High-quality Care (high-quality + care)

Distribution by Scientific Domains

Selected Abstracts

Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias

Pat Croskerry MD
Clinical decision making is a cornerstone of high-quality care in emergency medicine. The density of decision making is unusually high in this unique milieu, and a combination of strategies has necessarily evolved to manage the load. In addition to the traditional hypothetico-deductive method, emergency physicians use several other approaches, principal among which are heuristics. These cognitive short-cutting strategies are especially adaptive under the time and resource limitations that prevail in many emergency departments (EDs), but occasionally they fail. When they do, we refer to them as cognitive errors. They are costly but highly preventable. It is important that emergency physicians be aware of the nature and extent of these heuristics and biases, or cognitive dispositions to respond (CDRs). Thirty are catalogued in this article, together with descriptions of their properties as well as the impact they have on clinical decision making in the ED. Strategies are delineated in each case, to minimize their occurrence. Detection and recognition of these cognitive phenomena are a first step in achieving cognitive de-biasing to improve clinical decision making in the ED. [source]

The Heart of the Matter: An Essay about the Effects of Managed Care on Family Therapy with Children,

FAMILY PROCESS, Issue 4 2001
Ellen Pulleyblank Coffey Ph.d.
This essay is based on a pilot study that examined the effects of managed care on the treatment of children and families, with special attention to community mental health. We embarked on the pilot study to test the accuracy and generalizability of our impression that family therapy and other systemic practices have been marginalized in ordinary clinics and agencies, and to understand the reasons why. We interviewed managed care providers, researchers, family therapy trainers, and clinicians in the Northeast. Our findings led to seven themes that support our impression that, even though there is a consensus about the need for coordinated family-based services, there is a disconnection between state policies, contractual requirements and what is actually occurring at the implementation level. This study suggests that our knowledge of human systems may be in danger of being disqualified and lost, with damaging consequences for the care of children. Yet, as systemic thinkers and practitioners, it is our belief that ethical and effective treatment need not be at odds with care that is cost-efficient. The direction of our future research will be to study whether the involvement of all stakeholders at all levels of planning and training leads to systemic family-based practices that consistently save costs and provide high-quality care. [source]

Improving geriatric mental health nursing care: Making a case for going beyond psychotropic medications

Philippe Voyer
ABSTRACT Providing high-quality mental health nursing care should be an important and continuous preoccupation in the gerontological nursing field. As the proportion of elderly people in our society is growing, the emphasis on high-quality care will receive increasing attention from administrators, politicians, organized groups, researchers and clinical nurses. Recent findings illustrate unequivocally the important contribution of nurses to achieving the goal of high-quality geriatric care. However, the quality of care for the elderly with psychological difficulties has not been addressed. The objective of this article is to illustrate that while nurses can accomplish much to improve the well-being and mental health of the elderly, their skills are often underutilized. Psychotropic drugs are often the first-line interventions used by health-care professionals to treat mental health concerns of elderly persons. Alternative therapies that could be implemented and evaluated, such as psychological counselling, supportive counselling, education and life review, are infrequently used. Nevertheless, current scientific data suggest that it would be very advantageous if nurses were to play a dominant role in the care of elderly people who are depressed or experiencing sleep pattern disturbances. The same can be said about elderly chronic users of benzodiazepines, as well as those with cognitive impairment. Evidence for the use of psychotropic medications as a viable treatment option for the elderly both in the community and in the long-term care setting who are experiencing mental health challenges is examined. Alternative non-pharmacological approaches that nurses can use to augment care are also briefly discussed. [source]

The economic burden of depression and the cost-effectiveness of treatment

Philip S. Wang
Abstract Cost-of-illness research has shown that depression is associated with an enormous economic burden, in the order of tens of billions of dollars each year in the US alone. The largest component of this economic burden derives from lost work productivity due to depression. A large body of literature indicates that the causes of the economic burden of depression, including impaired work performance, would respond both to improvement in depressive symptomatology and to standard treatments for depression. Despite this, the economic burden of depression persists, partly because of the widespread underuse and poor quality use of otherwise efficacious and tolerable depression treatments. Recent effectiveness studies conducted in primary care have shown that a variety of models, which enhance care of depression through aggressive outreach and improved quality of treatments, are highly effective in clinical terms and in some cases on work performance outcomes as well. Economic analyses accompanying these effectiveness studies have also shown that these quality improvement interventions are cost efficient. Unfortunately, widespread uptake of these enhanced treatment programmes for depression has not occurred in primary care due to barriers at the level of primary care physicians, healthcare systems, and purchasers of healthcare. Further research is needed to overcome these barriers to providing high-quality care for depression and to ultimately reduce the enormous adverse economic impact of depression disorders. Copyright 2003 Whurr Publishers Ltd. [source]

