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PubMed1984

Development of clinician-educator faculty track at the University of Pennsylvania.

As resources grow scarcer , universities have become reluctant to increase the long-term institutional commitments involved in faculty appointments with tenure. The restrict tenured appointments, universities in recent years have adopted more stringent criteria for approving them and in many cases have set a limit on the number of new appointments and promotions with tenure. The educational and service missions of the medical school, however, necessitate a large cadre of clinical faculty members. The establishment and evolution of the clinician-educator faculty track at the University of Pennsylvania provide a case study of a process taking place in many medical schools to meet the need for nontenured full-time faculty appointments.

Faculty, Medical↗
PubMed2000

Assessing the operating efficiencies of teaching hospitals by an enhancement of the AHA/AAMC method. American Hospital Association/Association of American Medical Colleges.

In the ongoing effort to control costs, comparisons among hospitals' efficiency levels, if valid, can help identify "best practices" across institutions and uncover situations that need corrective intervention. The authors present an extension of the "adjusted cost per equivalent discharge" approach, which incorporates case-mix-severity differences, regional labor cost differentials, and inpatient/outpatient mix, but does not take into account such factors as the differences in hospital sizes, extents of the teaching mission, or quality of care delivered. The alternative approach yields information that suggests where an institution's total operating costs might be reduced with no change in any of the hospital's outputs or operating environment, through comparison with a "peer group" of other hospitals, matched according to the subject hospital's number of beds, the quality of care the hospital delivers, the extent of medical education carried out, the level of case-mix-adjusted discharges, and outpatient activities. A difficulty with this approach (as with others) is that measurement of some of the additional facets (e.g., quality of care) is still evolving, so its main contribution at this time is to provide a construct and method capable of incorporating these important added considerations. Hospital rankings achieved by applying the current and alternative approaches to a real set of teaching hospitals operating in FY 1987 are compared. While the rankings produced by the two approaches are loosely similar, the authors show that some significant differences do appear and can be at least partially explained by the incorporation of the additional factors mentioned above.

Ambulatory Care↗
PubMed2002

Measuring, monitoring, and reducing medical harm from a systems perspective: a medical director's personal reflections.

The author describes five critical elements for reducing and, ultimately, preventing harm to patients-from a systems perspective. In the element called leadership and culture, leaders must advocate patient safety as a primary goal and foster an institutional culture where change that promote patient safety can occur. In internal surveillance, systems are established to actively monitor for deviations in quality and guide efforts to engineer risk of harm out of the institution's practices; they can also demonstrate absence of risk or harm. Although incident reporting can be controversial and is sometimes avoided because its use in "blame attacks," etc., it can be valuable if built on a continuous improvement approach and a system approach to error prevention. External surveillance involves the identification and response to "sentinel events," such as wrong-sided surgery, and serves to remind all those involved in care just how risky and unforgiving medical practice can be. Finally, those involved in promoting safety must believe that hazard and risk are not inevitable and can be managed. The author illustrates this approach by describing his hospital's successful efforts to prevent the rise of aspergillus infections during a major hospital construction project. The author closes by describing selected challenges and opportunities to reduce harm from a systems perspective, such as using teams, involving patients and the public, using lessons learned from other industries with strong safety cultures, and using advances in information systems for a variety of safety-oriented tasks.

Culture↗
PubMedDate not supplied

Osteoarthritis of the hip. A survey of treatment.

Of 2,712 Board certified orthopedic surgeons selected from the directory of the American Academy of Orthopaedic Surgery, 1,683 (62.1%) responded to a mailed questionnaire concerning their preferred treatment for osteoarthritis of the hip in a specified active 53-year-old man. A Müller total hip arthroplasty was the most frequently performed operation in 1973; only 23 per cent of the respondents considered osteotomy the preferred treatment.

Arthrodesis↗
PubMed1999

The hospitalist: the new addition to the inpatient management team.

To coordinate care and manage costs, physicians are being added to the inpatient management team. To assist the chief nurse executive in assimilating this new team member into the patient care provider group, the authors describe the role of the hospitalist, the goals of the organization in using the new role, questions to ask and steps to take to ensure success for the whole-care team and the organization.

