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PubMed1992

Physicians in the Department of Veterans Affairs. Another perspective.

There is an ongoing discussion pertaining to the mutually beneficial relationship between the medical centers of the Department of Veterans Affairs (VA) and their affiliated medical schools. An earlier article analyzed the interorganizational conflicts prevalent at times between the VA medical centers and the medical school affiliates and assigned as reasons for such frictions value differences between professionals and administrators as well as between the VA medical centers and the medical schools. I propose somewhat different explanations for such conflicts and draw attention to the inapplicability of some of the old organizational theories that are being overtaken by the dynamics of modern health care organizations and their dependence on total quality management and resource allocation methods driven by diagnosis related groups. Furthermore, the strivings of other health professionals in the VA for equal treatment and the reluctance of physicians to concede coequality to others, the prevalence of risk avoidance as a necessary behavioral attribute for success within the VA, and the prevailing practice of allowing VA physicians to accept salary supplementation from the medical schools are major factors contributing to interorganizational conflicts.

Conflict, Psychological↗

PubMedDate not supplied

Influence of the teleradiology technology (N-ISDN and ATM) on the inter-hospital management of neurosurgical patients.

We set out to assess the influence of a teleradiology network on the relations between a general hospital and a 100 km distant university hospital in the context of neurosurgical emergencies, and compared a commercially available technology, N-ISDN (Narrowband Integrated Service/Digital Network), to an emerging technology, ATM (Asynchronous Transfer Mode). The evaluation was conducted using records of advice request calls and patient transfers. Three phases were considered: without teleradiology, with transfer of digitized images over N-ISDN at 64 kbps, and with an experimental ATM network at 10.5 Mbps with DICOM image transfers and videoconferencing. Additionally, staff meetings over ATM videoconferencing were set up. To assess the ATM service, we used log files and questionnaires, 108 advice requests were studied over a 18 month period. The average transmission time for one examination was 38 s with full DICOM image resolution over ATM, versus 150 s with 10:1 JPEG (Joint Photographic Expert Group) compression over N-ISDN. Up to 50% unnecessary patient transfers were avoided. Advice requests increased fourfold, and non-urgent advice requests increased from 0 to 21%. Despite the experimental configuration of the ATM network, the service gave satisfaction to all the physicians. Videoconferencing was unanimously regarded as a prominent tool to improve the quality of interaction. It was particularly useful for non-urgent cases and distant staff meetings. Teleradiology can improve the relations between hospitals through an increase of urgent and non-urgent advice requests. Asynchronous transfer mode is an efficient way for fast transfer of radiological examinations in DICOM format and for discussing them through high-quality videoconferencing.

Brain Neoplasms↗

PubMed1994

Bereavement care: relationships between the intensive care unit and the general practitioner.

This study examines relationships between an intensive care unit and the general practitioners within a local health authority in respect of bereavement care. A questionnaire to all 113 local general practitioners generated a response from 67 (59.3%). While about two-fifths of respondents reported at least one of their patients dying on the intensive care unit, half said that they were often first informed by relatives. Although four-fifths of inner city general practitioners offered some form of bereavement service, it ranked lowest in terms of priority on time, and a further one-seventh provided no service at all. Half the respondents thought that hospital staff could do more to help. The implications for practice are discussed.

Bereavement↗

PubMed2003

The use of regional coordinating centers in large clinical trials: the DIG trial.

The Digitalis Investigation Group (DIG) trial was a large simple clinical trial that involved 302 participating centers in the United States and Canada. In order to encourage participation by Canadian investigators, to provide additional help to what were expected to be largely research-inexperienced investigators in Canada, and to provide the study's data coordinating center with resources in Canada to deal with potentially different rules, regulations, and cultural differences, regional coordinating centers were established in four regions of Canada: the maritime provinces, Quebec, Ontario, and western Canada. Canadian centers recruited significantly better than their U.S. counterparts and had slightly better retention and follow-up. While it is not possible to declare that the regional coordinating centers were responsible for this improvement, it is believed that these regional centers did play a role. This role included being able to identify investigators who could be expected to do well, providing one-on-one training and instruction to investigators, and being able to solve problems and implement change in the relatively fewer centers in their regions. The regional coordinating center also reduced the intensity of the workload on the data coordinating center by serving as the primary point of contact for Canadian investigators. The use of regional coordinating centers in studies with a large number of participating centers is highly recommended.

