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PubMed2000

Professional nursing practice in an HMO: the future is now.

Managed care forms of service delivery now dominate the nursing practice environment. Nursing is potentially a key resource for helping the system to meet the increased and evolving demands, maintaining quality while decreasing costs. However, nurses need additional competencies to function effectively in this environment. Nurse educators need to prepare nurses for these new roles. This paper describes trends influencing nursing roles and identifies the nine categories of competencies needed by professional nurses practicing in HMO settings. Cost-reduction pressures have driven profound changes in the health care system in recent years. Countering these demands for cost-reduction are increases in costs driven by new, more expensive treatments and higher patient expectations. While the future of health care is anything but clear, certain features of the health care system seem relatively certain: major changes will continue to be cost-driven; more hospitals will close, or consolidate or collaborate to compete; and inpatient acuity will continue to increase. In addition, corporate America will increasingly influence how care is delivered and demands for information on health plan performance, such as the Health Employers Data Information System (HEDIS) (National Committee for Quality Assurance, 1997) will increase. These forces will inevitably redirect use of resources within health care organizations. Other external forces that will continue to influence how care is delivered are discussed below.

Cost-Benefit Analysis↗

PubMed1992

Tools, teamwork, and tenacity: an office system for cancer prevention.

BACKGROUND: Despite national priorities in cancer control, the number of people with established ongoing medical care who do not receive indicated preventive services is substantial. Proven strategies to optimize preventive care in community practice are limited. METHODS: In the Cancer Prevention in Community Practice Project (CPCP), 50 primary care providers were randomly assigned to receive an "office system" intervention. The intervention led to reorganization of office operations based on four functional core components: identifying patients' needs for services; monitoring their status over time; providing positive reinforcement to patients; and establishing an internal feedback component consisting of a brief audit to assess how the system is operating. Implementation of the CPCP system in each practice was accomplished using trained facilitators, and involved incorporating one or more tools developed to meet the functional components of the practice. RESULTS: One hundred percent of the practices were successful in implementing some changes in their office operations that met CPCP office system functional criteria. All study practices implemented customized flow sheets, while use of other office system tools were incorporated at between 32% to 75% of study sites. Identifying patients in need of preventive services was performed most often by the clinical staff (39%), whereas monitoring patients' receipt of preventive services over time and reinforcing positive patient behavior were performed most often by physicians (63% and 46%, respectively). Changes made in practices were maintained for at least 12 months. CONCLUSIONS: Primary care practices in community settings can implement significant and lasting changes in their practice environment that will improve their performance of preventive activities. The functional components of the CPCP office system design proposed and tested here are applicable to a wide variety of practice settings.

Adult↗

PubMed1998

Nurses' knowledge, experiences, and attitudes concerning living wills.

A random sample of 974 registered nurses in Nova Scotia were surveyed during the 1995-96 registration year to determine their understanding of living wills legislation; their experiences, roles, and attitudes related to living wills; and their perceptions of the barriers to and resources for using living wills in their practice. Responses from 157 nurses indicated that they were unfamiliar with the Medical Consent Act, the Hospitals Act, and the Powers of Attorney Act. Although they revealed that they had a positive attitude towards living wills, and they identified nurses as the appropriate health professional to initiate discussions about living wills with patients, very few had any actual experience in this role. Respondents rated their understanding of living wills as low, and many indicated that they were uncomfortable discussing the topic with clients. Respondents saw both the individual nurse and the practice environment as barriers to the use of living wills, and they clearly indicated the need for interdisciplinary educational strategies to facilitate the use of living wills in their nursing practice.

Adult↗

PubMed2000

A comparison of hourly block appointments with sequential patient scheduling in a dermatology practice.

