterventionist, and heavily reliant on quantitative assessments of "success"", which is "outcome-or
Quantitative data management in quality improvement collaboratives
Mireille van den Berg, Rianne Frenken, Roland Bal
BMC Health Services Research , 2009, DOI: 10.1186/1472-6963-9-175
Abstract: This paper discusses complications and dilemma's observed in the set-up of data management for QICs. An overview is presented of signals that were picked up by the data management team. These signals were used to improve the strategies for data management during the program and have, as far as possible, been translated into practical solutions that have been successfully implemented.The recommendations coming from this study are:From our experience it is clear that quality improvement programs deviate from experimental research in many ways. It is not only impossible, but also undesirable to control processes and standardize data streams. QIC's need to be clear of data protocols that do not allow for change. It is therefore minimally important that when quantitative results are gathered, these results are accompanied by qualitative results that can be used to correctly interpret them.Monitoring and data acquisition interfere with routine. This makes a database collecting data in a QIC an intervention in itself. It is very important to be aware of this in reporting the results. Using existing databases when possible can overcome some of these problems but is often not possible given the change objective of QICs.Introducing a standardized spreadsheet to the teams is a very practical and helpful tool in collecting standardized data within a QIC. It is vital that the spreadsheets are handed out before baseline measurements start.Quality collaboratives have gained in attention since the formulation of the "quality chasm" by the US Institute of Medicine [1] and its spread across the Western world. The Breakthrough method developed by the Institute of Health Improvement has been one of the major instruments put to use in such collaboratives. Quality improvement collaboratives (QICs) are seen as a means to spread evidence-based practices quickly across care organizations, as there is some evidence that the integration of quality instruments leads to synergistic effects [2].
Inter-organisational communication networks in healthcare: centralised versus decentralised approaches
Habibollah Pirnejad,Roland Bal,Arjen P. Stoop,Marc Berg
International Journal of Integrated Care , 2007,
Abstract: Background: To afford efficient and high quality care, healthcare providers increasingly need to exchange patient data. The existence of a communication network amongst care providers will help them to exchange patient data more efficiently. Information and communication technology (ICT) has much potential to facilitate the development of such a communication network. Moreover, in order to offer integrated care interoperability of healthcare organizations based upon the exchanged data is of crucial importance. However, complications around such a development are beyond technical impediments. Objectives: To determine the challenges and complexities involved in building an Inter-organisational Communication network (IOCN) in healthcare and the appropriations in the strategies. Case study: Interviews, literature review, and document analysis were conducted to analyse the developments that have taken place toward building a countrywide electronic patient record and its challenges in The Netherlands. Due to the interrelated nature of technical and non-technical problems, a socio-technical approach was used to analyse the data and define the challenges. Results: Organisational and cultural changes are necessary before technical solutions can be applied. There are organisational, financial, political, and ethicolegal challenges that have to be addressed appropriately. Two different approaches, one “centralised” and the other “decentralised” have been used by Dutch healthcare providers to adopt the necessary changes and cope with these challenges. Conclusion: The best solutions in building an IOCN have to be drawn from both the centralised and the decentralised approaches. Local communication initiatives have to be supervised and supported centrally and incentives at the organisations' interest level have to be created to encourage the stakeholder organisations to adopt the necessary changes.
Co-Regulation of Metabolic Genes Is Better Explained by Flux Coupling Than by Network Distance
Richard A Notebaart,Bas Teusink,Roland J Siezen,Balázs Papp
PLOS Computational Biology , 2008, DOI: 10.1371/journal.pcbi.0040026
Abstract: To what extent can modes of gene regulation be explained by systems-level properties of metabolic networks? Prior studies on co-regulation of metabolic genes have mainly focused on graph-theoretical features of metabolic networks and demonstrated a decreasing level of co-expression with increasing network distance, a na?ve, but widely used, topological index. Others have suggested that static graph representations can poorly capture dynamic functional associations, e.g., in the form of dependence of metabolic fluxes across genes in the network. Here, we systematically tested the relative importance of metabolic flux coupling and network position on gene co-regulation, using a genome-scale metabolic model of Escherichia coli. After validating the computational method with empirical data on flux correlations, we confirm that genes coupled by their enzymatic fluxes not only show similar expression patterns, but also share transcriptional regulators and frequently reside in the same operon. In contrast, we demonstrate that network distance per se has relatively minor influence on gene co-regulation. Moreover, the type of flux coupling can explain refined properties of the regulatory network that are ignored by simple graph-theoretical indices. Our results underline the importance of studying functional states of cellular networks to define physiologically relevant associations between genes and should stimulate future developments of novel functional genomic tools.
