For the welfare of children: the origins of the relationship between US public health workers and pediatricians.
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The majority of children living in the United States today enjoy excellent health and access to health care. This was not always so; before the late 19th century, the field of pediatric medicine scarcely existed, and the combination of harsh and unsanitary living conditions in the urban areas where most immigrants settled, infectious diseases, and improper handling of milk was particularly deadly for infants and children. This article discusses the relationship between pediatric medicine and the broader children's health and public health movements in the United States in the early decades of the 20th century. That relationship resulted in 3 developments that had a profound impact on children's health: the establishment of dispensaries and milk stations that served impoverished children, campaigns to educate parents about illness prevention and child rearing, and the medical inspection of public schools and schoolchildren. Today, American children face both new threats to health and the reemergence of infectious diseases that were once thought conquered. Pediatricians and public health professionals must work together in the same spirit of social activism and community responsibility to meet these challenges. (+info)
Management of sickness absence: a quality improvement study from Slovenia.
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PROBLEM: A need to improve the communication system between general practitioners (GPs) and the national health insurance institute's (NHII) committee of experts for the referral and approval of sickness leave for patients. DESIGN: A structured low cost quality improvement method for motivating GPs to change their current practice was developed. BACKGROUND AND SETTING: The study was done in Kranj health district in Slovenia. GPs and members of the committee of experts identified potential problems using a cause and effect diagram. The study period for baseline data collection was from November 1996 to December 1996, and the re-evaluation took place in May 1997. All GPs in Kranj health district (n = 78) took part. Data were collected on 443 patients referred by GPs to the NHII committee during the first phase of the study and 590 patients during the re-evaluation phase. KEY MEASURES FOR IMPROVEMENT: Reducing the number of cases reported by members of the committee of experts as causing problems after the intervention. Feedback to GPs about the success of the process. STRATEGIES FOR CHANGE: A combination of methods was used: posted feedback, a guideline on record keeping, and a guideline, called AID (analysis of incidental deviations from expected service--in Slovene: analiza izjemnih dogodkov), on processing medical documentation. EFFECTS OF CHANGE: An overall drop was observed in the number of cases that caused problems (from 44% to 26%, p < 0.001). The most common problem at baseline (19.4% of the problems) was the seventh most common at the re-evaluation, then contributing only 9.2% of total problems (p = 0.02). LESSONS LEARNT: The results support a quality improvement philosophy that empowers "owners" of the process to be the key resource in managing change, and they show the importance of the inner motivation of those involved. Despite working in a country undergoing transition, medical professionals were still willing to improve their performance. Nevertheless, structures and funding are needed to foster quality improvement initiatives and implement national policy on quality in health care. (+info)
Reviewing audit: barriers and facilitating factors for effective clinical audit.
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OBJECTIVE: To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process. DESIGN: A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of "audit", "audit of audits", and "evaluation of audits" and a handsearch of the indexes of relevant journals for key papers. RESULTS: Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation. The main barriers to clinical audit can be classified under five main headings. These are lack of resources, lack of expertise or advice in project design and analysis, problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, effective training, dedicated staff, protected time, structured programmes, and a shared dialogue between purchasers and providers. CONCLUSIONS: Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing effective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise. (+info)
PACS (picture archiving and communication systems): filmless radiology.
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A picture archiving and communication system (PACS) is a computerised means of replacing the roles of conventional radiological film. This review describes the Hammersmith PACS, and discusses the advantages and disadvantages of PACS systems. (+info)
Development of a competency based training programme to support multidisciplinary working in a combined biochemistry/haematology laboratory.
