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Abstract
OBJECTIVES To examine the basis of multidisciplinary teamwork. In real-world healthcare settings, clinicians often cluster in profession-based tribal silos, form hierarchies and exhibit stereotypical behaviours. It is not clear whether these social structures are more a product of inherent characteristics of the individuals or groups comprising the professions, or attributable to a greater extent to workplace factors. SETTING Controlled laboratory environment with well-appointed, quiet rooms and video and audio equipment. PARTICIPANTS Clinical professionals (n=133) divided into 35 groups of doctors, nurses and allied health professions, or mixed professions. INTERVENTIONS Participants engaged in one of three team tasks, and their performance was video-recorded and assessed. PRIMARY AND SECONDARY MEASURES Primary: teamwork performance. Secondary, pre-experimental: a bank of personality questionnaires designed to assess participants' individual differences. Postexperimental: the 16-item Mayo High Performance Teamwork Scale (MHPTS) to measure teamwork skills; this was self-assessed by participants and also by external raters. In addition, external, arm's length blinded observations of the videotapes were conducted. RESULTS At baseline, there were few significant differences between the professions in collective orientation, most of the personality factors, Machiavellianism and conservatism. Teams generally functioned well, with effective relationships, and exhibited little by way of discernible tribal or hierarchical behaviours, and no obvious differences between groups (F (3, 31)=0.94, p=0.43). CONCLUSIONS Once clinicians are taken out of the workplace and put in controlled settings, tribalism, hierarchical and stereotype behaviours largely dissolve. It is unwise therefore to attribute these factors to fundamental sociological or psychological differences between individuals in the professions, or aggregated group differences. Workplace cultures are more likely to be influential in shaping such behaviours. The results underscore the importance of culture and context in improvement activities. Future initiatives should factor in culture and context as well as individuals' or professions' characteristics as the basis for inducing more lateral teamwork or better interprofessional collaboration.
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How strict is galactose restriction in adults with galactosaemia? International practice. Mol Genet Metab 2015; 115:23-6. [PMID: 25873073 DOI: 10.1016/j.ymgme.2015.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 03/29/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
Dietary management of 418 adult patients with galactosaemia (from 39 centres/12 countries) was compared. All centres advised lactose restriction, 6 restricted galactose from galactosides ± fruits and vegetables and 12 offal. 38% (n=15) relaxed diet by: 1) allowing traces of lactose in manufactured foods (n=13) or 2) giving fruits, vegetables and galactosides (n=2). Only 15% (n=6) calculated dietary galactose. 32% of patients were lost to dietetic follow-up. In adult galactosaemia, there is limited diet relaxation.
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Abstract
INTRODUCTION Clinician-led diabetes education is a fundamental component of care to assist people with Type 1 diabetes (T1D) self-manage their disease. Recent initiatives to incorporate a more patient-centered approach to diabetes education have included recommendations to make such education more individualized. Yet there is a dearth of research that identifies patients' perceptions of clinician-led diabetes education. We aimed to describe the experience of diabetes education from the perspective of young adults with T1D. METHODS We designed a self-reported survey for Australian adults, aged 18-35 years, with T1D. Participants (n = 150) were recruited by advertisements through diabetes consumer-organizations. Respondents were asked to rate aspects of clinician-led diabetes education and identify sources of self-education. To expand on the results of the survey we interviewed 33 respondents in focus groups. RESULTS SURVEY The majority of respondents (56.0%) were satisfied with the amount of continuing clinician-led diabetes education; 96.7% sought further self-education; 73.3% sourced more diabetes education themselves than that provided by their clinicians; 80.7% referred to diabetes organization websites for further education; and 30.0% used online chat-rooms and blogs for education. Focus groups: The three key themes that emerged from the interview data were deficiencies related to the pedagogy of diabetes education; knowledge deficiencies arising from the gap between theoretical diabetes education and practical reality; and the need for and problems associated with autonomous and peer-led diabetes education. CONCLUSION Our findings indicate that there are opportunities to improve clinician led-diabetes education to improve patient outcomes by enhancing autonomous health-literacy skills and to incorporate peer-led diabetes education and support with clinician-led education. The results provide evidence for the potential value of patient engagement in quality improvement and health-service redesign.
