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PubMed2002

The effects of organizational culture on nursing professionalism: implications for health resource planning.

The organizational structure of many hospitals conflicts with the practice of professional nursing, adversely affecting patient outcomes. The ability of nurses to practise in a professional manner may be influenced by the organizational culture of their work environment. Personal attributes may also play a role. Patient outcomes depend on the identification and promotion of scarce health resources. Personal investment theory was used as the conceptual foundation for this study because of its ability to blend environmental context and personal behaviours associated with motivation. Secondary data analysis was undertaken to determine whether organizational culture and personal sense of accomplishment can predict nursing professionalism. Multiple regression analysis showed that organizational culture predicted over 16% of the variance in nursing professionalism. Therefore, nursing professionalism and hospital environment featuring a strong organizational culture are two health resources that can promote improved patient outcomes.

Adult↗

PubMed1994

Sex differences in psychiatrists' practice patterns and incomes.

OBJECTIVE AND METHOD: Using data from the APA's 1988-1989 Professional Activities Survey, the authors compared male and female psychiatrists on demographic characteristics, training, practice patterns, and income. RESULTS: In keeping with previous studies' findings, female respondents on the average were younger than male respondents and more likely to have taken a residency or fellowship in child or adolescent psychiatry, worked fewer hours per week, allocated their working hours differently among types of activities, saw fewer patients per week, and worked in somewhat different settings. Multiple regression analysis showed that women had significantly lower mean net annual income than men after the effects of those predictors were statistically controlled. CONCLUSIONS: Differences in age, training, hours worked in specific settings, and numbers of patients do not completely account for the gender gap in psychiatrists' annual incomes.

Adolescent Psychiatry↗

PubMed2002

Medicare payment changes and physicians' incomes.

An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.

Academic Medical Centers↗

PubMed1996

Improving the cancer chemotherapy use process.

PURPOSE: Reports of the tragic consequences of erroneous cancer chemotherapy overdoses at a prominent cancer center and a university hospital prompted a review of our institution's practices and those of 123 other hospitals to ascertain for each the current in-house process to prevent chemotherapy errors. METHODS: A multidisciplinary committee of oncologists, nurses, and pharmacists reviewed the chemotherapy use process and identified opportunities for improvement. A 1-page facsimile survey was answered by 150 of 215 members of the American Society of Clinical Oncology (ASCO) who received it. RESULTS: We further restricted the writing of cytotoxic chemotherapy orders to physicians who were board-certified or -eligible in hematology or medical, pediatric, and gynecologic oncology and their approved fellows. Dispensation of drugs is limited to oncology-certified pharmacists, and administration to chemotherapy-certified nurses. Standard orders are used either on special oncology forms or designated order sets in the computer. Procedures to regulate the ordering of antineoplastic drugs for nonmalignant indications by nononcology specialists are outlined. A process to prevent chemotherapy errors is in place in 95% of hospitals. Dedicated medical oncology units are ubiquitous, and most cancer centers and university hospitals have dedicated gynecologic and pediatric oncology units. Chemotherapy orders are generally written by oncology fellows and countersigned by an attending oncologist in cancer centers and university hospitals, whereas private oncology attending physicians write them in most community hospitals. Drugs are administered by oncology-certified nurses in most institutions. CONCLUSIONS: These recommendations should improve the safety and effective use of chemotherapy and reduce the error rate to as close to zero as human fallibility will allow.

Antineoplastic Agents↗

PubMedDate not supplied

Hospitalists: Evolution, evidence, and eventualities.

