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National Service Frameworks (NSFs) set out standards for health and social care provided by the NHS and social services in England. The latest in this series--the NSF for Long Term Conditions--was published recently. This editorial discusses some of the challenges for its development and implementation.
Coding accuracy is difficult enough with inconsistent and incomplete medical records adding to the challenge. But since the HCFA implementation of DRGs in 1983 to determine Medicare payments, coding has taken on an ethical dimension. In this article Leslie Ann Fox discusses the causes underlying this dilemma and proposes some solutions.
The total quality management (TQM) revolution that is fueling the interest of CEOs and the JCAHO will present big leadership challenges to department administrators. Successfully implementing TQM concepts will require basic changes in operational methods and highly visible leadership commitment. Lasting change can only occur with a strategy that is understood by all employees and is periodically updated. Operational improvements will result from actions you take to better serve internal and external customers, as well as personal commitment from each employee. Quality teams are the core of TQM philosophy. Any strategy to implement TQM will require extensive training and/or study of quality improvement tools and methods, as well as a plan for managing cultural change. Aligning the department within the organization requires input from the rank and file as well as those at the executive level.
For more than a decade, radiology professionals have hoped that picture archiving and communications systems (PACS) would improve efficiency and reduce costs. However, pioneer PACS systems were extremely expensive, and they didn't always meet their users' needs. Recent changes mean that PACS are more accessible. Advances in technology have resulted in decreased costs and increased computer power, and many radiologists recognize that they must consider new tools, such as teleradiology, to compete. There are roughly five classes of digital image systems used by radiologists: modality clusters, on-call review and teleradiology, remote primary diagnosis, mini-PACS and PACS. Even though hospitals seem to view PACS as inevitable, the challenge is to manage PACS implementation economically. One answer is to install PACS incrementally. Once teleradiology and mini-PACS are in place, they can be used as the building blocks of full-fledged PACS. Because PACS have a broad impact on healthcare facilities, careful planning is needed. Design your system to support future, as well as current, applications. Another important planning step is to set goals for improved efficiency and cost reduction.
Master patient scheduling can be a strategic weapon for your organization as it battles the pressures posed by a steadily more demanding marketplace. The enhanced continuity offered by master patient scheduling can unlock the power of self-directed teams and collaboration between your organization and physicians. This power, in turn, can help you continuously improve quality and service levels while keeping operating costs under control. Still, implementing master patient scheduling poses challenges. Those who take on these challenges are convinced that continuity is the secret to their future success.
The purpose of our research is the development of a new technology, teleimmersion, which will make possible 3D visual communication between people distributed over the globe. We are putting together a low-end, PC-based, affordable hardware system, and are developing the software for a teleimmersion node (T-node). The software is based on accurate polynocular stereo. We will describe a testbed for the system, show results, and discuss challenges for future research and implementation.
A distance learning nursing course is offered via two-way interactive video and the Internet from the University of North Carolina at Wilmington to nursing students at Mie Prefecture College of Nursing in Japan. The course was designed to teach Japanese students nursing practices and issues in the United States. The classroom environment used a combination of synchronous (two-way interactive video connections over an Integrated Services Digital Network) and asynchronous technologies (electronic mail, Internet-based discussion forums, and World Wide Web pages). Students' course evaluations highlighted areas of success, and pointed out some of the challenges that remain for effective implementation of international education courses.
Implementing laparoscopic surgery is a challenge that should prompt educational research in an attempt to establish a link between instruction and the quality of patient care. This randomized study was undertaken to compare the impact of instruction versus passive observation on laparoscopic skills. The task was stitching and tying a surgeon's knot on a perforated ulcer in a foam stomach placed in a simulator. Outcome measures were accuracy error, goal-directed and non-goal-directed actions, operating time, and tissue damage. Time/motion analysis was carried out by an masked assessor. Twelve participants were well matched for hand-eye coordination at pretesting. Regardless of whether instruction was given or not, a positive correlation was found between overall actions and operating time, non-goal-directed actions and operating time, and overall actions and non-goal directed actions. Intraoperative instruction decreased errors, but this study did not have sufficient power to detect small differences in other outcome measures. The teaching of minimal-access surgery should increasingly be based on educational research data rather than on unstructured rating by attending surgeons.
