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Managing the aftermath of medication errors: managed care's role.

OBJECTIVE: To discuss managed care's role in managing an organization's response to a medication error and to provide specific recommendations for that response. DATA SOURCES: Published articles and reports related to crisis management, service failure, public relations, ethics, psychology, management, marketing, health care, and law. Review of the literature on crisis management and service failure was extensive. ProQuest and MEDLINE databases were searched. Search terms were medication error, medical error, and organizational crisis. STUDY SELECTION: Studies were selected on the basis of their relevance to practitioners. DATA SYNTHESIS: Medication errors place practitioners, pharmacies, and health care organizations under severe emotional, physical, and financial stress. Managed poorly, a medication error can have disastrous consequences for all involved. When the response is managed correctly, a medication error presents a challenge, but one that is survivable and potentially instructive. Managed care should develop and disseminate best practices for responding to errors and lead the development and adoption of technologies and systems designed to curtail the number of errors and reduce the costs associated with those errors. Effectively responding to a medication error allows the pharmacy organization to maintain or resume its core activities while minimizing stakeholders' losses. The lessons learned in the process of managing the aftermath of a medication error should be incorporated into ongoing quality improvement programs. CONCLUSION: Based on the literature review and the ideas presented, specific recommendations for responding to catastrophic medication errors are made. Following those recommendations would allow those in the health care system--managed care organizations and individual practitioners--to improve their image and do good at the same time.

Attitude of Health Personnel↗

Comprehensive case management: implications for program managers.

Management of comprehensive case management programs could be improved with an understanding of work issues facing case managers. Interviews with case managers from health departments revealed these issues to be types of client, case manager, program, and community problems in doing the work of case management, as well as solutions and perceptions about case management. Implications for having and managing case management programs are organized and discussed using a Model of Comprehensive Case Management.

Allied Health Personnel↗

Conservative management of post prostatectomy incontinence.

BACKGROUND: Urinary incontinence after prostatectomy is a common problem. Conservative management of this condition includes pelvic floor muscle training, biofeedback, electrical stimulation using a rectal electrode, transcutaneous electrical nerve stimulation, or a combination of methods. OBJECTIVES: To assess the effects of conservative management for urinary incontinence after transurethral, suprapubic, radical retropubic or perineal prostatectomy. SEARCH STRATEGY: The Cochrane Incontinence Group's trials register, Medline, Cinahl, Embase, PsycLit and ERIC all up to January 1999, and reference lists of relevant articles. We contacted investigators to locate studies and we handsearched the following conference proceedings: American Urological Association (1989-1999); Society of Urologic Nurses and Associates (1991-1998); Wound Ostomy and Continence Nurses (1996-1999); and International Continence Society (1980-1998). Date of most recent searches: January 1999. SELECTION CRITERIA: Randomised or quasi-randomised trials which evaluated conservative management aimed at improving urinary continence after prostatectomy. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the methodological quality of studies and abstracted data from included trials onto a standard form. MAIN RESULTS: Only five randomised trials were identified which included 365 men, each evaluating different treatments, and all studying men after radical prostatectomy. The trials were of moderate quality and data were not available for many of the pre-stated outcomes. Confidence intervals for both dichotomous and continuous data were wide; it was not possible to reliably identify or rule out a useful effect. Men's symptoms tended to improve over time, irrespective of management. REVIEWER'S CONCLUSIONS: The value of the various approaches to conservative management of post prostatectomy incontinence remains uncertain. Further well designed trials are needed.

Biofeedback, Psychology↗

The cost-effectiveness of dextranomer/hyaluronic acid copolymer for the management of vesicoureteral reflux. 2. Reflux correction at the time of diagnosis as a substitute for traditional management.

