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PubMed2003

Aligning quality and payment for heart failure care: defining the challenges.

Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues. A conflict between the highest quality of care and financial solvency does not serve the interests of patients, physicians, hospitals, or payers. In principle, resolution of this conflict is simple: reimbursement systems should reward higher quality care. In practice, resolving the conflict is not simple. A recent roundtable discussion sponsored by the Heart Failure Society of America identified 4 major challenges to the design and implementation of reimbursement schemes that promote higher quality care for heart failure: defining quality, accounting for differences in disease severity, crafting novel payment mechanisms, and overcoming professional parochialism. This article describes each of these challenges in turn.

Delivery of Health Care↗
PubMedDate not supplied

The challenge: developing a preceptorship program in the midst of organizational change.

The implementation of educational programs during ongoing organizational change is a challenge. Our hospital nursing education department was successful in developing a department-wide preceptorship program during significant institutional change. This article outlines an analysis of the process of implementing such a program from the perspective of the unfreezing, moving, and refreezing components of change theory. An examination of the driving and restraining forces before and after the initiation of the program provides rationale for the success of the program. Factors that contributed to achievement of our goals include effective communication, senior administrative support, and education. From this analysis one could conclude that it is possible to initiate major educational initiatives during concurrent organizational change.

Curriculum↗
PubMed2006

Development and implementation of a nutrition education program for medical students: a new challenge.

CONTEXT: Teaching nutrition to medical students is constrained by limitations in curricular time and competition with other topics. OBJECTIVES: To identify time slots and teaching methods for incorporating nutrition into the medical school curriculum, determine students' nutritional knowledge following the program, and their perception of the effectiveness of the program. METHODS: A nutritional workshop was added to the clinical experience weeks of second-year medical students. The first class included 66 students and the second class included 56 students. In order to fully acquaint the students with nutrition, four topics were included: nutritional policy, dietary assessment, nutritional recommendations, and obesity. Students were encouraged to actively participate in the program which included dietary intake interviews, debates regarding nutritional treatments, and actual practice in class. The main outcome measures were nutritional knowledge and evaluation of the program by the students. FINDINGS: Over 90% of the students answered the knowledge questions correctly. The effectiveness of the training was graded (on a scale of 1-7) between 3.7-5.4 in the first year and 3.4-5.7 in the second year. CONCLUSIONS: The ten-hour nutritional workshops within the clinical weeks were well-received by second-year medical students. Using cases relevant to the students' age seems to enhance their interest in the program.

Adult↗
PubMed2006

Thorough planning and full participation by pharmacists is key to MOE/MAR success.

The successful implementation of the Medication Order Entry/Medication Administration Record project was dependent on the Pharmacy department working collaboratively with many other stakeholders in the organization. To do this, the Pharmacy department faced numerous technical, staffing, workflow and clinical practice challenges during the design and implementation of MOE/ MAR.

Diffusion of Innovation↗
PubMed2005

Leprosy: too complex a disease for a simple elimination paradigm.

Can leprosy be eliminated? This paper considers the question against the background of the WHO programme to eliminate leprosy. In 1991 the World Health Assembly set a target of eliminating leprosy as a public health problem by 2000. Elimination was defined as reaching a prevalence of < 1 case per 10 000 people. The elimination programme has been successful in delivering highly effective antibiotic therapy worldwide. However, despite this advance, new-case detection rates remain stable in countries with the highest rates of endemic leprosy, such as Brazil and India. This suggests that infection has not been adequately controlled by antibiotics alone. Leprosy is perhaps more appropriately classed as a chronic stable disease than as an acute infectious disease responsive to elimination strategies. In many countries activities to control and treat leprosy are being integrated into the general health-care system. This reduces the stigma associated with leprosy. However, leprosy causes long-term immunological complications, disability and deformity. The health-care activities of treating and preventing disabilities need to be provided in an integrated setting. Detecting new cases and monitoring disability caused by leprosy will be a challenge. One solution is to implement long-term surveillance in selected countries with the highest rates of endemic disease so that an accurate estimate of the burden of leprosy can be determined. It is also critical that broad-based research into this challenging disease continues until the problems are truly solved.

Communicable Disease Control↗
PubMedDate not supplied

The quality improvement process: one approach to education.

Quality improvement (QI) is a practice now expected of the healthcare industry. The Joint Commission on Accreditation of Healthcare Organizations has incorporated continuous QI into its standards; furthermore, the implementation of QI is a major challenge facing healthcare institutions today. The authors describe the educational approach taken by one institution as it implemented the QI process in a facility that recently merged three acute care hospitals and explain the necessary commitment and structure for a successful QI program. The importance of the educational process cannot be overemphasized.

Education, Continuing↗
PubMed2002

Capital assets and intercultural borderlands: socio-cultural challenges for natural resource management.

