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PubMed1993

Public health advocacy on behalf of women in São Paulo: learning to participate in the planning process.

In 1988, a new Constitution was adopted in Brazil in which guidelines for community participation in the development and implementation of the national health system were delineated. The health and welfare of women and children were given priority. Implementation of these guidelines presents a major challenge in a city such as São Paulo with a population of 15 million, of which an estimated 5.8 million are women of childbearing age. In order to determine the extent to which community organizations are actively participating in planning health services for women and children in São Paulo, a study was undertaken to examine the experience of community and professional organizations in public health advocacy. This paper describes a sample of these organizations, their constituents, membership, history, funding, advocacy objectives, and strategies used and results obtained. The information gathered indicates that the community organizations are involved in activities that include major efforts to improve access to health care by providing specialized courses in women's health, including the status of women's work, sexuality, discrimination, family planning, and the politics of health; publishing newsletters; producing radio programs; engaging in legal action; and using petitions, demonstrations, and public meetings to garner public support on specific issues.

Brazil↗

PubMed1995

Do-not-resuscitate orders: towards a policy in Singapore.

Despite the fact that the pioneers of cardio-pulmonary resuscitation (CPR) designed the techniques for victims who were meant to be "salvable", currently CPR is largely applied to anyone who collapses, regardless of their underlying illness. However, the central fact is that CPR (and all its related complex and expensive technology) has a very low success rate (in terms of eventual hospital discharge) and the most important determinant of survival has always been the nature and stage of the underlying illnesses. All these bespeak of a need to have do-not-resuscitate (DNR) orders which will incorporate the pertinent medical, ethical, socio-cultural and legal components. In this discussion paper some guidelines for DNR orders relevant to Singapore are proposed, the main rationale of the guidelines are explained and some challenges and needed changes associated with its implementation are addressed.

Attitude to Health↗

PubMed1996

Assessment tools in psychiatry.

With the advent of managed care, administrators of mental health care will need to implement outcomes measurement systems that will provide information for cost control and quality improvement. These systems must take into account the changes occurring in the delivery of mental health care, such as the broad range of settings in which mental health care occurs, and allow for the measurement of outcomes over time. A useful system must also be flexible, allowing measures to tailor the system to individual needs. Two types of systems are currently being used. Simple systems measure general outcomes, such as patient satisfaction, at baseline and discharge. More complex systems are disorder-specific and can be used to compare different types of treatments or different groups of patients. The simple systems are less costly but are not as useful to quality improvement. The disorder-specific systems are more expensive, but the information gathered with these systems can be used in quality management. As implementation of these systems becomes more commonplace, challenges such as lack of standardization, patient reluctance to fill out forms, and the need for sensitive measurement instruments will need to be addressed.

Humans↗

PubMed1996

Sesamoid complex disorders.

Disorders of the hallux sesamoids and associated soft-tissue structures are commonly seen. With a differential diagnosis consisting of no fewer than 30 conditions, establishing an accurate diagnosis can be challenging but is important to appropriate treatment implementation. An understanding of first metatarsophalangeal joint anatomy, function, and current diagnostic technology aids the practitioner in the diagnosis and successful treatment of these often overlooked and anecdotally managed disorders.

Diagnosis, Differential↗

PubMed2000

Improving prenatal nutrition in developing countries: strategies, prospects, and challenges.

In developing countries, the health and nutrition of females throughout their entire life is affected by complex and highly interrelated biological, social, cultural, and health service-related factors. Rather than focusing exclusively on the prenatal period, we describe a life cycle approach to improving maternal nutrition, which goes beyond the traditional provision of nutrition services during pregnancy, by addressing risk factors that are present well before pregnancy, even before childbearing age. This approach involves specific policy initiatives and a "minimum package" program that is targeted at females. Policy actions and the components for effective implementation of the program are described. The prospects and challenges to be overcome-which include translating scientific knowledge into action, removing conceptual and implementational constraints, identifying biologically meaningful indicators for problem identification, and improving understanding of physiologic and social adaptation mechanisms-are discussed, as are persistent problems with health care delivery systems.

Developing Countries↗

PubMedDate not supplied

Trying something new: Implementing and evaluating narrative pedagogy using a multimethod approach.