PURPOSE: The use of dextranomer/hyaluronic acid copolymer has become increasingly popular as an alternative to ureteral reimplantation in the treatment of vesicoureteral reflux. We compared the cost-effectiveness of performing dextranomer/hyaluronic acid injection at the time of diagnosis of reflux to that of traditional management. MATERIALS AND METHODS: A model to estimate the costs of managing vesicoureteral reflux has previously been created. We updated the model to compare the costs of managing vesicoureteral reflux by traditional methods with the costs of managing reflux if dextranomer/hyaluronic acid injection is performed at the time of diagnosis. The success rate required for dextranomer/hyaluronic acid injection at diagnosis to be as cost effective as traditional management was estimated. We used 2 models of dextranomer/hyaluronic acid injection at diagnosis-injection at diagnosis proceeding to traditional management if injection failed (scenario 1), and injection at diagnosis proceeding to ureteral reimplantation if injection failed (scenario 2). RESULTS: If reflux is stratified by grade in scenario 1, for grades III, IV and V respective success rates of 88.5%, 66.6%, and 55.6% for unilateral reflux and 97.5%, 89.7% and 91.4% for bilateral reflux must be achieved to have equal cost-effectiveness to traditional management, while grades I and II reflux can never achieve equal cost-effectiveness. Stratified by grade for scenario 2, for grades III, IV and V respective success rates of 86.9%, 70.8% and 55.8% for unilateral reflux, and 97.6%, 89.8% and 89.8% for bilateral reflux must be achieved to attain equal cost-effectiveness compared to traditional management. In scenario 2 dextranomer/hyaluronic acid injection at diagnosis for grades I and II unilateral and bilateral reflux can never achieve equal cost-effectiveness compared to traditional management. CONCLUSIONS: Based on the results of this study, in most clinical situations dextranomer/hyaluronic acid injection at the time of diagnosis is unlikely to be as cost effective as traditional management of vesicoureteral reflux.

Adjuvants, Immunologic↗

Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy.

BACKGROUND: The justification and preference for operative versus nonoperative management of hepatic injuries caused by blunt trauma remains ambiguous. This review assesses the outcome of operative and nonoperative management of liver injury after blunt trauma. METHODS: We retrospectively reviewed the demographics, severity of injury, severity of liver injury, associated concomitant injuries, management scheme, and outcome of patients with documented hepatic injury from 1993 to 2003. RESULTS: The overall mortality rate was 9.4%, with 3.7% caused by the liver injury itself. Fifty-nine percent (330 of 561) of liver injuries were of low severity (grades I and II), with an overall mortality rate of 6.6% caused by concomitant injuries and liver-related mortality of 0%. Forty-one percent (231 of 561) of liver injuries were high-severity injuries (grades III, IV, and V). Mortality for nonoperative management of high-severity liver injuries was 2.2%. If operative intervention was required because of hemodynamic instability or concomitant injuries then the mortality rate was significantly higher at 30%. Forty-two of the 378 (11%) liver injuries treated nonoperatively required an adjunctive procedure for successful management. CONCLUSIONS: Selective management of liver injuries presented a low liver-related mortality rate. Low-grade injuries can be managed nonoperatively with excellent results. High-grade injuries can be managed nonoperatively, if operative intervention is not required for hemodynamic instability or associated injuries, with a low mortality. In these patients, adjunctive procedures will be required selectively for successful nonoperative management of high-grade liver injuries. High-grade injuries requiring operative management because of hemodynamic instability or concomitant injuries continue to have significantly higher mortality.

Adult↗

Reverse quality management: developing evidence-based best practices in health emergency management.

The British Columbia Ministry of Health's Framework for Core Functions in Public Health was the catalyst that inspired this review of best practices in health emergency management. The fieldwork was conducted in the fall of 2005 between hurricane Katrina and the South Asia earthquake. These tragedies, shown on 24/7 television news channels, provided an eyewitness account of disaster management, or lack of it, in our global village world. It is not enough to just have best practices in place. There has to be a governance structure that can be held accountable. This review of best practices lists actions in support of an emergency preparedness culture at the management, executive, and corporate/governance levels of the organization. The methodology adopted a future quality management approach of the emergency management process to identify the corresponding performance indictors that correlated with practices or sets of practices. Identifying best practice performance indictors needed to conduct a future quality management audit is described as reverse quality management. Best practices cannot be assessed as stand-alone criteria; they are influenced by organizational culture. The defining of best practices was influenced by doubt about defining a practice it is hoped will never be performed, medical staff involvement, leadership, and an appreciation of the resources required and how they need to be managed. Best practice benchmarks are seen as being related more to "measures" of performance defined locally and agreed on by 2 or more parties rather than to achieving industrial standards. Relating practices to performance indicators and then to benchmarks resulted in the development of a Health Emergency Management Best Practices Matrix that lists specific practice in the different phases of emergency management.

Benchmarking↗

Changing domains in the management process. Radiographers as managers in the NHS.