In their design or implementation, many natural resource management (NRM) programs ignore critical socio-cultural dimensions of the challenge to advance sustainability. Building on particular ideas about culture and human ecosystems, we combine the strengths of the capital assets model of sustainability and the idea of intercultural borderlands to respond to this gap. To advance our thesis about the utility of these tools, we critically reviewed and analysed a cross-disciplinary literature relating to the socio-cultural dimensions of NRM. This paper stems from that labour and examines particular tensions that arise in land management as a result of Australians' specific colonial and postcolonial legacies. These tensions--related to ethnicity, gender, population, age and health--are among the threads in the larger tapestry that comprises the socio-cultural dimensions of NRM. For the Australian case, they are central, longstanding and persistent, and thus worthy of analysis; and they are applicable in general terms to other places with similar histories of settlement and land use.

Adult↗
PubMed1999

The challenges of employing performance monitoring in public health community-based efforts: a case study.

The development of community-based coalitions has acquired great popularity as a health promotion strategy. The Institute of Medicine recommends that community-based health coalitions employ a performance monitoring process in their efforts. The results of the current study indicate that in the community setting, implementing a performance monitoring process and sustaining the specialized functions entailed in this strategy are challenging. Many of the challenges result from fundamental differences between the organizational environment of bureaucracies--in which these techniques are developed, supported, and greatly successful--and the realities of the loosely-structured and resource-limited community environment. The performance monitoring process is measurement-driven. One challenge of implementing this process at the community level is that public health problems of local concern are not always documented in current surveillance systems and thus a performance monitoring strategy is not always, or immediately, applicable. When data which document a health problem of local concern are available, a second challenge facing community-based coalitions is acquiring the resources, especially the wide-range of specialized expertise, required to fully implement and sustain the performance monitoring process. These issues are examined in the context of the Massachusetts Department of Public Health's Community Health Network Area (CHNA) Initiative which entails the formation of coalitions of local health service providers. The CHNA initiative is a statewide project in which health service providers in specified geographic regions work collaboratively on health improvement projects.

Adolescent↗
PubMedDate not supplied

Challenges in improving care for high-risk seniors in Medicare.

Despite strong interest in improving care for high-risk elders, demonstration projects typically show negative results. This paper examines one large foundation-sponsored initiative to gain insight on why success often is so elusive. The findings indicate that specific flaws in concept, design, and implementation each make it more challenging for demonstrations to achieve their intended goals, especially those involving cost and utilization reductions. We speculate that part of the reason for this is that organizational and political processes lead to fundamentally conservative demonstrations that assume that small amounts of resources directed at incremental change can be effective in generating substantial change in organizations and can do so rapidly.

Aged↗
PubMed2006

Implementation and maintenance of quality improvement for treating depression in primary care.

OBJECTIVE: Little is known about the long-term success of quality improvement efforts for the treatment of depression in primary care. This study assessed factors associated with the successful implementation, maintenance, and spread of such efforts. METHODS: The authors conducted an independent process evaluation of data from monthly progress reports and 18-month telephone interviews from multidisciplinary quality improvement teams in 17 diverse primary care organizations that participated in the Institute for Healthcare Improvement's Breakthrough Series for Depression from February 2000 through March 2001. RESULTS: All sites made changes toward improving care in three of six categories: delivery system redesign, self-management strategies, and information systems. The changes that were most commonly viewed as major successes were delivery system changes (ten sites, or 59 percent) and information system changes (nine sites, or 53 percent); these types of changes were also the most often sustained over time (ten sites, or 59 percent, and 16 sites, or 94 percent, respectively). Fifteen sites made changes in decision support, community linkages, and health system support but were less likely to view these changes as major successes or to sustain them. Organizational structure and leadership support were the most common facilitators. Staff resistance, time constraints, and information technology were the most common barriers. Implementation strategies varied with sets of barriers. CONCLUSIONS: Despite substantial challenges, there was evidence of broad success at implementation and maintenance of quality improvement for depression treatment in primary care.

Depressive Disorder↗
PubMed2005

Developing a cultural competence assessment tool for people in recovery from racial, ethnic and cultural backgrounds: the journey, challenges and lessons learned.

In 1997, Maryland implemented a new managed care mental health system. Consumer satisfaction, evaluation and cultural competency were considered high priorities for the new system. While standardized tools for measuring consumer satisfaction were readily available, no validated, reliable and standardized tool existed to measure the perception of people from minority groups receiving mental health services. The MHA*/MHP* Cultural Competency Advisory Group (CCAG) accepted the challenge of developing a consumer assessment tool for cultural competency. The CCAG, composed of people in recovery, clinicians and administrators used their collective knowledge and experiences to develop a 52-item tool that met standards for validity and reliability. Consultation from a researcher helped to further develop the tool into one possessing tremendous potential for statewide implementation within Maryland's Public Mental Health System. Recognizing the limitations of the study and the need for further research, this instrument is a work in progress. Strategies to improve the instrument are currently underway with the Mental Hygiene Administration's Systems Evaluation Center of the University of Maryland and several national researchers.

Adult↗
PubMedDate not supplied

Practitioners' perspectives on effective practices for Hispanic teenage pregnancy prevention.

