The Freiburg approach to ethics consultation: process, outcome and competencies. (57/872)

The paper describes how ethics consultation can be valuable to health professionals, patients and their families in understanding and evaluating ethical values and their consequences in a particular situation. Ethics consultation as it is practised at the university hospital of Freiburg is a special professional service offered by members of an academic institution. The practical approach and the goals are illustrated by a case study showing the difficulties of deciding about the limitation of intensive care medicine after heart surgery in the setting of maximum treatment. Here, the ethics consultation was initiated by the relatives of the patient who wanted a decision to withhold further life-sustaining treatment. Following the experiences in Freiburg, it is concluded that clinical ethicists have to cover a variety of relevant fields of knowledge, need special analytical skills, and should have professional competence in counselling, including conflict mediation or crisis intervention.  (+info)

Clinical governance--watchword or buzzword? (58/872)

In the latest reform of the National Health Service great emphasis has been placed on the achievement and maintenance of quality. Mechanisms for ensuring this are being set up under the general title of "clinical governance". What is the meaning of this term? The metaphor behind the phrase is of navigation through stormy seas, but who guides the helmsman? Clinical ethics committees could have a part to play in these changes, provided their role is properly understood. Clinical governance is concerned with management according to an agreed set of aims. The task of ethics committees is Socratic rather than managerial. They should ask fundamental questions about the ethical norms of the services provided and give critical appraisal of the moral character of institutional policies. If these tasks are carried out then governance may become a watchword rather than just another buzzword.  (+info)

Snapshots of five clinical ethics committees in the UK. (59/872)

Each of the following papers gives an account of a different UK clinical ethics committee. The committees vary in the length of time they have been established, and also in the main focus of their work. The accounts discuss the development of the committees and some of the ethical problems that have been brought to them. The issues raised will be relevant for other National Health Service (NHS) trusts in the UK that wish to set up such a committee.  (+info)

Waiting lists for radiation therapy: a case study. (60/872)

BACKGROUND: Why waiting lists arise and how to address them remains unclear, and an improved understanding of these waiting list "dynamics" could lead to better management. The purpose of this study is to understand how the current shortage in radiation therapy in Ontario developed; the implications of prolonged waits; who is held accountable for managing such delays; and short, intermediate, and long-term solutions. METHODS: A case study of the radiation therapy shortage in 1998-99 at Princess Margaret Hospital, Toronto, Ontario, Canada. Relevant documents were collected; semi-structured, face-to-face interviews with ten administrators, health care workers, and patients were conducted, audio-taped and transcribed; and relevant meetings were observed. RESULTS: The radiation therapy shortage arose from a complex interplay of factors including: rising cancer incidence rates; broadening indications for radiation therapy; human resources management issues; government funding decisions; and responsiveness to previous planning recommendations. Implications of delays include poorer cancer control rates; patient suffering; and strained doctor-patient relationships. An incompatible relationship exists between moral responsibility, borne by government, and legal liability, borne by physicians. Short-term solutions include re-referral to centers with available resources; long-term solutions include training and recruiting health care workers, improving workload standards, increasing compensation, and making changes to the funding formula. CONCLUSION: Human resource planning plays a critical role in the causes and solutions of waiting lists. Waiting lists have harsh implications for patients. Accountability relationships require realignment.  (+info)

Syringe prescription to prevent HIV infection in Rhode Island: a case study. (61/872)

Injection drug users (IDUs) are a population at high risk for many diseases, including AIDS, and are clearly in need of medical and substance abuse treatment. Access to sterile syringes is critical for lowering the risk of transmission of HIV and other blood-borne pathogens among IDUs. Previously tried strategies include needle exchange programs and changing laws to allow the legal purchase and possession of syringes. An alternative strategy is to have physicians prescribe syringes to IDUs. To the best of our knowledge, this has previously been tried by only a few physicians in rare situations and never on a programmatic basis. This report describes the genesis of physician's syringe prescription in Rhode Island and some of the lessons learned to date. Because of the illicit nature of drug use, a tremendous amount of mistrust and fear on the part of IDUs often leads to poor interaction with the medical establishment. Prescription of syringes by a physician can serve as a tool for reaching out to a high-risk and often out-of-treatment population of drug users. It is a way for the health care community to tap into drug-using networks and bring those populations into a medical care system.  (+info)

