Impact of litigation on senior clinicians: implications for risk management.
(9/1663)
OBJECTIVES: To investigate the impact of litigation on consultants and senior registrars and to establish their views on methods of reducing adverse events and litigation. DESIGN: Postal survey. SETTING: Acute hospitals in the North Thames (West) Regional Health Authority. SUBJECTS: 1011 consultants and senior registrars in acute hospitals. MAIN MEASURES: Perceived causes and effects of adverse events; views on methods of reducing litigation and adverse events. RESULTS: 769 (76%) doctors responded. 288 (37%) had been involved in litigation at some point during their career; 213 surgeons (49%) and 75 (23%) doctors in the medical specialties. Anger, distress, and feeling personally attacked were common responses to litigation. Clinicians' views on reducing litigation emphasised the need for change at the clinical level. Supervision of junior staff, workload, and training in communication skills were to the fore. CONCLUSIONS: The high frequency of doctors who have experienced litigation and the emotional responses described indicate that clinicians require support at several levels. At a personal level, support can be offered to clinicians going through the litigation process or after an adverse event. Also, managerial support is needed by offering financial and practical help in correcting the factors that have been consistently identified as producing high risk situations to minimise the possibility of a reoccurrence. Accidents in medicine are, by their very nature, costly in human and financial terms and the root causes must be tackled. Recommendations are made for clinicians and risk management teams. (+info)
What are hospitals doing about clinical guidelines?
(10/1663)
OBJECTIVES: To assess the attitudes of senior hospital staff towards clinical guidelines, and to ascertain the perceived extent and benefits of their local use; to identify those hospitals with current or planned future written strategies for the systematic development of clinical guidelines, and the staff responsible for leading them; and to establish the essential elements of existing strategies, and the methods used to ensure the proper development, dissemination, implementation, and evaluation of local guidelines. DESIGN: Cross sectional survey. PARTICIPANTS: Senior staff of 270 acute hospitals in the United Kingdom (response rate 202/270 (75%)) in 1995. RESULTS: 197/199 (99%) of respondents thought that clinical guidelines were a good idea, and 176/196 (90%) were aware of some guideline activity occurring within their hospitals. The most important benefits of local guideline activity were increased healthcare efficiency and effectiveness, greater consistency of treatment, and team building. 174/194 (90%) of respondents were in favour of the development of a readily accessible national repository of evidence-based clinical guidelines. 38/201 (19%) of respondents had a clinical guidelines strategy and a further 91/201 (45%) said that they had plans to develop one in the near future. The need to improve clinical outcomes was most often reported as the reason for developing a strategy. Medical directors most commonly had formal responsibility to lead the strategy, but someone without formal responsibility ran the operation in half the hospitals. Only 18/36 (50%) of strategies gave advice on the development of guidelines; and only a few strategies made explicit statements on which clinical services to target for guideline development, or the methods to be used for their validation and promotion. Some strategies lacked explicit statements on methods to monitor adherence, routine review, and update of guidelines. Internal literature searches (29/31 (94%)), the use of national guidelines (29/32 (91%)), local consensus conferences (28/32 (88%)), and peer group review (21/24 (88%)) were the most popular methods of validation used in hospitals with a strategy. Methods used to promote the dissemination, implementation, and evaluation of clinical guidelines included clinical audit (31/32 (97%)), peer review (25/30 (83%)), continuing education (23/29 (79%)), targeting of opinion leaders (17/26 (65%)), use of structured case notes (14/31 (45%)), patient mediated interventions (9/26 (35%)), and patient specific reminders (8/26 (31%)). CONCLUSIONS: Most senior hospital staff have a favourable attitude towards clinical guidelines. Most hospitals are undertaking some guideline activity, but few seem to be doing so within a locally agreed hospital wide strategy in which guideline development, dissemination, implementation, and evaluation are systematically considered. Many of the current methods used to validate guidelines locally are inadequate. Evidence-based clinical guidelines should be developed nationally, leaving hospitals to focus their energies on the local adaptation, dissemination, implementation, and evaluation of such guidelines. Only in this way will local guidelines achieve their full potential to improve clinical care and patient outcomes. (+info)
Evaluation of joint medical and nursing notes with preprinted prompts.
(11/1663)
OBJECTIVE: To determine the views of doctors and nurses about two recent innovations in the structure of case notes: the use of preprinted prompts and the use of joint medical and nursing notes. DESIGN: Questionnaire survey of all doctors and nurses working on the children's wards. SETTING: Children's wards in a district general hospital. MAIN OUTCOME MEASURES: Whether or not respondents wanted to return to traditional notes; positive and negative aspects of the two innovations. RESULTS: There was an 81% response rate. 45 of 48 respondents (94%) did not want to return to traditional notes. Positive features of joint notes that were identified included: promotes team work (21/48 respondents), improves access to information (14/48), and reduces duplication (14/48). Negative features included uncertainty about identity of writer (8/48) and incompletely filled in sheets (7/48). Positive features of preprinted prompts included: less information omitted (29/48), easier to read and find information (28/48), and quicker to write (21/48). Negative features included: not enough space (19/48) and clerking too mechanical (16/48). CONCLUSION: Advantages of both innovations outweighed their disadvantages to the extent that only three out of 48 respondents wanted to return to writing traditional notes. (+info)
Physicians' perceptions of managed care.
