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PubMed2003

Risk identification, assessment and management in public health practice: a practical approach in one public health department.

BACKGROUND: The continuing identification, assessment and management of risks are key themes for clinical governance. These themes are being integrated into both primary and secondary care practice; however, integration into public health practice appears much slower. This paper describes the recent approach that we have taken in Sheffield, and proposes a model for public health departments to identify, assess and manage risks, which complements other risk management processes and is transferable to other settings. It assumes that public health practice is not a risk-free activity and holds that the process of identifying, assessing and managing risks is a key component to raising standards. METHODS: A number of risk 'management' models were reviewed and a primary care approach was applied to public health practice. A list of potential risks was identified using a number of methods including reflective practice, information from complaints and/or critical incidents. Risks were assessed by likelihood and impact, and were captured in a risk framework. RESULTS: By March 2002, 21 risks had been identified and characterized, and progress had been made to manage 11 of these risks. CONCLUSION: This process, and the development of a risk framework, was useful in identifying a prioritized work programme to improve standards of public health practice in this department. This model can also be used not only for planning risk management activities, continual identification and assessment of risks but also to provide inspiration for other clinical governance activities including public health audit.

England↗
PubMed1992

Association between clinical experiences in family practice or in primary care and the percentage of graduates entering family practice residencies.

In 1990 the authors surveyed all U.S. medical schools in order to solicit information about students' clinical experiences in family practice and in primary care. Of 126 schools, 104 (82.5%) responded. Survey data were correlated with each school's quartile ranking based on the average percentage of graduates who entered family practice residencies. A significant association (p = .0013) was found between required family practice clerkships or preceptorships and institutions ranked in the highest quartile (i.e., having more than 17% of their graduates enter family practice). A similarly significant association (p = .0056) was found for those 12 institutions that had more than 30% of their students select family practice options in required primary care clerkships or preceptorships. The authors suggest that active recruiting of students to take such options may increase the number of graduates who enter family practice.

Career Choice↗
PubMed1998

Associations between primary care-oriented practices in medical school admission and the practice intentions of matriculants.

PURPOSE: To assess associations of primary-care-oriented medical school admission practices with matriculants practice intentions. METHOD: The authors performed cross-sectional, secondary analyses of databases from the Association of American Medical Colleges (AAMC). The independent variables were four medical school admission practices. The control variable was school ownership (public vs private). The dependent variables were the proportions of matriculants at each school interested in generalism, rural practice, and locating in a socioeconomically deprived area. RESULTS: One hundred and twenty medical schools (95%) completed the AAMC's Survey of Generalist Physician Initiatives in either 1993 or 1994; 94% of matriculants replied to the AAMC's 1994 Matriculating Student Questionnaire. Twenty-five percent of the schools had admission committee chairs who were generalists, half had over 25% generalists on their admission committees, 64% gave admission preference to students likely to become generalists, and 33% reported premedical recruitment efforts that targeted applicants likely to become generalists. In multivariable analyses, premedical recruitment efforts and public school ownership (all p < .01) were associated with greater interest of matriculants in both generalism and rural practice. CONCLUSIONS: Public medical schools and schools with premedical recruitment activities targeting future generalists admitted greater proportions of students interested in primary care and rural practice.

Career Choice↗
PubMed2003

Perception of competency to perform procedures and future practice intent: a national survey of family practice residents.

PURPOSE: A national survey of family practice (FP) chief residents to identify the type of procedural skills they have completed, assess their perceptions of competence to perform those procedures, and identify the procedures they anticipate performing in practice. METHOD: A questionnaire asking about training and competency in 31 core procedures for family medicine (FM) was developed from the literature and pilot tested on residency directors for face validity and clarity. The questionnaires were mailed to chief residents at the 463 FM residency programs in the United States between July and October 2001. RESULTS: A total of 265 (57%) questionnaires were returned. Ninety-six percent of respondents were PGY3 seconds, and 40% were women. All residents had performed excision of a lesion, drainage of an abscess, and simple suturing. Residents were least likely to have performed vasectomy (46%), thoracotomy (41%), and rigid sigmoidoscopy (34%). The mean number of procedures performed during residency and the number of procedures the resident intended to perform in practice differed by gender. Residents who planned to practice in rural areas anticipated performing more procedures than did those who planned to practice in suburban areas (20 versus 17; p >/=.001). Over 90% of residents felt competent to perform obstetrics, but fewer than 50% planned to in practice. CONCLUSION: Despite reports that core procedural skills are taught, this study suggests significant numbers of residents are not being taught certain procedures in a manner that results in residents feeling competent to perform them.