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Abstract
BACKGROUND Shared decision-making (SDM) is at the core of patient-centered care. We examined whether young adults with type 1 diabetes perceived the clinician groups they consulted as practicing SDM. METHODS In a web-based survey, 150 Australians aged 18-35 years and with type 1 diabetes rated seven aspects of SDM in their interactions with endocrinologists, diabetes educators, dieticians, and general practitioners. Additionally, 33 participants in seven focus groups discussed these aspects of SDM. RESULTS Of the 150 respondents, 90% consulted endocrinologists, 60% diabetes educators, 33% dieticians, and 37% general practitioners. The majority of participants rated all professions as oriented toward all aspects of SDM, but there were professional differences. These ranged from 94.4% to 82.2% for "My clinician enquires about how I manage my diabetes"; 93.4% to 82.2% for "My clinician listens to my opinion about my diabetes management"; 89.9% to 74.1% for "My clinician is supportive of my diabetes management"; 93.2% to 66.1% for "My clinician suggests ways in which I can improve my self-management"; 96.6% to 85.7% for "The advice of my clinician can be understood"; 98.9% to 82.2% for "The advice of my clinician can be trusted"; and 86.5% to 67.9% for "The advice of my clinician is consistent with other members of the diabetes team". Diabetes educators received the highest ratings on all aspects of SDM. The mean weighted average of agreement to SDM for all consultations was 84.3%. Focus group participants reported actively seeking clinicians who practiced SDM. A lack of SDM was frequently cited as a reason for discontinuing consultation. The dominant three themes in focus group discussions were whether clinicians acknowledged patients' expertise, encouraged patients' autonomy, and provided advice that patients could utilize to improve self-management. CONCLUSION The majority of clinicians engaged in SDM. Young adults with type 1 diabetes prefer such clinicians. They may fail to take up recommended health services when clinicians do not practice this component of patient-centered care. Such findings have implications for patient safety, improved health outcomes, and enhanced health service delivery.
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Multidisciplinary diabetes team care: the experiences of young adults with Type 1 diabetes. Health Expect 2013; 18:1783-96. [PMID: 24345040 DOI: 10.1111/hex.12170] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2013] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND This research examined whether young adults with Type 1 diabetes engage with the multidisciplinary consultation process and if not, then why. METHODS We designed a web-based self-reported survey, available online from February to May 2011, for Australian adults 18-35 years with Type 1 diabetes. Respondents were asked about which clinicians they consulted to assist with self-management. To expand on the results of the survey, we interviewed 33 respondents. RESULTS SURVEY Respondents (n = 150) consulted with the following clinicians: endocrinologist and diabetes educators: 23.3%; endocrinologist only: 18.0%; endocrinologist, diabetes educators and dieticians: 14.6%; endocrinologist, diabetes educators, dietician and general practitioners (GP): 11.3%; endocrinologist and GP: 10.6%; GP only: 4.6%; all clinicians recommended to assist with self-management: 1.3%; 2.7% did not consult any clinician. Interview: Participants (n = 33) reported eight key disincentives to consultation with multidisciplinary clinicians. These were time constraints; provision of conflicting advice; inaccessibility of health services; variation in service standards; cost constraints; failure of clinicians to refer to other clinicians; lack of opportunity to build a therapeutic relationship; and failure of clinicians to engage in shared decision making. CONCLUSION Our results indicate that high attrition rates of young adults with Type 1 diabetes from recommended diabetes health services is linked to the failure of those services to meet the needs and preferences of their patients. The identified needs and preferences included joint consultation with multi-disciplinary team clinicians; flexible access to advice by email or telephone consultation; and shared decision making. Patient engagement in health-service re-design has implications for improved health-service delivery and enhanced treatment outcomes.
