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PubMed1985

Risk management in the dental office.

Owing to a massive increase in malpractice suits directed against dentists and an escalation in the amount of settlements and court ordered awards, professional liability premiums are increasing at an alarming rate. Perhaps more important to the dentist is the anguish caused by the legal process that exposes him or her to allegations made in the public arena of the courts and the press regarding the delivery of substandard care. In addition, the dentist may suffer considerable loss of money as a result of findings of negligence by the courts. The license to practice also is at risk. In today's environment, the practice of a health profession does not appear to be emotionally, professionally, or financially secure. Despite these disadvantages in the practice of dentistry, there is much the practitioner can do to reduce or eliminate legal vulnerability. In addition to maintaining a level of care that meets the standards of other dentists in the community through the process of quality assurance, legally sound office practices and practice management procedures may contribute significantly to minimizing legal risks. A process known as risk management is currently available to assist the practicing dentist in achieving these goals. The principles of risk management was borrowed from industry by the health care industry following the crisis in medical malpractice of the early 1970s. Its primary focus is the protection of resources from losses due to legal action. The activities associated with risk management are easily adapted to dental practice. The focus of these activities is directed at identifying areas of legal vulnerability, taking steps directed at reducing or eliminating them, and purchasing insurance to offset potential financial losses. The current areas of legal vulnerability center around issues of (1) absence of consent to care, (2) negligence, and (3) breach of contract. Consent to care, to be valid, must be informed and granted voluntarily. To meet the test of "informed," the information given to the patient must be in understandable language and contain the risks, benefits, and alternatives to the recommended treatment. In addition, the patient must be given an opportunity to have his or her questions answered. Obtaining consent from one having legal capacity to grant consent is another essential requirement. The treatment of minors and those that are emancipated, raises many problems with consent.(ABSTRACT TRUNCATED AT 400 WORDS)

Defensive Medicine↗
PubMed1997

Building healthier communities in a managed care environment: opportunities for advanced practice nurses.

Two paradigm shifts are occurring in health care: managed care and community partnerships. The distinct principles and trends of each paradigm are certain to determine the future practice of advanced practice nurses (APNs). The impact of managed care and community partnerships will affect the resource management, clinical decision making, and time management of APNs. Concomitantly, APNs will have opportunities to influence practice guidelines, individual and community decision making, cultural competence, and the cost-effectiveness of care in communities. Capitalizing on these opportunities will enhance the value of APNs to their managed care plan employer and their community.

Community Health Nursing↗
PubMed1996

Effect of managed care on cardiovascular specialists: involvement, attitudes and practice adaptations.

OBJECTIVES: This study was undertaken to determine the extent to which cardiovascular specialists are involved with and affected by managed care and to ascertain their attitudes toward it. This survey also served as the follow-up to an initial study on the subject performed by the American College of Cardiology in 1993. BACKGROUND: The initial 1993 study was performed to address the lack of any comprehensive examination of the impact of managed care on cardiovascular specialists. In 1995, to reexplore this question and follow up the 1993 findings, the College conducted a survey of its membership in the following areas: 1) physician relationship with managed care plans; 2) number of managed care contracts; 3) breakdown of revenue by payment source; 4) changes in practice in response to managed care; and 5) physician attitudes toward managed care. To the extent feasible, the 1995 questionnaire paralleled the 1993 instrument to facilitate comparisons. METHODS: A questionnaire was mailed to 5,147 practicing College members in the United States, who were categorized by specialty as pediatric cardiologists, adult cardiologists or cardiovascular surgeons. Mailings were sent to 1) all pediatric cardiologists and cardiovascular surgeons; 2) randomly selected adult cardiologists practicing in 10 states with high managed care penetration; and 3) randomly selected adult cardiologists in the nine U.S. census areas who were not practicing in the 10 states with high managed care penetration. RESULTS: Usable surveys were returned by 1,236 respondents, for an overall response rate of 24%. Involvement with at least one type of managed care organization was reported by 89% of respondents, up from 76% in 1993. Although managed care relationships had increased across physician age, region, practice and specialty, respondents indicated that, on average, well below 50% of their practice revenues stem from managed care contracts. To adapt to the managed care environment, strategic practice changes, such as joining a cardiovascular network, implementing continuous quality improvement systems and adopting clinical pathways, were being instituted by most respondent practices of nine or more physicians. Smaller groups were less active. Most respondents involved with managed care disliked its effects, particularly in clinical matters. Their attitudes toward the assumption of risk, managed fee-for-service arrangements and a private versus single-payer system show that there is no uniformity of opinion regarding the best means to contain costs and promote efficiency. CONCLUSIONS: Managed care has become an established part of cardiovascular specialist practice in the United States. Although this trend is viewed with some disfavor, most respondents are making practice changes to adapt to this new environment.

