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PubMed2003

Integrating reproductive health services in a reforming health sector: the case of Tanzania.

Universal access to comprehensive reproductive health services, integrated into a well-functioning health system, remains an unfulfilled objective in many countries. In 2000-2001, in Tanzania, in-depth interviews were conducted with central level stakeholders and focus group discussions held with health management staff in three regional and nine district health offices, to assess progress in the integration of reproductive health services. Respondents at all levels reported stalled integration and lack of synchronisation in the planning and management of key services. This was attributed to fear of loss of power and resources among national level managers, uncertainty as to continuation of donor support and lack of linkages with the Health Sector Reform Secretariat. Among reproductive health programmes, sexually transmitted infection (STI) control alone retained its vertical planning, management and implementation structures. District-level respondents expressed frustration in their efforts to coordinate STI service delivery with other, more integrated programmes. They reported contradictory directives and poor communication channels with higher levels of the Ministry of Health; lack of technical skills at district level to undertake supervision of integrated services; low morale due to low salaries; and lack of district autonomy in decision-making. Integration requires a coherent policy environment. The uncoordinated and conflicting agendas of donors, on whom Tanzania is too heavily reliant, is a major obstacle.

Attitude of Health Personnel↗
PubMed2001

Nurturing the transformation from staff nurse to leader.

A major component of nurse job satisfaction is autonomy of clinical practice, recognition by colleagues, and participation in decision making relative to patient outcomes. Shared governance provides the framework for autonomy and control of practice, yet implementation of this model implies staff participation as leaders. Staff nurses describe a transformation of perspective when adopting decision-making, leadership-oriented roles and recount the factors that influence and nurture their confidence and acceptance.

Clinical Competence↗
PubMed1994

What makes young HMO physicians satisfied?

While much attention has been paid to the effect of managed care on patient outcomes and health care costs, little attention has been focused on the ways in which managed care affects the satisfaction of physicians. Examination of the practice and career satisfaction of 189 young physicians practicing in group and staff model HMOs finds high levels of satisfaction. More than 82% are satisfied with their current practice. The most important factor influencing physician satisfaction appears to be the extent of perceived autonomy. Neither the number of hours worked per week nor yearly income were strongly associated with decreases in satisfaction. The fact that minority and female physicians report less satisfaction with some dimensions of practice raises important issues for HMO physicians and managers.

Adult↗
PubMed1995

To manage or to be managed: that is the question.

As managed care becomes more common, physicians must take part in its evolution or lose their autonomy. The author proposes "the Ben Franklin scenario," which emphasizes six elements: consumer-provider choice, enrolled population, community-weighted capitation, organized practice, prospective budgets, and cost-effective health care. Prototypes for health care reform are also examined.

Cost Control↗
PubMed2004

Common denominators: shared governance and work place advocacy - strategies for nurses to gain control over their practice.

It is important to the future of health care that we identify strategies that provide support for nurses as they take on the challenges of the new century. Shared governance has long been stressed as an effective strategy for enhancing autonomy and providing avenues for nurses to gain control over their practice. A newer strategy, defined at the local, state, and/or national level, is work place advocacy. This strategy builds upon many of the principles contained in shared governance. This article identifies common denominators found in both shared governance and work place advocacy.

Decision Making, Organizational↗
PubMedDate not supplied

Clinical decisions made by nurses in intensive care--results of a telephone survey.

A telephone survey of 89 GICUs in England was performed, using stratified quota sampling. 75 (84%) units reported changes in practice over the past 3 years. The reported changes were not only task orientated but also encompassed increased autonomy, organisational changes and increased workload. The absence of significant relationships between the activities suggests that nursing practice development is dependent on patient need and/or local factors. The lack of pattern suggests that it may be inappropriate to compare units for the purpose of nurse staffing.

Clinical Competence↗
PubMedDate not supplied

Improving quality in public sector hospitals in Indonesia.

Indonesia has successfully expanded its health system to improve access and quality of care for the population, promote equity, and expand primary health care. More recently, it has sought to undertake policy initiatives to promote involvement of the private sector and to introduce both incentives for efficiency and payment mechanisms which will increase sustainability. Certain public health sector facilities have been given financial autonomy to set prices, introduce and retain user fees, and promote prepayment mechanisms. The autonomous hospitals, Unit Swadana hospitals, have increased revenue sustainability while promoting quality assurance practices. The managers of these hospitals have become adept at introducing business practices into the hospital's operations to promote efficiency. These have attracted private investors to invest in public hospitals.

Developing Countries↗
PubMedDate not supplied

Understanding the interactions between physician assistants and their supervising physicians in the provision of patient care.