Medical evacuation helicopters are taken for granted in today's military. However, the first use of helicopters for this purpose in the Korean War was not done intentionally but as a result of the necessity of moving patients rapidly over difficult Korean terrain and of the early ebbing of the main battle line. The objective of this essay is to increase the historical awareness of military medical evacuation helicopters in the Korean War during this 50th anniversary year. By describing the many challenges and experiences encountered in implementing the use of helicopters for evacuation, the reader will appreciate how a technology developed for another use helped in the success of evacuating nearly 22,000 patients while contributing to establishing a mortality rate of wounded of 2.4%. The preparation to write this essay included archival research of historical reports, records, and oral histories from the archives of the U.S. Army Center for Military History. Additionally, a search of journal articles written during and after the Korean War was conducted. The result is a comprehensive description of the use of medical evacuation helicopters in the Korean War.
Strategies such as dietary diversification and food fortification have yielded significant results in controlling iron deficiency anaemia in developed countries. Reducing the prevalence of iron deficiency anaemia in developing countries is still a matter of importance. The major factors responsible for iron deficiency anaemia in the vulnerable segments of developing countries are reduced intake and poor bioavailability of dietary iron. Dietary diversification and food-based approaches pose considerable challenges before they can be implemented on a wide scale. Anaemia control programmes based on the administration of prophylactic doses of iron and folic acid tablets have been widely implemented. As the programmes were not effective in countries such as India, the dosage of iron was increased. The role of excess iron in causing intestinal oxidative stress has drawn attention to other approaches of iron supplementation. Prophylactic administration of iron along with antioxidants like vitamins E and C or foods rich in these vitamins is one such strategy. To reduce the intestinal oxidative stress, intermittent supplementation of iron is being considered. The potential benefits and shortcomings of these approaches are reviewed.
BACKGROUND: Modernization of medical regulation has included the introduction of the Professional Performance Procedures by the UK General Medical Council in 1995. The Council now has the power to assess any registered practitioner whose performance may be seriously deficient, thus calling registration (licensure) into question. Problems arising from ill health or conduct are dealt with under separate programmes. METHODS: This paper describes the development of the assessment programmes within the overall policy framework determined by the Council. Peer review of performance in the workplace (Phase 1) is followed by tests of competence (Phase 2) to reflect the relationship between clinical competence and performance. The theoretical and research basis for the approach are presented, and the relationship between the qualitative methods in Phase 1 and the quantitative methods in Phase 2 explored. CONCLUSIONS: The approach is feasible, has been implemented and has stood legal challenge. The assessors judge and report all the evidence they collect and may not select from it. All their judgements are included and the voice of the lay assessor is preserved. Taken together, the output from both phases forms an important basis for remediation and training should it be required.
Stuttering implements communication with interference through challenges other than sharing information, messages and emotion. This dramatic behaviour implies a phobic origin. The therapist must reproduce the symptom in its overall economy. Attentive listening, reassurance and non-submission of the esteem to the performance of expression should lead to a veritable reassessment of the challenges of expression.
This article provides the reader with a basic understanding of the Government Performance and Results Act of 1993. The Act requires federal agencies to institute a planning and reporting management framework to achieve results. It also identifies challenges federal agencies face in implementing a stronger results management approach and promising practices agencies can use in crafting their management approach.
This article demonstrates how the spread of HIV/AIDS in Mozambique may gave been affected by internal and external population movements which, in turn, contributed to the pronounced regional differences in adult HIV prevalence among the three regions of the country observed today. Further population movement may put certain individuals at higher risk of HIV infection but, even if these movements were to stop, in the absence of effective interventions to prevent new infections, HIV prevalence would remain high and perhaps continue to rise. The current regional differences in HIV prevalence and duration of the epidemic present different challenges for the development and implementation of prevention and mitigation services.
