Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior.

OBJECTIVES: To evaluate the effectiveness of an educational program for improving medical event reporting attitude and behavior in the ambulatory care setting among graduate medical trainees. DESIGN: One group pre- and post-test study. SETTING: The University of Texas Southwestern Medical Center at Dallas Family Medicine Residency Program. PARTICIPANTS: All family practice residents (n = 30). INTERVENTION: Patient safety educational program implemented through an introductory lecture and 6 monthly conferences, June to December 2002, involving medical events that occurred in the ambulatory care setting. OUTCOME MEASURES: Medical event reporting attitude and behavior at baseline and at 6 month follow up, and barriers to medical event reporting at the 6 month follow up. RESULTS: Program attendance was significantly correlated with medical event reporting attitude and behavior change (rho = 0.525, p = 0.003). The median change in medical event reporting attitude and behavior was zero and not statistically significant (p = 0.566). Major barriers to medical event reporting were lack of time, extra paper work, and concern about career and personal reputation. CONCLUSIONS: Attending the patient safety educational program was key for promoting a positive medical event reporting attitude and behavior change among graduate trainees. Major barriers to medical event reporting were lack of time, extra paper work, and concern about career and personal reputation. Future research will need to focus on reducing these barriers and to evaluate the effectiveness of such a program over longer periods of time, since making a positive change in medical event reporting attitude and behavior must be made at the individual and organizational levels.

The use of parent report to assess the quality of care in primary care visits among children with asthma.

OBJECTIVE: To determine the accuracy of parent report and the accuracy of the medical record in documenting physician performance of elements of pediatric asthma care in the primary care setting. METHODS: A convenience sample of 79 English-speaking parents of 4--12-year old children with asthma presenting to medical center--affiliated inner-city primary care pediatric clinics in the Bronx, Dallas, and Chicago was enrolled, and the office visit was audiotaped. Parents were interviewed 1--16 days after the visit by telephone. OUTCOME MEASURES: Accuracy of parent report was the primary outcome. The "reference standard" was an independent evaluation of the audiotaped record of the primary care visit. The National Asthma Education and Prevention Program was used as a guide to select data elements to assess quality of pediatric asthma care during primary care visits. RESULTS: Sufficient documentation was significantly (P <.001) less likely to be present in the medical record than in the follow-up interview for each element of care. When these elements were combined into a cumulative score, 71% of parent interviews but only 37% of medical records scored > or = 5 (out of a possible 6), with 29% of medical records scoring < 3. Parents were able to accurately report (concordance of parent data with audiotape reference standard) whether or not the visit had included performance of 5 of the 6 elements of care. CONCLUSIONS: Our study suggests that parent telephone interview within 2 weeks after the visit is more accurate than the medical record for documentation of the quality of asthma care in pediatric primary care visits. The medical record was not sufficient to assess the quality of primary care related to asthma, primarily because of missing data. Therefore, our data suggest that assessing quality of care using the medical record will not only bias the findings in the direction of more deficient care but will also make improvement in care more difficult. Further validation of our strategy for using parent report to assess the quality of care in primary care visits will require its application in a variety of other primary care settings.

Developing theoretical constructs for outcomes research.

BACKGROUND: In March of 1998, The Advisory Commission on Consumer Protection and Quality in Health Industry released a report in response to the US Presidential Executive Order that recommended increasing funding for outcomes research. This report indicated that outcomes research was critical to assessing the effectiveness of treatment and the quality of care. METHODS: A systematic review was conducted of the pertinent English literature that describes the development, methods, and limitations of outcomes research to identify methods for minimizing its limitations. RESULTS: Current evidence indicates that approximately 80% of commonly used medical treatments have not been shown to be efficacious, primarily because the necessary randomized controlled trials have not been conducted because of methodological problems, the time required for their execution, the expense, or ethical reasons. Therefore, physicians disagree on the value of many common clinical practices, which is reflected in the large variation in medical care prescribed for different populations. Outcomes research, which is conducted under actual clinical practice conditions using effectiveness studies, offers an efficient approach for investigating the link between medical care and outcomes. However, the major limitation of past outcomes research has been its limited ability to link medical care with outcomes, because of the lack of theory development to guide the research process, inadequate data sources, or both. CONCLUSIONS: The literature review suggests that the use of pertinent theoretical constructs to guide the outcomes research process will generate the results needed to assess the effectiveness of treatment and the quality of care.

Measuring and predicting academic generalists' work satisfaction: implications for retaining faculty.

PURPOSE: To develop a measure that could be used to identify interventions to improve the work satisfaction of academic generalists. METHODS: To field-test the measure, the authors surveyed the generalist faculty at the University of Texas Southwestern Medical Center at Dallas. Ninety-four (80%) of the faculty responded. The measure's reliability was established using Cronbach's alpha, and its validity was established with the Pearson correlation coefficient using a previously validated global work-satisfaction measure. Using ten work-satisfaction dimensions and selected faculty characteristics, the authors performed univariate and stepwise multiple regression analyses to predict the generalist faculty's global work satisfaction and intentions of leaving their positions. RESULTS: Work-satisfaction dimension predictors were autonomy in the workplace, professional status, teaching activities, clinical resources and activities, professional relationships, institutional governance, compensation, and professional advancement. Faculty characteristic predictors were gender, age, race or ethnicity, and living with children. CONCLUSION: The measure includes eight valid and reliable work-satisfaction dimensions that predict global work satisfaction or intentions to leave. Others may want to use this measure, along with the four faculty-characteristic predictors, as a management tool for improving academic generalists' work satisfaction and, ultimately, their performances and retention.

Using antecedents of medical care to develop valid quality of care measures.

OBJECTIVE: To present a new model for using the antecedents of medical care in outcomes assessment to develop valid quality of care measures. METHODS: The pertinent literature describing the history of outcomes assessment and the influence of patient and environmental risk factors on health status were reviewed. RESULTS: Past outcomes assessment studies have not consistently demonstrated a correlation between the processes and the outcomes of care. The use of the model described in this article indicates that the lack of correlation between process and outcome is probably because past outcomes assessment studies lacked the inclusion of medical care antecedents (primarily patient and environmental risk factors) that had a significant influence on the outcomes measured. Included is a description of a study that tests the utility of incorporating the antecedents of medical care into outcomes assessment to develop valid quality of care measures. CONCLUSION: The model presented in this article advances quality of care measure development by using: (i) qualitative research to characterize the pertinent antecedents of medical care; and (ii) as many of the pertinent antecedents of medical care as possible to develop risk adjustment models for measuring outcomes that are more likely to identify the true linkages between the processes and outcomes of care. Knowing the linkages between the processes and outcomes of care would provide the information needed to develop valid quality of care measures, so that quality can be measured accurately and the groundwork for its improvement can be laid.

Developing strategic plans for academic general internal medicine.

There is an increasing need to train more primary care physicians. Therefore, it would be advantageous for academic general internal medicine (GIM) to develop strategies to meet these demands. Our GIM division developed a strategic planning process with the participant groups being the division faculty, a pertinent literature review (the surrogate expert), and selected medical administrators. The IDEALS systems design provided the conceptual framework for the strategic planning process. This process used the Delphi technique to develop the theoretically ideal work system based on the division's vision for its future role, and the Nominal Group Process Technique to create the recommended work system, using the Delphi results. The strategic planning process was economical and division faculty agreed that it was useful.