Examines a group of radiographers developing management roles within the backdrop of a changing NHS. A comparative study of 25 Scottish and English radiographer managers were interviewed using semi-structured interviews. Interviews were based on a number of issues associated with moving from a clinical professional to a clinical manager and were analysed using domain theory. The interviews formed a number of emerging themes, which included management, professionalism, management style, conflicts between the role of both manager and professional, and role change. Radiographer managers are forming new "hybrid" manager roles, which have been developing within a changing NHS. A definite tension was seen in this role change. This transition was not easy for this group of radiographer managers. However, they have shown resilience in undertaking both operational and strategic management decisions, while using their clinical background to inform their decision making.

Attitude of Health Personnel↗

Acute management of pituitary apoplexy--surgery or conservative management?

BACKGROUND AND OBJECTIVE: The rarity of pituitary apoplexy renders it a difficult subject for audit; hence there are no evidence-based standards of optimum care for such patients. The key controversy in management relates to the role of acute neurosurgical intervention. In recent years we have adopted a relatively conservative approach towards patients presenting with pituitary apoplexy. Against this background, we aimed to determine whether our less-interventional approach affected long-term clinical outcome in these patients. PATIENTS AND DESIGN: A retrospective analysis was performed to evaluate clinical presentation, management and clinical outcomes in a cohort of patients who presented acutely with pituitary apoplexy during the period 1994-2004. Data from 33 patients (13 female) were included, with a mean age of 52 (range 27-79) years and mean follow-up duration of 3.7 (0.4-10.1) years. RESULTS: The most common presenting symptoms were headache (97%), visual deficits (82%) and nausea/vomiting (78%). Fifteen patients (46%) underwent transsphenoidal surgery while 18 were managed conservatively. Indications for surgery were deteriorating visual deficit (n = 13), hemiparesis (n = 1) and altered conscious level (n = 1). Eight patients in the surgical group had ocular paresis that resolved in 63% following surgery, and seven had visual field defects with recovery in 57% postsurgery. Conservative management was reserved for patients with absent, or evidence of resolving, visual deficits at presentation. In this group, seven presented initially with ocular paresis and six with visual field defects but all made full recoveries. Of the patients managed neurosurgically, 87% required long-term glucocorticoid replacement and 60% required long-term thyroid hormone replacement. Conservatively managed patients required glucocorticoid replacement in 72% and thyroid hormone replacement in 72% of cases (P = NS between the two groups). Sex steroid replacement was required in 67% and 83% of patients managed neurosurgically and conservatively respectively (P = NS). At latest follow-up one patient in the conservatively managed group had required surgery and one in the surgically managed group had received pituitary radiotherapy, in both instances due to evidence of tumour regrowth on magnetic resonance imaging (MRI). CONCLUSION: Our findings suggest that patients presenting with pituitary apoplexy in whom visual deficits are stable or improving may be managed expectantly as there is no identifiable deleterious effect on visual or endocrine outcome. One patient from each group experienced tumour regrowth that necessitated further treatment intervention, highlighting the importance of long-term follow-up in patients with pituitary apoplexy.

Acute Disease↗

Factors impacting on nurse managers' ability to be innovative in a decentralized management structure.

Several studies indicate that management styles and knowledge of organizational structures have an impact on the potential for staff innovation. This exploratory study was conducted to investigate the implications of such variables in relation to nursing managers in a public sector health organization in Victoria, Australia. It reviewed factors that appeared to impact and encourage innovative behaviour amongst nurse managers within a decentralized management structure. To evaluate nurse managers' ability to be innovative, a 55-item survey consisting of both open questions and Likert-type scale questions was developed and distributed to 140 nurse managers working in a public sector health organization. The response rate was 58% yielding 82 usable responses. The study findings revealed that factors of management structures and management styles, in conjunction with the nurse unit managers' perceptions and communication skills, had an impact on nurse manager's ability to exhibit innovative behaviour in the 21st century workplace.

Attitude of Health Personnel↗

Using total quality management in long-term care case management.

Long-term care (LTC) case management has emerged as a way of addressing problems in the long term care system. Case managers serve as links between chronically ill and disabled individuals and the services these individuals need but of which they often are unaware. In this capacity, case managers address the fragmentation in the long-term care system. In guiding clients to cost-effective ways of meeting their long-term care needs, case managers also address the need for cost containment in long-term care. To ensure that case management is effectively addressing these and other problems, attention to quality is essential. However, quality assurance programs too often focus on minutiae rather than on true indicators of quality. In addition, people who are not involved in the related areas frequently make decisions about quality. These decisions impose additional, and sometimes unnecessary, restrictions on the people who are required to implement them. Total quality management (TQM) offers a new approach. In this article, a proposal is made to incorporate TQM principles into LTC case management. The LTC case management demonstration project currently underway in Virginia serves as the case study for this proposal. The proposal demonstrates a process in which quality can be built into a case management system in a way that involves the people who will implement the resultant changes. The proposal shows how case management staff members can learn to identify areas where quality is impaired and to use techniques to aid them in identifying the causes of problems. A procedure for testing solutions and for incorporating the findings into the project is described.

