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Managed care challenges pathologists to a paradoxical cultural transition requiring clinical participation in the community while refining competitive managerial skills to maintain a livelihood. This presentation explores several role changes that a pathologist may undertake to acquire perceived clinical and economic value in a managed care system.
The proper timing of corrective and reconstructive surgical operations for the management of congenital abnormalities in infancy and childhood is exceptionally important. Although no hard and fast rules apply, each deformity should be evaluated in the light of specific features of local and general relationship. Correlation to growth and development must be stressed as an important feature. Evaluation of the congenital abnormality in the light of its many relationships provides for a basis of better complete handling, follow-up, and ultimate result with the aim directed toward elimination of tumor threat, restoration of function and esthetic improvement.
OBJECTIVE: To assess the association between HMO practice, time pressure, and physician job satisfaction. DESIGN: National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one's career and one's specialty. Linear regression-modeled satisfaction (on 1-5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. "HMO physicians" (9% of total) were those in group or staff model HMOs with > 50% of patients capitated or in managed care. RESULTS: Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P <.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P <.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P <.05) and from job, career, and specialty satisfaction (P <.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P <.05 after Bonferroni's correction). CONCLUSIONS: HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians' satisfaction with staff, community, resources, and the duration of new patient visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined.
In addition to dental hospital clinical activity, dental students at Paris Rene Descartes University have the opportunity in their final year of study to practise clinically in a dental office, as associates. This paper outlines a pilot, experimental study designed to assess student reaction to this Vocational Clinical Activity (VCA) in order to identify relevant weaknesses of the undergraduate programme. Using questionnaires, data were collected for each of the following clinical or management skills: clinical difficulty, therapeutic decision-making, patient/practitioner relationship, time management, administrative matters and technical problems. Students were asked to rank each item in order of difficulty (1, high level to 6, low level). A high response rate was observed (90%) among the 50 undergraduate VCA students. The results pointed out three main difficulties encountered by undergraduate students during the VCA: time management (90% of the students), administrative matters (85% of the students) and clinical decision-making (80% of the students). These preliminary results need further investigation. However, they give us the incentive to carry on with this type of assessment and to extend it to young, qualified colleagues' perceptions and to other French Universities.
AIMS: The aims of the research were to explore the issues around the perception of District Nurses in an inner London Primary Health Care Trust of their use of work-time and leisure-time, and to reveal how the boundaries between these two aspects can become blurred and impinge on each other. BACKGROUND: Time use is helpful in considerations of wider issues such as satisfaction at work and work-life balance. METHODS: The data were collected by a questionnaire to seek the views of managers and field staff on issues such as the impact on the quality of patient care of the nurses' perception of work-time and leisure-time. RESULTS: The research identified the different perception of "work-time" that employees have in relation to their place within the hierarchical structure. CONCLUSIONS: The findings answered the question of whether time is perceived differently, dependent on one's occupation within the Trust.
Continued and even accelerated growth in managed care is expected. Managed care organizations achieve their objectives through pricing practices, carefully defined provider networks, risk-sharing reimbursement, and medical care management. These organizations are succeeding in managing cost and at the same time are experiencing equal or better medical outcomes. This article will examine some of the elements necessary to provide a successful managed care organization. It will show how each facet of a managed care organization supports all other facets.
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BACKGROUND: It has been suggested that the modality of brain death and time from brain death until harvest impact survival and rejection after heart transplantation. METHODS: Donor files from 475 adult heart-transplant recipients were examined. From these files, a total management time (time from incident leading to brain death until aortic cross clamp) was determined, and the cause of brain death was noted. Recipient characteristics, details of postoperative course, as well as survival were obtained from the Stanford University Medical Center Heart Transplantation Database. RESULTS: Two hundred and thirty (48.4%) donors sustained traumatic injuries, 112 (23.6%) suffered a subarachnoid hemorrhage, and 102 (21.4%) died of a gunshot wound to the head. The modality of brain death did not influence medium and long-term survival. A management time longer than 72 hours was associated with poorer outcome of the heart-transplant recipients. There were significantly more treated rejection episodes in recipients whose donor sustained traumatic injuries. CONCLUSION: Modality of brain death does not impact survival but appears to influence rejection. Increased management time is associated with adverse survival trends in heart-transplant recipients.
PURPOSE: The purpose of this paper is to present a conceptual framework that would enable the effective application of time based competition (TBC) and work in process (WIP) concepts in the design and management of effective and efficient patient processes. DESIGN/METHODOLOGY/APPROACH: This paper discusses the applicability of time-based competition and work-in-progress concepts to the design and management of healthcare service production processes. A conceptual framework is derived from the analysis of both existing research and empirical case studies. FINDINGS: The paper finds that a patient episode is analogous to a customer order-to-delivery chain in industry. The effective application of TBC and WIP can be achieved by focusing on through put time of a patient episode by reducing the non-value adding time components and by minimizing time categories that are main cost drivers for all stakeholders involved in the patient episode. RESEARCH LIMITATIONS/IMPLICATIONS: The paper shows that an application of TBC in managing patient processes can be limited if there is no consensus about optimal care episode in the medical community. PRACTICAL IMPLICATIONS: In the paper it is shown that managing patient processes based on time and cost analysis enables one to allocate the optimal amount of resources, which would allow a healthcare system to minimize the total cost of specific episodes of illness. Analysing the total cost of patient episodes can provide useful information in the allocation of limited resources among multiple patient processes. ORIGINALITY/VALUE: This paper introduces a framework for health care managers and researchers to analyze the effect of reducing through put time to the total cost of patient episodes.