Magnet Recognition and Practice Development: Two journeys towards practice improvement in health care

Zoe Jordan BA MA (Communications Studies)
Health service providers continue to struggle with recruitment, retention, evidence-based practice and practice improvement in order to provide high-quality care for the communities they serve. In doing so, they are often required to implement strategies, which require considerable change at both organizational and ward/unit levels. The question remains, how do health service providers instigate processes that will result in positive and sustainable changes to practice and better outcomes for staff and patients? This paper outlines two increasingly used strategies for practice improvement (namely Magnet Recognition and Practice Development), their points of convergence and divergence and makes some broad recommendations for those seeking effective strategies for change that are cognizant of context and culture. [source]

Nurses' perception of the quality of care they provide to hospitalized drug addicts: Testing the Theory of Reasoned Action

Merav Ben Natan PhD RN
A correlational design was used to examine nursing staff attitudes and subjective norms manifested in intended and actual care of drug users based on the Theory of Reasoned Action. One hundred and thirty-five nursing staff from three central Israeli hospitals completed a questionnaire examining theory-based variables as well as sociodemographic and professional characteristics. Most respondents reported a high to very high level of actual or intended care of drug users. Nurses' stronger intentions to provide quality care to drug users were associated with more positive attitudes. Nursing staff members had moderately negative attitudes towards drug users. Nurses were found to hold negative stereotypes of drug addict patients and most considered the management of this group difficult. Positive attitudes towards drug users, perceived expectations of others and perceived correctness of the behaviour are important in their effect on the intention of nurses to provide high-quality care to hospitalized patients addicted to drugs. [source]

Proposing indicators for the development of nursing care quality in Iran

M. Pazargadi phd
Background:, Nursing has come a long way in developing frameworks for the delivery of high-quality care; however, it is still grappling with identifying key performance indicators and defining the patient outcomes that are directly or indirectly affected by nurses. Objective:, The study aimed to determine performance quality indicators in nursing care based on the healthcare system in Iran. Methods:, A descriptive exploratory study was conducted and 220 nurses from seven provinces in Iran were selected by quota sampling. A questionnaire including 97 indicators in seven categories was developed to collect data and respondents were asked to rate each indicator for importance, scientific acceptability and feasibility of implementation. Results:, Of the initial 220 distributed questionnaires, 74% (n = 119) nurse managers and 26% (n = 42) expert nurses (total: n = 161) returned questionnaires (73% response rate). The mean scores for all categories showed that the most of the indicators were important and scientifically acceptable (mean > 2.40), but difficult to implement in hospitals (mean < 2.15). An analysis using ANOVA showed that there were no significant differences between seven categories for the ,importance' aspect, but there were significant differences between ,time and quality of care' and ,job satisfaction', for ,scientific acceptability' (P = 0.004) and significant differences between most of categories for ,feasibility of implication'(P = 0.000). Conclusion:, The researchers have proposed the most significant nursing quality indicators for the clinical setting in Iran. These indicators would be useful for nurse managers as a first step to assess the quality of nursing care in hospitals. [source]

Using cost-analysis techniques to measure the value of nurse practitioner care

D. Vincent PhD
Abstract Nurse practitioners are in a unique position to deliver high-quality care to a variety of populations and are being utilized in many countries worldwide. Although certain aspects of the nurse practitioner role may differ from country to country, limited financial support and competition for access to patients make it incumbent on nurse practitioners to document the cost-effectiveness of their care. Cost analysis, a business tool that can be used by any practitioner in any health care system, was used to examine business practices of an academic-based nurse-managed centre. In order for this tool to be effective, nurse practitioners must become comfortable with using cost-analysis techniques in their practices. Linking outcome data with cost data was found to be one method for explicating the value of nurse practitioner practice. Nurse practitioners must also recognize that they are competing with primary-care physician practices and other primary health-care practices. It is vital for nurse practitioners to document both the quality and the costs of their care in order to compete with physicians and other health care providers, in order to influence policy and other health-care decision makers. [source]