Clinical Competence↗
PubMedDate not supplied

Medical practices' sensitivity to patients' needs. Opportunities and practices for improvement.

This article presents the results of a national study of medical practices' patient satisfaction using data collected from January to December 2001 with Press Ganey Associates' Medical Practice Survey (n = 503,407). The question, "Our sensitivity to your needs" (r = 0.85), most highly correlated with overall patient satisfaction. Patients' age, sex, or first visit were not predictors of sensitivity to patients' needs. Responses highly correlated with sensitivity to patients' needs: (1) concern for patients' privacy, (2) cheerfulness of practice, (3) care received during visit, and (4) likelihood to recommend practice. Patient perception and satisfaction with medical practices' sensitivity to patient needs and recommended practices for improvement are discussed.

Ambulatory Care↗
PubMedDate not supplied

Rebuilding a professional practice model. The return of role-based practice accountability.

There is no patient care without clinical practice. To improve the quality of health care, organizations must build a finely tuned and resilient clinical enterprise, one founded on clear role accountability and decision authority within the team. The author views scope of practice and professional standards as the foundation for practice accountability and decision authority. A case is made that an interdisciplinary, professional practice model is an appropriate delivery model in today's health care environment; a model that places the professional role in its rightful place as decision maker and supports the role's inherent accountability to evaluate and monitor practice performance. The importance of measuring professional practice performance is seen as a key link toward better understanding ways to reduce error and ensure patient safety.

Decision Making, Organizational↗
PubMed1999

Developing practice protocols for advanced practice nursing.

In most states, the role of an advanced practice nurse is dependent on practice protocols that provide an organized method for analyzing and managing a disease or major symptom. They are also used to control the process of medical care and to specify steps in the delivery of that care. Creating appropriate practice protocols is one of the most important precursors to implementing the advanced practice role, because they virtually drive the clinician's ability to treat or manage clinical situations or disease states. This article outlines the steps involved in developing practice protocols and discusses the content that should be included in a protocol, providing an example of narrative and algorithm format protocols. Pros and cons, as well as legal issues related to practice protocols, are also presented.

Algorithms↗
PubMed2005

Tandem practice model: a model for physician-nurse practitioner collaboration in a specialty practice, neurosurgery.

PURPOSE: To describe the benefits of a physician-nurse practitioner (NP) collaborative practice model, specifically that of a tandem practice model, using a neurosurgeon and a primary care NP in the clinic and inpatient setting. DATA SOURCES: Selected journal articles from Medline and CINAHL, and anecdotal clinical experience. CONCLUSIONS: This collaborative practice model, in which the physician and NP deliver patient care in tandem, is beneficial to patients and their families because they receive comprehensive care that is patient oriented and holistic. Further, the model benefits multiple disciplines across the healthcare continuum by providing efficient communication of patient needs, accessibility of the specialty team, and timely implementation of patient interventions. The collaboration of the physician specialist and primary care NP provides a holistic approach to the care of diverse and challenging patient populations. IMPLICATIONS FOR PRACTICE: Patients seen in a specialty practice, particularly that of neurosurgery, often have little understanding of their problem and may be frightened or confused because of their perceptions of the unknown. Providing care to such specialized patient populations in a constantly changing healthcare environment may prove demanding to the specialist. The introduction of a primary care NP into such specialty settings offers patients, their families, consultants, and staff members an additional resource for evaluation, intervention, education, and communication, improving the continuity and comprehensiveness of care to challenging patient populations. This model is an option for physician specialists interested in augmenting their practice and provides further resources for meeting the holistic needs of selected patient populations regardless of the setting.

Attitude of Health Personnel↗
PubMed2006

Practice development 'without walls' and the quandary of corporate practice.