To meet the challenges of rapidly changing health care systems, teacher-scholars are rethinking conventional approaches to education and developing new pedagogies that offer new ways of thinking about and using current approaches. The practices, strategies, and assumptions of teaching and learning that are now taken for granted are being challenged, critiqued, and deconstructed with these new approaches. There are very few studies in the higher education or nursing literature that evaluate these pedagogies in actual classroom situations. This article reports the findings of a multimethod study that was developed to document how to implement an alternative pedagogy to develop new partnerships among teachers and students, how implementation is experienced by the teacher and students, and how Narrative Pedagogy influenced students' perceptions of the classroom learning climate.

Education, Nursing↗

PubMed1989

Decision support systems for health care marketing managers.

Health care organizations are encouraged to implement decision support systems geared to meeting the challenges of tomorrow. The author outlines a decision support system (DSS) and illustrates its usefulness for health care marketing managers. A schematic representation of a DSS is described. Applications of DSS in strategic marketing and planning, product, promotion, pricing, and distribution decisions are discussed. Potential problems of integrating DSS into the health care organization are identified and some useful guidelines for implementation are offered.

Decision Support Systems, Management↗

PubMed2001

Joining them up: the challenges of organisational change in the professional politic of general practice.

Primary health care in the UK is currently centred around independent contractor organisations (general practices). Although the development of these organisations is considered necessary to improve the quality of health care, no structures exist to support the systematic development necessary to attain this goal. Part of the failure to change clinical processes has been the requirement that general practitioners attend passive educational events for continuing professional development, without reference to organisational or local health priorities. A feasibility study to integrate professional and practice development planning sought to overcome this mismatch. NHS Staff College Wales, as a facilitating organisation in this study, developed a model to assist practices to identify, prioritise and implement developments, interlinked with individuals' professional development. The paper summarises the experiences of facilitators supporting this integrated approach, using Senge's model of the challenges to the successful implementation of change. The role of facilitation in negotiating these challenges is also explored. The paper concludes that the approach is effective in the integration of professional and practice development and offers a useful framework to progress the quality improvement agenda.

Cooperative Behavior↗

PubMed2006

Resistance to change in surgical residency: an ethnographic study of work hours reform.

BACKGROUND: Although the practical challenges to work hour restrictions have been the focus of much discussion, cultural resistance to such change has received less attention. Surgical residency has its own unique social structure, and we hypothesized that challenges to this would provide impediments to successful implementation of duty hours reform. STUDY DESIGN: We used ethnographic research methods to study the efforts at work hour restriction over a 15-month period before the introduction of the Accreditation Council for Graduate Medical Education regulations. These methods, validated for studying institutional change, build on intense periods of observation. Records of observations are then analyzed and coded to uncover cultural and political challenges. The frequency of successful hand-offs in sign-out situations between day and night float residents was measured as an objective index of success. RESULTS: Practical issues were addressed initially by scheduling adjustments including creating a night float system. The hand-offs that this system required, however, were successful only 14% of the time. Subsequent steps to address the challenge to resident identity by top-down support of a new definition of professionalism increased the number of successful hand-offs to 39%. Finally, a reduction in a noted hierarchy violation led to successful hand-offs 79% of the time. CONCLUSIONS: These results demonstrate that practical solutions alone may not be a sufficient basis for change in surgical residency. While we face other challenges to the traditional surgical culture, attention to social and political issues may enhance the success of our efforts.

Boston↗

PubMed2001

Innovative approaches to educating medical students for practice in a changing health care environment: the National UME-21 Project.

In today's continually changing health care environment, there is serious concern that medical students are not being adequately prepared to provide optimal health care in the system where they will eventually practice. To address this problem, the Health Resources and Services Administration (HRSA) developed a $7.6 million national demonstration project, Undergraduate Medical Education for the 21st Century (UME-21). This project funded 18 U.S. medical schools, both public and private, for a three-year period (1998-2001) to implement innovative educational strategies. To accomplish their goals, the 18 UME-21 schools worked with more than 50 organizations external to the medical school (e.g., managed care organizations, integrated health systems, Area Health Education Centers, community health centers). The authors describe the major curricular changes that have been implemented through the UME-21 project, discuss the challenges that occurred in carrying out those changes, and outline the strategies for evaluating the project. The participating schools have developed curricular changes that focus on the core primary care clinical clerkships, take place in ambulatory settings, include learning objectives and competencies identified as important to providing care in the future health care system, and have faculty development and internal evaluation components. Curricular changes implemented at the 18 schools include having students work directly with managed care organizations, as well as special demonstration projects to teach students the knowledge, skills, and attitudes necessary for successfully managing care. It is already clear that the UME-21 project has catalyzed important curricular changes within 12.5% of U.S. medical schools. The ongoing national evaluation of this project, which will be completed in 2002, will provide further information about the project's impact and effectiveness.

