[Operational planning of health services: How do we make it possible?] / Planificación operativa en servicios sanitarios: ¿cómo lo hacemos posible?

INTRODUCTION AND OBJECTIVE: The Catalan Health Service carries out the operational planning of service delivery and organization. The goal is to describe the methodology and procedure followed to perform these functions. METHODS: The process of operational planning in healthcare services (OPHS) is continuous, dynamic, participatory, objective, and adaptable. OPHS can be divided into three stages prior to implementation and evaluation: Service delivery planning, Organization of healthcare resources, and Procurement planning. RESULTS: Three examples of projects are presented following the POSS framework. It is essential to adapt the process to the characteristics of each project. CONCLUSIONS: The proposed framework is useful to achieve high quality and equity in access to services.

Delivering Value Through Equitable Care for Low Back Pain: A Renewed Call to Action.

SYNOPSIS: Equitable care for low back pain (LBP) is key to ensuring the value and sustainability of services delivered by physical therapists. In this Viewpoint, we discuss how social determinants of health, implicit provider biases, structural characteristics of the health care system, and health care policies contribute to disparate care for many individuals with LBP. We aim to increase awareness of equity as a key component of value in physical therapy and highlight steps physical therapists can take to improve equitable LBP care. This "call to action" underscores the need to study, demonstrate, and advance equitable care for LBP by physical therapists to improve outcomes for patients and ensure the growth and sustainability of the physical therapy profession. J Orthop Sports Phys Ther 2022;52(7):414-418. Epub: 17 May 2022. doi:10.2519/jospt.2022.10815.

Care Practices to Promote Patient Engagement in VA Primary Care: Factors Associated With High Performance.

PURPOSE: Patient engagement has been broadly defined as the process of actively involving and supporting patients in health care and treatment decision making. The aim of this study was to identify organizational factors that are associated with greater use of patient engagement care practices in Veterans Health Administration primary care clinics. METHODS: We conducted a cross-sectional analysis of data from the 2016 Patient-Aligned Care Team (PACT) national survey of direct care clinicians (primary care clinicians, registered nurses, and clinical associates). Exploratory factor analysis was used to group conceptually related patient engagement survey items into 3 subscales: planning and goal setting; motivational interviewing; and organizational strategies to promote self-management. Our independent variables included literature-based factors reported to promote team-based care and interdisciplinary collaboration in primary care. We used generalized estimating equations with multivariate logistic regression analysis to identify independent correlates of high performance on each patient engagement domain (top 25th vs bottom 25th percentile). RESULTS: A total of 2,478 direct care clinicians from 609 clinics completed all patient engagement items in the PACT survey. For all patient engagement sub-scales, respondents at high-performing clinics were more likely to report having regular team meetings to discuss performance improvement and having leadership responsible for implementing PACT. For 2 of 3 patient engagement subscales, high performance was also associated with having fully staffed PACT teams (≥3 team members per primary care clinician) and role clarity. CONCLUSIONS: Several desirable organizational and contextual factors were associated with high performance of patient engagement care practices. Strategies to improve the organizational functioning of primary care teams may enhance patient engagement in care.

Patient Care Documentation in the Secondary School Setting: Unique Challenges and Needs.