BACKGROUND: There is significant demand for dermatologic care, and manpower is limited. Increasing patient encounters stress office processes. Analyses of the effects of schedule manipulation in a high-volume dermatology office have not been described. OBJECTIVE: The purpose of this article is to study the effects of block versus sequential scheduling on patient waiting times, length of patient encounters, and physician patient-free time in two busy dermatology clinics. METHODS: A dermatologist attended at two dermatology clinics, one using sequential patient scheduling and the other, block hourly scheduling. Time of patient arrival, scheduled appointment time, waiting time, time of physician entry into the examining room, face-to-face time with the physician, appointment type, number of same-day cancellations and nonattendance by visit type, length of each clinic, time of clinic closure, and patient-free time were recorded for each clinic and patient encounter. RESULTS: There were no significant differences between patient waiting times at the two clinics. Patients were seen by the physician a mean of 2.6 minutes before their scheduled appointment time using block scheduling of appointments and 6 minutes after their scheduled appointment times with sequential scheduling. Similar times were spent by the physician with the patients at both sites. After adjustment for differing nonattendance rates, block scheduling yielded 330 minutes of additional patient-free time during the course of this study when compared with sequential scheduling. With block scheduling, the clinic finished a mean of 35 minutes earlier than clinics using sequential scheduling. CONCLUSION: Within the parameters of this study, block scheduling did not significantly affect patient waiting times. Block scheduling created more patient-free time for the physician and clinical staff than did sequential scheduling. Block scheduling increased the quality of the practice environment from the perspective of the physician and the staff.

Appointments and Schedules↗

PubMed1991

The leadership crisis in internal medicine: what can be done?

During the 1990s, internal medicine will change. Whether that change will be in directions desired by internists will depend on whether effective leadership of the discipline is accepted by the academic department chairs. Individually, and as a group, they are the only ones with sufficient authority to take control and initiate and sustain needed change. The time frame for action is short and diminishing. Opportunities still exist for effective leadership to present the discipline as more attractive to students by demonstrating that they can play an important role in helping to solve problems in health care. Unmet societal needs underlie much of the public's disaffection with the profession, and the chairpersons must begin to solve those needs. Today's practice environment is ever less appealing with increasing regulation and intrusive third-party actions. These stresses will increase until internists understand from research the value of what they do in practice and learn to choose what is effective in outcome and cost. Practice models integrating the skills and talents of internists, as these are focused on the needs of patients, are experiments that can be started in academic departments. Initiatives for such changes depend on active leadership--now sorely lacking in internal medicine.

Internal Medicine↗

PubMedDate not supplied

The electronic medical record in multi-site family practice. Part II: The implementation phase.

Electronic medical records are being successfully implemented on a regular basis. They provide real benefits. This is a detailed explanation of how this medical group implemented and created a paperless medical practice environment and an electronic medical record (EMR). This includes an explanation of hardware and software components, the method of creating the EMR, the benefits, pitfalls, and the impact on the practices.

Computer User Training↗

PubMed2004

Physician-citizens--public roles and professional obligations.

Although leaders and other commentators have called for the medical profession's greater engagement in improving systems of care and population health, neither medical education nor the practice environment has fostered such engagement. Missing have been a clear definition of physicians' public roles, reasonable limits to what can be expected, and familiarity with tasks that are compatible with busy medical practices. We address these issues by proposing a definition and a conceptual model of public roles that require evidence of disease causation and are guided by the feasibility and efficacy of physician involvement. We then frame a public agenda for individual physicians and physician organizations that focuses on advocacy and community participation. By doing so, we aim to stimulate dialogue about the appropriateness of such roles and promote physician engagement with pressing health issues in the public arena.

Community Participation↗

PubMed2002

Inclusion of a competency-based curriculum in medical pharmacology.

Medical education programs have emphasized the acquisition of basic scientific knowledge and practical skills in well-defined subject areas using lecture and role modeling as the principle means of instruction. The need to address changes in the practice environment, the recognition that alternative instructional models may be desirable in some cases, and the fact that instruction in the traditional subject areas does not prepare students for all aspects of medical practice have driven recent curricular changes at many schools. Indiana University School of Medicine, with multiple instructional sites distributed throughout the state, has adopted a school-wide plan that specifies desired educational outcomes and provides an instrument for rating student achievement. In this report we describe the implementation of new media and pedagogical methods in a two-semester medical pharmacology course with the goal of fostering and assessing competency in the nine areas outlined in this educational plan. The general conclusion is that these changes not only furthered the broader educational goals of the competency-based curriculum, but also may exert a positive influence on student learning of discipline-specific material.