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BACKGROUND: Tele-echocardiography has the potential to bring real-time diagnoses to neonatal facilities without in-house pediatric cardiologists. Many neonates in rural areas, smaller cities, and community hospitals do not have immediate access to pediatric sonographers or echocardiogram interpretation by pediatric cardiologists. This can result in suboptimal echocardiogram quality, delay in initiation of medical intervention, unnecessary patient transport, and increased medical expenditures. Telemedicine has been used with increased frequency to improve efficiency of pediatric cardiology care in hospitals that are not served by pediatric cardiologists. Initial reports suggest that telecardiology is accurate, improves patient care, is cost-effective, enhances echocardiogram quality, and prevents unnecessary transports of neonates in locations that are not served by pediatric cardiologists. OBJECTIVE: We report the largest series to evaluate the impact of telemedicine on delivery of pediatric cardiac care in community hospitals. We hypothesized that live telemedicine guidance and interpretation of neonatal echocardiograms from community hospitals is accurate, improves patient care, enhances sonographer proficiency, allows for more efficient physician time management, increases patient referrals, and does not result in increased utilization of echocardiography. METHODS: Using desktop videoconferencing computers, pediatric cardiologists guided and interpreted pediatric echocardiograms from 2 community hospital nurseries 15 miles from a tertiary care center. Studies were transmitted in real-time using the H.320 videoconferencing protocol over 3 integrated services digital network lines (384 kilobits per second). This resulted in a frame rate of 23 to 30 frames per second. Sonographers who primarily scanned adult patients but had received additional training in echocardiography of infants performed the echocardiograms. Additional views were suggested as deemed necessary by the interpreting physician, and interpretations were made during the videoconference. The results of the echocardiogram and recommendations for patient care were communicated to the referring physician over the telemedicine system. Analyses of accuracy, patient treatment, echocardiogram quality, time to diagnosis, pediatric cardiologist practice time management, patient referral patterns, and echocardiography utilization were conducted prospectively. RESULTS: A total of 500 studies in 364 patients were transmitted during a 30-month period. The most common indication for echocardiography was to rule out congenital heart disease (208 of 500 studies). Signs and symptoms that prompted this concern included cyanosis, murmur, tachypnea, genetic syndrome, arrhythmia, abnormal fetal echocardiogram, and maternal diabetes. Other indications included suspected patent ductus arteriosus (PDA; 182 of 500 studies), intracardiac clot or catheter position, persistent pulmonary hypertension, and hemodynamic instability. Cardiac diagnoses included complex congenital heart disease (n = 16), noncritical heart disease (n = 107), and PDA (n = 86). Additional diagnoses included persistent pulmonary hypertension (n = 12), septal hypertrophy (n = 18), right atrial mass/clot/vegetation (n = 11), and decreased cardiac function (n = 6). An umbilical venous catheter was visualized in the left atrium in 9% (45 of 500) of all studies. No significant abnormalities were found in 244 studies. Major diagnoses were confirmed by subsequent review of videotape in all studies. Comparison of final videotape interpretation to initial telemedicine diagnosis resulted in 1 minor diagnostic change (membranous versus inlet ventricular septal defect). Echocardiograms were performed in subsequent visits in 264 patients. The diagnosis was altered in 3 patients. Telemedicine had an immediate impact on patient care in 151 transmissions. The most common interventions were indomethacin treatment for PDA (n = 76), retraction of umbilical venous catheters from the left atrium (n = 45), inotropic or anticongestive therapy (n = 19), anticoagulation (n = 8), and prostaglandin infusion (n = 8). Nineteen patients were transported to our hospital because of the telemedicine diagnosis. Inpatient or outpatient cardiology follow-up was recommended in an additional 131 studies and did not result in any change in the initial management. The most common diagnoses in these patients were ventricular septal defect (n = 56), atrial septal defect (n = 21), septal hypertrophy (n = 9), intracardiac thrombosis (n = 8), and pulmonary valve stenosis (n = 4). We speculate that the immediate availability of an echocardiographic diagnosis likely prevented unnecessary transport in 14 cases. Recommendations for additional views or adjustment of echocardiography machine settings were made in 95% of transmissions. Real-time guidance was especially helpful in suprasternal notch and subcostal sagittal imaging. Depth, color Doppler sector size, and color Doppler scale were frequently adjusted from routine adult settings during the teleconference. The average time from request for echocardiogram to completion of the videoconference was 28 +/- 14 minutes. This was significantly shorter than the waiting time (12 +/- 16 hours) for the videotape to be delivered by courier. Telemedicine eliminated the need for consultation in 194 cases and allowed the cardiologist to delay the visit until the end of the day in an additional 26 cases. This resulted in average time savings of 4.2 person-hours/wk based on travel and consultation time. Utilization of echocardiography was similar before (35 of 1000 births) and after (33 of 1000 to 43 of 1000) telemedicine installation. The percentage of neonatal echocardiograms that were interpreted by our practice increased from 63% to 81% at 1 hospital and from 0% to 100% at the other hospital. CONCLUSION: Real-time transmission of neonatal echocardiograms from community hospitals over 3 integrated services digital network lines is accurate and has the potential to improve patient care, enhance echocardiogram quality, aid sonographer education, and have a positive impact on referral patterns and time management without increasing the utilization of echocardiography.