CONTEXT: Athletic trainers (ATs) recognize patient care documentation as an important part of clinical practice. However, ATs using 1 electronic medical record (EMR) platform reported low accountability and lack of time as barriers to documentation. Whether ATs using paper, other EMRs, or a combined paper-electronic system exhibit similar behaviors or experience similar challenges is unclear. OBJECTIVE: To explore ATs' documentation behaviors and perceived challenges while using various systems to document patient care in the secondary school setting. DESIGN: Qualitative study. SETTING: Individual telephone interviews. PATIENTS OR OTHER PARTICIPANTS: Twenty ATs (12 women, 8 men; age = 38 ± 14 years; clinical experience = 15 ± 13 years; from National Athletic Trainers' Association Districts 2, 3, 6, 7, 8, 9, and 10) were recruited via purposeful and snowball-sampling techniques. DATA COLLECTION AND ANALYSIS: Two investigators conducted semistructured interviews, which were audio recorded and transcribed verbatim. Following the consensual qualitative research tradition, 3 researchers independently coded transcripts in 4 rounds using a codebook to confirm codes, themes, and data saturation. Multiple researchers, member checking, and peer reviewing were the methods used to triangulate data and enhance trustworthiness. RESULTS: The secondary school setting was central to 3 themes. The ATs identified challenges to documentation, including lack of time due to high patient volume and multiple providers or locations where care was provided. Oftentimes, these challenges affected their documentation behaviors, including the process of and criteria for whether to document or not, content documented, and location and timing of documentation. To enhance patient care documentation, ATs described the need for more professional development, including resources or specific guidelines and viewing how documentation has been used to improve clinical practice. CONCLUSIONS: Challenges particular to the secondary school setting affected ATs' documentation behaviors, regardless of the system used to document care. Targeted professional development is needed to promote best practices in patient care documentation.

Proposição de um Modelo Matemático para Reduzir Custos no Processo de Psicodiagnóstico / A Mathematical Model Proposal to Cost Reduction During Psychodiagnosis / Proposición de un Modelo Matemático para Reducir Costos en el Proceso de Psicodiagnóstico

O psicodiagnóstico, a partir da aplicação de testes psicológicos validados cientificamente, sustenta o exame clínico convencional. Esses testes apresentam variações relacionadas à validade, amostras de estudo, evidências teóricas e empíricas que fundamentam sua pertinência, qualidade do material disponível, tempo necessário para sua aplicação e custos relacionados à aquisição do material de testagem e aos honorários profissionais necessários para concluir o processo de diagnóstico. Propõe-se, com um modelo matemático, um processo racional de psicodiagnóstico. Trata-se de um estudo quantitativo, descritivo-exploratório, baseado em dados de custo e tempo para aplicação de testes de inteligência. O modelo matemático criado permitiu a elaboração de um protocolo de psicodiagnóstico de deficiência intelectual para aplicação em crianças e adultos considerando-se o melhor custo e efetividade. (AU)

The psychodiagnosis supports conventional clinical examination by psychological tests application. The available psychological tests present variations related to validity, samples, theoretical and empirical evidences, material's quality, time required for its application, and costs related to the acquisition of test material and the psychologist's earnings. This research proposes a rational process of psychodiagnosis. It is a quantitative, descriptive-exploratory study based on cost and time data for the application of standardized intelligence tests. We created a mathematical model that allowed the elaboration of a psychodiagnosis protocol for intelligence tests in children and adults considering the best cost-effectiveness. (AU)

El psicodiagnóstico, a partir de la aplicación de pruebas psicológicas validadas científicamente, sostiene el examen clínico convencional. Estas pruebas presentan variaciones relacionadas con la validez, muestras de estudio, evidencias teóricas y empíricas que fundamentan su pertinencia, calidad del material disponible, tiempo necesario para su aplicación, y costos relacionados con la adquisición del material de prueba y los honorarios profesionales necesarios para concluir el proceso de diagnóstico. Se propone, con un modelo matemático, un proceso racional de psicodiagnóstico. Se trata de un estudio cuantitativo, descriptivo-exploratorio, basado en datos de costo y tiempo para aplicación de pruebas de inteligencia. El modelo matemático creado permitió la elaboración de un protocolo de psicodiagnóstico de deficiencia intelectual para aplicación en niños y adultos considerando el mejor costo y efectividad. (AU)

Medical Student Consulting: Providing Students Leadership and Business Opportunities While Positively Impacting the Community.