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The aim of this study was to develop a competency based training programme to support multidisciplinary working in a combined biochemistry and haematology laboratory. The training programme was developed to document that staff were trained in the full range of laboratory tests that they were expected to perform. This programme subsequently formed the basis for the annual performance review of all staff. All staff successfully completed the first phase of the programme. This allowed laboratory staff to work unsupervised at night as part of a partial shift system. All staff are now working towards achieving a level of competence equivalent to the training level required for state registration by the Council for Professions Supplementary to Medicine. External evaluation of the training programme has included accreditation by the Council for Professions Supplementary to Medicine and reinspection by Clinical Pathology Accreditation (UK) Ltd. The development of a competency based training system has facilitated the introduction of multidisciplinary working in the laboratory. In addition, it enables the documentation of all staff to ensure that they are fully trained and are keeping up to date, because the continuing professional development programme in use in our laboratory has been linked to this training scheme. This approach to documentation of training facilitated a recent reinspection by Clinical Pathology Accreditation (UK) Ltd. (+info)
Perceived role of primary care physicians in Nova Scotia's reformed health care system. Qualitative study.
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OBJECTIVE: To determine primary care physicians' perceptions of their role in a reformed health system. DESIGN: Qualitative study using in-depth interviews. SETTING: Province of Nova Scotia. PARTICIPANTS: Purposefully selected sample of 14 practising primary care physicians. MAIN OUTCOME FINDINGS: Participants identified seven aspects of their role: primarily, diagnosis and treatment of patient's medical problems; then coordination, counseling, education, advocacy, disease prevention, and gatekeeping. The range of activities and degree of responsibility assumed by participants, however, varied. Factors affecting role perception fell into three categories: philosophical view of health and medicine, willingness to collaborate, and practical realities. Participants differed in their understanding of primary health care and their overall vision of the health system. Remuneration policies and concerns about sharing accountability were factors preventing an integrated, collaborative approach to care. Personal, patient, and structural realities also limited physicians' roles. CONCLUSIONS: This sample of primary care physicians had diverse perceptions of their role. Results of this study could provide information for identifying issues that need to be addressed to facilitate changes taking place in the health care system. (+info)
Sources of influence on medical practice.
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OBJECTIVES: To explore the opinion of general practitioners on the importance and legitimacy of sources of influence on medical practice. METHODS: General practitioners (n=723) assigned to Primary Care Teams (PCTs) in two Spanish regions were randomly selected to participate in this study. A self administered questionnaire was sent by mail and collected by hand. The dependent variable collected the opinion on different sources that exert influence on medical practice. Importance was measured with a 9 item scale while legitimacy was evaluated with 16 items measured with a 1 to 7 point Likert scale. RESULTS: The most important and legitimate sources of influence according to general practitioners were: training courses and scientific articles, designing self developed protocols and discussing with colleagues. The worst evaluated were: financial incentives and the role played by the pharmaceutical industry. CONCLUSIONS: The development of medical practice is determined by many factors, grouped around three big areas: organisational setting, professional system and social setting. The medical professional system is the one considered as being the most important and legitimate by general practitioners. Other strategies of influence, considered to be very important by the predominant management culture (financial incentives), are not considered to be so by general practitioners. These results, however, are not completely reliable as regards the real network of influences existing in medical practice, which reflect instead different "value systems". (+info)
Pediatric emergency room response to community pediatricians' expectations.
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BACKGROUND: In Israel the pediatric emergency room functions as an urgent primary care clinic in addition to dealing with life-threatening situations. Due to health insurance stipulations, most patients come to the PER with a referral from the community clinic. The relationship between the referring physician's expectations and the subsequent management of the referred patient in the PER is not well defined. OBJECTIVES: To evaluate the relationship between the expectations of the primary care physician and the management of referred patients in the PER, assess the type of information provided by the referring physician, and examine the effect of additional information obtained from the referring physician on patient management in the PER. METHODS: We reviewed the records of patients presenting at the PER with referrals from primary care physicians as well as additional information obtained by telephone interviews with the referring physicians. RESULTS: The expectations of the referring physicians were not fully documented in the referral form. The PER responded to the patient as if the PER was the initial contact. There was no significant difference in the response of PER physicians with or without additional information from the referring physicians. CONCLUSIONS: The PER acts as an independent unit with no obligation to satisfy the expectations of the referring physicians. The relationship between the PER and the referring physicians needs to be clarified. Guidelines and structured PER referral forms should be implemented in all primary care clinics to improve patient management and communication between health providers. (+info)