AIM: The context of this study is a group of clinical nurse specialists from across a Trust seeking accreditation as a practice development unit. The university was asked to facilitate the accreditation process via 11 2-hour learning sessions (including a one-hour focus group). During initial discussions between the university and practice development unit, the overarching research question for this study was set as: 'what are the main roles and responsibilities of clinical nurse specialists?' BACKGROUND: Although there is no known study of a practice development unit based beyond a ward or speciality, the central tenet of the practice development unit literature is that units must demonstrate their worth if they are to survive and harness senior management support in doing so. DESIGN AND METHODS: Data gleaned from the transcribed audio tape-recordings of the learning sessions were studied at least three times to ensure transcription accuracy and produce detailed charts. Ethical approval was granted by the appropriate Local Research Ethics Committee and written informed consent obtained from clinical nurse specialists. The study lasted 30 months and ended in October 2004. RESULTS: The four crucial statements that give meaning to specialist practice are: quality care giver; expert; information giver and initiator of change. Further analysis reveals the area of corporate and political practice as being missing from this and other lists of clinical nurse specialist attributes found in the literature. Clinical nurse specialists characterize their relationship with the Trust in terms of dichotomy--differing agendas and perceptions of value. CONCLUSIONS: The specialist role requires professional development in the areas of corporate and political acumen and professional business management. While the findings of this study relate to one Trust and a group of 16 clinical nurse specialists, with careful application they may be transferable to other settings and groups of senior nurses.

Accreditation↗
PubMed2006

Exploring the continuum: medical information to effective clinical practice. Paper I: the translation of knowledge into clinical practice.

This paper investigates the translation of medical information into clinical practice and the role of thoughtful dissent by exploring the influence of sociological factors on change, the impact of evidence-based medicine (EBM), and the role of industry. Changing practice related to hormone therapy for menopausal and post-menopausal women provides context for this discussion. Medical change involves diffusion of ideas to potential users and ongoing reconciliation of new information with old ideas; this process is influenced by sociological factors including values and experiences, interpersonal relationships and local context. While EBM has alerted doctors to the importance of high quality research and theoretically provides a tool for translating research into practice, there are important problems with its application: (1) it has resulted in a reductionist approach to research and illness; (2) there is a considerable gap between research findings and the complex environment of clinical practice; and (3) EBM has been appropriated by experts, thus corporately developed 'standard-of-care' documents have become instruments of external regulation, and EBM has ceased to be a tool in the hand of individual clinicians. In addition, industry impacts the translation of knowledge by significantly influencing academia, researchers, medical publications, consensus conferences, and practising doctors. While questioning doctrinaire practices or directives is a daunting prospect for individual clinicians, the translation of knowledge into practice and evolution of medical thought is dependent on the progressive role of thoughtful dissent.

Biomedical Research↗
PubMed2004

Integrating the principles of evidence-based practice into clinical practice.

This series of articles illustrates many considerations relevant to the application of clinical practice guidelines (CPGs). This particular column describes the actions of a nurse practitioner (NP) striving to understand the foundations of recommendations that are based largely on expert opinion. Although application of CPGs does not generally require this degree of investigation, it is essential that providers understand the processes used to interpret the basis of recommendations, including the application of the basic statistical concepts, when making decisions about how recommendations apply to individual patient scenarios. Utilizing evidence-based practice when providing patient care requires a range of skills that allows the NP to locate appropriate research evidence, to develop an understanding of the statistics used in interpreting and reporting research, and to evaluate the effects of interventions on patient outcomes. The application of the key concepts of evidenced-based practice within the primary care setting is explored through a hypothetical patient scenario, which was created as the focal point for three articles that illustrate principles of evidence-based practice. The goal of this series of articles is to provide a basic understanding of evidence-based practice and its application in clinical practice. This article explores the use of interventions selected from CPGs and investigates the potential effects of recommended interventions on patient outcomes. Commonly encountered statistical concepts are reviewed, and examples of their application in interpreting and reporting research are demonstrated. The principles of relative risk, relative risk reduction, absolute risk reduction, and numbers needed to treat are described. This review provides the NP with some basic skills to determine both the quality and usefulness of research.

Clinical Competence↗
PubMed2003

Assessing the quality of care of multiple conditions in general practice: practical and methodological problems.