Introduction: Medical schools are increasingly attempting to prepare future physicians for diverse new leadership roles in the health care system. Many schools have implemented didactic leadership curricula, with varying levels of structure and success. Project-based learning via completion of real-world projects using a team-based approach remains an underutilized approach to developing student leadership skills. Methods: We designed and implemented the Medical Educational Consulting Group (Med ECG)-a student-run consulting program that provides medical students with opportunities to develop leadership skills by completing consulting projects with local clients. We provide an overview of the Med ECG model, including a combination of didactic training sessions and project-based learning via both simulation and real-world projects. Surveys were used to evaluate the value of Med ECG to clients, the community, and students. Results: Fourteen medical students (eight first-years, two second-years, three third-years, and one fourth-year, including five dual-degree candidates) completed the Med ECG program. Client feedback pointed to the value of Med ECG's projects and their impact on the community through partner organizations. Finally, linear regression analysis showed a strong positive correlation (R2 = .61) between the amount of effort devoted to various leadership attributes and the perceived improvement while working with Med ECG. Discussion: Med ECG's experiences show that a medical student-led project-based learning program is a novel way to develop leadership skills for future physician leaders. Efforts to replicate these types of programs will help additional students develop their leadership and business skills, making a positive impact outside of the classroom.

Demographic and Clinical Factors Associated with Patient Adherence to Acupuncture Treatment.

Objectives: Acupuncture uses needle stimulation upon the body's meridian points to alleviate physical and psychologic symptoms. In clinical practice, acupuncturists often recommend patients to attend follow-up treatment to achieve cumulative benefit over time. Adherence to acupuncture treatment was studied, and demographic and clinical factors were tested that may predict adherence. Design and subjects: A retrospective chart review at an acupuncture teaching clinic was conducted using data from 2014, where patients routinely received recommendations to return for follow-up visits to continue their management of the same health condition. A total of 131 patients were included with an initial consultation in this analysis (mean age = 43 ± 15, 40% male). Outcome measures: Rates of adherence to acupuncture follow-up treatment were determined by tracking whether patients had any subsequent follow-up visits in 30 days after their initial consultation. Demographic and clinical characteristics that differed between adherers (≥1 follow-up visit) and nonadherers (no follow-up visit) were then tested. Among the adherer sample, the authors tested whether these characteristics were associated with a higher number of follow-up visits was tested. Results: Half (50%) of the patient sample adhered to ≥1 follow-up visits in 30 days after their initial consultation. Patients reporting multiple chief complaints were more likely to have a follow-up visit than those with a single complaint (63% vs. 42%, p = 0.02). Receipt of a treatment plan (incidence rate ratio [IRR]: 1.37, p = 0.02) and first follow-up visit within 7 days of initial treatment (IRR: 1.42, p = 0.01) were associated with a higher number of follow-up visits among adherers, after adjusting for covariates. The predicted number of follow-up visits for patients with a treatment plan was 2.5 (standard error [SE] = 0.3) and that for those without a treatment plan was 1.8 (SE = 0.2) among adherers. Conclusion: The rate of return to an acupuncture clinic for follow-up treatment was low (50%). Patient adherence to acupuncture follow-up treatments may be improved by clinical administrative protocols that formalize treatment plans and appointment scheduling.

A Capable Surgeon and a Willing Electrologist: Challenges to the Expansion of Transgender Surgical Care in the United States.

Since 2014, public and private insurance coverage for transgender Americans' surgical care has increased exponentially. Training clinicians and equipping institutions to meet the surge in demand has not been as rapid. Through ethnographic research at a surgical workshop focused on trans- genital reconstruction and in a U.S. hospital working to grow its transgender health program, this article shows that effects of the decades-long insurance exclusion of trans- surgery are not easily remedied through the recent event of its inclusion because patient access is not the only thing that has been restricted by coverage denial. Decades of excluding coverage for trans- genital reconstructive surgery have limited the development and circulation of technical skills required to perform these procedures, as well as the administrative processes needed to integrate them into existing clinical workflows. One surgeon estimates that turning expanded access into realized care is "a five or six-year problem."

Medical Claims at National Collegiate Athletic Association Institutions: The Athletic Trainer's Role.