Use of Medicare and Department of Veterans Affairs Health Care by Veterans with Dementia: A Longitudinal Analysis

Carolyn W. Zhu PhD
The objectives of this study were to examine longitudinal patterns of Department of Veterans Affairs (VA),only use, dual VA and Medicare use, and Medicare-only use by veterans with dementia. Data on VA and Medicare use were obtained from VA administrative datasets and Medicare claims (1998,2001) for 2,137 male veterans who, in 1997, used some VA services, had a formal diagnosis of Alzheimer's disease or vascular dementia in the VA, and were aged 65 and older. Generalized ordered logit models were used to estimate the effects of patient characteristics on use group over time. In 1998, 41.7% of the sample were VA-only users, 55.4% were dual users, and 2.9% were Medicare-only users. By 2001, 30.4% were VA-only users, 51.5% were dual users, and 18.1% were Medicare-only users. Multivariate results show that greater likelihood of Medicare use was associated with older age, being white, being married, having higher education, having private insurance or Medicaid, having low VA priority level, and living in a nursing home or dying during the year. Higher comorbidities were associated with greater likelihood of dual use as opposed to any single system use. Alternatively, number of functional limitations was associated with greater likelihood of Medicare-only use and less likelihood of VA-only use. These results imply that different aspects of veterans' needs have differential effects on where they seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure that patients receive high-quality care, especially patients with multiple comorbidities. [source]

A Multidisciplinary Program for Delivering Primary Care to the Underserved Urban Homebound: Looking Back, Moving Forward

Kristofer L. Smith BA
The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost,benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program. [source]

Development of Geriatric Competencies for Emergency Medicine Residents Using an Expert Consensus Process

Teresita M. Hogan MD
Abstract Background:, The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes. Objectives:, The objective was to develop a consensus document, "Geriatric Competencies for Emergency Medicine Residents," by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training. Methods:, This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project. Results:, In Phase I, participants (n = 363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n = 24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions. Conclusions:, The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population. ACADEMIC EMERGENCY MEDICINE 2010; 17:316,324 2010 by the Society for Academic Emergency Medicine [source]

Staff Activity in Supported Housing Services

David Felce
Background Variation in staff performance between small community housing services indicates the need for research on the factors which predict high-quality care. Methods The associations between service sector, staffing levels, staff characteristics, internal organization or working practices, non-institutional milieu, and staff activity and the nature and extent of staff attention to residents were explored in a study of 10 statutory, 10 voluntary and nine private sector community housing schemes. Results There were few significant differences between sectors after differences in resident abilities were taken into account. Higher staff to resident ratios predicted greater resident receipt of attention and assistance but also a lower proportion of time during which each member of staff was directly concerned with residents. A greater range in resident ability predicted lower resident receipt of attention and assistance. A higher proportion of qualified staff was not shown to be a positive attribute but greater prior experience was associated with staff spending more time directly concerned with residents, less time doing ,other' activity and residents receiving more assistance. Measures of the internal organization and non-institutional milieu of the settings were not strongly related to staff activity. Conclusions The findings are consistent with previous research that there are diminishing marginal returns associated with increasing staff. Size of residence was unimportant. Links between service organization and staff performance require further research but retaining experienced staff appears to be important. As resident receipt of attention and assistance was unrelated to their adaptive behaviour level, there is a need to find ways to ensure that staff support matches the needs of residents better. [source]

Non,housestaff medicine services in academic centers: Models and challenges

Niraj L. Sehgal MD
Abstract Non,housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non,housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the "academic hospitalist"), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission. Journal of Hospital Medicine 2008;3:247,255. 2008 Society of Hospital Medicine. [source]

Why do some hospital leaders "speak no evil" about their organizations' medical errors?