Hospitalists↗
PubMed1998

Trauma care fellowships: current status and future survival.

BACKGROUND AND METHODS: To determine the current status and future direction of trauma care fellowships, a phone survey was conducted with the 45 program directors reporting information to the American Association for the Surgery of Trauma and the Eastern Association for the Surgery of Trauma. RESULTS: Forty programs (89%) were operational, with 86 positions. The duration of the fellowship was 1 year for 16 (40%) and 2 or more years for 24 (60%). Accreditation Council for Graduate Medical Education accreditation (ACGME) (for surgical critical care) was held by 28 (70%). Mean salary was $39,600 at the first-year level. A funding shift from institutional to practice revenue sources is foreseen. Thirteen directors (32.5%) saw future recruitment potential as increasing and 11 (27.5%) saw it as decreasing. CONCLUSION: The essence, structure, and funding of trauma fellowships are changing. One-year exclusive trauma fellowships are being replaced by 1- to 2-year trauma or surgical critical care fellowships with Accreditation Council for Graduate Medical Education accreditation increasingly seen as essential. The challenge for fellowships in an era of budgetary constraints will be to provide adequate training in the full spectrum of tramatology within a reasonable time frame supported by a predictable funding mechanism.

Accreditation↗
PubMed2002

In-house trauma surgeons do not decrease mortality in a level I trauma center.

BACKGROUND: The value of an in-house trauma surgeon is debated. Previous studies focus on comparing in-house and on-call surgeons at different institutions or different periods in time. The purpose of this study was to simultaneously evaluate in-house and on-call trauma surgeons in a single Level I trauma center and to determine the impact of in-house trauma surgeons on the mortality of severely injured patients. METHODS: All records were reviewed for patients classified as major resuscitations from July 1997 through November 1999. Multiple logistic regression was performed to determine predictors of mortality on the basis of trauma surgeon status (in-house vs. on-call) and response time, while controlling for Injury Severity Score (ISS) and Revised Trauma Score. RESULTS: Of the 4,278 admissions, 537 were trauma codes. Mean ISS was 20.16 +/- 11.59. There was no difference between groups admitted by in-house surgeons versus on-call surgeons with respect to ISS or Revised Trauma Score. Mortality for the group was 24.8% (133 of 537); no statistical difference existed between observed and expected mortality by TRISS. The average response time was 3.96 minutes for the in-house group and 14.70 minutes for the on-call group (p < 0.001). Neither the call status nor the response time of the trauma surgeon significantly decreased emergency department or hospital mortality. There was a trend for improved outcome in those patients cared for by an in-house surgeon who were upgraded to a code, transferred into the institution, admitted during the night, or neurologically impaired. This trend did not reach statistical significance. CONCLUSION: When the trauma surgeon was rapidly available (< 15 minutes), there was no difference in emergency department or hospital mortality between in-house and on-call trauma surgeons. Selected subgroups of severely injured patients may benefit from an in-house trauma surgeon. If trauma surgeons are not readily available in an institution, an in-house call policy may be necessary for the prompt resuscitation of critically ill patients.

Adult↗
PubMed1976

Black physicians and minority group health care--the impact of NMF.

This paper is part of a study conducted in 1973-1974 to assess the programs of National Medical Fellowships, Inc. (NMF). NMF is a private organization founded in 1946 to improve medical services to black communities and, later, to all minority groups. The approach of NMF was to provide aid for training of black physicians. Data from questionnaire returns from NMF grant recipients and from "other" black physicians, as well as records of the organization, indicate that NMF was successful in increasing the number of black physicians who have specialty board certification, who have faculty appointments at predominantly white medical schools, and who have staff appointments at predominantly white hospitals. NMF recipients also were active in breaking down racial barriers. However, the data we collected do not indicate that these developments have improved the medical services to lower class minority communities.

Black or African American↗
PubMed1977

Interdiagnosis relationships of physician performance measures in hospitals.

