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While the relationship between shared governance and evidence-based practice is still in its early stages, the Albert Einstein Healthcare Network believes these separate models of care share the same processes and equate to solid, successful nursing.
The Department of Health in Taiwan initiated community health development (CHD), a new approach to national community health care. Community-based research and evaluation approaches have recently been shifting from 'traditional' research to 'participatory' research. However, there is vagueness about the theoretical foundation of CHD and the appropriateness of using participatory action research (PAR) to evaluate CHD. This article explores theoretical concepts of CHD and discusses the compatibility of PAR and CHD in the theoretical and philosophical foundations. Community health development is a developing and changing process that involves both the social and the health contexts. It operates on the basis of three approaches to care: primary care, health promotion and community development. Partnership and empowerment between community health nurses and the community are concurrently involved in the entire process of CHD practice. The fundamental tenet of PAR focuses on the development of knowledge through partnership and empowerment between the researcher and the community, and the creation of critical consciousness leading to necessary action and effective change. Unlike empirical community-based research, PAR is flexible enough to capture an understanding of the complex social and health phenomena in the CHD framework. Furthermore, utilizing the PAR approach is appropriate not only for the methodological framework of the CHD evaluation, but also for the enhancement of the CHD actualization.
As physician group practices grow and consolidate, they have an increasing interest in developing close capital partnerships to ensure access to capital. Yet as many healthcare organizations have sought to divest poorly performing acquired physician practices, physicians have seen their pool of potential capital partners shrink. Under these conditions, hospitals have a new opportunity to present themselves to physician group practices as attractive capital partners. To understand the nature of this opportunity, one needs to know why group practices seek capital, how groups approach their investment strategies, and what criteria they use to compare prospective capital partners. To build stronger relationships with physicians, hospitals should focus on turning around their poorly performing acquired physician practices and pursue strategies such as collaborating with physician practice management companies and developing new models for partnering with physicians (e.g., special purchase agreements and more advanced management services organizations).
The four models that form the University Community Health Services (UCHS) group practice include (1) Primary Care Centers, (2) Physician Partnerships, (3) Outsourcing of Nurse Practitioners, and (4) Employee-Based Health Care. Success is demonstrated by the following: UCHS practitioners deliver quality health care at 23% below the average cost of all other primary care providers, UCHS hospital inpatient rate is 21% below the average of all other primary care providers; the UCHS lab utilization rate is 24% below the other primary care providers; prescription drug utilization is 42% below average; and the latest patient satisfaction survey suggests that 82% of all patients (respondents) are very satisfied with their quality of care and on a scale of 1 to 4 (4 being the best) UCHS patients averaged services at 3.56. All the data suggest that UCHS providers have demonstrated above-average performance in cost-efficiency while delivering top quality health care.
Understanding the stages of growth, saturation and transition is the first step to setting meaningful career goals. While this concept is fairly new in dentistry, it is not new in other commercial enterprises. Business managers and owners have known for decades that growth stagnates after a period of time. At that point, a new infusion of energy and a reformation of the business's objectives and methods are needed to launch forward into the next phase of growth. Transition management in dentistry represents periods of growth that are followed by saturation and a comparatively rapid changeover to a new practice form. Saturation occurs when the clinical capacity of a practice is exceeded by the needs of a growing patient base. The key transitions in the career of a dentist are those from school to practising, and practising to retirement. A great number of dentists (due to low motivation, the comfort level or poor management skills) never reach the saturation point during their practising career. For these dentists, starting out and retirement are the only transitions that will ever apply to them. Dentists evaluating transition options must first identify which career stage they belong to since their objectives will be different at each stage. Dentists in the growth phase should focus on practice management and achieving saturation before attempting a transition. Since transitions like start-up, retirement, partnerships, associateships and buy-ins have pivotal roles in the life cycle of a practice, transitions must be managed carefully to achieve successful results.(ABSTRACT TRUNCATED AT 250 WORDS)
Variations research has broken new ground by moving analysis of Medicare data from the community to the hospital level. The California study of hospitals further illustrates the power of comparing performance to demonstrate the levels of efficiency that can be achieved. WellPoint, replicating the Dartmouth approach with its commercial data, is partnering with medical specialty societies to make data "actionable" and move beyond benchmarking to help providers alter practice patterns. The shared goal is to achieve a material reduction in practice variation throughout health care. Key elements of their partnership include establishing national databases, reducing the administrative burden for pay-for-performance programs and using evidence-based metrics.