OBJECTIVE: To investigate practical and methodological problems in assessing the quality of care of multiple conditions in general practice. SETTING: Sixteen general practices from two socioeconomically diverse regions in the UK. METHOD: Quality of care was assessed in 100 randomly selected patient records in each practice using an established set of quality indicators covering 23 conditions commonly seen in primary care. Inter-rater reliability assessment was carried out for five of the conditions. RESULTS: Conducting simultaneous quality assessment across multiple conditions is highly resource intensive. Poor data quality and the low prevalence of some items of care defined by the indicators are significant problems. Scores for individual indicators require very large samples for reliable assessment. Quality scores are more reliable when reported at a higher unit of analysis. This is particularly true for indicators and conditions with low prevalence where data may need to be aggregated to the level of groups of conditions or organisational providers. There is no single ideal way of aggregating quality scores. CONCLUSION: The study identified some of the practical and methodological difficulties in assessing quality of care across multiple conditions. For improved quality assessment, advances in information technology and improvements in data quality are required for more efficient and reliable data extraction from medical records, together with the development of methods for combining scores across indicators, conditions, and practices. However, electronic data extraction methods will still be based on the assumption that the care recorded reflects the care provided.

Disease↗
PubMed1980

Practice settings and prescribing profiles: the simulation of tension headaches to general practitioners working in different practice settings in the Montreal area.

The purpose of this study was to determine whether physicians practicing in one type of setting manage a medical problem differently than those practicing in another type of setting. The investigation took the form of presenting physicians with a simulated case of tension headache with a history going back three years, for which diazepam had been taken daily for the past year. Four simulated patients (aged 20-23) visited a stratified random sample of 111 general practitioners practicing in health centers funded by government (CLSCs) and in private group practice clinics in the Montreal area. Fifty-one per cent of group practice physicians recommended therapy rated as "inadequate" compared to 25 per cent in CLSCs; in addition, the data show significant differences between CLSC and group practice physicians in performing various aspects of the clinical examination. Alternative explanations for the observed differences are discussed.

Adult↗
PubMed2001

Medical emergencies in general practice in south-east Queensland: prevalence and practice preparedness.

OBJECTIVE: To determine the type and frequency of emergencies in general practice, and the extent to which general practices are equipped to appropriately respond to emergencies. DESIGN: Random-sample, cross-sectional questionnaire survey of general practitioners, October 1999 - March 2000. SETTING: General practices in south-east Queensland. PARTICIPANTS: 512 of 900 eligible GPs in current clinical practice. MAIN OUTCOME MEASURES: The type and frequency of medical emergencies presenting to GPs, and descriptive details of emergency drugs and equipment available in their practices. RESULTS: 512 GPs (response rate, 57%) reported managing a cumulative total of 5640 emergencies over the preceding 12 months. Non-metropolitan GPs saw about 30% more emergencies than their metropolitan counterparts (median, 9 and 7, respectively; P=0.02). The most common emergencies (seen by more than 30% of all GPs) were acute asthma, psychiatric emergencies, convulsions, hypoglycaemia, anaphylaxis, impaired consciousness, shock, poisoning and overdose. Most GPs (77%) stocked 15 or more of the 16 emergency doctor's bag drugs, but a smaller proportion (67%) had all of the basic emergency equipment items considered essential. CONCLUSIONS: A substantial number of patients with potentially life-threatening emergencies present to GPs. Doctor's bag emergency drugs are available in most general practices, but availability of basic emergency equipment is suboptimal.

Adult↗
PubMed1995

Practice parameters/clinical policies: the new approach to the practice of medicine.

Practice parameters or clinical policies and the future practice of medicine are covered in a series of three articles. In Part I, the term practice parameters is defined, and the background of practice parameters at the federal, AMA, and specialty society level is discussed. In Part II, the development, application, dissemination, and monitoring of practice parameters, including the clinical usage and impact, will be discussed. In Part III, the advantages, disadvantages, and legal implications of practice parameters will be reviewed.

American Medical Association↗
PubMed2000

Relationship between patient practice-oriented knowledge and metabolic control in intensively treated Type 1 diabetic patients: results of the validation of the Knowledge and Practices Diabetes Questionnaire.