Correlations among ten diagnostic categories of hospital care physican performance measures are reported. Using measures of conformance to predetermined criteria for optimal performance, mean scores of individual physican performances within diagnostic categories were calculated and correlated. Measurement reliability estimates were computed and it was suggested that a minimum of four cases in each diagnostic category be used for measurement of performance on the individual physician level of analysis. There appeared to be homogeneity of performance measures among some but not all diagnoses studied. This finding reinforces the need to examine interdiagnostic correlations before attempting to measure overall individual physican performance by combining measures from separate diagnostic categories.

Acute Disease↗
PubMed1978

An index of hospital performance.

The purpose of this paper is to describe a simple index for computing relative hospital performance. An analysis of 33 short-stay general hospitals in New South Wales was used to develop the index. The index is based on patterns of admissions for each hospital, adjusting the hospital's crude death rate for the age distribution of patients treated and variations in the severity of their diagnoses. The index is relatively simple to calculate, but is nevertheless a valid indicator of hospital performance.

Australia↗
PubMed1990

Physician integration strategies and hospital output. A comparison of rural and urban institutions.

Physician integration strategies are attempts to bring physicians into hospital administration by giving them a role on the hospital board, employing them in administrative or clinical capacities, or expanding the administration issues dealt with by medical staff committees. This study used a production function model to examine whether such strategies affect hospital output, measured as case mix-adjusted discharges. The article hypothesizes that less management depth, smaller medical staffs, and an absence of nearby hospitals make physician integration a more important strategy for rural than urban hospitals. American Hospital Association data on 1,309 hospitals from 1982 showed there is no statistically significant evidence that physician integration affects the output of urban hospitals. However, four of the five measures were associated with more patient discharges in rural hospitals. Furthermore, rural and urban hospitals differ in their use of other inputs. It was concluded that physician integration can be an effective mechanism to enhance rural hospital output and that more research on rural hospitals is needed.

Decision Making↗
PubMed2002

Does the implementation of responsibility centers, total quality management, and physician fee programs improve hospital efficiency? Evidence from Taiwan hospitals.

OBJECTIVES: This study evaluates whether the implementation of various types of hospital-physician integration strategies, such as the responsibility centers system, total quality management, and physician fee programs, enhance efficiency for Taiwan hospitals. Because hospitals in Taiwan are structurally similar to staff-model HMOs, the study has implications beyond Taiwan. RESEARCH DESIGN: The Data Envelopment Analysis model is applied to measure hospital efficiency. Hospital efficiency refers to the ability to produce more outputs (eg, ambulatory and emergency visits, inpatient days, and inpatient visits) with the same inputs (eg, physicians, nurses, ancillary labor, and hospital beds). The sample consists of 90 general hospitals in Taiwan from 1994 to 1996. In addition, multitobit regression analysis is used to simultaneously estimate the effects of the hospital-physician integration strategies and provide better control for the effect of other factors (eg, size, degree of competition, ownership structure, teaching status, and the change in regulatory regime) that may also affect hospital efficiency. RESULTS: When evaluating the hospital-physician integration strategies individually, hospitals that implemented the responsibility centers system, total quality management, and physician fee programs were more efficient than hospitals that did not. Controlling for other factors using the multitobit model, hospitals that implemented physician fee programs remained significantly more efficient than others. In addition, hospitals that implemented total quality management were more efficient when they had implemented the strategy for at least 2 years. Hospitals that implemented the responsibility centers system were more efficient but only when integrating the system with formal incentive schemes. CONCLUSIONS: Physician fee programs seem to provide the most direct and robust incentives to enhance hospital efficiency under a fee-for-service regime like that in Taiwan. Because of time-lagged effects, hospitals that implemented the total quality management programs were more efficient but only when the programs had been implemented for at least 2 years. The responsibility centers system can also be effective when the system was associated with formal incentive schemes. The results indicate the importance of having both the individual-based and team-based incentives in place. Finally, the hospital-physician integration strategies appear to be effective individually, but the results change significantly when they are evaluated simultaneously, together with other control variables, in the tobit model. This indicates the importance of investigating hospital-physician integration strategies as a portfolio instead of a single tool.

Decision Making, Organizational↗