A framework and a measurement instrument for sustainability of work practices in long-term care
Sarah S Slaghuis, Mathilde MH Strating, Roland A Bal, Anna P Nieboer
BMC Health Services Research , 2011, DOI: 10.1186/1472-6963-11-314
Abstract: The exploratory methodological design consisted of three phases: a) framework development; b) instrument development; and c) field testing in former improvement teams in a quality improvement program for health care (N teams = 63, N individual = 112). Data were collected not until at least one year had passed after implementation.Underlying constructs and their interrelations were explored using Structural Equation Modeling and Principal Component Analyses. Internal consistency was computed with Cronbach's alpha coefficient. A long and a short version of the instrument are proposed.The χ2- difference test of the -2 Log Likelihood estimates demonstrated that the hierarchical two factor model with routinization and institutionalization as separate constructs showed a better fit than the one factor model (p < .01). Secondly, construct validity of the instrument was strong as indicated by the high factor loadings of the items. Finally, the internal consistency of the subscales was good.The theoretical framework offers a valuable starting point for the analysis of sustainability on the level of actual changed work practices. Even though the two dimensions routinization and institutionalization are related, they are clearly distinguishable and each has distinct value in the discussion of sustainability. Finally, the subscales conformed to psychometric properties defined in literature. The instrument can be used in the evaluation of improvement projects.It is unclear how health care organizations can sustain changed work practices [1]. Although studies on quality improvement and organizational change have yielded important insights in improvement processes, they also seem to have a strong focus on effectiveness of projects and outcome indicators. As a result of this, evidence on effectiveness of actual work practices often has not been obtained [2]. Moreover, many studies analyze improvement processes within the boundaries of projects only (ibid), without noting effectiven
Coping with methodological dilemmas; about establishing the effectiveness of interventions in routine medical practice
Yvonne JFM Jansen, Roland Bal, Marc Bruijnzeels, Marleen Foets, Rianne Frenken, Antoinette de Bont
BMC Health Services Research , 2006, DOI: 10.1186/1472-6963-6-160
Abstract: For this study an ethnographic design was used. We observed and interviewed the researchers and the practice nurses. All gathered research documents, transcribed observations and interviews were analysed thematically.Conducting a pragmatic trial is a continuous balancing act between meeting methodological demands and implementing a complex intervention in routine primary health care. As an effect, the research design had to be adjusted pragmatically several times and the intervention that was meant to be tailor-made became a rather stringent procedure.A pragmatic trial research is a dynamic process that, in order to be able to assess the validity and reliability of any effects of interventions must also have a continuous process of methodological and practical reflection. Ethnographic analysis, as we show, is therefore of complementary value.The question has been raised to what extent evidence from controlled clinical trials on prevention interventions is of value in the routine clinical practice of primary care [1-6]. Explanatory trials, the randomised controlled trials (RCTs) measuring the treatments' efficacy, meet the criteria for valid evaluation through randomisation, recruiting a sufficiently large number of subjects and using control situations [7-9] plus reliable measurements. Pragmatic trials, as opposed to explanatory RCTs, measure the effectiveness of treatments in routine clinical practice [8,10,11]. In pragmatic trials, the definition of the treatments is more or less standardised to correspond with daily clinical decision-making. Additionally, the heterogeneity of patients is reflected, fewer exclusion criteria are used, and blinding, randomisation and control situations may not always be used. As Hotopf argues, pragmatic trials are preferable when health care provision and services are to be evaluated, because their external validity to the extent of their usefulness in routine clinical practice is not compromised [12]. In the literature, pragmatic t
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