OBJECTIVE: To design and implement a robust assessment scheme to more effectively identify student midwives' fitness for midwifery practice. DESIGN: Five inter-related action research cycles. Methods included: documentary analysis, interviews, observation, questionnaires, focus groups. SETTING: A large university in England. PARTICIPANTS: Student midwives, practising midwives and midwife teachers, childbearing women, course planning team and EME project team collaborators. FINDINGS: Whilst there was evidence that the majority of students are fit for midwifery practice by the end of the course, assessment schemes were found to be unreliable. In particular there was the potential for 'borderline' students to register as midwives if assessors were inadequately prepared for their responsibilities; assessment documentation was not 'user' friendly; evidence of competence was inadequately recorded or there was a lack of systematic monitoring by university teachers and examiners of the assessment in practice scheme. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The gap between curriculum aspirations and actual implementation needs to close. The assessment matrix, developed as part of the national evaluation study, could usefully be used as a framework when designing assessment schemes. The difficulties for midwife assessors in each locality need to be identified and solutions incorporated into workable but robust strategies. University midwife teachers/lectures have a responsibility to work in partnership with assessors and students to monitor assessment in practice schemes and, where local circumstances and confidence in reliability permit, grade and award credits for practice-based assessment of student capability.
The University of California Los Angeles School of Dentistry/Nara Bank, a public-private partnership, is a model of collaboration between an academic institution and the private finance world. At the outset, none of those involved anticipated these diverse entities would have common ground. But through a series of open and frank discussions, the leadership of the School of Dentistry and Nara Bank identified business opportunities that are not only mutually beneficial, but also central to their respective core values of providing community service. To date, this partnership has generated a commitment from Nara Bank to provide funding and facilities support for community-based health fairs, the creation of a patient care fund, and practice loans for recent graduates who commit to practicing in underserved areas. The concept of a public-private partnership of dissimilar business entities offers the possibility of a new means of support for dental schools.
BACKGROUND: The popularity of complementary medicine continues to be asserted by the professional associations and umbrella organisations of these therapies. Within conventional medicine there are also signs that attitudes towards some of the complementary therapies are changing. AIM: To describe the scale and scope of access to complementary therapies (acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, and osteopathy) via general practice in England. DESIGN OF STUDY: A postal questionnaire sent to 1226 individual general practitioners (GPs) in a random cluster sample of GP partnerships in England. GPs received up to three reminders. SETTING: One in eight (1226) GP partnerships in England in 1995. METHOD: Postal questionnaire to assess estimates of the number of practices offering 'in-house' access to a range of complementary therapies or making National Health Service (NHS) referrals outside the practice; sources of funding for provision and variations by practice characteristics. RESULTS: A total of 964 GPs replied (78.6%). Of these, 760 provided detailed information. An estimated 39.5% (95% CI = 35%-43%) of GP partnerships in England provided access to some form of complementary therapy for their NHS patients. If all non-responding partnerships are assumed to be non-providers, the lowest possible estimate is 30.3%. An estimated 21.4% (95% CI = 19%-24%) were offering access via the provision of treatment by a member of the primary health care team, 6.1% (95% CI = 2%-10%) employed an 'independent' complementary therapist, and an estimated 24.6% of partnerships (95% CI = 21%-28%) had made NHS referrals for complementary therapies. The reported volume of provision within any individual service tended to be low. Acupuncture and homoeopathy were the most commonly available therapies. Patients made some payment for 25% of practice-based provision. Former fundholding practices were significantly more likely to offer complementary therapies than non-fundholding practices, (45% versus 36%, P = 0.02). Fundholding did not affect the range of therapies offered, and patients from former fundholding practices were no more likely to pay for treatment. CONCLUSION: Access to complementary health care for NHS patients was widespread in English general practices in 1995. This data suggests that a limited range of complementary therapies were acceptable to a large proportion of GPs. Fundholding clearly provided a mechanism for the provision of complementary therapies in primary care. Patterns of provision are likely to alter with the demise of fundholding and existing provision may significantly reduce unless the Primary Care Groups or Primary Care Trusts are prepared to support the 'levelling up' of some services.
Global health care is now considered a component of core knowledge for 21st century professional nursing practice. The authors describe laying the groundwork for an international experience and projects resulting from a partnership with a nursing program in the developing country of Guyana. In addition, the outcomes from undergraduate nursing international learning experiences for students and practicing nurses are reported. These outcomes provide support for the integration of study abroad as a strategy for enhancing the undergraduate nursing curriculum and ultimately professional nursing practice during the early years of practice.