Canada↗

PubMed2001

Communicating advance directives from long-term care facilities to emergency departments.

Many residents of long-term care (LTC) facilities are transferred to Emergency Departments without advance directives (AD). The goal of this study was to describe an ideal model for the transfer of AD from LTC facilities to Emergency Departments. Health care providers were asked to describe their ideal model for the completion and transfer of the ADs of LTC residents. A grounded theory methodology was used to identify significant themes. The model we present as a result of this analysis acknowledges the importance of simplifying and standardizing ADs, but focuses more attention on the process of completing and transferring the AD. A key feature of this model is an emphasis on the education of LTC residents and their relatives about ADs and advance-care planning. This education should involve a variety of resources used in creative ways; it should begin as soon as LTC placement is being considered, and the emphasis should be on providing information and discussing options rather than pressuring residents to make a decision.

Adult↗

PubMed2001

Models and mechanisms for building and funding partnerships.

The Canadian Institutes of Health Research (CIHR) recently replaced two former federal agencies, the Medical Research Council and the National Health Research and Development Program. CIHR has attracted widespread international attention as a grand experimental model that emphasizes excellence, interdisciplinarity, networking, partnership, and a collective process for priority setting, alongside continuing support for the best ideas of the most talented investigators. CIHR identified four cross-cutting health research themes (biomedical research; clinical research; health service; systems research; and research into the societal, cultural, and environmental determinants of health) across its 13 virtual institutes. Each institute is required to bring together investigators working in specific aspects of health research, as they relate to the mandate of the institute, in order to stimulate novel interdisciplinary research approaches. The challenge to Canadian members of the Society for Healthcare Epidemiology of America and their collaborators from other countries is to engage in partnership with CIHR, so that together we can ensure unparalleled quality, safety, and efficacy of healthcare systems in Canada and around the world.

Budgets↗

PubMed1980

Evaluation of television consultations between a large neonatal care hospital and a community hospital.

Two-way television consultations between community hospital nurses and neonatologists at a nearby teaching hospital were conducted over a two- and one-half year period of time and were evaluated with respect to a baseline time period in which the television was not available. Screening for illness and prematurity in neonates occurred in a high risk population residing in a black, economically deprived, innercity area. Outcomes including transfer of sick babies from the community hospital to the large teaching hospital are analyzed in relation to prenatal maternal risk characteristics. Apgar scores, birth weight and gestational age. Evidence available suggests that television consultations facilitated formation of appropriate criteria for interhospital transfer and that routine clinical screening tests were performed more consistently following initiation of interhospital consultations.

Age Factors↗

PubMed2001

The challenge of civil-military relations in international peace operations.

The relationship between military and civilian humanitarian organisations has developed in an increasingly integrative way. Military initiatives to institutionalise the relationship, since the interventions in Somalia and the Balkans, entail a dilution of humanitarian independence as was manifested in practice in Kosovo. Further, the state-centric foundations of military intervention run counter to the potential for humanitarian organisations to foster a cosmopolitan ethos that would not only preserve humanitarian principles but also contest statist assumptions about conflict, development and power.

Altruism↗

PubMed2000

The academic surgeon and industry.

Academic surgeons should be aware of the tremendous potential that exists to partner with private companies on projects relating either to basic or clinical research. This is particularly timely now because many of these companies are experiencing unprecedented growth and market valuation. The development of these relationships requires knowing who to deal with as well as how to negotiate. Most academic medical centers have individuals who have expertise in developing sponsored research agreements, and young investigators should take advantage of this expertise.