Hospitalists are physicians who spend at least 25% of their professional time serving as the physicians-of-record for inpatients, during which time they accept "hand-offs" of hospitalized patients from primary care providers, returning the patients to their primary care providers at the time of hospital discharge. The hospitalist movement is only about 5 years old, yet at least 7000 hospitalists practice today and an estimated 19,000 will ultimately practice, approximately the current number of emergency medicine physicians. The emerging positivist literature on hospitalists' impact is the subject of this review. It traces the nature and evolution of the hospitalist movement; summarizes empirical evidence about costs, clinical outcomes, patient satisfaction, and education; and appraises whether the hospitalist model is indeed novel. The review concludes by outlining research questions about the hospitalist model's viability over time, the mechanisms by which it produces benefits, and especially hospitalists' longitudinal effect on continuity of patient care. A literature "scorecard" might rank evidence to date on costs as positive, evidence on clinical outcomes and education as nonnegative, and evidence on patient satisfaction and continuity of care as inconclusive. Above all, longitudinal research must illuminate whether hospitalists' advantages comeat the cost of the doctor-patient relationship.

Continuity of Patient Care↗

PubMed2001

Screening for psychosocial risk in an urban prenatal clinic population: a retrospective practice-based research study.

Recognition of the need for early identification of risk factors led a "practice-based research" (Epstein, 1995) team of social workers in the prenatal clinic at Mount Sinai to develop a standardized, comprehensive screening, monitoring and evaluation instrument for all patients in their service. To explore the effects of psychosocial risk factors empirically, available information collected from 435 women screened with the original instrument between 1992-93 was converted into a quantitative data-base. The intention was to conduct a retrospective study of the prenatal patient population, including demographic characteristics, problems presented, social work interventions, and treatment outcomes. Among the findings anxiety and ambivalence related to pregnancy were significant risk factors. This model of social work service delivery is consistent with the focus of prenatal care as clinical preventative medicine.

Adult↗

PubMed1976

Factors determining the quality of physician performance in patient care.

The study determined the separate and joint effects of 1) physician specialty, 2) type of medical school attended, 3) time in practice, 4) type of ambulatory care setting, and 5) type of hospital on the quality of physician performance in patient care. The sample consisted of 454 physicians in 18 specialty categories. Multiple Classification Analysis was used to determine the effects of these predictors on the quality of physician performance. The study found that the organization of hospital care had a large independent effect, but that the other four predictors had relatively small effects on the quality of physician performance. The findings imply that the organization of the setting in which care is provided has more influence than the education and training that physicians had attained. All five predictors together explained 20 per cent of the variance. Methodological suggestions were made to improve the explanatory power of the variables, and various pragmatic for medical care administrators were presented.

Ambulatory Care↗

PubMed2005

Neonatal outcome in the United Arab Emirates: the effect of changes in resources and practices.

Selective improvements in neonatal care resources and practices were instituted between 1992/1994 (period 1) and 1995/1998 (period 2) following a neonatal audit in the United Arab Emirates. We evaluated the effect of these changes on neonatal mortality rate (NNMR), birth-weight-specific mortality rates and causes of mortality. Overall there was a 17% decline in the NNMR from periods 1 to 2. Mortality rates in infants with birth weight < 1000 g and > 2500 g decreased by 36% and 35% respectively from periods 1 to 2. Modest declines in deaths from asphyxia, sepsis and complications of preterm births occurred from periods 1 to 2 but the differences were not statistically significant.

Adrenal Cortex Hormones↗

PubMed2005

Health care market trends and the evolution of hospitalist use and roles.