Community involvement in health through community partnerships (CPs) has been widely advocated. Putting CPs into practice is complex and represents a challenge for all the stakeholders involved in the change process. Employing data from five CPs aiming to bring together communities, academics and health service providers in South Africa, this paper aims to examine and compare the views of the health care professionals with those of the community members with respect to each other's skills and abilities. Five domains of expertise in partnership working are examined: educational competencies; partnership fostering skills; community involvement expertise; change agents proficiencies; and strategic and management capacities. The findings suggest that the community recognizes the expertise and abilities brought by the professional staff to the CPs. Community members have a positive view of the capabilities of the professionals, in particular their abilities as resource persons in the areas of budget management, policy formulation and the introduction and management of change. The professionals, on the other hand, are cautious regarding the level of skill and capability in communities. The limited appreciation of community skills by the professionals covered all the five domains of expertise examined. The findings suggest that if joint working is to survive, the professionals will need to increase their valuation of the indigenous proficiencies inherent in their community partners. We conclude that programme models need to consciously incorporate in their design and implementation, capacity building, skills transfer and empowerment strategies.
OBJECTIVE: To develop and report the results of a system of audit of computer records in general practice. DESIGN: A retrospective audit of records in practices using the same computer system. Information about recorded preventive procedures was collected by sending the same audit program to each practice on floppy disk. Other characteristics of the practices were determined by postal questionnaire. SETTING: Forty five general practices, widely distributed in England and Wales. SUBJECTS: All 430,901 patients registered with the practices. MAIN OUTCOME MEASURES: Within each practice the percentage of patients in specified age groups for whom certain preventive procedures were recorded as having been carried out. These measures were analysed in relation to practice characteristics. RESULTS: Practice characteristics and recording rates for preventive procedures varied over a wide range. Recording rates were higher in practices with computer terminals on every doctor's desk. Only one practice achieved the new contract target of 90% coverage for recorded primary immunisations, and fewer than two thirds recorded 80% coverage for cervical cytology in the past five years. Practices holding clinics did no better than those without. Smaller partnerships and smaller doctors' list sizes were associated with better performance. CONCLUSIONS: Centrally programmed audit of computerised records is a feasible method of providing data on a regular basis for epidemiological purposes and for performance review. The fact that practices with smaller list sizes had higher levels of recorded preventive care suggests that the trend towards larger lists promoted by the new contract might militate against the intended effect of better preventive care.
The Alma Ata Declaration is now 28 years old. This article uses its framework to assess the changes that have occurred in recent years in the English health system. It summarises the health reform changes that have occurred internationally and those in the English health system in two eras, pre- and post-1997 - when the Labour Party came to power. It concludes that linked forces of managerialism and consumerism have had an impact on the health system which has undergone a number of structural changes in recent years. It suggests that the original Alma Ata focus on equity is being modified by the concept of choice. The tensions between central priorities, often reflected in targets, and local accountability and needs are explored. There appears to be a greater interest in seeking genuine health (rather than solely health care) change, with attendant public health and partnership policies, however the gap between policy and practice still needs to be bridged, and questions as to the appropriate locus and leadership for health promotion activities addressed. However there have been numerous institutional changes which carry the danger of distracting from the purpose of achieving health change, and which continue to raise questions as to the appropriateness of a market model for health. Finally the paper argues that the PHC framework of Alma Ata remains a useful framework for assessing health systems, but needs to be tailored to, and prioritised within, a political dynamic.
OBJECTIVE: As part of a study of men's responses to a videotape decision aid [Rovner DR, Wills CE, Bonham V, Williams G, Lillie J, Kelly-Blake K, Williams MV, Holmes-Rovner M. Decision aids for benign prostatic hyperplasia: applicability across race and education. Med Decis Making 2004;24:359-66], preferences for BPH treatment options were assessed. METHODS: One hundred and sixty men stratified by race and education completed a semi-structured interview that included assessments of treatment preferences. RESULTS: Most men initially and ultimately favored watchful waiting over other options, and 56.6% never changed their preference rank orders while viewing the videotape. BPH severity in context of treatment risk avoidance, efficacy, and expert opinion factors were frequently cited reasons for preference orders. Lesser education was associated with higher likelihood of changing preferences (r = -.30, p < .001), and percent increase in BPH knowledge pre- to post-videotape was weakly associated with fewer non-dominant preference shifts (r = -.19, p < .05). CONCLUSION: Conservatism regarding BPH treatment is moderated by context-specific factors, including new information. PRACTICE IMPLICATION: Counseling in a provider-patient partnership model should address both sources of variance in men's treatment preferences.