CONTEXT: National Collegiate Athletic Association (NCAA) institutions are required to certify insurance coverage of medical expenses for injuries student-athletes sustain while participating in NCAA events. Institutions assign this role to a variety of employees, including athletic trainers (ATs), athletic administrators, business managers, secretaries, and others. In 1994, Street et al observed that ATs were responsible for administering medical claim payments at 68.1% of institutions. Anecdotally, ATs do not always feel well suited to perform these tasks. OBJECTIVE: To investigate the ways athletic associations and departments coordinate athletic medical claims and the role of ATs in this process. DESIGN: Cross-sectional study. SETTING: Online Web-based survey. PATIENTS OR OTHER PARTICIPANTS: All 484 National Athletic Trainers' Association members self-identified as a head AT within an NCAA collegiate or university setting were solicited to respond to the online Web-based survey. Responses from 184 (38%) head ATs employed in collegiate settings were analyzed. MAIN OUTCOME MEASURE(S): Institutional demographic characteristics, type of insurance coverage, person assigned to handle insurance claims, hours spent managing claims, and training for the task. RESULTS: In 62% of institutions, an AT was responsible for processing athletic medical claims. The head and assistant ATs spent means of 6.17 and 10.32 hours per week, respectively, managing claims. Most respondents (62.1%) reported no formal training in handling athletic medical insurance claims. When asked when and how it was most appropriate to learn these concepts, 35.3% cited within an accredited athletic training program curriculum, 32.9% preferred on-the-job training, and 31.1% selected via continuing education. CONCLUSIONS: At NCAA institutions, ATs were responsible for administering athletic medical claims, a task in which most had no formal training. An AT may not possess adequate skills or time to handle athletic medical claims. Even if ATs are not solely responsible for this task, they remain involved as the coordinators of care. Athletic training programs, professional organizations that offer continuing education, and hiring institutions should consider focusing on and training appropriate personnel to manage athletic medical claims.

Working to Full Scope: The Reorganization of Nursing Work in Two Canadian Community Hospitals.

Work relationships between registered nurses (RNs) and practical nurses (LPNs) are changing as new models of nursing care delivery are introduced to create more flexibility for employers. In Canada, a team-based, hospital nursing care delivery model, known as Care Delivery Model Redesign (CDMR), redesigned a predominantly RN-based staffing model to a functional team consisting of fewer RNs and more LPNs. The scope of practice for LPNs was expanded, and unregulated health care assistants introduced. This study began from the standpoint of RNs and LPNs to understand their experiences working on redesigned teams by focusing on discourses activated in social settings. Guided by institutional ethnography, the conceptual and textual resources nurses are drawing on to understand these changing work relationships are explicated. We show how the institutional goals embedded in CDMR not only mediate how nurses work together, but how they subordinate holistic standards of nursing toward fragmented, task-oriented, divisions of care.

How and why do countries differ in their governance and financing-related administrative expenditure in health care? An analysis of OECD countries by health care system typology.

INTRODUCTION: Administration is vital for health care. Its importance may increase as health care systems become more complex, but academic attention has remained minimal. We investigated trends in administrative expenditure across OECD countries, cross-country spending differences, spending differences between health care system typologies, and differences in the scale and scope of administrative functions across typologies. METHODS: We used OECD data, which include health system governance and financing-related administrative activities by regulators, governance bodies, and insurers (macrolevel), but exclude administrative expenditure by health care providers (mesolevel and microlevel). RESULTS: We find that governance and financing-related administrative spending at the macrolevel has remained stable over the last decade at slightly over 3% of total health spending. Cross-country differences range from 1.3% of health spending in Iceland to 8.3% in the United States. Voluntary private health insurance bears much higher administrative costs than compulsory schemes in all countries. Among compulsory schemes, multiple payers exhibit significantly higher administrative spending than single payers. Among single-payer schemes, those where entitlements are based on residency have significantly lower administrative spending than those with single social health insurance, albeit with a small difference. DISCUSSION: These differences can partially be explained because multi-payer and voluntary private health insurance schemes require additional administrative functions and enjoy less economies of scale. Studies in hospitals and primary care indicate similar differences in administrative costs across health system typologies at the mesolevel and microlevel of health care delivery, which warrants more research on total administrative costs at all the levels of health systems.