CONTEXT: In the United States, the pregnancy rate and birthrate of Hispanic teenagers are higher than those of other races and ethnicities. Although recommendations for culturally appropriate pregnancy prevention programs are commonplace, little is known about how practitioners address such recommendations. METHODS: In individual interviews, 58 teenage pregnancy prevention practitioners who work primarily with Mexican American female teenagers from two regions in California were asked about their understanding of recommendations for best practices and discussed the strategies they have used and challenges they have faced in implementing the recommendations. Qualitative methods were used to categorize responses and identify themes. RESULTS: Practitioners indicated that knowledge and awareness of Hispanic culture are essential, as is commitment to teenagers and their needs. They regard activities that encourage educational and career achievement as critical program components, and view both male partners' and family members' involvement in programs as important but challenging. Furthermore, practitioners feel that the implicit program goals of continued education and female self-sufficiency are often at odds with traditional Hispanic cultural values. CONCLUSIONS: Practitioners have valuable insight into the reality of implementing culturally sensitive programs. Programs need to balance the often competing values and goals of prevention programs with those of Hispanic youth culture and experiences.

Adolescent↗
PubMed1993

Implementing modular nursing in a long-term care facility.

Nurse administrators in long-term care are challenged to maintain the quality of nursing care under constant fiscal and staffing pressures. Restructuring nursing care delivery is one method often used to meet this challenge. The authors describe their experience of implementing a nursing care delivery model that resulted in improved continuity of care, accountability for client outcomes, and the effective use of different staff levels.

Communication↗
PubMed1990

Cultural diversity: a resource in planning and implementing nursing care.

America's cultural diversity challenges the ability of nurses to respond with sensitivity to client needs. Enhancement of the client's health practices is contingent on the nurse's ability to use the individual's culturally based beliefs and values as an integral component in the design of nursing interventions. Nurse and client engage in a truly collaborative planning and implementation of care only after there is mutual understanding of the special meaning of beliefs and values from which health behaviors are derived. Educational preparation with experience in applying cultural knowledge is essential to the development of sensitive nursing practice. Integrating such information and experiences into baccalaureate nursing curricula through a sociocultural project will enhance student awareness of client values and beliefs and their potential nursing implications. Strategies exist for helping students recognize, accept, and use these features in planning and implementing nursing care.

Community Health Nursing↗
PubMedDate not supplied

Thinking about tomorrow for nursing: changes and challenges.

Many changes will be forthcoming in planning and implementing nursing practice in community-based settings in the future. Nursing education will experience major challenges in planning and developing curricula as a response to more mature people becoming nurses for the first time. Clinical practice "without walls," a change from what we have traditionally known, will require creative approaches toward bringing nurse colleagues along who have only practiced in institutions. This article is intended to stimulate new ideas and solutions for nursing to meet new challenges brought on by health care reform.

Community Health Nursing↗
PubMed2002

Reforming China's urban health insurance system.

China's urban health insurance system is mainly consisted of labor insurance schemes (LIS) and government employee insurance scheme (GIS). LIS is a work unit-based self-insurance system that covers medical costs for the workers and often their dependents as well. GIS covers employees of the State institutions, is financed by general revenues. Since 1980s, China has implemented series of health insurance system reforms, culminating in the government's major policy decision in December of 1998 to establish a social insurance program for urban workers. Compared with the old insurance systems under LIS and GIS, the new system expands coverage to private sector employees and provides a more stable financing with its risk pool at the city level. Despite of these advantages, implementation of China's health insurance reform program is faced with several major challenges, including risk transfer from work units to municipal governments, diverse need and demand for health insurance benefits, incongruent roles of the central and regional governments. These challenges may reflect practical difficulties in policy implementation as well as some deficiencies in the original program design.

China↗
PubMed2006

Using school staff to establish a preventive network of care to improve elementary school students' control of asthma.

School-based asthma interventions delivered by nonschool staff have been successful but are limited in their reach because of the cost and effort of bringing in outside educators and their inability to establish improved communication about asthma between schools, families, and primary care providers (PCPs). To address these problems, Columbia University and the New York City Department of Education and the New York City Department of Health and Mental Hygiene undertook a randomized controlled trial to test the efficacy of a comprehensive school-based asthma program. In this intervention, school nurses were trained to facilitate the establishment of a preventive network of care for children with asthma by coordinating communications and fostering relationships between families, PCPs, and school personnel. PCPs also received training regarding asthma management. There was limited support for this model. While case detection helped nurses identify additional students with asthma and nurses increased the amount of time spent on asthma-related tasks, PCPs did not change their medical management of asthma. Few improvements in health outcomes were achieved. Relative to controls, 12-months posttest intervention students had a reduction in activity limitations due to asthma (-35% vs -9%, p < .05) and days with symptoms (26% vs 39%, p = .06). The intervention had no impact on the use of urgent health care services, school attendance, or caregiver's quality of life. There were also no improvements at 24-months postintervention. We faced many challenges related to case detection, training, and implementing preventive care activities, which may have hindered our success. We present these challenges, describe how we coped with them, and discuss the lessons we learned.

Absenteeism↗