Clinical complaints and their handling: a time for change? (1/1458)

OBJECTIVES: To assess the performance of the hospital complaints procedure for complaints proceeding to peer review and the quality of responses to complainants. DESIGN: Retrospective study of data on clinical complaints proceeding to peer review during 1986-91 from clinical records, correspondence, reports of the complaints investigations, and expert review of written responses to complainants. SETTING: Northern Regional Health Authority, covering three million people. SUBJECTS: All 71 clinical complaints investigated to the third stage of the hospital complaints procedure and a sample of 65 written responses to complainants. MAIN MEASURES: Characteristics, duration, and outcome of complaints; findings of peer review; and quality of written responses at various stages in the procedure as evaluated by an expert panel against eight agreed criteria. RESULTS: The median duration of a complaint investigated through all stages of the procedure was 381 days. The longest median stages were those involving attempted resolution locally (131 days) and in which peer review was being arranged (113 days). More complaints alleging failure of communication were upheld by peer review (46/59, 78%) than those alleging misapplication of clinical skills (20/98, 20%) or failure to initiate appropriate investigations or treatment (8/32, 25%). Written responses commonly fell below the standards agreed by the expert panel. CONCLUSIONS: The hospital complaints procedure takes too long and its final peer review stage may not demonstrate sufficient impartiality. The written responses suggest that criticism is not welcomed as a way of improving service. IMPLICATION: The clinical complaints procedure needs to be reformed to ensure true accountability to patients.  (+info)

Strengthening health management: experience of district teams in The Gambia. (2/1458)

The lack of basic management skills of district-level health teams is often described as a major constraint to implementation of primary health care in developing countries. To improve district-level management in The Gambia, a 'management strengthening' project was implemented in two out of the three health regions. Against a background of health sector decentralization policy the project had two main objectives: to improve health team management skills and to improve resources management under specially-trained administrators. The project used a problem-solving and participatory strategy for planning and implementing activities. The project resulted in some improvements in the management of district-level health services, particularly in the quality of team planning and coordination, and the management of the limited available resources. However, the project demonstrated that though health teams had better management skills and systems, their effectiveness was often limited by the policy and practice of the national level government and donor agencies. In particular, they were limited by the degree to which decision making was centralized on issues of staffing, budgeting, and planning, and by the extent to which national level managers have lacked skills and motivation for management change. They were also limited by the extent to which donor-supported programmes were still based on standardized models which did not allow for varying and complex environments at district level. These are common problems despite growing advocacy for more devolution of decision making to the local level.  (+info)

Exposure to trichloroethylene III. Psychological functions. (3/1458)

The effect of exposure to the solvent trichloroethylene (TRI) on the performance of tests of numerical ability, reaction time (simple and choice), and short-term memory was studied in 15 healthy male subjects. The subjects were tested individually on three different occasions during exposure to 540 and 1,080 mg/m3 of TRI in inspiratory air and under control conditions, respectively. At predetermined times during the three 70-min exposure periods, samples were taken of the subjects' alveolar air. Neither the reaction time tests nor the short-term memory test showed any signs of performance decrement during exposure to TRI as compared to those administered under control conditions. However, a statistically significant decrement in performance was obtained on the test of numerical ability during exposure to TRI. The results as a whole indicate that there should not be any risk of an acute effect on central nervous functions at concentrations which do not considerably exceed the Swedish threshold limit value for the solvent (160 mg/m3).  (+info)

Context-dependent, neural system-specific neurophysiological concomitants of ageing: mapping PET correlates during cognitive activation. (4/1458)

We used PET to explore the neurophysiological changes that accompany cognitive disability in ageing, with a focus on the frontal lobe. Absolute regional cerebral blood flow (rCBF) was measured in 41 healthy volunteers, evenly distributed across an age range of 18-80 years, during two task paradigms: (i) the Wisconsin Card Sorting Test (WCST), which depends heavily on working memory and is particularly sensitive to dysfunction of the dorsolateral prefrontal cortex (DLPFC); and (ii) Raven's Progressive Matrices (RPM), which may also have a working memory component, but depends more on visuo-spatial processing and is most sensitive to dysfunction of postrolandic regions. We used voxel-wise correlational mapping to determine age-related changes in WCST and RPM activation and developed a method to quantitate and localize statistical differences between the correlation maps for the two task paradigms. Because both WCST and RPM performance declined with age, as expected, correlational analyses were performed with and without partialling out the effect of task performance. Task-specific reductions of rCBF activation with age were found in the DLPFC during the WCST and in portions of the inferolateral temporal cortex involved in visuo-spatial processing during the RPM. We also found reduced ability to suppress rCBF in the right hippocampal region during the WCST and in mesial and polar portions of the prefrontal cortex during both task conditions. Task-dependent alterations with age in the relationship between the DLPFC and the hippocampus were also documented; because the collective pattern of changes in the hippocampal-DLPFC relationship with ageing was opposite to that seen in a previous study using dextroamphetamine, we postulated a dopaminergic mechanism. These results indicate that, despite some cognitive overlap between the two tasks and the age-related cognitive decline in both, many of the changes in rCBF activation with age were task-specific, reflecting functional alteration of the different neural circuits normally engaged by young subjects during the WCST and RPM. Reduced activation of areas critical for task performance (i.e. the DLPFC during the WCST and posterior visual association areas of the inferolateral temporal cortex during the RPM), in conjunction with the inability to suppress areas normally not involved in task performance (i.e. the left hippocampal region during the WCST and mesial polar prefrontal cortex during both the WCST and RPM), suggest that, overall, reduced ability to focus neural activity may be impaired in older subjects. The context dependency of the age-related changes is most consistent with systems failure and disordered connectivity.  (+info)

