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Challenges in developing physician leadership and management.

Many of the issues confronting healthcare organizations require physician involvement and understanding, and the physician executive is a tool to achieving physician participation. Physician leaders can become the mediators between physicians and organizational management, minimizing miscommunication and maximizing agreement and understanding. Yet few doctors seem willing to stand up and speak positively for the plans and proposals that will move the institution forward, and healthcare executives are often frustrated by physician leadership that fails to articulate and implement the vision and objectives of the organization. Understanding physician leadership and exploring the challenges in managing and leading physicians require an understanding of the physician mindset--a completely different mindset than that of the typical healthcare executive. Beginning with a discussion of the unique situation faced by physicians in leadership positions, this article attempts to define the obstacles faced by both the physician and the executive in developing the role of physician executive. After reviewing the opportunities open to physician executives for improving leadership ability, the author presents the essential characteristics and core skills for effective leadership. The second half of the article suggests ways in which an organization can reemphasize physician leadership development within an organization from selection of potential candidates to creating training and networking opportunities and offering appropriate incentives.

Communication↗

Beyond informatics: an electronic community infrastructure for public health.

Public health agencies are in the early stages of building an electronic infrastructure that will link them to each other and eventually to the "information superhighway." Emphasis in planning and development is on data systems and the information and training services that can enhance essential public health services. This article argues for a larger vision of the potential of electronic networks for public health. It discusses the health and other challenges facing public health, the limitations of conventional efforts, and the emerging consensus on public health core functions. Finally, it examines current and potential uses of information technology. The article concludes by proposing that the public health community should develop a collaborative and inclusive vision of public health in an electronic world and provide guidance and support for agency implementation to ensure a stronger system that can meet the health and health equity challenges ahead.

Community Networks↗

[Evidence-based guidelines as tools for medical knowledge transfer. The work mode of the Medical Knowledge Network evidence.de].

The amount of medical knowledge is growing with increasing speed. Physicians are confronted with more and more--and often useless--information. However, the time lag between the creation of new knowledge and its implementation into daily medical practice is often exceeding a decade. In view of these challenges the knowledge network of the medical faculty of the University Witten/Herdecke is focusing on two different tasks: It provides evidence based medical guidelines in a format that is meant for easy access and use in daily practice. It scientifically explores different ways of presenting and transferring evidence based guidelines in order to develop better and easier ways of implementation. National and international guidelines and studies are screened, evaluated, updated and adapted for its use in the academic network by a team of five university based physicians. In addition, clinical specialists as well as primary care physicians provide expertise for detailed scientific adaptations and for adequate implementation strategies. The implementation process of the guidelines among the faculty based primary care physicians is continuously monitored and evaluated. The main goal of this concept is to create a learning environment for the complex process of medical knowledge transfer.

Decision Making↗

Developing the role of the generic healthcare support worker: phase 1 of an action research study.

This paper reports on the first phase of an action research practice development project to explore, develop and evaluate the role of the generic healthcare support worker in a high dependency rehabilitation service. The project is being jointly conducted by staff from the University of Southampton, the University of Portsmouth and the Isle of Wight Healthcare NHS Trust and phase 1 is supported by a grant from the NHS Executive (South and West). The aim of phase 1 of the project is to explore the attitudes of staff towards the implementation of the role of the generic healthcare support worker, particularly regarding the practical, professional and ethico-legal problems of the role. Professional and support staff from different parts of the service were interviewed in groups and the interviews were tape recorded, transcribed and subjected to a simple thematic analysis. Four themes emerged from the data relating to the challenge to professional boundaries, being a generic worker, outcomes for service and patients and implementing the role. As an action research project, the aim was not to produce findings that are generalizable beyond the practice areas in which they were generated, but it is nevertheless hoped that the reader might be able to apply some of the conclusions to his or her own setting.

Attitude of Health Personnel↗

Randomized, double-blind, placebo-controlled, food allergy challenge to olestra snacks.

Following approval of the fat replacer olestra for use in preparing savory snacks, Procter & Gamble implemented a postmarketing surveillance program to monitor marketplace introduction. Three and one-half percent of all health effects reported by consumers to the surveillance toll-free number were allergy-type symptoms (e.g., rash, itching, edema, hives, dyspnea). Because of these reports, we investigated whether olestra or some component of olestra snacks was a likely allergen in some subset of the population. A single center, randomized, double-blind, placebo-controlled, within-subject crossover food challenge study was conducted to confirm or refute the allergenicity of olestra snacks. Of the 65 subjects who reported symptoms consistent with immediate hypersensitivity to olestra's postmarketing surveillance program, 14 men and women traveled to the Arkansas Children's Hospital Research Institute to participate in this study. Each subject underwent a standard skin prick test at the beginning of the study, to help determine what component, if any, of the olestra product was allergenic. Following the skin prick test, subjects ate in random order, olestra-containing potato chips and regular fat-containing potato chips. The dose of potato chips consumed at each challenge was at least the amount alleged to have caused the symptoms that prompted the consumer to phone the postmarketing surveillance toll-free number. No subject experienced an allergic reaction after consuming the olestra-containing chips. Nor did any subject elicit a positive response to olestra following the skin prick testing. Two subjects had positive reactions consistent with immediate hypersensitivity after consuming the regular-fat, placebo potato chips. The results of this study confirm that olestra is unlikely to have an allergenic potential.