A great deal of discussion and debate has surrounded the issue of autonomy of practice among physician assistants (PAs) and other non-physician clinicians. This study further explores this issue by closely examining the interactions between PAs and their supervising physicians in the provision of patient care. Utilizing a national sample of 1,112 full-time practicing physician assistants, PA-MD interaction patterns are measured and weighted in a scale as a proxy for autonomy of practice. Further, these measures are then used as the dependent variable in a regression analysis to better explain the dynamics between PA personal and practice characteristics and autonomy of practice. Overall, the tested model explained 29% of the variation in PA-MD interaction patterns. Independent variables that were particularly influential in the model were proximity to supervisor, clinical productivity, the percentage of PA patients treated using written clinical guidelines, specialty of practice, and practice setting.

Humans↗
PubMedDate not supplied

Job design for nurse case managers. Intended and unintended effects on satisfaction and well-being.

As managed care expands, nursing case management is becoming increasingly widespread. Yet little is known about the characteristics of the case manager job and its effects on nurses' workplace well-being. This study investigated hypothesized differences between the characteristics of nurse case manager and staff nurse jobs, including both intended positive and unintended negative effects associated with changes incorporated in the nurse case manager job. Nurse case managers reported significantly higher levels of autonomy, job identity, feedback from agents, and collaboration with physicians than staff nurses; however, they also reported higher levels of required interaction, role conflict, overload, and ambiguity. These findings have important implications for nurse case manager and the organizations that employ them, in relation to job design, career/candidate selection, and orientation and ongoing development.

Adult↗
PubMed1994

Promoting situational support for nurses in practice.

Situational support entails promoting autonomy, control over practice, group cohesion, manager consideration, and substantive exchange. Support can reinforce nurses' coping mechanisms, preserve their integrity, and thereby promote quality patient care. Using concept clarification and case examples the authors identify support mechanisms and coping styles for nurses at work and discuss how situational support can be used to cope with stress.

Adaptation, Psychological↗
PubMed1996

Integrated delivery systems: has their time come in Canada?

In the 1990s every Canadian province is struggling to reduce health care expenditures without jeopardizing access to health care or quality of care. The authors propose a new model for health care delivery: the Canadian Integrated Delivery System (CIDS). A CIDS is a network of health care organizations; it would provide, or arrange to provide, a coordinated continuum of services to a defined population and would be held clinically and fiscally accountable for the outcomes in and health status of that population. A CIDS would serve 100,000 to 2 million people; the care it would provide would be funded on a capitation basis. For providers, there would be explicit financial incentives to minimize costs. At the same time, service quality and consumer choice of primary care practitioner would be maintained. Primary care physicians and specialists would work with other health care service providers to offer a full spectrum of care. CIDS providers would form strategic alliances with community agencies, hospitals, the private sector and other health care services not managed by the CIDS, as needed. For physicians, affiliation with a CIDS that provided strong clinical leadership could be beneficial to their income stability and autonomy. Pilot projects of this model in several communities would determine whether this concept is feasible in the Canadian health care context.

Canada↗
PubMedDate not supplied

The management of health services in Tanzania: a plea for health sector reform.

There are essentially four main approaches used in attempts to strengthen the management of health services in developing countries. These are: information system development; management training; use of planning and evaluation methodologies; and, health sector reform. As part of a collaborative research project based in Kisarawe District, Tanzania, we tested the hypothesis that a combination of the first three of these approaches would be sufficient to ensure that decisions and actions were taken to bring about major improvements in the management of health services. It was assumed that the decentralization, which took place as part of the 1982 reorganization of local government responsibilities, had provided managers with sufficient decision-making autonomy to allow them to bring about improvement in health service performance, provided that the other conditions were met. In fact, it was found that despite being presented with clear evidence of serious inefficiencies and inequities in the allocation of health resources, managers were often highly reluctant to decide upon actions which would alleviate the problems in situations where there were potential losers as well as winners, even if the benefits greatly outweighed the costs. This article argues that interventions based solely on training, information systems, or planning and evaluation protocols will make only marginal improvements to health service management, and that changes to the system as a whole are needed in order to provide managers and health professionals with incentives to rectify performance failings. Some ideas for health sector reform, to give managers power and incentives for improving efficiency and quality of care, are put forward. Since it is likely that the systemic problems of the health sector in Tanzania are shared by many other developing countries, the lessons drawn from this study probably have more general applicability.

Administrative Personnel↗
PubMed1999

The struggle for recognition: The nurse practitioner in New South Wales, Australia.

Recognition of clinical expertise seems to be a worldwide struggle for nurses. In New South Wales (NSW), Australia, nurse practitioners (NPs) are currently struggling for formal recognition of their position. The role of NP is seen as a means of fulfilling the desire of expert nurses for optimal autonomy and recognition in the health care system. This article examines advanced nursing practice within the context of the Australian health care system and the NP movement in NSW, including the pilot projects conducted. Discussion includes contentious issues such as nurse-prescribed medications, Medicare funding, and support for the NP role from within the nursing and medical professions.

Humans↗
PubMed2002

Primary care trusts. Ready, steady, stop.