Matrix support in mental health in Primary Health Care: Barriers and facilitating factors / Apoio matricial em saúde mental no contexto da Atenção Primaria à Saúde: barreiras e fatores facilitadores

O artigo discute as barreiras e os fatores facilitadores à descentralização em saúde mental por meio do apoio matricial. Trata-se de uma pesquisa qualitativa, realizada com apoiadores matriciais ‒ psicólogos e psiquiatras da região metropolitana de Porto Alegre, Rio Grande do Sul, Brasil. Os resultados evidenciam como obstáculos ao apoio matricial a não validação plena da gestão; a sobreposição das questões políticas em detrimento das técnicas; a incongruência entre os valores institucionais e os profissionais; as diferentes configurações da rede em Unidades de Saúde tradicionais e Unidades de Saúde da Família, que demandam arranjos organizacionais diferentes. Dentre os fatores facilitadores, evidenciam-se as relações personalizadas entre os apoiadores e os profissionais de referência, a disponibilidade, o comprometimento, a comunicação fluida, a corresponsabilização e a sistematicidade dos encontros. Conclui-se que, apesar dos diferentes obstáculos, a manutenção do apoio matricial decorre essencialmente da motivação dos apoiadores à descentralização em saúde mental.

The present study addresses the barriers and facilitators to the decentralization of mental health systems through matrix support. This qualitative research was carried out with matrix supporters ‒ psychologists and psychiatrists from the metropolitan region of Porto Alegre, Rio Grande do Sul, Brazil. The results revealed the following barriers to matrix support: non-recognition and full validation of matrix support from the management; overrating political issues at the expense of technical issues; incongruence between institutional and professional values; and different network settings in traditional Health care Units and Family Health Units requiring different organizational arrangements. The facilitators include personalized relationships between the matrix supporters, and the team formed by reference health professionals, and the professionals' availability and commitment, effective communication, co-responsibility, and regularity and organization of meetings. It was concluded that, despite the various obstacles, matrix support arises mainly from the motivation of the supporters towards the decentralization of mental health systems.

Athletic Trainers' Reasons for and Mechanics of Documenting Patient Care: A Report From the Athletic Training Practice-Based Research Network.

CONTEXT: Documenting patient care is an important responsibility of athletic trainers (ATs). However, little is known about ATs' reasons for documenting patient care and the mechanics of completing documentation tasks. OBJECTIVE: To understand ATs' perceptions about reasons for and the mechanics of patient care documentation. DESIGN: Qualitative study. SETTING: Individual telephone interviews with Athletic Training Practice-Based Research Network members. PATIENTS OR OTHER PARTICIPANTS: Ten ATs employed in the secondary school setting (age = 32.6 ± 11.4 years, athletic training experience = 7.1 ± 7.8 years) were recruited using a criterion-based sampling technique. Participants were Athletic Training Practice-Based Research Network members who used the Clinical Outcomes Research Education for Athletic Trainers electronic medical record system and practiced in 6 states. DATA COLLECTION AND ANALYSIS: We used the consensual qualitative research tradition. One investigator conducted individual telephone interviews with each participant. Data collection was considered complete after the research team determined that data saturation was reached. Interviews were transcribed verbatim and independently analyzed by 4 research team members following the process of open, axial, and selective coding. After independently categorizing interview responses into categories and themes, the members of the research team developed a consensus codebook, reanalyzed all interviews, and came to a final agreement on the findings. Trustworthiness was established through multiple-analyst triangulation and member checking. RESULTS: Participants identified 3 reasons for documenting patient care: communication, monitoring patient care, and legal implications. Four subcategories emerged from the mechanics-of-documentation theme: location, time of day, length of time, and criteria for documenting. The ATs described different criteria for documenting patient care, ranging from documenting every injury in the same manner to documenting time-loss and follow-up injuries differently. CONCLUSIONS: Whereas ATs recognized individual mechanisms that enabled them to document patient care, they may need more guidance on the appropriate criteria for documenting various patient care encounters and strategies to help them document more effectively.

Methodological Aspects of Focus Groups in Health Research: Results of Qualitative Interviews With Focus Group Moderators.