The first blush of the new millennium represents the dawn of a Renaissance Period in health care. Executives must consider the opportunities appearing directly in front of them and design a new vision and a new model of health care delivery. In this report, I outline the opportunities that never existed before the current period. I also discuss 5 steps critical to the odyssey of managing a health care business in the new millennium, thus providing a basis for why it is the best time, not the worst time, to be managing a health care business.
CONTEXT: Although physicians' communication skills have been found to be related to clinical outcomes and patient satisfaction, teaching of communication skills has not been fully integrated into many medical school curricula or adequately evaluated with large-scale controlled trials. OBJECTIVE: To determine whether communications training for medical students improves specific competencies known to affect outcomes of care. DESIGN AND SETTING: A communications curriculum instituted in 2000-2001 at 3 US medical schools was evaluated with objective structured clinical examinations (OSCEs). The same OSCEs were administered to a comparison cohort of students in the year before the intervention. PARTICIPANTS: One hundred thirty-eight randomly selected medical students (38% of eligible students) in the comparison cohort, tested at the beginning and end of their third year (1999-2000), and 155 students in the intervention cohort (42% of eligible students), tested at the beginning and end of their third year (2000-2001). INTERVENTION: Comprehensive communications curricula were developed at each school using an established educational model for teaching and practicing core communication skills and engaging students in self-reflection on their performance. Communications teaching was integrated with clinical material during the third year, required clerkships, and was supported by formal faculty development. MAIN OUTCOME MEASURES: Standardized patients assessed student performance in OSCEs on 21 skills related to 5 key patient care tasks: relationship development and maintenance, patient assessment, education and counseling, negotiation and shared decision making, and organization and time management. Scores were calculated as percentage of maximum possible performance. RESULTS: Adjusting for baseline differences, students exposed to the intervention significantly outperformed those in the comparison cohort on the overall OSCE (65.4% vs 60.4%; 5.1% difference; 95% confidence interval [CI], 3.9%-6.3%; P<.001), relationship development and maintenance (5.3% difference; 95% CI, 3.8%-6.7%; P<.001), organization and time management (1.8% difference; 95% CI, 1.0%-2.7%; P<.001), and subsets of cases addressing patient assessment (6.7% difference; 95% CI, 5.9%-7.8%; P<.001) and negotiation and shared decision making (5.7% difference; 95% CI, 4.5%-6.9%; P<.001). Similar effects were found at each of the 3 schools, though they differed in magnitude. CONCLUSIONS: Communications curricula using an established educational model significantly improved third-year students' overall communications competence as well as their skills in relationship building, organization and time management, patient assessment, and negotiation and shared decision making-tasks that are important to positive patient outcomes. Improvements were observed at each of the 3 schools despite adaptation of the intervention to the local curriculum and culture.
OBJECTIVE: The objective of this study was to examine factors such as academic competence, test competence, time management, strategic studying, and test anxiety, and identify whether these factors could distinguish differences among students, based on academic performance and enrollment in the experiential program. METHODS: A cross-sectional study design utilizing questionnaires measuring previously validated constructs was used to evaluate the effect of these factors on students with low and high cumulative grade point averages (GPAs). Pharmacy students (N = 198) enrolled at the University of Houston participated in the study. RESULTS: Academic performance was significantly associated with factors such as academic competence and test competence. Students with a cumulative GPA of 3.0 or greater significantly differed in their level of test competence than those with a GPA of less than 3.0. Students enrolled in their experiential year differed from students enrolled in their second year of curriculum on factors such as test anxiety, academic competence, test competence, and time management skills. CONCLUSION: Test competence was an important factor to distinguish students with low vs. high academic performance. Factors such as academic competence, test competence, test anxiety and time management improve as students' progress in their experiential year.
Emergency room management means time management. A time and four color based algorithm is described to improve workflow, follow up of diagnostic procedures and initial treatment. As a result introducing the time based interdisciplinary emergency algorithm within 60 minutes all necessary treatment and diagnostic procedures were completed. This algorithm is an effective tool to improve emergency room treatment.
On September 11, 2000, the First Ministers of Canada issued a communiqué pledging to develop and report on waiting times for a number of diagnostic and treatment services. Reporting is to begin by September 2002. Given this commitment, what are the ideal characteristics of such a data collection system? This article defines and evaluates methods of measuring waiting times, and recommends a prioritized waiting-time information system to permit both measurement and management.
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