Adult↗

Factors contributing to intervention fidelity in a multi-site chronic disease self-management program.

BACKGROUND AND OBJECTIVES: Disease self-management programs have been a popular approach to reducing morbidity and mortality from chronic disease. Replicating an evidence-based disease management program successfully requires practitioners to ensure fidelity to the original program design. METHODS: The Florida Health Literacy Study (FHLS) was conducted to investigate the implementation impact of the Pfizer, Inc. Diabetes Mellitus and Hypertension Disease Self-Management Program based on health literacy principles in 14 community health centers in Florida. The intervention components discussed include health educator recruitment and training, patient recruitment, class sessions, utilization of program materials, translation of program manuals, patient retention and follow-up, and technical assistance. RESULTS: This report describes challenges associated with achieving a balance between adaptation for cultural relevance and fidelity when implementing the health education program across clinic sites. This balance was necessary to achieve effectiveness of the disease self-management program. The FHLS program was implemented with a high degree of fidelity to the original design and used original program materials. Adaptations identified as advantageous to program participation are discussed, such as implementing alternate methods for recruiting patients and developing staff incentives for participation. CONCLUSION: Effective program implementation depends on the talent, skill and willing participation of clinic staff. Program adaptations that conserve staff time and resources and recognize their contribution can increase program effectiveness without jeopardizing its fidelity.

Journal Article↗

The design of coiled-coil structures and assemblies.

Protein design allows sequence-to-structure relationships in proteins to be examined and, potentially, new protein structures and functions to be made to order. To succeed, however, the protein-design process requires reliable rules that link protein sequence to structure?function. Although our present understanding of coiled-coil folding and assembly is not complete, through numerous bioinformatics and experimental studies there are now sufficient rules to allow confident design attempts of naturally observed and even novel coiled-coil motifs. This review summarizes the current design rules for coiled coils, and describes some of the key successful coiled-coil designs that have been created to date. The designs range from those for relatively straightforward, naturally observed structures-including parallel and antiparallel dimers, trimers and tetramers, all of which have been made as homomers and heteromers-to more exotic structures that expand the repertoire of Nature's coiled-coil structures. Examples in the second bracket include a probe that binds a cancer-associated coiled-coil protein; a tetramer with a right-handed supercoil; sticky-ended coiled coils that self-assemble to form fibers; coiled coils that switch conformational state; a three-component two-stranded coiled coil; and an antiparallel dimer that directs fragment complementation of larger proteins. Some of the more recent examples show an important development in the field; namely, new designs are being created with function as well as structure in mind. This will remain one of the key challenges in coiled-coil design in the next few years. Other challenges that lie ahead include the need to discover more rules for coiled-coil prediction and design, and to implement these in prediction and design algorithms. The considerable success of coiled-coil design so far bodes well for this, however. It is likely that these challenges will be met and surpassed.

Amino Acid Sequence↗

The promise of e-Health - a Canadian perspective.

Canadians value their health care system above any other social program. Canada's system of health care faces significant financial and population pressures, relating to cost, access, quality, accountability, and the integration of information and communication technologies (ICTs). The health-system also faces certain unique challenges that include care delivery within a highly decentralised system of financing and accountability, and care delivery to a significant portion of the population sparsely distributed across a landmass of 10 million square kilometres, in areas of extreme climatic conditions. All of these challenges are significant catalysts in the development of technologies that aim to significantly mitigate or eliminate these selfsame challenges.The system is undergoing widespread review, nationally, and within each province and territory, where the bulk of care provision is financed and managed. The challenges are being addressed by national, regional and provincial initiatives in the public, private and not-for-profit sectors.The promise of e-Health lies in the manner and degree to which it can mitigate or resolve these challenges to the health system and build on advancements in ICTs supporting the development of a health infostructure. Canada is actively developing and implementing technological solutions to deliver health information and health care services across the country. These solutions, while exciting and promising, also present new challenges, particularly in regard to acceptable standards, choice of technologies, overcoming traditional jurisdictional boundaries, up-front investment, and privacy and confidentially.Many organisations and governments are working to address these challenges. The Canadian Institute for Health Information (CIHI) will play an increasingly significant role in these initiatives, as the management of health information becomes a more crucial factor in the successful delivery of health care services in the new millennium.

