Would evidence-based regulation improve the practice and management of patient care?

The use of evidence to achieve sound medical diagnoses and optimal treatment plans is considered a standard of practice for healthcare providers. Indeed, failure to do so is prima facie evidence of malpractice. Health and medical care managers have begun espousing a similar philosophy: to make decisions that are data-driven rather than based on logic, intuition, personal preference, or last experience. Unfortunately, regulatory policies and practices in patient care are not always founded upon strong evidence. As a result, unintended consequences often surface after the passage of legislation or the adoption of policies by nongovernmental entities. These dysfunctions might be avoided if policymakers embraced evidence-based protocols commonly found throughout medicine and its management. This paper reviews the dilemmas that unfold when policy is formed without giving sufficient attention, in advance, to "hard" evidence.

Strategic planning to reduce medical errors: Part II--therapy.

In Part I of this series, medical errors were analyzed from a systems dynamics viewpoint. It was noted that despite extensive dialogue and a continuing stream of proposed medical practice revisions, medical errors and adverse impacts persist. Connectivity of vital elements is often underestimated or not fully understood. In Part II, our analysis suggests that the most fruitful strategies for dissolving medical errors include facilitating physician learning, educating patients about appropriate expectations surrounding treatment regimens, and creating "systematic" patient protections rather than depending on (nonexistent) perfect providers.

Strategic planning to reduce medical errors: Part I--diagnosis.

Despite extensive dialogue and a continuing stream of proposed medical practice revisions, medical errors and adverse impacts persist. Connectivity of vital elements is often underestimated or not fully understood. This paper analyzes medical errors from a systems dynamics viewpoint (Part I). Our analysis suggests in Part II that the most fruitful strategies for dissolving medical errors include facilitating physician learning, educating patients about appropriate expectations surrounding treatment regimens, and creating "systematic" patient protections rather than depending on (nonexistent) perfect providers.

The shocking cost of turnover in health care.

Review of turnover costs at a major medical center helps health care managers gain insights about the magnitude and determinants of this managerial challenge and assess the implications for organizational effectiveness. Here, turnover includes hiring, training, and productivity loss costs. Minimum cost of turnover represented a loss of >5 percent of the total annual operating budget. Editor's Note: This article is being reprinted with permission from Health Care Management Review 29(1), 2-7.

Healthcare CEOs and physicians: reaching common ground.

A survey of 670 hospital and health system CEOs was conducted to understand why they chose a career path to CEO, what characteristics typify their career paths, and what major concerns they have about the future. Respondents expressed very strong altruistic reasons for becoming CEO, a finding that is consistent with the rationale many physicians express for entering medical practice. Early CEO career paths were diverse but typically led respondents to a senior managerial position before becoming CEO. Nine percent started as direct providers of healthcare. The respondents' most frequently expressed concerns for the future centered on reimbursement/financing issues and staffing shortages. Physicians may be surprised to learn that healthcare CEOs share their core values, experience similar frustrations, and have identical fears about the future of healthcare. Rather than emphasizing the differences between CEOs and doctors as a stumbling block to alliance, we urge the establishment of a common ground based on similar core values and purposes that will lead to improved communication and the powerful combination of talents derived from collegial collaboration.

Improving medical practice outcomes by retaining clinicians.

Turnover of medical care providers has become so commonplace that callous disregard or weary resignation are prevailing sentiments among remaining staff members when a colleague leaves. This article analyzes reasons for turnover of caregivers and the consequences. Turnover is particularly detrimental in medical practice because it undermines learning, as well as acquisition of judgment and adaptability. Medical practice managers may be unaware of the magnitude of the hidden costs-financial, strategic, and quality-associated with turnover. Strategies are proposed to assist medical care organizations in retaining clinicians and thereby improving healthcare effectiveness and efficiency.

Creating a favorable practice environment for nurses.

Chronic nurse turnover and attendant personnel shortages threaten patient care. Inadequate pay and benefits are primary factors leading to nurses' job dissatisfaction and, subsequently, to turnover. However, recent meta-analyses suggest that a favorable practice setting can improve nurses' satisfaction and minimize turnover. The practice environment's potential to positively influence nurses' job satisfaction is analyzed in a large academic medical center. Nurse supervisors, job characteristics, management style, and service quality emphasis--not just money and benefits--surface as key factors associated with a positive practice milieu. Implications for raising nurses' job satisfaction, reducing turnover, and improving care delivery are discussed.

The shocking cost of turnover in health care.

Review of turnover costs at a major medical center helps health care managers gain insights about the magnitude and determinants of this managerial challenge and assess the implications for organizational effectiveness. Here, turnover includes hiring, training, and productivity loss costs. Minimum cost of turnover represented a loss of >5 percent of the total annual operating budget.

Corporate culture: the missing piece of the healthcare puzzle.

The U.S. healthcare system requires radical, not incremental, change. Management issues in healthcare delivery are fundamentally different from those in the business world. Systems thinking forces a focus on corporate culture, about which there is little hard data. The use of cost/benefit analysis suffers from the lack of any accepted measure of long-term "benefit." The authors make four observations: (1) corporate culture is both part of the cause and part of the cure for healthcare; (2) long-term financial and functional measures are necessary to make evidence-based decisions; (3) valid, nationwide data must be developed regarding the corporate culture of medicine; and (4) direct (unmodified) application of management theory or practices will not achieve sustainable improvements.

Learning curves in health care.

This article explores the uses of learning curve theory in medicine. Though effective application of learning curve theory in health care can result in higher quality and lower cost, it is seldom methodically applied in clinical practice. Fundamental changes are necessary in the corporate culture of medicine in order to capitalize maximally on the benefits of learning.

Managing system errors and failures in health care organizations: suggestions for practice and research.

The inherent design of health delivery systems predisposes them to errors and gradual rates of improvement. Health care executives and researchers should understand the importance of system errors and the role of leadership in removing perturbations that adversely affect health care organization performance. This article presents insights on strategies for addressing system errors and for reducing the magnitude of the problem.

La atención primaria de salud y la política gubernamental / Primary health care and public policy

Various efforts have been made in Ecuador to extend primary health care coverage, particularly in the rural areas. Some community health workers have been trained but they have often been poorly supervised and inadequately supplied with medicines and equipment. Severe economic difficulties and the tenency for rural communties to desintegrate, as peasants seek work in the urban fringes, have hindered progress in health matters. However, only by maintaining primary health care as a major part of the country's development strategy can the needs of both rural and urban people be met