Aged↗

Changing domains in the management process: imaging services managers in the post-1990 National Health Service.

Much of the current literature on healthcare professionals developing management roles has focused almost exclusively upon hospital doctors. This paper seeks to redress this imbalance and explores the emergence of the professions allied to medicine (PAMs) as clinical managers. A comparative study of 25 English and Scottish radiographer managers were interviewed. From the interviews, a number of themes were developed associated with moving from a clinical professional to a clinical manager and were analysed using domain theory. These themes included management, professionalism, management style, conflicts between the role of both manager and professional, and role change. Radiographer managers are forming new 'hybrid' managerial roles, which have been developing within a changing NHS. A definite tension was seen in this role change, and the transition has not been easy for this group of PAMs. However, they have shown resilience in undertaking both operational and strategic management decisions, while using their clinical background in their decision-making and have much to offer the management process.

Conflict, Psychological↗

Problem solving in diabetes self-management: a model of chronic illness self-management behavior.

Management of chronic illnesses is a significant public health concern that is made more challenging by problems of regimen adherence. Effective self-management of chronic illnesses such as diabetes requires not only technical skill to perform regimen behaviors but also problem-solving skills to manage daily barriers to regimen adherence and to make appropriate adjustments to the self-care regimen. A review of the empirical literature on the relation between problem solving and disease self-management in diabetes, a chronic illness exemplar, illuminates methodological limitations that indicate a need for a theoretical framework for problem solving applied to chronic disease self-management. A problem-solving model of chronic disease self-management is proposed, derived from theories of problem solving in cognitive psychology, educational/learning theory, and social problem solving. Four essential components of problem solving in disease self-management are identified: (a). problem-solving skill, (b). problem-solving orientation, (c). disease-specific knowledge, and (d). transfer of past experience. The model is illustrated, and empirical support for this problem-solving model in the diabetes literature is discussed. The model has utility in driving testable hypotheses regarding the relation of disease-specific problem solving to chronic illness management, in developing problem-solving assessment instruments relevant to disease self-management, and in guiding disease self-management training and interventions.

Attitude to Health↗

Management and leadership: analysis of nurse manager's knowledge.

Nurses have assumed management positions in many health institutions. To properly accomplish the demands of this role, it is important that they be competent in both management and leadership. For appropriate performance, knowledge of management and supervision styles is a priority. Therefore, the goal of this investigation is to identify the nurse manager's knowledge regarding management and leadership. A structured questionnaire containing twenty-seven questions was applied to twelve Brazilian nurse managers of primary care center called "Family Basic Health Units". Data analysis suggested that the nurse manager lower knowledge in management and leadership is related to visionary leadership, management and leadership conceptual differences, leader's behavior, and situational leadership. And, nurse manager greater knowledge is related to power; team work, and coherence between values and attitudes.

Adult↗

Physicians in health care management: 1. Physicians as managers: roles and future challenges.

Physicians are increasingly expected to assume responsibility for the management of human and financial resources in health care, particularly in hospitals. Juggling their new management responsibilities with clinical care, teaching and research can lead to conflicting roles. However, their presence in management is crucial to shaping the future health care system. They bring to management positions important skills and values such as observation, problem-solving, analysis and ethical judgement. To improve their management skills physicians can benefit from management education programs such as those offered by the Physician-Manager Institute and several Canadian universities. To manage in the future environment they must increase their knowledge and skills in policy and political processes, financial strategies and management, human resources management, systems and program quality improvement and organizational design.

Canada↗

Managed oncology care: the disease management model.

BACKGROUND: As oncology becomes an increasing financial burden on the U.S. health care system, effort is being focused on finding methods to more effectively deliver, manage, and monitor the highly complex panoply of cancer care services required by patients. This issue has growing significance and importance in light of an aging U.S. population and the rapid penetration of managed care. METHODS: SalickNet, Salick Health Care's disease management and managed care company, has been a pioneer in the development and implementation of cancer disease management programs. The cornerstone is a proprietary computer-based disease management system called OMARS (Oncology Management Assessment Reporting System). The flexible yet sophisticated architecture allows for the management of integrated care, data processing, and the generation of compelling custom reporting, fulfilling the goal of maximizing coordinated and effective patient care. CONCLUSIONS: Based on data collected and analyzed across critical clinical, quality of life, and patient satisfaction outcome measures, strong evidence exists that the SalickNet Disease Management Model is a highly effective vehicle for bringing about cost, quality, and outcomes advantages in cancer care.