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Continuing differences between health professions' attitudes: the saga of accomplishing systems-wide interprofessionalism. Int J Qual Health Care 2012. [PMID: 23203766 DOI: 10.1093/intqhc/mzs071] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare four health professions' attitudes towards interprofessional collaboration (IPC) and their evaluations of a programme aimed at enhancing IPC across a health system. DESIGN Questionnaire survey. SETTING Australian Capital Territory health services. PARTICIPANTS Sample of medical (38), nursing (198), allied health (152) and administrative (30) staff. INTERVENTION s) A 4-year action research project to improve IPC. MAIN OUTCOME MEASURE Questionnaire evaluating the project and responses to the 'Attitudes toward Health Care Teams' and 'Readiness for Interprofessional Learning' scales. RESULTS Significant professional differences occurred in 90% of the evaluation items. Doctors were the least and administrative staff most likely to agree project aims had been met. Nurses made more favourable assessments than did allied health staff. Doctors made the most negative assessments and allied health staff the most neutral ratings. Improved interprofessional sharing of knowledge, teamwork and patient care were among the goals held to have been most achieved. Reduction in interprofessional rivalry and improved trust and communication were least achieved. Average assessment of individual goals being met was agree (31.9%), neutral (56.9%) and disagree (11.2%). On the two attitude scales, allied health professionals were most supportive of IPC, followed by nurses, administrators and doctors. CONCLUSIONS Although overall attitudes towards IPC were favourable, only a third of participants reported that project goals had been achieved indicating the difficulties of implementing systems change. The response profiles of the professions differed. As in the previous research, doctors were least likely to hold favourable attitudes towards or endorse benefits from social or structural interventions in health care.
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An empirical test of accreditation patient journey surveys: randomized trial. Int J Qual Health Care 2012; 24:495-500. [PMID: 22789665 DOI: 10.1093/intqhc/mzs035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness of utilizing the patient journey survey (PJS) method in healthcare accreditation processes. DESIGN Randomized trial of the PJS method in parallel with the current accreditation survey (CAS) method of the Australian Council on Healthcare Standards (ACHS). SETTING Acute healthcare organizations in Australia. PARTICIPANTS Seventeen organizations, 28 organizational staff, nine surveyors and 38 patients. MAIN OUTCOME MEASURES The results of each surveying method were compared. Participants provided feedback, via 18 interviews and 40 questionnaire surveys, about the benefits and disadvantages of a PJS compared to a CAS. RESULTS The PJS method is not as comprehensive as the CAS method for accreditation assessment. In matched assessments the majority of items were rated lower by the PJS method than by the CAS. PJSs were shown to be appropriate for assessing mandatory clinical criteria, but were less effective for assessing corporate and support criteria. The two methods diverged in their final assessments of which organizations met the accreditation threshold. Participants endorsed the use of PJSs within accreditation processes. CONCLUSIONS The PJS methodology complements but is not a substitute for existing accreditation methods. There is significant stakeholder support for the inclusion of the PJS method within the current accreditation programme.
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A four-year, systems-wide intervention promoting interprofessional collaboration. BMC Health Serv Res 2012; 12:99. [PMID: 22520869 PMCID: PMC3359212 DOI: 10.1186/1472-6963-12-99] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 04/20/2012] [Indexed: 11/22/2022] Open
Abstract
Background A four-year action research study was conducted across the Australian Capital Territory health system to strengthen interprofessional collaboration (IPC) though multiple intervention activities. Methods We developed 272 substantial IPC intervention activities involving 2,407 face-to-face encounters with health system personnel. Staff attitudes toward IPC were surveyed yearly using Heinemann et al's Attitudes toward Health Care Teams and Parsell and Bligh's Readiness for Interprofessional Learning scales (RIPLS). At study's end staff assessed whether project goals were achieved. Results Of the improvement projects, 76 exhibited progress, and 57 made considerable gains in IPC. Educational workshops and feedback sessions were well received and stimulated interprofessional activities. Over time staff scores on Heinemann's Quality of Interprofessional Care subscale did not change significantly and scores on the Doctor Centrality subscale increased, contrary to predictions. Scores on the RIPLS subscales of Teamwork & Collaboration and Professional Identity did not alter. On average for the assessment items 33% of staff agreed that goals had been achieved, 10% disagreed, and 57% checked neutral. There was most agreement that the study had resulted in increased sharing of knowledge between professions and improved quality of patient care, and least agreement that between-professional rivalries had lessened and communication and trust between professions improved. Conclusions Our longitudinal interventional study of IPC involving multiple activities supporting increased IPC achieved many project-specific goals. However, improvements in attitudes over time were not demonstrated and neutral assessments predominated, highlighting the difficulties faced by studies targeting change at the systems level and over extended periods.