Training for quality management: report on a nationwide distance learning initiative for physicians in Spain. (5/1458)

Under the sponsorship of a pharmaceutical firm, a distance-learning course on Quality Management methods was developed at the University of Murcia (Spain) and offered nationwide to primary health care physicians working in the public system. A total of 7104 physicians (47.7% of the census) signed up (at least one in 92.2% of the health centres). The course content follows the author's model of quality improvement, monitoring and design trilogy, but focuses mainly on methods for a quality improvement cycle using a learning-by-doing and problem-solving approach. The unexpected success of this initiative has led us to reflect on the interest in learning about quality improvement methods shown by physicians, the usefulness of the distance-learning approach, and also to continue the project with new initiatives such as: a summary poster, software containing all the necessary tools and data analysis for quality improvement, and a manual.  (+info)

The effects of neurocognitive remediation on executive processing in patients with schizophrenia. (6/1458)

Approaches to cognitive remediation have differed across studies. Most of the larger studies have concentrated on group treatments designed without the benefit of recent laboratory-based studies. The current study describes a randomized trial of an intensive cognitive remediation program involving individual daily sessions of 1 hour for up to 3 months. It targets executive functioning deficits (cognitive flexibility, working memory, and planning) that are known to be problematic in people with schizophrenia. Procedural learning, as well as the principles of errorless learning, targeted reinforcement, and massed practice, was the basis of the intervention. The program was compared with an alternative therapy (intensive occupational therapy) to control for some of the effects of therapeutic contact. Some improvements in cognition followed both therapies. A differential effect in favor of cognitive remediation therapy was found for tests in the cognitive flexibility and the memory subgroups. There was a trend for those receiving atypical antipsychotic medication to benefit more from cognitive remediation for tests of cognitive flexibility. Although there were no consistent changes in symptoms or social functioning between groups, if improvement in cognitive flexibility tasks reached a threshold then there is some evidence that social functioning improved, even over the short duration of the trial. In addition, cognitive remediation differentially improved self-esteem. This study supports the view that cognitive remediation can reduce cognitive deficits and that this reduction may affect social outcome, at least in the short term.  (+info)

"What" and "how": evidence for the dissociation of object knowledge and mechanical problem-solving skills in the human brain. (7/1458)

Patients with profound semantic deterioration resulting from temporal lobe atrophy have been reported to use many real objects appropriately. Does this preserved ability reflect (i) a separate component of the conceptual knowledge system ("action semantics") or (ii) the operation of a system that is independent of conceptual knowledge of specific objects, and rather is responsible for general mechanical problem-solving skills, triggered by object affordances? We contrast the performance of three patients-two with semantic dementia and focal temporal lobe atrophy and the third with corticobasal degeneration and biparietal atrophy-on tests of real object identification and usage, picture-based tests of functional semantic knowledge, and a task requiring selection and use of novel tools. The patient with corticobasal degeneration showed poor novel tool selection and impaired use of real objects, despite near normal semantic knowledge of the same objects' functions. The patients with semantic dementia had the expected deficit in object identification and functional semantics, but achieved flawless and effortless performance on the novel tool task. Their attempts to use this same mechanical problem-solving ability to deduce (sometimes successfully but often incorrectly) the use of the real objects provide no support for the hypothesis of a separate action-semantic system. Although the temporal lobe system clearly is necessary to identify "what" an object is, we suggest that sensory inputs to a parietal "how" system can trigger the use of objects without reference to object-specific conceptual knowledge.  (+info)

How pigeons discriminate the relative frequency of events. (8/1458)

This study examined how pigeons discriminate the relative frequencies of events when the events occur serially. In a discrete-trials procedure, 6 pigeons were shown one light nf times and then another nl times. Next, they received food for choosing the light that had occurred the least number of times during the sample. At issue were (a) how the discrimination was related to two variables, the difference between the frequencies of the two lights, D = nf - nl, and the total number of lights in the sample, T = nf + nl; and (b) whether a simple mathematical model of the discrimination process could account for the data. In contrast with models that assume that pigeons count the stimulus lights, engage in mental arithmetic on numerons, or remember the number of stimuli, the present model assumed only that the influence of a sample stimulus on choice increases linearly when the stimulus is presented, but decays exponentially when the stimulus is absent. The results showed that, overall, the pigeons discriminated the relative frequencies well. Their accuracy always increased with the absolute value of the difference D and, for D > 0, it decreased with T. Performance also showed clear recency, primacy, and contextual effects. The model accounted well for the major trends in the data.  (+info)