Clinical Clerkship↗

PubMedDate not supplied

Electronic data capture (EDC)--a new mantra for clinical trials.

Pharmaceutical companies, over a period of time, have attempted to use innovative and modern technologies for quicker and more efficient methods of clinical data capture and analysis. In today's scenario, Electronic Data Capture (EDC) is considered to be the preferred technology that can provide significant benefits over existing manual methods. This article highlights the lacunae of the traditional data capture method and discusses the advantages of using EDC for better data quality, improved performance and productivity, and reduced cost in clinical trial management. It also emphasizes the need for IT infrastructure, training, and 21 CFR Part 11 compliance issues. The authors have also described the challenges to be faced by the investigators and sponsors in implementing EDC. Finally, the article concludes emphasizing the fact that EDC is the future mantra for the clinical trials and all stake holders should face challenges of infrastructure, technology, regulations, and training to make it a success.

Clinical Trials as Topic↗

PubMed2004

Electronic implementation of national nursing standards--NANDA, NOC and NIC as an effective teaching tool.

With the increased interest in evidence-based medicine, Internet access and the growing emphasis on national standards, there is an increased challenge for teaching institutions and nursing services to teach and implement standards. At the same time, electronic clinical documentation tools have started to become a common format for recording nursing notes. The major aim of this paper is to ascertain and assess the availability of clinical nursing tools based on the NANDA, NOC and NIC standards. Faculty at 20 large nursing schools and directors of nursing at 20 hospitals were interviewed regarding the use of nursing standards in clinical documentation packages, not only for teaching purposes but also for use in hospital-based systems to ensure patient safety. A survey tool was utilized that covered questions regarding what nursing standards are being taught in the nursing schools, what standards are encouraged by the hospitals, and teaching initiatives that include clinical documentation tools. Information was collected on how utilizing these standards in a clinical or hospital setting can improve the overall quality of care. Analysis included univariate and bivariate analysis. The consensus between both groups was that the NANDA, NOC and NIC national standards are the most widely taught and utilized. In addition, a training initiative was identified within a large university where a clinical documentation system based on these standards was developed utilizing handheld devices.

Interviews as Topic↗

PubMed2006

Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.

BACKGROUND: Disseminating new safe practices has proved challenging. In a statewide initiative we developed a framework for (1) selecting two safe practices, (2) developing operational details of implementation, (3) enlisting hospitals to participate, and (4) facilitating implementation. METHODS: Potential topics were selected by a multistep process to identify candidate practices, review the evidence for efficacy and feasibility, and then select them on the basis of importance, efficacy, feasibility, and impact. A multi-stakeholder advisory group representing all constituencies selected two practices: reconciling medications (RM) and communicating critical test results (CTR). Operational details and strategies for implementation were then developed for each practice using a consensus process of discipline stakeholders led by content experts. Hospital CEOs were solicited to participate by the Massachusetts Hospital Association which made the project a "flagship" initiative. A collaborative model was used to facilitate implementation, following the IHI Model for Improvement. In addition to providing exposure to content and method experts, we gave teams a "toolkit" containing recommendations, a change package, and implementation strategies. Each collaborative met four times over an 18 month period. Results were assessed using the IHI team assessment scale and surveys of teams and hospital leaders. RESULTS: Hospital participation rate was high with 88% of hospitals participating in one or both collaboratives. Partial implementation of the practices was achieved by 50% of RM teams and 65% of CTR teams. Full implementation was achieved by 20% of teams for each. CONCLUSIONS: Major factors leading to hospital participation included the intrinsic appeal of the practices, access to experts, and the availability of implementation strategies. Team success was correlated with active engagement of a senior administrator, engagement of physicians, increased use of PDSA cycles, and attendance at collaborative meetings. The prior development of subpractices, recommendations and implementation strategies was essential for the hospital teams. These should be well worked out before hospitals are required to implement any guideline.