Although focus groups are commonly used in health research to explore the perspectives of patients or health care professionals, few studies consider methodological aspects in this specific context. For this reason, we interviewed nine researchers who had conducted focus groups in the context of a project devoted to the development of an electronic personal health record. We performed qualitative content analysis on the interview data relating to recruitment, communication between the focus group participants, and appraisal of the focus group method. The interview data revealed aspects of the focus group method that are particularly relevant for health research and that should be considered in that context. They include, for example, the preferability of face-to-face recruitment, the necessity to allow participants in patient groups sufficient time to introduce themselves, and the use of methods such as participant-generated cards and prioritization.

Innovation Network Development Model in Telemedicine: A Change in Participation.

OBJECTIVES: This paper introduces a telemedicine innovation network and reports its implementation in Tehran University of Medical Sciences. The required conditions for the development of future projects in the field of telemedicine are also discussed; such projects should be based on the common needs and opportunities in the areas of healthcare, education, and technology. METHODS: The development of the telemedicine innovation network in Tehran University of Medical Sciences was carried out in two phases: identifying the beneficiaries of telemedicine, and codification of the innovation network memorandum; and brainstorming of three workgroup members, and completion and clustering ideas. The present study employed a qualitative survey by using brain storming method. Thus, the ideas of the innovation network members were gathered, and by using Freeplane software, all of them were clustered and innovation projects were defined. RESULTS: In the services workgroup, 87 and 25 ideas were confirmed in phase 1 and phase 2, respectively. In the education workgroup, 8 new programs in the areas of telemedicine, tele-education and teleconsultation were codified. In the technology workgroup, 101 and 11 ideas were registered in phase 1 and phase 2, respectively. CONCLUSIONS: Today, innovation is considered a major infrastructural element of any change or progress. Thus, the successful implementation of a telemedicine project not only needs funding, human resources, and full equipment. It also requires the use of innovation models to cover several different aspects of change and progress. The results of the study can provide a basis for the implementation of future telemedicine projects using new participatory, creative, and innovative models.

Treatment targets in emergency departments: nurses' views of how they affect clinical practice.

AIMS AND OBJECTIVES: To understand nurses' views and experiences of four-hour treatment targets in the emergency department and how this impacts clinical decision-making throughout acute secondary care hospitals. BACKGROUND: In many countries, national treatment targets in the emergency department have been introduced. However, research and a recent enquiry into poor clinical care in one hospital in the UK have highlighted that patient care may be compromised by the need to meet these targets. DESIGN: Qualitative descriptive study as part of a case study approach. METHODS: Semi-structured interviews were conducted with 31 nurses working in UK secondary care hospitals which had an emergency department. Nurses were purposively sampled from three specialties: emergency arenas (emergency department, n = 5; medical assessment n = 4 surgical receiving n = 2) (n = 11), surgical wards (n = 11) and medical wards (n = 9). RESULTS: Nurses in emergency arenas reported considerable burden, in terms of a very high workload and pressure from senior staff to meet the target. Respondents reported that negative impact on patient care for the majority of patients, excluding the most sick, for whom emergency arena nurses reported that they ensured received appropriate treatment, regardless of breaching treatment targets. Around half of the nurses working outside emergency arenas felt pressure and amended their work practices to enable colleagues in emergency arenas to meet treatment targets. CONCLUSIONS: Four-hour targets were not viewed as clinically helpful by the majority of nurses, some of whom questioned their appropriateness for patient care. RELEVANCE TO CLINICAL PRACTICE: Policy makers and senior managers should consider the suitability of treatment targets in the emergency department, particularly in relation to working conditions for nurses and other health professionals and its potential for negative impacts on patient care. While targets remain in place, senior nurses and managers should support nurses who breach the target to provide optimum clinical care.

