Assessment of competence to complete advance directives: validation of a patient centred approach.
OBJECTIVE: To develop a patient centred approach for the assessment of competence to complete advance directives ("living wills") of elderly people with cognitive impairment. DESIGN: Semistructured interviews. SETTING: Oxfordshire. SUBJECTS: 50 elderly volunteers living in the community, and 50 patients with dementia on first referral from primary care. MAIN OUTCOME MEASURES: Psychometric properties of competence assessment. RESULTS: This patient centred approach for assessing competence to complete advance directives can discriminate between elderly persons living in the community and elderly patients with dementia. The procedure has good interrater (r=0.95) and test-retest (r=0.97) reliability. Validity was examined by relating this approach with a global assessment of competence to complete an advance directive made by two of us (both specialising in old age psychiatry). The data were also used to determine the best threshold score for discriminating between those competent and those incompetent to complete an advance directive. CONCLUSION: A patient centred approach to assess competence to complete advance directives can be reliably and validly used in routine clinical practice. (+info)
Putting continuous quality improvement into accreditation: improving approaches to quality assessment.
The accreditation systems of the United States, Canada, and Australia have been restructured to reflect the adoption by health services of the industrial model of continuous quality improvement. The industrial model of quality makes assumptions about management structures and the relation of process to outcome which are not readily transferable to the assessment of quality in health care. The accreditation systems have therefore had to adapt the principles of continuous quality improvement to reflect the complex nature of health service organisations and the often untested assumptions about the relation between process and outcome. (+info)
Goal attainment scaling in a geriatric day hospital. Team and program benefits.
PROBLEM BEING ADDRESSED: The Geriatric Day Program (GDP) of the Capital Health Region in Victoria, BC, is concerned with effective team processes, accountability for health service outcomes, and improving the quality of programs. The GDP identified a need to improve its interdisciplinary processes and generate useful patient outcome data. OBJECTIVE OF PROGRAM: To determine whether Goal Attainment Scaling (GAS) could be introduced to facilitate interdisciplinary processes and to generate useful health outcome data. MAIN COMPONENTS OF PROGRAM: The GAS procedures were incorporated into clinical routines based on published guidelines. The authors determined GAS outcome scores for patients who completed the program and developed outcome scores for specific geriatric problem areas requiring intervention. Outcome scores were made available to the clinical care team and to program managers for continuous quality improvement purposes. CONCLUSIONS: The GAS process was successfully implemented and was acceptable to clinicians and managers at the GDP. Team processes were thought to be improved by focusing on patient goals in a structured way. The GAS provided data on both patient outcomes and outcomes of interventions in specific problem areas. Accountability for patient care increased. Goal Attainment Scaling provided indicators of care for which clinicians could develop program quality improvements. (+info)
Prescribing psychotropic medication for elderly patients: some physicians' perspectives.
BACKGROUND: The inappropriate use of psychotropic medication is widespread and has potential consequences for the autonomy of elderly people. This study explored physicians' perceptions and attitudes and the decision-making process associated with prescribing psychotropic medications for elderly patients. METHODS: In this qualitative study conducted between February and April 1996, 9 of 12 physicians who offered consultation services for elderly people in private apartment buildings in a suburban region of Montreal were interviewed. The transcripts of the interviews were analysed quantitatively using an iterative process. The authors assessed the physicians' perceptions of the elderly patient population, the decision-making process leading to the prescription of psychotropic medication and the nature of follow-up. RESULTS: All of the physicians interviewed perceived the aging process as a negative experience and stated that the long-term use of psychotropic medication is justified by the distress of their aging patients and the few negative side effects that are noticed. Most said that, when they re-prescribe, they see their role as a "gatekeeper" to monitor and control the type and quantity of medication prescribed. Most physicians felt that the solutions to the inappropriate prescribing of psychotropic medication were beyond the scope of the individual physician. INTERPRETATION: Physicians interviewed in this study had a patient-centered perspective. From a public health viewpoint this calls for an innovative approach to involve physicians in a multidisciplinary intervention strategy to examine the inappropriate use of psychotropic medication among elderly patients. (+info)
Clinical interventions and outcomes of One-to-One midwifery practice.