AIMS: To validate a newly developed questionnaire for the measurement of patients' knowledge and practices, with particular attention to its ability in predicting HbA1c levels. RESEARCH DESIGN AND METHODS: The Knowledge and Practices Diabetes Questionnaire (KPDQ) is a questionnaire composed of two scales, investigating patient knowledge and practices. Twenty-two questions, 12 dealing with patients' knowledge and 10 relative to patients' practices, were initially identified. Factor analysis and reliability analysis were used to validate the questionnaire. The ability of the two scales in predicting metabolic control was then evaluated. The questionnaire was administered to a population of Type 1 diabetic subjects intensively treated and regularly attending the diabetes outpatient clinic of Pescara General Hospital. The mean of all HbA1c measurements performed after patients were taken in charge by the clinic was used as an indicator of metabolic control. RESULTS: Out of 133 Type 1 patients identified, 77 (58 %) filled in the questionnaire. Respondents had a mean age (+/- SD) of 37 +/- 13 years and a mean diabetes duration of 13 +/- 9 years. The application of factor and reliability analyses led to the definition of two final scales composed of 10 (Knowledge Score, KS) and 5 items (Practice Score, PS), respectively. Item-scale correlation was > or = 0.40 for all the items investigated. Cronbach's alpha coefficient exceeded the value of 0.70 for both scales. The mean number of HbA1c determinations during a median period of observation of 4 years was of 11 +/- 5. The mean HbA1c value for the whole population was of 7.0% +/- 1.4, while the proportion of patients with values < or = 7.0% was of 57%. After adjusting for clinical and patient-related characteristics, the KS was the only independent predictor of metabolic control. Patients in the lowest quartile of the KS showed a more than 20-fold increased risk of having mean HbA1c values > or = 7.0% as opposed to those in the highest quartile (odds ratio, OR=23.3;p=0.009). No association emerged between metabolic control and PS. CONCLUSIONS: The KPDQ presents excellent psychometric properties. The KS also shows a very impressive association with the mean HbA1c values over a period of 4 years. These findings are particularly remarkable in that many studies have failed in documenting such a relationship. The KS can thus be considered as a quick and efficient screening tool to be used in an ambulatory setting to monitor the level of practice-oriented knowledge of patients with Type 1 diabetes as well as to identify those subjects who need individualized educational interventions.

Adult↗
PubMed2000

Prescribing patterns of advanced practice nurses: contrasting psychiatric mental health CNS and NP practice.

Advanced practice nurses (APNs) play a key role in delivering health care and increasingly include prescriptive authority in their practices. To date, few systematic studies have investigated APN prescribing patterns. The purpose of this investigation was to explore the prescriptive practice of APNs, assess differences in prescriptive patterns by specialty, and determine barriers to prescriptive practice. Fifty-one percent (n = 1352) of 2,651 nurse practitioners (NPs) and psychiatric clinical nurse specialists (CNSs) in Massachusetts responded to a self-administered survey; 59% had incorporated prescriptive authority. Identified barriers included fees, the process of obtaining prescriptive authority, and lack of physician supervision. Significantly more psychiatric CNSs than NPs had difficulty obtaining physician supervisors. Prescriptive authority is integral to advanced practice, but differences in ability to implement this in practice exist among specialties.

Adult↗
PubMedDate not supplied

[Clinical practice in mental health and educational needs in general practice].

AIM: To obtain information regarding general practitioners' perception of their practice in mental health care, opinions, difficulties and educational needs. METHODS: All general practitioners attending the last annual session of continuing medical education (October-December 2000) were asked to complete the questionnaire regarding: 1) perception of current practice in mental health care and difficulties in managing mental health problems; 2) opinions regarding their practice; 3) educational needs and perception of benefit from strategies to improve mental health care. RESULTS: 254 general practitioners completed the questionnaire (response rate 70%). 81.4% recognize their role in mental health care and 89.9% report they should develop the necessary skills to deal with mental health problems, perceived as difficult to treat in general practice (77.3%). Educational priorities concern mainly anxiety, depression and somatization; further competences and skills are mainly necessary in doctor-patient communication and psychopharmacological treatment. Main difficulties concern the involvement degree with the specialists (44%) and the time patients need during the consultations (40.4%). Information about local mental health services, supervision and discussion with specialists and continuing medical education are considered useful to improve mental health care. CONCLUSIONS: As regard their role in mental health care, general practitioners perceive a lack of knowledge and skills. Relationship with specialists and mental health services, daily practice characteristics and time necessary to deal with patients represent barriers detracting from optimal mental health care in general practice.

Education, Medical, Continuing↗