The Medicare program likely faces restructuring over the long term, but payment mechanics are not expected to change over the short term. As Medicare payment continues to challenge hospitals, providers need to implement effective strategies to survive. A review of hospital Medicare inpatient and outpatient data found that providers that can manage costs and revenue will be successful.
Coronary artery bypass surgery is endorsed by the excellent, well-documented, long-term results that follow complete revascularization and the use of 1 or 2 mammary artery grafts. This article contains a review of the current indications for and the results of such surgery and an evaluation of new challenges and opportunities, including the implementation of safer and less aggressive surgery, and surgery associated with other operative procedures. The aim was to develop a strategy linked to a cycle of innovation that could be used to adapt surgery to the needs of the population, to new technologies, and to pioneering developments.
UNLABELLED: Remarkable progress has been made in the development of antimicrobial therapy, effective vaccines and pneumonia management guidelines in the past 50 years. However, pneumonia is currently the leading cause of death in children younger than 5 years in developing countries, accounting for approximately 20% of childhood deaths. This article reviews changes in the epidemiology, management and prevention of childhood pneumonia in developing countries, specifically in Africa and South Africa, and addresses future challenges. MAIN FINDINGS: The HIV epidemic has sharply increased the incidence, severity of, and mortality due to, childhood pneumonia. Bacterial infection remains a major cause of pneumonia mortality. Additional pathogens such as Pneumocystis jirovecii and Gram-negative bacteria are found in HIV-infected children, associated with a high mortality. Mycobacterium tuberculosis is an important cause of acute pneumonia in both HIV-infected and uninfected children. Use of case management guidelines can substantially reduce neonatal, infant and under-5 mortality and pneumonia-specific mortality. General preventive interventions including micronutrient supplementation with zinc and vitamin A, and immunisations can substantially reduce the burden of childhood pneumonia. Despite a lower efficacy in HIV-infected children, vaccination protects against disease in a significant proportion of children. In South Africa, new advances over the past 50 years have included greater access to primary health care for children, the use of Integrated Management of Childhood Illness guidelines in primary care, development of guidelines for diagnosis and management of childhood pneumonia and adoption of an expanded immunisation programme that includes coverage for Haemophilus influenzae type b. The pneumococcal conjugate vaccine recently licensed in South Africa also has the potential to significantly reduce the burden of childhood pneumonia. Recent roll-out of the national antiretroviral programme can reduce the incidence and severity of HIV-associated pneumonia through the prevention of HIV infection, use of cotrimoxazole prophylaxis and treatment with antiretrovirals. CONCLUSION: Available, effective interventions for prevention and treatment of childhood pneumonia exist; the challenge is to achieve widespread implementation and high coverage rates in developing countries. Greater access to newer vaccines and to antiretroviral therapy and co-trimoxazole prophylaxis in HIV-infected children is necessary to further reduce the burden of childhood pneumonia and the discrepancies in global child lung health.
The design of genetic association studies using single-nucleotide polymorphisms (SNPs) requires the selection of subsets of the variants providing high statistical power at a reasonable cost. SNPs must be selected to maximize the probability that a causative mutation is in linkage disequilibrium (LD) with at least one marker genotyped in the study. The HapMap project performed a genome-wide survey of genetic variation with about a million SNPs typed in four populations, providing a rich resource to inform the design of association studies. A number of strategies have been proposed for the selection of SNPs based on observed LD, including construction of metric LD maps and the selection of haplotype tagging SNPs. Power calculations are important at the study design stage to ensure successful results. Integrating these methods and annotations can be challenging: the algorithms required to implement these methods are complex to deploy, and all the necessary data and annotations are deposited in disparate databases. Here, we present the SNPbrowser Software, a freely available tool to assist in the LD-based selection of markers for association studies. This stand-alone application provides fast query capabilities and swift visualization of SNPs, gene annotations, power, haplotype blocks, and LD map coordinates. Wizards implement several common SNP selection workflows including the selection of optimal subsets of SNPs (e.g. tagging SNPs). Selected SNPs are screened for their conversion potential to either TaqMan SNP Genotyping Assays or the SNPlex Genotyping System, two commercially available genotyping platforms, expediting the set-up of genetic studies with an increased probability of success.