Innovation Network Development Model in Telemedicine: A Change in Participation / 대한의료정보학회지

OBJECTIVES: This paper introduces a telemedicine innovation network and reports its implementation in Tehran University of Medical Sciences. The required conditions for the development of future projects in the field of telemedicine are also discussed; such projects should be based on the common needs and opportunities in the areas of healthcare, education, and technology. METHODS: The development of the telemedicine innovation network in Tehran University of Medical Sciences was carried out in two phases: identifying the beneficiaries of telemedicine, and codification of the innovation network memorandum; and brainstorming of three workgroup members, and completion and clustering ideas. The present study employed a qualitative survey by using brain storming method. Thus, the ideas of the innovation network members were gathered, and by using Freeplane software, all of them were clustered and innovation projects were defined. RESULTS: In the services workgroup, 87 and 25 ideas were confirmed in phase 1 and phase 2, respectively. In the education workgroup, 8 new programs in the areas of telemedicine, tele-education and teleconsultation were codified. In the technology workgroup, 101 and 11 ideas were registered in phase 1 and phase 2, respectively. CONCLUSIONS: Today, innovation is considered a major infrastructural element of any change or progress. Thus, the successful implementation of a telemedicine project not only needs funding, human resources, and full equipment. It also requires the use of innovation models to cover several different aspects of change and progress. The results of the study can provide a basis for the implementation of future telemedicine projects using new participatory, creative, and innovative models.

Integrating acupuncture in an inpatient setting.

Acupuncture, a licensed health care profession in the United States, is poorly integrated into the American health care system, despite the evidence of its effectiveness. The purpose of this study was to offer a phenomenological description of the experience of acupuncturists who delivered acupuncture care in a tertiary teaching hospital in New York City. We analyzed data using methodology proposed by Colaizzi and identified four major clusters of themes: (a) acupuncturists' excitement about practicing in a hospital setting and frustration about organizational obstacles to effective acupuncture integration; (b) pride in being holistic practitioners; (c) attempts to preserve the holism and effectiveness of acupuncture while adjusting to the limitations of an inpatient setting, and (d) acupuncturists' realization that the medical staff knew very little about acupuncture and "it's all about trust." Practitioners of other healing traditions and therapies might find our study helpful in their own efforts toward similar integration.

Understanding the value of emergency care: a framework incorporating stakeholder perspectives.

BACKGROUND: In the face of escalating spending, measuring and maximizing the value of health services has become an important focus of health reform. Recent initiatives aim to incentivize high-value care through provider and hospital payment reform, but the role of the emergency department (ED) remains poorly defined. OBJECTIVES: To achieve an improved understanding of the value of emergency care, we have developed a framework that incorporates the perspectives of stakeholders in the delivery of health services. METHODS: A pragmatic review of the literature informed the design of this framework to standardize the definition of value in emergency care and discuss outcomes and costs from different stakeholder perspectives. The viewpoint of patient, provider, payer, health system, and society is each used to assess value for emergency medical conditions. RESULTS: We found that the value attributed to emergency care differs substantially by stakeholder perspective. Potential targets to improve ED value may be aimed at improving outcomes or controlling costs, depending on the acuity of the clinical condition. CONCLUSION: The value of emergency care varies by perspective, and a better understanding is achieved when specific outcomes and costs can be identified, quantified, and measured. Using this framework can help stakeholders find common ground to prioritize which costs and outcomes to target for research, quality improvement efforts, and future health policy impacting emergency care.

Clinician acceptance is the key factor for sustainable telehealth services.

Telehealth, the delivery of health care services at a distance using information and communications technology, has been slow to be adopted and difficult to sustain. Researchers developing theories concerning the introduction of complex change into health care usually take a multifactorial approach; we intentionally sought a single point of intervention that would have maximum impact on implementation. We conducted a qualitative interview study of 36 Australian telehealth services, sampled for maximum variation, and used grounded theory methods to develop a model from which we chose the most important factor affecting the success of telehealth. We propose that clinician acceptance explains much of the variation in the uptake, expansion, and sustainability of Australian telehealth services, and that clinician acceptance could, in most circumstances, overcome low demand, technology problems, workforce pressure, and lack of resourcing. We conclude that our model offers practical advice to those seeking to implement change with limited resources.