Ruby A. Rouse
Sentinel events, preventable medical errors resulting in serious disability or death, are a significant problem for hospital leaders. Accreditation agencies, such as the Joint Commission, urge hospitals to voluntarily disclose information about medical errors. However, some healthcare leaders "speak no evil" by choosing not to release sentinel-event data. In an effort to increase the reporting of medical errors, several states passed laws mandating disclosure of sentinel events to the government. The state-reported medical error rates of Indiana hospitals were compared with their leaders' perceptions of quality of care. Regardless of the number of sentinel events occurring at their hospitals, leaders consistently claimed their organizations provided high-quality care. Two theories, rationalization and gaming, are presented to explain why leaders do not acknowledge the presence of serious quality-management problems in their organizations. [source]

Process-oriented group supervision implemented during nursing education: nurses' conceptions 1 year after their nursing degree

Aim, To describe the variation in how nurses conceive process-oriented group supervision, implemented during nursing education, 1 year after their nursing degree. Background, Process-oriented group supervision can be an effective support system for helping nursing students and nurses to reflect on their activities. Methods, A descriptive qualitative design was chosen for the study. Conceptions were collected through interviews with 18 strategically selected Swedish nurses in 2005. Results, Three descriptive categories comprising seven conceptions were emerged. Supportive actions comprised: a sense of security, belonging and encouragement. Learning actions involved: sharing and reflecting while developmental actions described: enabling professional identity and facilitating personal development. Conclusions, Process-oriented group supervision has a lasting influence on nurses' development. The possibility to reflect over new stances during nursing education was a prerequisite for the provision of high-quality care. Process-oriented group supervision can make an important contribution to nursing education. Implications for Nursing Management, Process-oriented group supervision provides nurses with the strength to achieve resilience to stress in their work. It may lead to autonomy as well as clarity in the nurse's professional function. This indicates the need for nurse managers to organize reflective group supervision as an integral part of the nurse's work. [source]

A New Information Exchange System for Nursing Professionals to Enhance Patient Safety Across Europe

Dr. Alessandro Stievano RN
Abstract Purpose: Ensuring safe healthcare services is one of today's most challenging issues, especially in light of the increasing mobility of health professionals and patients. In the last few years, nursing research has contributed to the creation of a culture of safety that is an integral part of clinical care and a cornerstone of healthcare systems. Organizing Constructs: European institutions continue to discuss methods and tools that would best contribute to ensuring safe and high-quality care, as well as ensuring access to healthcare services. According to the European Commission between 8% and 12% of patients admitted to hospitals in the European Union member states suffer from adverse events while receiving care, although some of these events are part of the intrinsic risk linked to receiving care. However, most of these adverse events are caused by such avoidable healthcare errors as, for instance, diagnosis mistakes, inability to act on the results of tests, medication errors, failures of healthcare equipment and hospital infections. Nosocomial infections alone are estimated to affect 4.1 million inpatients, that is, about 1 of every 20 inpatients, causing avoidable suffering and mortality, as well as an enormous loss of financial resources (at least ,5.48 billion a year). Conclusions: The Internal Market Information (IMI) System, developed by the European Commission, aims at contributing to patient safety by means of a timely and updated exchange of information among nursing regulatory bodies on the good standing and scope of practice of their registrants. Through the IMI System, the European Federation of Nursing Regulators will improve its electronic database on nurses to allow national nursing regulatory bodies to exchange the information needed to recognize the nurses' educational and professional qualifications and competencies. This process both facilitates the mobility of professionals and ensures high-quality nursing practice in an even and consistent way across the European Union. Clinical Relevance: On a national basis, nursing regulatory bodies play an important role in ensuring patient safety through high standards of nursing education and competence, whereas on an international basis, patient safety can assured by a better exchange of information between national regulatory bodies on the good professional standing of nurses. [source]

Cultural competence: a conceptual framework for teaching and learning

Conny Seeleman
Objectives, The need to address cultural and ethnic diversity issues in medical education as a means to improve the quality of care for all has been widely emphasised. Cultural competence has been suggested as an instrument with which to deal with diversity issues. However, the implementation of culturally competent curricula appears to be difficult. We believe the development of curricula would profit from a framework that provides a practical translation of abstract educational objectives and that is related to competencies underlying the medical curriculum in general. This paper proposes such a framework. Methods, The framework illustrates the following cultural competencies: knowledge of epidemiology and the differential effects of treatment in various ethnic groups; awareness of how culture shapes individual behaviour and thinking; awareness of the social context in which specific ethnic groups live; awareness of one's own prejudices and tendency to stereotype; ability to transfer information in a way the patient can understand and to use external help (e.g. interpreters) when needed, and ability to adapt to new situations flexibly and creatively. Discussion, The framework indicates important aspects in taking care of an ethnically diverse patient population. It shows that there are more dimensions to delivering high-quality care than merely the cultural. Most cultural competencies emphasise a specific aspect of a generic competency that is of extra importance when dealing with patients from different ethnic groups. We hope our framework contributes to the further development of cultural competency in medical curricula. [source]