Communication↗

PubMed1997

Development and implementation of a perioperative assistant training program.

Due to health care reform, many institutions have had to examine the way they deliver patient care. This article describes how, in response to this challenge, an interdisciplinary OR team at North Shore University Hospital, Manhasset, NY, developed and implemented the role of perioperative assistant in the OR. The authors describe the education curriculum for program completion, along with specific results. The program's difficulties and challenges are described, as well as what was learned as the program proceeded. The authors stress that program implementation depended on the efforts of all staff members, their willingness to help develop the perioperative assistant role, and their ability to function as a team.

Curriculum↗

PubMed2000

Evidence-based treatment of schizophrenia.

People with schizophrenia can be helped greatly with pharmacologic and psychosocial interventions that are known to be effective. Several interventions are now supported by research: use of medications following specific guidelines, training in illness self-management, case management based on principles of assertive community treatment, family psychoeducation, supported employment, and integrated substance abuse treatment. However, few patients actually receive these evidence-based interventions because they are not provided in routine mental health settings. Therefore, implementing effective treatments in mental health treatment programs is a critical challenge for the field. We review the six areas of evidence-based treatment of schizophrenia, as well as knowledge regarding implementation of mental health programs in routine practice settings.

Antipsychotic Agents↗

PubMed2006

AIDS epidemic at age 25 and control efforts in China.

In the first 10 years of AIDS epidemic in China, intravenous drug users (IDUs) and Former Plasma Donors (FPDs) were hardly hit in the late 1980s and mid 1990s respectively. In the last 10 years, while IDU epidemic keeps at a fast pace, sexual transmitted cases of HIV have been steadily increasing. All signs indicate that the HIV epidemic in China is at a turning point, spreading from high risk groups to the general population. Learning from the SARS epidemic, China has recently launched an impressive AIDS campaign by making serious political commitments, and by strengthening the public health system and implementing an aggressive Four Free One Care Policy. There remains huge challenges both at the societal level which form the roots of the AIDS epidemic and at increasing the capabilities of the implementation teams. In addition to other needed efforts, enhancing AIDS research through international collaborations will strengthen China's ability to conduct her huge control program efficiently. Only with a scientific approach and evidence-based strategy, can China seize the opportunity to stop AIDS at an early stage.

China↗

PubMed2005

The Integrated Children's System: challenges of information sharing.

Information has to be shared within and between agencies if Every Child Matters (DH 2003a) is to bring real benefits to children in need and their families. The Integrated Children's System is a theoretical framework that offers a single approach to assessing, planning, intervention and reviewing based on an understanding of children's developmental needs in the context of their families and communities. It should not be seen as an IT project, but is closely linked to the electronic social care record and to NHS care record service developments. Health and social care professionals attempting to improve information management as part of better interagency working face a number of challenges including: confidentiality; a single identifier for children; common language and information exchange; system, organisational and staff issues. Despite many benefits, implementation of the integrated children's system presents managerial and organisational challenges which will require additional support.

Child↗

PubMed2000

Effective detection of HIV.

Biomedical advances, new HIV testing technologies, and policy shifts in the last 15 years have created substantial new challenges and opportunities for service providers, policy makers, and researchers regarding broad scale identification of HIV-seropositive persons. Effective HIV testing will be achieved when we: (1) increase the number of high-risk persons tested; (2) decrease the time from HIV infection to detection; (3) increase testing acceptability; (4) increase the proportion of individuals tested who receive their results; and (5) increase the proportion of individuals tested seropositive who are linked to care. Strategies to enhance effectiveness include implementing new testing technologies and delivery modalities; expanding access to client-controlled testing; targeting providers' knowledge, attitudes, and behaviors regarding HIV testing; mainstreaming HIV testing as routine clinical care; targeting persons who engage in high-risk behaviors and those in high-risk groups; and implementing a national behavioral surveillance system. Addressing these challenges will improve HIV detection in the United States, which is vital to both HIV prevention and treatment.

Antiretroviral Therapy, Highly Active↗