Disease Management↗

Opinions of disease management programs among medical directors of managed care organizations.

Medical directors of managed care organizations (MCOs) were surveyed about their views on disease management programs in their facilities. A survey was mailed to 600 MCO medical directors. The survey consisted of 14 Likert-type items related to disease management programs, 4 demographic items, and 1 item related to satisfaction. Seventy-nine usable surveys were received, for a net response rate of 14%. There were 48 medical directors (61%) with disease management programs at their MCO; 25 (52%) were working independently. A majority (71%) of programs were targeted at asthma. Seventy percent of the 48 medical directors were completely to somewhat satisfied and 13% dissatisfied to some extent with their disease management programs. Satisfaction was significantly related to the MCO's partnerships for these programs. A majority of medical directors agreed or strongly agreed that disease management programs could improve outcomes and decrease health care costs at their MCO, that an independent consultant could help analyze their MCO's prescription and medical data, and that they would be willing to accept grants or funds from pharmaceutical companies to initiate and support an independent disease management program at their MCO. MCO medical directors who responded to a national survey indicated that their organization could benefit from disease management programs, that internal resources might be insufficient to manage these programs, and that their MCO might be willing to contract with external organizations for support.

Disease Management↗

Developing a decision support system to meet nurse managers' information needs for effective resource management.

This article describes the development of a decision support system called CLASSICA, which assists nurse managers in financial management, resource allocation, activity planning, and quality control. CLASSICA integrates information about patient flow and activity, staffing, and the cost of nursing care at the nursing-unit level. The system provides assistance in planning activities, balancing the budget, and identifying barriers to unsatisfactory resource management. In addition, CLASSICA contains forecasting and simulation options to analyze the influence of factors that affect nursing costs. This article describes the system's development process steps to tailor it to the needs of nurse managers and their existing work practices. Nurse managers actively participated in defining their tasks and responsibilities; identified barriers and difficulties in managing these tasks; defined information needs, data input, and output and interface requirements; and identified expected benefits. Clear communication of project goals, strong user involvement, and purposeful benefit planning was used to achieve the goals for CLASSICA: (1) to provide essential information and decision support for effective financial management, resource allocation, activity planning, and staffing; (2) to improve nurse managers' competence in financial management and decision making; (3) to improve cost containment; and (4) to provide a helpful and easy to use tool for decision support.

Decision Support Systems, Management↗

Commercial managed care plans leaving the Medicaid managed care program in New York State: impact on quality and access.

UNLABELLED: To develop sufficient managed care capacity to accomplish the goal of transitioning Medicaid recipients into managed care, state policymakers have relied on commercial health maintenance organizations to open their panels of providers to the Medicaid population. However, while commercial health maintenance organization involvement in Medicaid managed care was high initially, since 1996 New York State has had 14 commercial plans leave the New York State Medicaid Managed Care Program. It has been speculated that the exodus of these commercial plans would have a negative impact on Medicaid enrollees' access and quality of care. This paper attempts to evaluate the impact of this departure from the perspective of quality and access measures and plan audit performance. Univariate and multivariate analyses were performed to evaluation the effect of commercial managed care plans leaving the Medicaid program. The overall performance of plans that remained in the program was compared to that of the plans that chose to leave for the two time periods 1996-1997 and 1998-2000. Access to care, quality of care, and annual audit performance data were analyzed. The departure of commercial health plans from the New York State Medicaid Managed Care Program has not had a statistically significant negative effect on the quality of care provided to Medicaid recipients as evaluated by standardized performance measures. In addition, there were no instances when there was a negative impact of the exit of the commercial plans on access to care. Managed care plans that chose to remain in Medicaid passed the Quality Assurance Reporting Requirements audit at a significantly (P < .01) higher rate than plans that chose to leave. CONCLUSIONS: A program consisting of health plans voluntarily participating and committed to Medicaid managed care can provide Medicaid recipients with appropriate access to high-quality health care. The exodus of commercial health plans from New York's Medicaid Managed Care Program during the time periods studied did not result in a detectable adverse impact on the quality of care for enrollees.

Adolescent↗