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An empirical test of short notice surveys in two accreditation programmes. Int J Qual Health Care 2011; 24:65-71. [PMID: 22140191 DOI: 10.1093/intqhc/mzr074] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate short notice surveys in accreditation programmes. DESIGN Two trials using short notice surveys were conducted independently: a study of 20 healthcare organizations with the Australian Council on Healthcare Standards (ACHS) and a study of 7 general practices with the Australian General Practice Accreditation Limited (AGPAL). Participating organizations volunteered. ACHS and AGPAL selected 17 and 13 surveyors, respectively, and provided training for them on short notice surveys. METHODS Each agency's short notice surveys were an abbreviated version of their current advanced notification surveys. Short notice surveys assessed accreditation programme criteria or indicators that corresponded to the Australian Commission on Safety and Quality in Health Care's priority issues. Fifteen (out of 45) ACHS criteria and 48 (out of 174) AGPAL indicators that aligned to the Commission's criteria were evaluated. Participating organizations were given 2 days notice prior to the short notice surveys. Ratings from the short notice surveys were compared with those from the most recent advanced notification surveys, and statistical tests were performed to detect differences and potential confounding factors. Surveyors and organizational staff completed a post-survey feedback questionnaire which was analysed thematically and by inferential statistics. RESULTS The short notice survey approach overall produced ratings congruent with the advanced notification survey for both accreditation programmes. However, for both programmes short notice surveys assessed that more organizations would not reach the accreditation threshold as compared with the previous survey. Organizations in both programmes were judged to have achieved less successful performance against clinical standards by the short notice survey than the advanced notification survey. There was support from surveyors and organizational staff for short notice survey to be adopted. However, there were mixed views about the impact of short notice surveys and whether they validated trial participants' continuous improvement efforts. CONCLUSIONS The study demonstrated that short notice surveys are more critical in their assessment of clinical than administrative or corporate items. Short notice surveys, while broadly comparable with existing advanced notification survey practice, produced different accreditation outcomes for a significant proportion of the study organizations. The overall value and worth of short notice surveys remains to be proved.
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Strengthening organizational performance through accreditation research-a framework for twelve interrelated studies: the ACCREDIT project study protocol. BMC Res Notes 2011; 4:390. [PMID: 21981910 PMCID: PMC3199265 DOI: 10.1186/1756-0500-4-390] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 10/09/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Service accreditation is a structured process of recognising and promoting performance and adherence to standards. Typically, accreditation agencies either receive standards from an authorized body or develop new and upgrade existing standards through research and expert views. They then apply standards, criteria and performance indicators, testing their effects, and monitoring compliance with them. The accreditation process has been widely adopted. The international investments in accreditation are considerable. However, reliable evidence of its efficiency or effectiveness in achieving organizational improvements is sparse and the value of accreditation in cost-benefit terms has yet to be demonstrated. Although some evidence suggests that accreditation promotes the improvement and standardization of care, there have been calls to strengthen its research base.In response, the ACCREDIT (Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork) project has been established to evaluate the effectiveness of Australian accreditation in achieving its goals. ACCREDIT is a partnership of key researchers, policymakers and agencies. FINDINGS We present the framework for our studies in accreditation. Four specific aims of the ACCREDIT project, which will direct our findings, are to: (i) evaluate current accreditation processes; (ii) analyse the costs and benefits of accreditation; (iii) improve future accreditation via evidence; and (iv) develop and apply new standards of consumer involvement in accreditation. These will be addressed through 12 interrelated studies designed to examine specific issues identified as a high priority. Novel techniques, a mix of qualitative and quantitative methods, and randomized designs relevant for health-care research have been developed. These methods allow us to circumvent the fragmented and incommensurate findings that can be generated in small-scale, project-based studies. The overall approach for our research is a multi-level, multi-study design. DISCUSSION The ACCREDIT project will examine the utility, reliability, relevance and cost effectiveness of differing forms of accreditation, focused on general practice, aged care and acute care settings in Australia. Empirically, there are potential research gains to be made by understanding accreditation and extending existing knowledge; theoretically, this design will facilitate a systems view of accreditation of benefit to the partnership, international research communities, and future accreditation designers."Accreditation of health-care organisations is a multimillion dollar industry which shapes care in many countries. Recent reviews of research show little evidence that accreditation increases safety or improves quality. It's time we knew about the cost and value of accreditation and about its future direction." [Professor John Øvretveit, Karolinska Institute, Sweden, 7 October 2009].