Community assessment in a vertically integrated health care system. (62/872)

OBJECTIVES: In this report, the authors present a representative case of the implementation of community assessment and the subsequent application of findings by a large, vertically integrated health care system. METHODS: Geographic information systems technology was used to access and analyze secondary data for a geographically defined community. Primary data included a community survey and asset maps. RESULTS: In this case presentation, information has been collected on demographics, prevalent health problems, access to health care, citizens' perceptions, and community assets. The assessment has been used to plan services for a new health center and to engage community members in health promotion interventions. CONCLUSIONS: Geographically focused assessments help target specific community needs and promote community participation. This project provides a practical application for integrating aspects of medicine and public health.  (+info)

A case study of hospital closure and centralization of coronary revascularization procedures. (63/872)

BACKGROUND: Despite nation-wide efforts to reduce health care costs through hospital closures and centralization of services, little is known about the impact of such actions. We conducted this study to determine the effect of a hospital closure in Calgary and the resultant centralization of coronary revascularization procedures from 2 facilities to a single location. METHODS: Administrative data were used to identify patients who underwent coronary artery bypass grafting (CABG), including those who had combined CABG and valve procedures, and patients who underwent percutaneous transluminal angioplasty (PTCA) in the Calgary Regional Health Authority from July 1994 to March 1998. This period represents the 21 months preceding and the 24 months following the March 1996 hospital closure. Measures, including mean number of discharges, length of hospital stay, burden of comorbidity and in-hospital death rates, were compared before and after the hospital closure for CABG and PTCA patients. Multivariate analyses were used to derive risk-adjustment models to control for sociodemographic variables and comorbidity. RESULTS: The number of patients undergoing CABG was higher in the year following than in the year preceding the hospital closure (51.6 per 100,000 before v. 67.3 per 100,000 after the closure); the same was true for the number of patients undergoing PTCA (129.8 v. 143.6 per 100,000). The burden of comorbidity was significantly higher after than before the closure, both for CABG patients (comorbidity index 1.3 before v. 1.5 after closure, p < 0.001) and for PTCA patients (comorbidity index 1.0 before v. 1.1 after, p = 0.04). After adjustment for comorbidity, the mean length of hospital stay was significantly lower after than before the closure for CABG patients (by 1.3 days) and for PTCA patients (by 1.0 days). The adjusted rates of death were slightly lower after than before the closure in the CABG group. The adjusted rates of death or CABG in the PTCA group did not differ significantly between the 2 periods. INTERPRETATION: Hospital closure and the centralization of coronary revascularization procedures in Calgary was associated with increased population rates of procedures being performed, on sicker patients, with shorter hospital stays, and, for CABG patients, a trend toward more favourable short-term outcomes. Our findings indicate that controversial changes to the structure of the health care system can occur without loss of efficiency and reduction in quality of care.  (+info)

Public release of performance data and quality improvement: internal responses to external data by US health care providers. (64/872)

Health policy in many countries emphasises the public release of comparative data on clinical performance as one way of improving the quality of health care. Evidence to date is that it is health care providers (hospitals and the staff within them) that are most likely to respond to such data, yet little is known about how health care providers view and use these data. Case studies of six US hospitals were studied (two academic medical centres, two private not-for-profit medical centres, a group model health maintenance organisation hospital, and an inner city public provider "safety net" hospital) using semi-structured interviews followed by a broad thematic analysis located within an interpretive paradigm. Within these settings, 35 interviews were held with 31 individuals (chief executive officer, chief of staff, chief of cardiology, senior nurse, senior quality managers, and front line staff). The results showed that key stakeholders in these providers were often (but not always) antipathetic towards publicly released comparative data. Such data were seen as lacking in legitimacy and their meanings were disputed. Nonetheless, the public nature of these data did lead to some actions in response, more so when the data showed that local performance was poor. There was little integration between internal and external data systems. These findings suggest that the public release of comparative data may help to ensure that greater attention is paid to the quality agenda within health care providers, but greater efforts are needed both to develop internal systems of quality improvement and to integrate these more effectively with external data systems.  (+info)