Academic Medical Centers↗

PubMed2000

Direct support in supported employment and its relation to job typicalness, coworker involvement, and employment outcomes.

Supported employment is a comprehensive package of strategies continually evolving and designed to successfully employ people with disabilities. The emerging nature of natural support is receiving extensive attention. Understanding and improving natural support strategies is a means to provide uniquely distinctive personalized supports. It is this underlying theme that has driven four previous research reports regarding typical employment features and their relation to employment outcomes for people with disabilities. In this report we investigate the previously raised issue that high levels of direct support are associated with less typicalness, integration, and wages. This study shows that wage and integration outcomes can be increased, even if there is a high level of direct support, if there is coworker training.

Adolescent↗

PubMed2000

Public health and home care: historical roots & current partnerships.

This article explores the evolution of home care from a component of public health services to its current position in the American health care system. Values related to public health and philanthropic roots are discussed in contrast to the current business orientation. Because nursing was the initial, and remains the primary, discipline in home care, examples from nursing service and education are used to illustrate this evolution. Educational implications are highlighted because of the importance of educational systems in supplying personnel to the field.

Community Health Nursing↗

PubMed2002

[Emergency preparedness based on coherent integration of crisis response resources: workshop on mass casualty management in Bethlehem in June 1999].

In June 1999, the Humanitarian Action Division of the Foreign Affairs Department organized a training course on the mass casualty management within the framework of religious festivities related to the Bethlehem 2000 project. This initiative was undertaken at the request of the Palestinian Authority and the General Consulate of France in Jerusalem. Palestinian and French specialists in the field worked together in three workshops devoted to rescue, search and first aid; medical outposts and triage; and emergency and surgical care in referring hospitals.

Disaster Planning↗

PubMed1999

"Out-of-the-mainstream" youth as partners in collaborative research: exploring the benefits and challenges.

Forming collaborations between university-based researchers and community-based organizations (CBOs) serves to improve health promotion research and service. Unfortunately, members of the targeted populations are typically not included in such collaborations. This article describes the development and maintenance of a successful university-CBO collaboration that was formed to explore HIV-related risk rates and prevention strategies for suburban street youth and discusses the benefits and challenges of including out-of-the-mainstream youth as full collaborative partners in the research. Specific benefits included population-specific modifications of the research methods and instruments, recruitment of hard-to-reach youth, greater ease in tracking participants, and increased project acceptability and credibility. Among the challenges were issues related to boundaries, confidentiality, commitment, and burnout. Although such collaborations require increased time and commitment, the synergistic knowledge and experience of university researchers, community-based service providers, and out-of-the-mainstream youth can result in the development of unique and informative research and service programs.

Adolescent↗

PubMed2001

Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness.

OBJECTIVES: This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness. STUDY SETTING: A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites. DATA SOURCES: Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews. RESEARCH DESIGN: Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement. PRINCIPAL FINDINGS: Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support. CONCLUSION: Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.

Case Management↗

PubMed2003

The nationwide investigation of endocrine disruptors in sediment of harbours.

Various types of endocrine disruptors or environmental hormones flow from their sources down into harbours through rivers and other watercourses, and are accumulated in sediment on the sea bottom. Tributyltin, which has been used as paint for ship bottoms, is considered one of the endocrine disruptors. In close cooperation with the other ministries and agencies, the Ports and Harbours Bureau of the Ministry of Land, Infrastructure and Transport carried out an investigation in 1999 to determine the actual condition of 12 endocrine disruptors in the sediment of 39 harbours, in order to gather fundamental data to be used in future examinations of policy. Furthermore, in 2000 the bureau chose seven harbours out of the above 39 harbours as subjects of an additional investigation regarding the surface distribution of endocrine disruptors in the harbour areas and the synchronistic change of accumulation of dioxin and other substances. As the result of the investigation regarding the surface distribution of endocrine disruptors accumulated in seven harbours, relatively high concentrations were measured in the innermost parts of harbours and the mouths of rivers. Synchronistic changes in the amount of dioxin and other substances accumulated in sediments of five harbours were determined. Small amounts of dioxin and other substances, including an especially small amount of coplanar-PCBs, were found in the layers formed before or around 1950. Relatively large amounts of these substances were measured in the upper layers formed during roughly 1960-1990, though no significant yearly differences in concentration could be identified. This result coincides with the facts that, during roughly 1960-1980, PCP and CNP were used as agricultural chemicals and full-scale production of PCBs started in 1960.