Competency-Based Education↗

PubMed1994

Where is here and when is now? The adaptational challenge of mental health reform for group psychotherapy.

The structure of health care delivery is in a period of rapid change. An understanding of psychotherapy service use patterns indicates the importance of time categories as well as the relevance of group techniques. Traditional interpersonal and psychodynamic group techniques may be modified for time-limited use without sacrificing basic values and with demonstrated effectiveness. Adapting to a more fiscally stringent practice environment requires the clinician to undertake a difficult process of transition. As professionals our task is to prepare ourselves for this challenge and to let the health care system know that proper practice guidelines are necessary to achieve effective treatment for our patients.

Cost Control↗

PubMed1986

Some issues related to research utilization in occupational therapy.

The importance of research in the rehabilitation fields, including occupational therapy, has been widely recognized in the past decade. The production of credible research literature has received high priority as occupational therapy strives to achieve professional status within the hierarchy of rehabilitation service providers. To accomplish this goal, research that establishes a scientific basis for therapy must be produced, and this research must be integrated with clinical practice. Occupational therapy appears to be making progress in producing research literature related to clinical practice; however, the issue of research utilization has remained largely unexplored. This paper discusses methods of applying research findings and procedures in practice environments and explores some issues related to research utilization. Research utilization is viewed as a complex process involving multiple components related to individual decision making, theory development, and the documentation of clinical practice.

Humans↗

PubMedDate not supplied

Implementing clinical paths in a managed care environment.

The survival of health care institutions depends upon a delivery system focusing on appropriate use of resources and controlling length of stay while monitoring clinical progress toward identified outcomes. Using a clinical path as a tool for managing resources, research activities, continuous quality improvement, and increased collaborative practice can enhance the professional practice environment and benefit patient care.

Critical Pathways↗

PubMed2004

The personal dental service as a setting for an undergraduate clinical programme.

OBJECTIVE: To investigate the feasibility and benefits of placing dental undergraduates into a general dental practice setting for part of their clinical programme. SETTING: Two six-surgery general dental practices in the North West of England operating within the personal dental service of the NHS. METHOD: Six volunteer final year students worked within the practices for one-day-per week for 11 weeks. Evaluation included patients', practitioners' and students' views obtained from questionnaires and/or interviews and an analysis of students' clinical records. RESULTS: The students saw a large positive impact from: working alongside a dental nurse; developing their clinical skills; working in a busy practice environment; and developing interpersonal skills. Patients were very positive with 98% (44/45) being complimentary about the treatment they received, and commenting that they would be willing to participate in future student training programmes. The practice principals would also welcome continuation of the programme. CONCLUSION: The programme was both feasible and educationally beneficial. The financial implications need further research.

Attitude of Health Personnel↗

PubMed2002

Hospital practice more than specialty influences the choice of regional or general anesthesia for Cesarean section.

PURPOSE: Describe the influence of specialty certification and practice style upon the anesthetic technique used for Cesarean deliveries. METHODS: Alberta physician claims and hospital abstracts between April 1, 1998 to March 31, 2000 were used to determine the technique of anesthesia (regional or general). The influence of practice (volume of deliveries, geographic location, presence of regional analgesia providers) and specialty (anesthesiologist or family/general practice) is explored by logistic regression. RESULTS: Hospital abstracts of 13,884 Cesarean sections were analyzed. Anesthesiologists performed 76% of the anesthetics: epidural (33%), spinal (45%), and general anesthesia (22%). Comparing only regional and metropolitan hospitals, the percent of general anesthesia performed by anesthesiologists varied between 5% to 50%. After adjusting for other factors, we found, in order of importance, the following determined the use of general anesthesia for Cesarean sections: 1) hospitals with more epidural procedure providers during labour were 3% less likely to have providers choose general anesthesia; 2) larger, regional and metropolitan hospitals were less likely to have providers choose general anesthesia; 3) hospitals with a high volume epidural procedure provider during labour were 64% less likely to have providers choose general anesthesia; 4) anesthesiologists were 32% less likely to choose general anesthesia. CONCLUSION: The overall use of regional anesthesia for Cesarean sections in Alberta is high. The chance of receiving a general anesthetic for a Cesarean delivery varies across the province and was more related to practice environment than specialty.