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Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study. Qual Saf Health Care 2010; 19:14-21. [DOI: 10.1136/qshc.2009.033928] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Attitudes toward the large-scale implementation of an incident reporting system. Int J Qual Health Care 2008; 20:184-91. [PMID: 18337286 DOI: 10.1093/intqhc/mzn004] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE An electronic Incident Information Management System implemented system-wide by the Department of Health, New South Wales, Australia was evaluated. We hypothesized that health professionals (i) would support the system via utilization and favourable attitudes and (ii) that their usage and attitudes would vary according to profession with nurses being most, and doctors least, favourably disposed. DESIGN, SETTING AND PARTICIPANTS An online, anonymous questionnaire survey of 2185 health practitioners. MAIN OUTCOME MEASURES Undertaking system training, satisfaction with training, reporting incidents, incident reporting rates since system introduction and attitude questions focusing on use, security and evaluation of the system and workplace safety cultures. RESULTS The first hypothesis received partial support. The majority of respondents had undertaken training and rated it highly. Most had reported incidents and maintained their previous reporting levels. Most attitudes regarding using the system and its security were favourable. Mixed attitudes were held about workplace safety cultures and the value of the system. Deficiencies in quality of reporting, feedback on incident reports and resources to analyse incident data were problems identified. The second hypothesis was confirmed. Nurses were most, and doctors least, likely to undertake training, report incidents and express favourable attitudes. Allied health responses were intermediate to those of the other professions. CONCLUSIONS The system implementation was relatively successful, but more so with some professions. Problems identified indicated that expectations as to the goals achievable in the short term were optimistic, but these are amenable to planned interventions.
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Religion and sex in a university sample: Data bearing on mol's hypothesis. AUSTRALIAN JOURNAL OF PSYCHOLOGY 2007. [DOI: 10.1080/00049537308255833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Epidermal lipid metabolism of cultured skin substitutes during healing of full-thickness wounds in athymic mice. Wound Repair Regen 2007; 5:329-38. [PMID: 16984443 DOI: 10.1046/j.1524-475x.1997.50407.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cultured epidermal keratinocytes provide an abundant supply of biologic material for wound treatment. Because restoration of barrier function is a definitive criterion for efficacy of wound closure and depends on the lipids present in the epidermis, we analyzed lipid composition of the epidermis in cultured skin substitutes in vitro and after grafting to athymic mice. The cultured skin substitutes were prepared from human keratinocytes and fibroblasts attached to collagen-glycosaminoglycan substrates. After 14 days of incubation, cultured skin substitutes were grafted orthotopically onto full-thickness wounds in athymic mice. Samples for lipid analysis were collected after 14 and 34 days of in vitro incubation, and 3 weeks and 4 months after grafting. Both in vitro samples show disproportions in epidermal lipid profile as compared with the native human epidermis, i.e., a low amount of phospholipids (indicating imbalance in proliferation and differentiation); a large excess of triglycerides (storage lipids); and low levels of free fatty acids, gluco-sphingolipids, cholesterol sulfate, and ceramides-suggesting abnormal composition of stratum corneum barrier lipids. Fatty acid analysis of cultured skin substitutes in vitro revealed insufficient uptake of linoleic acid, which resulted in increased synthesis of and substitution with monounsaturated fatty acids, mainly oleic acid. These abnormalities were partially corrected by 3 weeks after grafting; and 4 months after grafting, all epidermal lipids, with some minor exceptions, were synthesized in proportions very similar to human epidermis. Results of this study show that grafting of cultured skin substitutes to a physiologic host permits the recovery of lipid in proportion to that required for barrier formation in normal human epidermis.