OBJECTIVE: To measure the effects of a Pharmaceutical Care Certificate Program (PCCP) in community pharmacists. DESIGN: This study compared the effects of the PCCP over time using a repeated measures design. SETTING: Retail, independent, and managed care pharmacy. PARTICIPANTS: 36 pharmacists who participated in the PCCP. INTERVENTIONS: PCCP, which was developed to train pharmacists in (1) practice re-engineering, (2) components of pharmaceutical care, and (3) drug therapy management of disease states. MAIN OUTCOME MEASURES: (1) pharmacist job functions, (2) pharmaceutical care job functions, (3) pharmaceutical care components, (4) pharmacist-perceived barriers to providing pharmaceutical care, and (5) proposed solutions for overcoming barriers. RESULTS: When comparing pharmacists at baseline and after 1 year, pharmacists after 1 year felt significantly better prepared to perform all pharmaceutical care components. CONCLUSION: Although the PCCP was successful in preparing pharmacists to perform the pharmaceutical care components covered in the program, time seems to be one of the major barriers for their actual implementation into practice. One proposed solution is the development of partnerships between pharmacists and schools of pharmacy.
While partnership approaches have the potential to achieve cost-effective quality health care, several attributes of the current context make partnerships difficult to achieve. This paper provides an analysis of the socio-cultural, structural and human challenges to building partnerships at both personal and organizational levels, together with an empowering interdisciplinary approach for overcoming these barriers. Premised on empirical evidence, 'flexible client-driven care', currently being tested in the home care sector in Canada, encompasses structures and processes that promote relationship-building and conscientious critical application of individual and collective potential for achieving health care. Strategies for implementing empowering partnership-building at both personal and organizational levels are elaborated, together with the challenges encountered. The practical issues addressed afford insights and ideas for others who may be attempting to achieve similar partnership aims.
Urban homeless populations suffer disproportionately high rates of premature death. In response to a wave of highly publicized deaths on the streets of Boston during the winter of 1998-1999, the Massachusetts Department of Public Health (MDPH) convened a task force to investigate these deaths and implement an integrated response to this public health crisis. Comprised of a broad coalition of public and private agencies as well as homeless persons and advocacy groups, the MDPH Task Force reviewed the circumstances surrounding the 13 deaths, monitored subsequent deaths among homeless persons in Boston, and implemented a comprehensive plan to address critical needs and prevent further deaths. Contrary to the task force's initial assumption, the 13 decedents had multiple recent contacts with the medical, psychiatric, and substance abuse systems. In response to this finding, the MDPH Task Force sought to improve continuity of care and prevent future deaths among Boston's street population. Coordination of needed services was achieved through the creation of new, and often unconventional, partnerships. This case study exemplifies a public health practice response to the vexing health care challenges confronting homeless people who must struggle to survive on the streets and in shelters.
BACKGROUND: Initial efforts to increase the availability of training positions, standardise training, and obtain national recognition for family physicians who wished to practise anaesthesia had stalled. OBJECTIVE: To describe the work undertaken to create and sustain family medicine anaesthesiology capacity in Canada. METHODS: In our review, we examined the critical aspects of successful intersectoral work, namely, involvement by key stakeholders; the development of decision-making mechanisms; clearly defined objectives, roles and responsibilities; official support and legitimisation from participating organisations and adequate resources for partnership building. SETTING: Canadian rural family medicine anaesthesiology practice. RESULTS: A small steering committee obtained funding for a national meeting of stakeholders and subsequent committee work over an 18-month period. The national meeting brought together the necessary stakeholders to review and discuss the issues and agree on a group-determined agenda, determine a work plan, identify priority areas and allow the College of Family Physicians of Canada to be the lead organisation in moving the work ahead. Within 18 months, the boards of the key organisations had accepted a common set of standards for training and a national curriculum. Work remains in the longer term to identify sustainable funding for training of family physician as well as the provision of continuing medical education for those trained. CONCLUSIONS: Appropriate attention to the key components of successful intersectoral work may enable previously stalled and complex work to move ahead despite opposition.