Attitude of Health Personnel↗
PubMed1990

The malpractice morass and practice activities of orthodontists.

This study examined the association between malpractice, measured by perception and experience scores, and practice activities of orthodontists. Data from 184 Florida orthodontists were obtained in the form of continuous/ordinal responses to survey questions in five areas: demographic, work load, personality, perception of the malpractice environment, and practice activities (malpractice experience, record taking, disclosure, and rapport). Mutually exclusive recency categories were selected on the basis of when an activity was last performed. Descriptive statistics and plots of the data were examined. A malpractice experience score for each respondent was determined by means of factor analysis procedures on the activity question responses. The association between perception/experience scores and responses to activity, demographic, work load, and personality questions were examined with the use of stepwise multiple regression procedures. The results indicated that practice activities, in the areas of record taking and doctor-patient rapport, were moderately associated with both experience scores (R2 = 0.47, p = 0.08) and perception scores (R2 = 0.29, p less than 0.06). Perception of the malpractice environment was associated with practice activities of orthodontists but to a lesser extent than active experiences in that environment were.

Dental Records↗
PubMedDate not supplied

Nuclear cardiology in private practice.

The provision of nuclear cardiology services in private-practice settings is probably currently the fastest growing segment of nuclear medicine. One reason is that myocardial perfusion scintigraphy, by determining which patients require coronary angiography and revascularization, has the potential to help a cardiology practice complete more successfully in the managed-care environment. Private practices can establish their own patient databases to determine how scintigraphic findings correlate with patient outcomes and with findings if coronary angiography is performed. Based on these data, pressure can be exerted to modify clinical responses to optimize the relationship between scintigraphic findings, quality of clinical care, and cost-effective patient management. To succeed in a managed-care setting, nuclear cardiologists must demonstrate that, without their services, the quality of cardiac care would be lower and the cost of caring for patients with heart disease would be higher. As in other settings, nuclear cardiologists in private practice must be involved managerially so they will be active participants in the development of clinical-care guidelines and the negotiation of capitated and other types of managed-care contracts.

Algorithms↗
PubMed2000

The safety climate and its relationship to safety practices, safety of the work environment and occupational accidents in eight wood-processing companies.

Employees continuously observe their work environment and the actions of their fellow workers and superiors, and they use such observations as a basis for the creation of cognitive models associated with safety. These models regulate their actions in the workplace and thus have an influence on safety. This study attempts to define the structure of the safety climate as perceived by workers and the correlations between the safety climate, on the one hand, and the safety practices of the company, the safety level of the work environment and occupational accidents on the other. The variables used in this study were the same as those employed in two previous Finnish safety climate studies carried out in the plywood industry, shipyards, the forestry industry, building construction and stevedoring. The safety climate was measured by means of a questionnaire. Workers from four sawmills, two plywood factories and two parquet plants participated. The total number of participants was 508 in 1990 and 548 in 1993. The variables formed four factors, whose contents and reliabilities closely resembled the results obtained in the earlier studies. These results indicate that the structure of the safety climate among Finnish workers is quite stable. The safety climate correlated both with the safety level of the work environment and with the safety practices of the company, but the correlation between the safety climate and the safety of the work environment was stronger. This result differs from those of the previous studies, in which the safety climate was defined specifically in terms of an individual's perceptions of the safety practices of the company and of the behavior of other employees. The two safety climate factors that described a company's attitudes to safety and its safety precautions correlated with the accident rates. The better the safety climate of the company was, the lower was the accident rate. Four companies with an accident rate below the average for the wood-processing industry had a better safety climate than four similar companies with an accident rate above the average.

Accidents, Occupational↗
PubMedDate not supplied

A practice change model for quality improvement in primary care practice.

Faced with a rapidly changing healthcare environment, primary care practices often have to change how they practice medicine. Yet change is difficult, and the process by which practice improvement can be understood and facilitated has not been well elucidated. Therefore, we developed a model of practice change using data from a quality improvement intervention that was successful in creating a sustainable practice improvement. A multidisciplinary team evaluated data from the Study To Enhance Prevention by Understanding Practice (STEP-UP), a randomized clinical trial conducted to improve the delivery of evidence-based preventive services in 79 northeastern Ohio practices. The team conducted comparative case-study analyses of high- and low-improvement practices to identify variables that are critical to the change process and to create a conceptual model for the change. The model depicts the critical elements for understanding and guiding practice change and emphasizes the importance of these elements' evolving interrelationships. These elements are (1) motivation of key stakeholders to achieve the target for change; (2) instrumental, personal, and interactive resources for change; (3) motivators outside the practice, including the larger healthcare environment and community; and (4) opportunities for change--that is, how key stakeholders understand the change options. Change is influenced by the complex interaction of factors inside and outside the practice. Interventions that are based on understanding the four key elements and their interrelationships can yield sustainable quality improvements in primary care practice.

Female↗