Agriculture↗

PubMed1999

Unintended outcomes of health care delivery and the need for a national risk management approach.

Unlike the situation in occupational health and safety, there is no nationally coordinated approach to risk management to prevent unintended outcomes of health care provision and improve health care quality. There is a related absence of linkages between quality assurance process, other programs aimed at patient injury prevention and professional indemnity insurance systems. This article discusses the Australian health policy direction and argues for a coordinated national health risk management approach developed through contract requirements which include duty of care and information provision, nationally approved standards and codes, professional liability requirements, and supporting health education, research and information technology development.

Australia↗

PubMedDate not supplied

Legislative Cardiovascular Health Check: a multidisciplinary health promotion experience for South Carolina lawmakers.

The South Carolina Department of Health and Environmental Control has conducted a Legislative Cardiovascular Health Check for the past 4 years. The primary purpose of the event, held in the lobby of the State Capitol Building, is to increase the awareness of State legislators about the leading causes of death in South Carolina and about community-based health promotion services that are available. The health check emphasizes the relationship between modifiable risk factors and the development of heart disease, cancer, and stroke. These legislative events are organized by State health department staff members, but they are conducted by local health department personnel from throughout South Carolina. This approach is intended to build the capacity of these local staff members to communicate more effectively with their legislators and to carry out similar events at the county or community level. The health check is staffed by a trained multidisciplinary team, including persons designated as legislative liaisons. The liaison people contact legislators prior to the event and provide them with health status data specific to their respective districts. The Legislative Cardiovascular Health Checks have been attended by members of the General Assembly and their staffs, members of the Governor's staff and the Lieutenant Governor's office, and other employees of the State Capitol. An average of 380 people have participated annually. Screening activities have included blood pressure and blood cholesterol checks, with risk factor counseling and educational materials provided to each screened participant. During the past year, activities were expanded to include a variety of interactive exhibits related to nutrition, exercise, and smoking. Feedback from participants has been positive. The Legislative Cardiovascular Health Check is encouraged and supported by the upper management of the State health department and is now established as an annual event of mutual benefit to legislators and to State and local health department staff members.

Blood Pressure↗

PubMedDate not supplied

Preventive medicine training and managed care: current status and models for the future.

The specialty of preventive medicine and managed care organizations share many common philosophies. Ties have been established between these two groups, but opportunities exist for strengthening and expanding relationships. I identified six preventive medicine residencies with strong rotations at managed care organizations and surveyed them for basic information regarding their affiliations. Six medical directors of managed care organizations who are board-certified in preventive medicine were also contacted and surveyed. Successful relationships between preventive medicine residencies and managed care organizations include (1) commitment to training in a managed care environment by the preventive medicine residency, (2) large, well-established managed care organizations, and (3) commitment by the managed care organization to preventive medicine, evidenced by a department of preventive medicine or a preventive medicine physician on staff. Issues related to the involvement of managed care in preventive medicine training include the uncertain interest of managed care organizations in graduate medical education and the growing need for managed care organizations to attain accreditation status that includes standards for preventive services. Preventive medicine and managed care should increase their ties in the future. Medical Subject Headings (MeSH): preventive medicine, managed care, health maintenance organization, graduate medical education, training, accreditation.

Clinical Competence↗