A survey of primary care groups and trusts in South West region found most felt they had little autonomy. Most were level-2 PCGs, taking responsibility for managing a budget for commissioning services. About a third were still relying heavily on their health authority for commissioning. The results suggest that the proposal to allocate 75 per cent of NHS funds to PCTs by 2004 will be unrealistic in some areas.

Attitude of Health Personnel↗
PubMed2005

[Guidelines and autonomy of physician decision. A critical survey under ethical aspects].

The convergence of Diagnosis Related Groups (DRG) and Evidence-based Medicine (EbM) in the present German Health Care System Reform (GMG) leads, due to time constraints, to a misuse of EbM as cook-book medicine. The communication level of physicians has already shifted to abstract discussions of Randomized Controlled Trials (RCT) and guidelines, inducing per sea preference for pre-defined clinical decisions. The inconsistencies of evidence definitions, together with the overwhelming number of guidelines and providers thereof, burden medical reasoning with superfluous complexity, and contributing to the development of cook-book mentality. Without comprehensive trial registration of all RCTs before the start of a study, a publication bias will continue to exist. In the clinical practice, it is necessary to reduce the impact of study results and guidelines to a degree that remains compatible with patient interests and economy. In this field, prospective controlled outcome registries may provide a control for over- and faulty regulation. Clinical professionalism is characterized in parallel by a critical implementation of EbM and a necessary degree of independent reasoning.

Diagnosis-Related Groups↗
PubMed2006

Midwives in Morocco: seeking recognition as skilled partners in women-centred maternity care.

Around the world, midwives are increasingly being called upon to provide skilled care for pregnant women and newborns. In Morocco, there is a persistent lack of professional recognition of midwifery, which is consistent with widespread gender inequality and women's low status. Midwifery training in Morocco has evolved since the 1960s into a three-year undergraduate programme. Despite this, there is currently a shortfall of midwives to attend the large number of births in Morocco. Midwives have only partially replaced traditional birth attendants, especially in rural areas. Maternal mortality remains high. However, several recent government policies reflect increased attention to women's needs, e.g. since February 2006, midwives may be eligible for reimbursement should a medical doctor be unavailable. Since 1990, the Moroccan Midwives Association has been actively encouraging midwifery curriculum review, improvements in training and the professional status of midwifery. Partnerships with international midwifery associations have revealed challenges encountered elsewhere and helped us to establish specific strategies for promoting the professional recognition, autonomy and visibility of midwifery in Morocco. In a cultural context such as Morocco's, a disciplinary link between midwives and the medical community seems crucial. However, only with recognition of midwives as competent, skilled and valued partners can midwifery practice in Morocco progressively evolve into women-centred maternity care.

Cultural Characteristics↗
PubMed2006

Medical education and the ACGME duty hour requirements: assessing the effect of a day float system on educational activities.

BACKGROUND: In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted new resident work hour mandates, which are being shown to improve resident well-being and patient safety. However, there are limited data on the impact these new mandates may have on educational activities. PURPOSES: To assess the impact on educational activities of a day float system created to meet ACGME work hour mandates. METHODS: The inpatient ward coverage was changed by adding a day float team responsible for new patient admissions in the morning, with the on-call teams starting later and being responsible for new patient admissions thereafter. I surveyed the residents to assess the impact of this new system on educational activities-resident autonomy, attending teaching, conference attendance, resident teaching, self-directed learning, and ability to complete patient care responsibilities. RESULTS: There was no adverse effect of the day float system on educational activities. House staff reported increased autonomy, enhanced teaching from attending physicians, and improved ability to complete patient care responsibilities. Additionally, house staff demonstrated improved compliance with the ACGME mandates. CONCLUSIONS: The implementation of a novel day float system for the inpatient medicine ward service improved compliance with ACGME work duty requirements and did not adversely impact educational activities of the residency training program.

Accreditation↗
PubMedDate not supplied

Polarity management: the key challenge for integrated health systems.

Integrated health systems are confronted with numerous dilemmas that must be managed. Many of these dilemmas are an inherent part of the system's structure, given that multiple competing hospitals, medical groups, and (sometimes) health plans are often under one organizational roof. This article presents an analysis of these dilemmas--referred to in the management literature as polarities--as they are found in six integrated health systems in Illinois. The nine polarities that must be managed include (1) hospital systems that want to be organizations of physicians; (2) system expansion by growing the physician component; (3) system centralization and physician decentralization; (4) centripetal and centrifugal forces involving physicians; (5) system objectives and physician interests; (6) system centralization and hospital decentralization; (7) primary care physicians and specialists; (8) physician autonomy via collectivization; and (9) vertical and virtual integration. The article identifies some of the solutions to the polarities that have been enacted by systems. In general, executives and physicians in integrated health systems must attend to the processes of integration as much as or more than the structures of integration.

Cooperative Behavior↗