OBJECTIVE: To describe local health care market dynamics that support increasing use of hospitalists' services and changes in their roles. DESIGN: Semistructured interviews in 12 randomly selected, nationally representative communities in the Community Tracking Study conducted in 2002-2003. Interviews were coded in qualitative data analysis software. We identified patterns and themes within and across study sites, and verified conclusions by triangulating responses from different respondent types, examining outliers, searching for corroborating or disconfirming evidence, and testing rival explanations. SETTING: Medical groups, hospitals, and health plans in 12 representative communities. PARTICIPANTS: One hundred seven purposively sampled executives at the 3-4 largest medical groups, hospitals, and health plans in each community: medical directors and medical staff presidents; chief executive and managing officers; executives responsible for contracting, physician networks, hospital patient safety, patient care services, planning, and marketing; and local medical and hospital association leaders. MEASUREMENTS AND MAIN RESULTS: We asked plan and hospital respondents about their competitive strategies, including their experience with cost pressures, hospital patient flow problems, and hospital patient safety efforts. We asked all respondents about changes in their local market over the past 2 years generally, and specifically: hospitals' and physicians' responses to market pressures; payment arrangements hospitals and physicians had with private health plans; and physicians' relationships with plans and hospitals. We drew on data on hospitalist practice structures, employment relationships, and productivity/compensation from the Society for Hospital Medicine's 2002 membership survey. Factors that fomented the creation of the hospital medicine movement persist, including cost pressures and primary care physicians' decreasing inpatient volume. But emerging influences made hospitalists even more attractive, including worsening problems with patient flow in hospitals, rising malpractice costs, and the growing national focus on patient safety. Local market forces resulted in new hospitalist roles and program structures, regarding which organizations sponsored hospitalist programs, employed them, and the functions they served in hospitals. CONCLUSIONS: These findings have important implications for patients, hospitalists, and their employers. Hospitalists may require changes in education and training, develop competing goals and priorities, and face new issues in their relationships with health plans, hospitals, and other physicians.

Arizona↗

PubMed2000

A continuous-improvement approach for reducing the number of chemotherapy-related medication errors.

A comprehensive, interdisciplinary approach for reducing the number of chemotherapy-related medication errors at the National Institutes of Health Clinical Center, where approximately 8500 doses of chemotherapy agents are dispensed annually, is described. Heightened awareness of the seriousness of chemotherapy-related medication errors prompted formation of an interdisciplinary task force in June 1995 to analyze and improve the hospital's system for ordering, checking, processing, and administering cancer chemotherapy agents. Problems were analyzed and rectified in accordance with the hospital's plan-do-check-act performance-improvement model. Performance monitors for the improvements included a system to record and categorize all chemotherapy-related prescribing errors and a hospital-wide occurrence-reporting system. The task force identified seven major categories in which improvements were needed: protocol development, computer-system enhancements, dose verification, information access, education for health care practitioners, error follow-up, and infusion pumps. Despite the Clinical Center's good safety-net system, 23 modifications were made to the existing system through December 1999. These changes resulted in an overall 23% decrease in prescribing errors and a 53% decrease in serious prescribing errors. The task force membership was recently broadened to include representatives of additional departments where chemotherapy agents are used, and this group recommended more than 20 additional system changes. The changes are being implemented, and their effect on reducing the number of chemotherapy-related errors will be measured. The continuous-improvement process used prospectively by the task force helps ensure that safe chemotherapy practices are instituted uniformly throughout the hospital.

Antineoplastic Agents↗

PubMed1990

Innovations in clinical practice through hospital-funded grants.

Improving patient outcomes while controlling the costs of care requires a partnership between clinical researchers and hospital management. To this end, Strong Memorial Hospital in Rochester, New York, dedicated hospital operating funds to a program of small grants designed to align the patient care and academic interests of clinicians with the goals of efficient hospital management. The grants gave clinicians an opportunity to test the efficacy of specific patient care maneuvers. These studies resulted in improved guidelines for the use of diagnostic and therapeutic modalities, new technology, and length of hospitalization. Annual marginal cost savings from implementing the first-year study results are projected to be $587,255, an 8 to 1 return on the first year's expenses. The authors conclude that a hospital-funded applied research program encourages those delivering patient care to identify inefficiencies and introduce change while ensuring quality patient care. This joint faculty-management effort can augment the hospital's quality-assurance, utilization management, and technology assessment programs while advancing the scholarship of faculty members.

Cost-Benefit Analysis↗

PubMed1998

Evidence-based care in nursing: reforms versus research, rhetoric versus reality.