Journal Article↗

The promise of e-health--a Canadian perspective.

Canadians value their health care system above any other social programme. Canada's system of health care faces significant financial and population pressures, relating to cost, access, quality, accountability, and the intergration of information and communication technologies (ICTs). The health-system also faces certain unique challenges that include care delivery within a highly decentralised system of financing and accountability, and care delivery to a significant portion of the population sparsely distributed across a land mass of 10 million square kilometres, in areas of extreme climatic conditions. All of these challenges are significant catalysts in the development of technologies that aim to significantly mitigate or eliminate these selfsame challenges. The system is undergoing widespread review, nationally and within each province and territory, where the bulk of care provision is financed and managed. The challenges are being addressed by national, regional and provincial initiatives in the public, private and not-for-profit sectors. The promise of e-health lies in the manner and degree to which it can mitigate or resolve these challenges to the health system and build on advancements in ICTs supporting the development of a health infostructure. Canada is actively developing and implementing technological solutions to deliver health information and health care services across the country. These solutions, while exciting and promising, also present new challenges, particularly in regard to acceptable standards, choice of technologies, overcoming traditional jurisdictional boundaries, up-front investment, and privacy and confidentiality. Many organizations and governments are working to address these challenges. Canada Health Infoway, a not-for-profit corporation, was founded by the first ministers in 2001 to accelerate the establishment of an interoperable, pan-Canadian electronic health record. It works with partners in the federal, provincial and territorial jurisdictions to define replicable solutions for establishment of the major elements necessary to achieve this goal. The Canadian Institute for Health Information (CIHI) will also continue to play an increasingly significant role in these initiatives, as the management of health information becomes a more crucial factor in the successful delivery of health care services in the new millennium.

Access to Information↗

CASP6 data processing and automatic evaluation at the protein structure prediction center.

We present a short overview of the system governing data processing and automatic evaluation of predictions in CASP6, implemented at the Livermore Protein Structure Prediction Center. The system incorporates interrelated facilities for registering participants, collecting prediction targets from crystallographers and NMR spectroscopists and making them available to the CASP6 participants, accepting predictions and providing their preliminary evaluation, and finally, storing and visualizing results. We have automatically evaluated predictions submitted to CASP6 using criteria and methods developed over the successive CASP experiments. Also, we have tested a new evaluation technique based on non-rigid-body type superpositions. Approximately the same number of predictions has been submitted to CASP6 as to all previous CASPs combined, making navigation through and understanding of the data particularly challenging. To facilitate this, we have substantially modernized all data handling procedures, including implementation of a dedicated relational database. An overview of our redesigned website is also presented (http://predictioncenter.org/casp6/).

Algorithms↗

Clinical information systems in intensive care.

OBJECTIVE: To review the requirements and functions of clinical information systems for the critical care environment. DATA SOURCES: Peer reviewed studies and articles reported from 1990-1998, identified through MEDLINE search and subsequent article references. SUMMARY OF REVIEW: Clinical information systems (CIS) utilise information technologies to improve and add value to information management, and critical care areas have provided clinical leadership in their development and implementation. Expectations for these systems are high, yet certain basic requirements must be fulfilled. Bedside charting functions of CIS are highly developed and successful. Clinical record keeping has been more challenging, particularly the requirement for electronic storage of a medico-legal record. Decision support ranges in its extent and requires further development. Successful integration with other hospital systems is highly desirable but may be made more difficult by the lack of rigorous technical standards in healthcare computing. The CIS clinical database is fundamental to the quality improvement, research and business reporting functions. The huge amount of data, the lack of common minimal and extensive data sets, and the technical challenges of software development, all combine to make this a resource expensive venture requiring on site customisation. Purchasing and implementing a CIS is costly in human and material resources. CONCLUSION: A high performance CIS is not yet available as an 'off the shelf' product. Close collaboration between the industry and clinicians is important for successful implementation. Clinical awareness of these issues will encourage product development and suitable purchasing strategies.

Journal Article↗

Challenges and opportunities in the analysis of raffinose oligosaccharides, pentosans, phytate, and glucosinolates.

In this paper, the status of the analytical technologies for assaying animal antinutritional compounds, such as raffinose oligosaccharides, pentosans, phytic acid, and glucosinolates, is reviewed in terms of selectivity, sensitivity, and sample throughput. The implementation of simplified sample preparation schemes, use of novel separation approaches, and alternate detector technologies are discussed. The challenges and opportunities posed by these assays are highlighted along with the recommendations for best analytical practices.

Animal Feed↗

Developing capacities of youth as lay health advisors: a case study with high school students.