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Turning the medical gaze in upon itself: Root cause analysis and the investigation of clinical error. Soc Sci Med 2006; 62:1605-15. [PMID: 16213643 DOI: 10.1016/j.socscimed.2005.08.049] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2005] [Indexed: 11/23/2022]
Abstract
In this paper, we discuss how a technique borrowed from defense and manufacturing is being deployed in hospitals across the industrialized world to investigate clinical errors. We open with a discussion of the levers used by policy makers to mandate that clinicians not just report errors, but also gather to investigate those errors using root cause analysis (RCA). We focus on the tensions created for clinicians as they are expected to formulate 'systems solutions' that go beyond blame. In addressing these matters, we present a discourse analysis of data derived during an evaluation of the NSW Health Safety Improvement Program. Data include transcripts of RCA meetings which were recorded in a local metropolitan teaching hospital. From this analysis we move back to the argument that RCA involves clinicians in 'immaterial labour', or the production of communication and information, and that this new labour realizes two important developments. First, because RCA is anchored in the principle of health care practitioners not just scrutinizing each other, but scrutinizing each others'errors, RCA is a challenging task. Second, thanks to turning the clinical gaze in on the clinical observer, RCA engenders a new level of reflexivity of clinical self and of clinical practice. We conclude with asking whether this reflexivity will lock the clinical gaze into a micro-sociology of error, or whether it will enable this gaze to influence matters superordinate to the specifics of practice and the design of clinical treatments; that is, the over-arching governance and structuring of hospital care.
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Rethinking clinical organisational structures: an attitude survey of doctors, nurses and allied health staff in clinical directorates. J Health Serv Res Policy 2005; 10:10-7. [PMID: 15667699 DOI: 10.1177/135581960501000105] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine assumptions made by proponents and critics of clinical directorate (CD) structures in hospitals. Proponents argue that CDs are supported by the health professionals who constitute them and confer organisational and clinical benefits compared with traditional structural configurations. Critics deny these benefits and suggest CDs can compromise clinicians by incorporating them into management, to their cost. We investigated the attitudes of health professionals working in CDs to gather and consider evidence for these claims. METHODS A questionnaire survey of 227 health professionals (78 doctors, 89 nurses and 60 allied health) in two large hospitals in Australia that had implemented CDs three years previously. RESULTS Respondents were more negative than positive about CDs. Significant attitudinal differences were found between professions. Doctors were the most negative and held their attitudes with the greatest certainty and intensity. Allied health staff were the most positive but their attitudes tended to lack strength or certainty. Nurses' attitudes were polarised and intense but more positive than were doctors'. Increased organisational politics was cited by 58% of respondents as CDs' most frequent effect, followed by improved accountability (48%) and dumping hard decisions on staff (39%). Only 26% thought patient care had improved. CONCLUSIONS Clinical directorates were designed to promote team approaches and to improve patient care delivery, but the results call for a rethink of what can be expected from structural reforms in organisations.
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Rethinking clinical organisational structures: an attitude survey of doctors, nurses and allied health staff in clinical directorates. J Health Serv Res Policy 2005. [DOI: 10.1258/1355819052801778] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Structure and function studies of cholera toxin. Toxicon 1997. [DOI: 10.1016/s0041-0101(97)84728-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Is There a Pattern of Psychological Reactions to Chronic Illness Which is Associated with Death. OMEGA-JOURNAL OF DEATH AND DYING 1995. [DOI: 10.2190/1m6q-28jd-648d-vdwc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In order to identify any pattern of psychological reactions to illness associated with later death, interview material from a sample of chronically ill people who died within months of being interviewed was compared with similar material from a sample of chronically ill people who did not die, as well as from a group of healthy people who did not die. The samples were matched for sex and age, and, where appropriate, for degree of disability and type of chronic illness. The comparisons were made by means of content analysis scales which were applied to a recorded segment of the interviews. A characteristic pattern of reactions among the chronically ill people who were later to die was established. This pattern included little uncertainty or directly expressed anger but much depression, guilt, and fear of bodily damage, together with many good feelings. In personal construct psychology terms, their construct systems were enabling them to anticipate what was happening to them more effectively than might have been expected.