The new evidence-based health care culture, together with nurses' demands for enhanced professional status, has embedded within its strategy the imperative to develop a corpus of nursing-specific research. These apparently compatible aims were intended to meet the need for enhanced professional status while at the same time enabling clinical nursing practice to be justified on scientific grounds. While the dual reform agendas brought with them the resistance that always accompanies radical amendments to the status quo, they also seem to have created an unanticipated reciprocal antagonism which has impeded the development of nursing research. The policy changes that were necessary to meet the prerequisites for professional status have had a detrimental effect on the potential for generating an adequate body of nursing research. This second paper discusses some of the key reforms to nursing that have been implemented over the last decade and their impact on nursing's progress towards creating its own esoteric research knowledge base that could inform clinical care. It is suggested that policy and research may be diametrically opposed, and that nursing, if it is committed to professionalization, may have to reconsider its allegiance to the scientific research culture in favor of achieving some of the other objectives on its agenda.

Education, Nursing↗

PubMed1997

Re-engineering the medical staff. Simplification is key.

Medical staffs are finding they must make do with less--less administrative support from financially strapped hospitals, and less volunteer physician member time from physicians who are distracted by managed care and by managing their changing practices. All too often the medical staff tries to do what they have always done, only faster, and with less help. This just frustrates those who were already working hard. The better alternative? Re-engineer the medical staff with the goal of simplifying operations. A critical look at the tasks undertaken by the medical staff often reveals that far too much time is spent doing unnecessary things. When asked, "Why do you do all this?" the answer is often, "because we are required to do it!" Yet scrutiny reveals that it is not required and that the task could be eliminated. Just because something "has always been done that way" does not mean it still must. It is time to look at the medical staff structure and procedures with a new set of questions: What is really required? What has great value for us? What can be jettisoned without affecting our operations?

Constitution and Bylaws↗

PubMed2004

Motivation and values of hospital consultants in south-east England who work in the national health service and do private practice.

In the UK, a small private health care sector has always existed alongside the national health service (NHS). The conventional assumption is that doctors who work as salaried employees of the NHS are guided in their clinical practice by professional values which encourage them to put their patients' interests first. A common suspicion is that doctors undertaking fee-for-service practice in the private sector are motivated by self-interest, with commitment to their patients compromised by consideration for their purse. The great majority of hospital consultants are salaried employees of the NHS, but most also undertake some private practice. This paper uses findings from an interview study of 60 surgeons and physicians engaged in dual practice of this kind to investigate their reasons for working in this way and look at how they reconcile their personal, professional and public sector values and responsibilities with the temptations of the market. The existence of the private sector and their own engagement in it was regarded by almost all respondents as a net benefit, not only to themselves and their private patients, but also to the NHS, so long as they handled it properly. The interviews revealed a complex range of beliefs and assumptions through which these doctors justify their activities and a variety of informal principles for dealing with such conflicts of interest as they acknowledge. Neither their values nor their actions can be adequately explained using generic concepts of professional self-interest or public service values without consideration of what such concepts represented in the specific social, economic, professional and policy context of health care in south-east England at the time of the study.

Career Choice↗

PubMed2005

Effectiveness of developmental intervention in the neonatal intensive care unit: implications for neonatal physical therapy.

PURPOSE: Interdisciplinary team members interact with infants to facilitate progressive physiologic stability. The focus of the physical therapist's role is promotion of sensorimotor development in infants born preterm. The aim of this review was to examine evidence for physical therapist practice in the neonatal intensive care unit (NICU) as it relates to developmental intervention (DI) for infants born prematurely and to present the evidence of physical therapy techniques used in the NICU. SUMMARY OF KEY POINTS: A literature review was performed resulting in identification of 26 articles that examined specific developmental intervention techniques. The articles were critiqued based on their design. Twelve articles were rated highly, indicating that sensory techniques implemented by physical therapists appear to be an appropriate and effective component of DI. The general consensus was that there is a lack of large, well-controlled, randomized studies in this area of pediatric outcome research. CONCLUSIONS: Neonatal physical therapy falls under the umbrella of DI. There is substantial agreement about the benefits of DI, but the multimodal and interdisciplinary nature of the evidence limits the ability to identify the effectiveness of any one healthcare professional in the provision of DI in the NICU.