Youth lay health advising, a form of support or helping, is an important potential resource for preventive intervention. This article describes a case study of a youth lay health advising program designed to provide high school students with support and guidance to handle challenges and concerns related to their health and quality of life. First, the planning, program development, and implementation of the approach are described. Second, a rapid formative evaluation presents quantitative and qualitative information on adolescent issues faced, the types and content of interactions, and peer helper satisfaction with the program. Third, the strengths and challenges of the peer helping program and the role of youth as lay health advisors are discussed. The article concludes with a discussion of the implications for practitioners on this approach to building the capacity of adolescents as lay advisors for community health.

Adolescent↗

Conditional use of a request for assistance.

PURPOSE: To establish the conditional use of requests for assistance as an alternative to escape maintained challenging behaviour. METHOD: The study involved a 12-year-old boy with a behaviour disorder. Experiment 1 involved the implementation of a reversal design comparing the learner's performance during "easy" and "difficult" addition problems. Experiment 2 involved the implementation of a quasi-experimental design to establish the conditional use of requests for assistance. RESULTS: Conditional use of requests for assistance successfully competed with escape maintained challenging behaviour. CONCLUSIONS: Our results suggest that for a newly acquired response to be displayed conditionally, two events must occur. First, the individual must learn the skill that has been associated with requests for assistance. Secondly, the contingencies must be such that reinforcement value is greater for an independent response than for a response that involves a request for assistance.

Behavior Therapy↗

Action research: a suitable method for promoting change in nurse education.

This paper arose from a research study and its follow-up in four schools of nursing and midwifery. The study was concerned with evaluating the extent to which a philosophy of health had been integrated into the educational curricula of nurses, midwives and health visitors. The purpose of the follow-up was to disseminate and implement the study findings in the four centres. The findings showed that the interpretation and implementation of a philosophy of health in nursing had been variable. Health was operationalized as both health education and health promotion ranging from individualized information giving and disease prevention. Action research was chosen as the appropriate methodology for the follow-up because of its emphasis on participation and partnership. As the follow-up study progressed a number of issues emerged which were indicative of the changes taking place in nurse education as its institutional base shifted into higher education. Other issues were associated with the gap between the rhetoric and reality of action research and the expectations and needs of the key partners. The authors conclude that the follow-up study presented both challenges and opportunities to nurse educators in their endeavour to undertaken research and implement educational change.

Curriculum↗

Implementing a national hospital accreditation program: the Zambian experience.

OBJECTIVES: This study describes the development of the Zambia Hospital Accreditation Program from 1997 to 2000. Ten major milestones are presented and discussed, as are challenges to the program. DESIGN: Data were collected through a review of written documents, interviews with major stakeholders, hospital visits, and discussions with implementers. MAIN OUTCOME MEASURES: Zambia has successfully developed hospital standards that are relevant and potentially achievable by its hospitals. Half of Zambia's 79 hospitals have received educational surveys, and 12 have also received the full accreditation survey. Significant improvement in compliance with standards occurred in overall scores, and in seven out of 13 functional areas. However, the program has stalled due to lack of sufficient funds, lack of legal standing for the Zambia Health Accreditation Council, difficulties in retaining qualified surveyors, and indecision on how to handle accreditation results. In addition, serious resource constraints in hospitals and the need for ongoing facilitation have hindered their full participation in the program. It is estimated that the program costs about 10000 dollars US per hospital to complete the cycle. CONCLUSIONS: Having a developing country sustain an accreditation program requires dedicated funds, government and donor commitment, continual adaptation, ongoing technical assistance to hospitals, and a functioning accreditation body. In Zambia, the accrediting Council was stymied by a heavy workload, lack of legitimacy and budget authority, and the government's indecision on incentives and feedback. Long delays arose between accreditation surveys and feedback of written results. Zambia has now begun to include some accreditation standards in performance audits and is considering decentralizing survey functions.

Accreditation↗

Thinking ahead--the importance of exit strategies to successful implementation of clinical effectiveness initiatives.

The Clinical Resource and Audit Group (CRAG) remains the focus for the development of clinical effectiveness with particular emphasis on strategic alignment and implementation. CRAG believes that early consideration and planning of exit strategies is essential to deliver successful dissemination and implementation of clinical effectiveness initiatives. Open sharing of results in encouraged, with due consideration of the challenges of presenting information fairly and clearly to avoid misinterpretation, particularly for the lay public. Valuable lessons from effectiveness initiatives should be shared widely and introduced quickly into normal clinical practice, releasing effectiveness resources for new challenges. CRAG will produce guidance to support the development of exit strategies later in the year; comments and contributions are welcome.

Clinical Competence↗

Evolution of peer review: enhancing communication through team review.

Few institutions have successfully implemented peer review. It is considered a hallmark of the nursing profession and in theory has positive effects by stimulating personal and professional development and challenging nurses to think critically about their practice. The key is that the change must be managed, unit readiness assessed, and an implementation plan developed. It is suggested that all members of the critical care team be involved in the review process. Characteristics of a unit that is ready to implement team review are presented and discussed.

Critical Care↗