Adult↗

PubMed1988

Identification and treatment of risk factors for coronary heart disease in general practice: a possible screening model.

A screening programme for the identification of risk factors for coronary heart disease in all patients aged 25-55 years in a general practice population was studied. The identification of risk factors included measurement of obesity, blood pressure, hypercholesterolaemia, and urinalysis, together with questions about family history, cigarette smoking, alcohol intake, and lifestyle. The patients with identified risk factors were invited to attend a lifestyle intervention clinic organised by the practice nurses and run by the health visitors, with the help of the local authority dietitian. Of 2646 (62%) patients who attended for screening, 78 (64%) of the 121 shown to have a high cholesterol concentration experienced a drop in cholesterol concentration. The mean fall in cholesterol concentration in the 78 patients who showed a positive response to intervention was 1.1 mmol/l. The study was intended as a possible flexible model for screening for coronary heart disease in general practice that could be complemented rather than replaced by opportunistic screening. The issues of organisation, cost, manpower, nonattendance, and effectiveness in a busy general practice environment are discussed.

Adult↗

PubMed2006

Modeling mentorship and collaboration for BSN and MSN students in a community clinical practicum.

This project uses an innovative approach to facilitate mentorship and collaboration among BSN and MSN students within a community health practice environment. In a pilot test using a clinical model, graduate and undergraduate students were matched as mentors and mentees. These students worked with faculty and clinic staff to develop a mentorship network and effective collaborative practice within an interdisciplinary team, while implementing health promotion education programs for clinic clients. Ten students participated in the process and evaluated it as effective and valuable in the development of professional roles, as well as in validating the model variables used in the project.

Adult↗

PubMed1999

HMO physicians' use of referrals.

Clinical uncertainty is a source of variation in medical decision-making as well as a source of work-related stress. Increasing enrollment in organized health care systems has intensified interest in understanding referral utilization as well as issues such as physician dissatisfaction and burnout. We examined whether primary care physicians' affective reactions to uncertainty and their job characteristics were associated with use of referrals and burnout. Data came from mail surveys of primary care physicians practicing in two large group model health maintenance organizations (HMOs) in the USA. Consistent with past research, we found that younger physicians had higher referral rates than older physicians, and that general internists had higher rates than either family practitioners or pediatricians. Greater stress from uncertainty increased referrals and referrals were negatively correlated with heavier work demands (patient visits per hour). Greater stress from uncertainty, perceived workload (too high) and a sense of loss of control over the practice environment were associated with higher levels of burnout.

Adult↗

PubMed2001

The why and the wherefore.

Through their clearly defined gatekeeper role, GPs have considerable market power to influence the flow of revenue associated with referrals and prescriptions. For this reason, and because the whole healthcare industry is going through a transition from a cottage industry to a more commercially sophisticated structure, corporatisation of general practice is on the increase. If properly and ethically run, corporatised general practices can provide high-quality, efficient primary care. There are four far-reaching, potential consequences of general practice corporatisation--an increase in healthcare spending; limitation of GPs' choice of practice environment; difficulty justifying GPs' legitimate fee increases; and de-skilling of GPs.

Attitude of Health Personnel↗

PubMed2005

Benefits and challenges in developing a program of research.

The ultimate goals of nursing research are knowledge generation and improvement in nursing practice. Designing studies that provide the evidence needed for practice change and that have clear implications for immediate application to current practice environments is particularly challenging. Research programs that consist of sequential studies, each building on and expanding on the results of the previous work, offer the greatest promise for generating understanding of the human phenomenon relevant to nursing practice. The authors review their experience with a series of studies of inpatient and postdischarge needs and interventions associated with chronic critical illness to illustrate the benefits of developing a longitudinal research program as well as the importance of strategies that will foster application of results. Recommendations for developing such a program are discussed.

Chronic Disease↗