Developmental Disabilities↗

PubMed1992

A national study of psychiatrists' professional activities.

OBJECTIVE AND METHOD: A mail survey was conducted in 1988-1989 to study the professional activities of U.S. psychiatrists. Data from the 19,431 active respondents are reported. RESULTS: Nineteen percent of the psychiatrists were women, an increase from the 17% reported in 1982. The median age of the respondents was 50 years. Nearly one-third of the respondents expressed interest in each of the following areas of subspecialization: adolescent psychiatry, substance abuse, geriatrics, and consultation-liaison psychiatry. More than one-fifth reported formal fellowship training in child/adolescent psychiatry. The psychiatrists worked an average of 48 hours per week--two-thirds in direct patient care--in an average of 2.3 different settings. The proportion of psychiatrists reporting private practice as their primary work setting showed a marked decline from 53% in 1982 to 45% in 1988. There was an increase from 4% in 1982 to 11% in 1988 in those whose primary work setting was a private psychiatric hospital. The typical caseload was over 60 patients, with roughly half that number seen each week. For inpatients treated, the two most common diagnoses were affective disorders and schizophrenic disorders. In a typical week psychiatrists treated about one-half of their outpatients with individual psychotherapy; three-fifths of these were also treated with medications. The average net income for psychiatrists working 35 hours or more per week was $99,850 for men and $73,174 for women. CONCLUSIONS: Major trends evident from this study are subspecialization, medicalization, privatization, feminization, and organizational diversification.

Adult↗

PubMed2006

Private or public? An empirical analysis of the importance of work values for work sector choice among Norwegian medical specialists.

In the aftermath of the Norwegian hospital reform of 2002, the private supply of specialized healthcare has increased substantially. This article analyses the likelihood of medical specialists working in the private sector. Sector choice is operationalized in two ways: first, as the likelihood of medical specialists working in the private sector at all (at least 1% of the total work hours), and second, as the likelihood of working full-time (90-100%) privately. The theoretical framework is embedded in work values theory and the results suggest that work values are important predictors of sector choice. All analyses are based on a postal questionnaire survey of medical specialists working in private contract practices and for-profit hospitals and a control group of specialists selected from the Norwegian Medical Association's member register. The analyses revealed that while autonomy values impact positively on the propensity for allocating any time at all to the private sector, professional values have a negative effect. Given that the medical specialist already works in the private sector, a high valuation of professional values and payment and benefit values increases the likelihood of having a dual sector job rather than a full-time private position. However, due to the cross-sectional structure of the data and limitations in the dataset, causality questions cannot be fully settled on the basis of the analyses. The relationship between work values and sector choice should, therefore, be regarded as associations rather than causality links. Finally, the likelihood of working in the private sector varies significantly at the municipality level, suggesting that medical specialist's location is important for sector choice.

Adult↗

PubMed2004

Reserved procedures in Dutch hospitals: knowledge, experiences and views of physicians and nurses.

The Individual Health Care Professions Act came into force in The Netherlands in 1997, introducing a mixed system for the regulation of the practice of medicine. One of its components, the reserved procedures regulations, was studied in hospitals to gain insight into the knowledge, experiences and views of physicians and nurses with regard to these regulations. Questionnaires were sent to representative samples of 250 gynaecologists, 350 internists, and 3200 nurses, response rates were 65, 60 and 71%, respectively. Almost all respondents were aware that physicians are authorised to perform reserved procedures on their own initiative (93-99%), and 48-63% knew that nurses are not authorised to do this. A substantial percentage of the nurses performed reserved procedures on their own initiative (17-53%). A majority of gynaecologists and internists presumed that the hospital had ensured the proficiency of the nurses to perform reserved procedures (58% resp. 65%), while 82% of the nurses determined their own proficiency for each procedure. Most respondents felt that the reserved procedures regulations offer adequate protection for patients (58-72%). Although recommendations are made for improvement, the functioning of the reserved procedures regulations in hospitals is considered to be moderately positive.

Attitude of Health Personnel↗