Telephone Appointment Visits for Head and Neck Surgery Follow-up Care,,

Jeffrey Eaton MD
Abstract Objectives/Hypothesis To test the hypothesis that patients with a variety of otolaryngologic diagnoses using telephone appointment visits would be equally as satisfied as patients receiving physician office visits, the study compared telephone appointment visits with physician office visits for health maintenance organization patients who needed routine follow-up care in a head and neck surgery clinic. Study Design Randomized, nonblinded cross-sectional study. Methods After their initial visit to either of two head and neck surgery clinics, new otolaryngology patients were randomly assigned into treatment and control groups. Patients in the treatment group (n = 73) received follow-up care in the form of telephone appointment visits, and patients in the control group (n = 80) received physician office visits for follow-up care. Study data were collected using telephone interviews and physician trackingforms. Results Patients receiving telephone appointment visits were significantly less satisfied with their visits than patients receiving physician office visits (,2 = 25.4, P <.005). Patients who had physician office visits were significantly more likely than were patients in the treatment group to agree "somewhat" or "strongly" that 1) the physician addressed their questions and concerns (,2 = 24.0, P <.005); 2) the physician provided personal care and attention (,2 =29.9, P <.005); and 3) the physician provided high-quality care (,2 =34.5, P <.005). Conclusions Patients who received telephone appointment visits were statistically significantly less satisfied with all aspects of their follow-up appointment than were patients who had physician office visits. The study findings indicate that telephone appointment visits may not be an ideal type of follow-up visit for all patients. Despite these findings, one third of patients in the treatment group would consider receiving a telephone appointment visit for future routine follow-up care, and 21.9% had no preference, perhaps a factor indicating willingness to receive a telephone appointment for a follow-up visit. [source]

Prevention of medication errors: detection and audit

Germana Montesi
1. Medication errors have important implications for patient safety, and their identification is a main target in improving clinical practice errors, in order to prevent adverse events. 2. Error detection is the first crucial step. Approaches to this are likely to be different in research and routine care, and the most suitable must be chosen according to the setting. 3. The major methods for detecting medication errors and associated adverse drug-related events are chart review, computerized monitoring, administrative databases, and claims data, using direct observation, incident reporting, and patient monitoring. All of these methods have both advantages and limitations. 4. Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of a culture of safe practice. Combining and comparing data from various and encourages the diffusion of a culture of safe practice sources increases the reliability of the system. 5. Error prevention can be planned by means of retroactive and proactive tools, such as audit and Failure Mode, Effect, and Criticality Analysis (FMECA). Audit is also an educational activity, which promotes high-quality care; it should be carried out regularly. In an audit cycle we can compare what is actually done against reference standards and put in place corrective actions to improve the performances of individuals and systems. 6. Patient safety must be the first aim in every setting, in order to build safer systems, learning from errors and reducing the human and fiscal costs. [source]

9 A Communication Tool for Emergency Medicine Residents to Improve Patient Care and Professional Development

Jacqueline Mahal
For every patient in the ED, a web of communication is created. A resident is at the center of this web , connecting team members in and outside the ED. Careful communication, a required ACGME competency, helps the team provide safe, high-quality care and master their respective specialties. We designed a three module curriculum that supports ACGME core competencies by providing training in professional communication and a framework with which to organize patient data. In the first module, residents are introduced to the concept that there is more to communication than content alone. Other elements include context, audience and forum. Together, these components comprise relevant communication. The second module introduces the Disposition, Situation, Background, Assessment, Recommendation, Safety (D-SBARS) Framework, an ED modification of The Joint Commission's communication tool. This framework will enable the resident to focus on communicating the relevant data for a particular audience in an appropriate manner. In the last module, residents participate in a case-based role-play. After presentation of a complicated patient, residents are each assigned a communication task. They communicate with attendings, ED staff and consultants. Each role is played by senior residents. Finally, participants deliver presentations to the on-coming team on "rounds" under time constraints, declining from two minutes to 30 seconds. Residents experience how the D-SBARS tool helps them communicate critical clinical and safety. [source]