(12/1663)
We wished to determine physicians' views and knowledge of managed care, particularly their beliefs about the provisions of managed care contracts in terms of legality and ethics. A questionnaire was sent to the 315 physicians of the medical staff of Norwalk Hospital in Connecticut regarding managed care and managed care contracts. Sixty-six responses were received within a 45-day period (20.9% return). Although only 1 of 11 contract provisions presented in one section of the questionnaire was illegal in Connecticut, a majority of physicians believed 7 of the 11 were illegal. On average, 50% of physicians polled thought each of the provisions was illegal, and a varying majority of physicians (53% to 95.4%) felt the various provisions were unethical. The majority of respondents (84.8% to 92.4%) believed that nondisclosure provisions were unethical. Ninety-seven percent thought managed care interferes with quality of care, and 72.7% of physicians felt that the managed care industry should be held legally responsible for ensuring quality of care. However, 92.4% of physicians considered themselves to be ethically responsible for ensuring quality of care. Physicians have a poor understanding of the legal aspects of managed care contracts but feel strongly that many provisions of these contracts are unethical. Physicians also believe that managed care is causing medicine to be practiced in a manner that is contrary to patients' interests and that legal recourse is needed to prevent this. (+info)
An approach to an index of hospital performance.
(13/1663)
Two indexes are described, based on measures of administrative effectiveness and patient care effectiveness. The measures used were selected and ranked by a Delphi panel from a list of 30 measures drawn from the literature. Weights were assigned by the panel to 19 selected measures. The resulting indexes did well in a test on data collected from 32 Texas hospitals. (+info)
Attitudes and behavioral intentions regarding managed care: a comparison of academic and community physicians.
(14/1663)
Physicians' attitudes toward managed care and the impact of these attitudes on behaviors that affect patient care are important factors in managed care reform. In addition, the attitudes of academic physicians may influence their willingness to reform medical education in an effort to prepare students to practice under managed care. Although it is a conventional opinion that the academic health center and its academic physicians are antagonistic toward managed care, there has not been a direct comparison of the attitudes of these physicians to those of practicing community physicians. We used a self-administered questionnaire to assess attitudes toward managed care and behavioral intentions regarding practices related to managed care; a sample of academic physicians (n = 129) was compared with a sample of community physicians (n = 307). Community physicians were less negative in their evaluations of the quality of care in a managed care environment, but no differences were identified between the two groups with regard to the cost-effectiveness, inevitability, or need to adapt to managed care. Academic specialists were more likely than academic primary care physicians to rate managed care as something to which they needed to adapt. Community physicians were less likely to report a willingness to change their referral patterns. Aggregating across practice type, we also uncovered systematic differences between primary care and specialist physicians. The data suggest that opinions about quality and cost-containment in managed care are significant correlates of intentions to change practice behaviors. (+info)
Physician and dietitian prescribing of a commercially available oral nutritional supplement.
(15/1663)
We examined whether a policy change transferring prescribing privileges for oral nutritional supplements to dietitians resulted in fewer inappropriate outpatient prescriptions. This was a pre/post study design using a retrospective review of physician and dietitian prescribing for ambulatory patients during two separate time periods: physician prescribing, October to December, 1994; dietitian prescribing, April to June, 1995. Inappropriate prescriptions during each period were defined as those given to patients with normal nutritional status or with a contraindication to a high-energy, electrolyte-containing solution. The study was conducted in outpatient clinics at a Veterans Affairs teaching hospital. We found that dietitians gave fewer prescriptions to outpatients who were not malnourished or to outpatients who had a contraindication to receiving a supplement (11% vs 34%; P = 0.002). In addition, dietitians more often completed relevant laboratory assessments (75% vs 43%; P = 0.001) and more frequently arranged follow-up dietetic evaluations (84% vs 30%, P < 0.001) for ambulatory patients receiving supplements. We conclude that transferring nutritional supplement prescribing privileges to dietitians led to fewer inappropriate outpatient prescriptions and to more comprehensive nutritional assessments, as measured by relevant laboratory use and dietetic follow-up. Physicians more frequently prescribed supplements to outpatients who were not malnourished or who had contraindications to receiving supplements. Our results suggest that physicians would benefit from assistance with and/or education concerning oral nutritional supplements. (+info)
Glove usage and reporting of needlestick injuries by junior hospital medical staff.
(16/1663)
The use of gloves when conducting invasive procedures and the reporting of needlestick injuries have been strongly encouraged. Despite this, neither practice appears to be universal. In order to determine the rates of glove usage and needlestick injury reporting, we conducted a survey of junior doctors in three hospitals in the UK. Of the 190 respondents, the majority rarely wore gloves for venesection, insertion of intravenous cannulas or arterial blood gas sampling. For more major procedures (insertion of central venous lines, insertion of thoracostomy tubes, suturing) gloves were invariably worn. Only 17.5% of needlestick injuries were reported. The rates of glove usage and needlestick injury reporting were lower than previous studies have demonstrated in North America. Surgeons suffered the most needlestick injuries and were the least likely to report them. The low reporting rate may have serious implications, particularly in view of the new Government guidelines on needlestick injuries which involve HIV-infected blood. By failing to use gloves and report needlestick injuries, junior doctors, in particular surgeons, are placing themselves and patients at increased risk of blood-borne transmissible diseases. (+info)