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Crystallization of two monoclonal Fab fragments of similar amino-acid sequence bound to the same area of horse cytochromecand interacting by potentially distinct mechanisms. ACTA CRYSTALLOGRAPHICA SECTION D: BIOLOGICAL CRYSTALLOGRAPHY 1994; 50:64-70. [PMID: 15299477 DOI: 10.1107/s0907444993009084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The mouse monoclonal antibodies (mAb), 2E5.G10 and 1F5.D1, are specific for horse cytochrome c and appear to bind the same epitope, since their heavy (H) and light (L) chains are functionally interchangeable. Comparison of the amino-acid sequences suggests that slightly different interactions may be involved in antigen recognition. In addition, the H chains differ at only a few amino-acid residues from the H chain of a rat cytochrome c-specific mAb suggesting that specificity for one protein over another may be determined by these amino-acid differences. To address these possibilities, the three-dimensional structures of the Fab portions of the mAb bound to cytochrome c are being determined by X-ray diffraction analysis. Here we describe the preparation and crystallization of the two complexes with horse cytochrome c. The complex of the Fab fragment of 2E5.G10 with horse cytochrome c yielded crystals of X-ray diffraction quality under two sets of conditions; in both the space group was P2(1). The corresponding complex of 1F5.D1 under one of these conditions crystallized in the P2(1)2(1)2(1) space group. Three-dimensional X-ray data for these two complexes have been collected with nominal resolutions of 2.86 and 2.48 A, respectively.
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Structure of the hirugen and hirulog 1 complexes of alpha-thrombin. J Mol Biol 1991; 221:1379-93. [PMID: 1942057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The isomorphous structures of the hirugen (N-acetylhirudin 53'-64' with sulfato-Tyr63') and hirulog 1 (D-Phe-Pro-Arg-Pro-(Gly)4 desulfato-Tyr63'-hirugen) complexes of human alpha-thrombin have been determined and refined at 2.2 A resolution to crystallographic R-factors of 0.167 and 0.163, respectively. The binding of hirugen to thrombin is similar to that of the binding of the C-terminal dodecapeptide of hirudin, including that of the terminal 3(10) helical turn. The sulfato Tyr63', which, as a result of sulfation, increases the binding affinity by an order of magnitude, is involved in an extended hydrogen bonding network utilizing all three sulfato oxygen atoms. The hirugen-thrombin complex is the first thrombin structure determined to have an unobstructed active site; this site is practically identical in positioning of catalytic residues and in its hydrogen bonding pattern with that of other serine proteinases. Hirulog 1, which is a poor thrombin substrate, is cleaved at the Arg3'-Pro4' bond in the crystal structure. The Arg3' of hirulog 1 occupies the specificity site, the D-Phe-Pro-Arg tripeptide is positioned like that of D-Phe-Pro-Arg chloromethylketone in the active site and the Pro4'(Gly)4 spacer to hirugen is disordered in the structure, as is the 3(10) turn of hirugen. The latter must be related to the simultaneous absence both of sulfation and of the last residue of hirudin (Gln65'). In addition, the autolysis loop of thrombin (Lys145-Gly150) is disordered in both structures. Changes in circular dichroism upon hirugen binding are therefore most likely the result of the flexibility associated with this loop.
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Search for orthodontic assistant personality profile. Am J Orthod Dentofacial Orthop 1988; 94:350-3. [PMID: 3177286 DOI: 10.1016/0889-5406(88)90060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A study of 124 orthodontists and 476 auxiliaries was undertaken to learn whether successful chairside assistants had a special personality as shown by the Cattell 16 PF test. The successful and unsuccessful orthodontic assistants differed significantly in only one respect. The successful assistants generally displayed more conscientiousness than the nonsuccessful assistants. This study suggests that most orthodontic assistants come from a group of women that differs little from the mean of the general population.
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Judgement of emotion: attention versus accuracy. THE BRITISH JOURNAL OF SOCIAL AND CLINICAL PSYCHOLOGY 1974; 13:383-9. [PMID: 4441804 DOI: 10.1111/j.2044-8260.1974.tb00133.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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