BACKGROUND: Changing Childbirth became policy for the maternity services in England in 1994 and remains policy. One-to-One midwifery was implemented to achieve the targets set. It was the first time such a service had been implemented in the Health Service. An evaluation was undertaken to compare its performance with conventional maternity care. METHODS: This was a prospective comparative study of women receiving One-to-One care and women receiving the system of care that One-to-One replaced (conventional care) to compare achievement of continuity of carer and clinical outcomes. The evaluation took place in The Hammersmith Hospitals NHS Trust, the Queen Charlotte's and Hammersmith Hospitals. This was part of a larger study, which included the evaluation of women's responses, cost implications, and clinical standards and staff reactions. The participants were all those receiving One-to-One midwifery practice (728 women), which was confined to two postal districts, and all women receiving care in the system that One-to-One replaced, in two adjacent postal districts (675 women), and expecting to give birth between 15 August 1994 and 14 August 1995. Main outcome measures were achievement of continuity of care, rates of interventions in labour, length of labour, maternal and infant morbidity, and breastfeeding rates. RESULTS: A high degree of continuity was achieved through the whole process of maternity care. One-to-One women saw fewer staff at each stage of their care, knew more of the staff who they did see, and had a high level of constant support in labour. One-to-One practice was associated with a significant reduction in the use of epidural anaesthesia (odds ratio (OR) 95 per cent confidence interval (CI) = 0.59 (0.44, 0.80)), with lower rates of episiotomy and perineal lacerations (OR 95 per cent CI = 0.70 (0.50, 0.98)), and with shorter second stage labour (median 40 min vs 48 min). There were no statistically significant differences in operative and assisted delivery or breastfeeding rates. CONCLUSIONS: This study confirms that One-to-One midwifery practice can provide a high degree of continuity of carer, and is associated with a reduction in the rate of a number of interventions, without compromising safety of care. It should be extended locally and replicated in other services under continuing evaluation. (+info)
The economics and challenges of breast cancer in a managed care environment. Based on a presentation by Alan H. Heaton, PharmD.
Breast cancer and its population effect are inseparable. One of the challenges managed care organizations (MCOs) face is instilling the idea that patients are part of a population, and in turn, that population is composed of patients. Therefore, there is a need to treat both patients individually and populations as a whole. Because breast cancer, like other major illnesses, involves large-scale expenditures for drugs, pharmaceutical benefit management companies are working with MCOs to look not only at drug costs but at global healthcare expenditures. Whereas treatment of breast cancer has direct costs to a healthcare plan, it is associated with a great deal of comorbidity as well. In dealing with such potential financial exposure, the challenge to health plans is to find individuals at risk, enable them to access the healthcare system, and see that they get proper care. A proactive communications effort involving such media as patient newsletters and a website can educate healthplan members, thereby facilitating the self-assessment of risk factors. (+info)
The virtue of nursing: the covenant of care.
It is argued that the current confusion about the role and purpose of the British nurse is a consequence of the modern rejection and consequent fragmentation of the inherited nursing tradition. The nature of this tradition, in which nurses were inducted into the moral virtues of care, is examined and its relevance to patient welfare is demonstrated. Practical suggestions are made as to how this moral tradition might be reappropriated and reinvigorated for modern nursing. (+info)
On becoming non-judgmental: some difficulties for an ethics of counselling.
The growth in the availability of counselling services has been accompanied by growing concern about the conduct of counsellors, which in turn has led to the expressed need for an ethics of counselling. This paper will argue that there is an inherent tension between this need and the central tenets of one variety of counselling, client-centred counselling. The tension is identifiable on the basis of an inquiry into the nature of moral judgment which results in the recognition of the implicit value base in client-centred counselling. It is only when this value base is made explicit that any adequate ethics of counselling becomes a viable possibility. (+info)