Designing Electronic Data Capture Systems for Sustainability in Low-Resource Settings: Viewpoint With Lessons Learned From Ethiopia and Myanmar.

Electronic data capture (EDC) is a crucial component in the design, evaluation, and sustainment of population health interventions. Low-resource settings, however, present unique challenges for developing a robust EDC system due to limited financial capital, differences in technological infrastructure, and insufficient involvement of those who understand the local context. Current literature focuses on the evaluation of health interventions using EDC but does not provide an in-depth description of the systems used or how they are developed. In this viewpoint, we present case descriptions from 2 low- and middle-income countries: Ethiopia and Myanmar. We address a gap in evidence by describing each EDC system in detail and discussing the pros and cons of different approaches. We then present common lessons learned from the 2 case descriptions as recommendations for considerations in developing and implementing EDC in low-resource settings, using a sociotechnical framework for studying health information technology in complex adaptive health care systems. Our recommendations highlight the importance of selecting hardware compatible with local infrastructure, using flexible software systems that facilitate communication across different languages and levels of literacy, and conducting iterative, participatory design with individuals with deep knowledge of local clinical and cultural norms.

Comparison of obstetric emergency clinical readiness: A cross-sectional analysis of hospitals in Amhara, Ethiopia.

Measuring facility readiness to manage basic obstetric emergencies is a critical step toward reducing persistently elevated maternal mortality ratios (MMR). Currently, the Signal Functions (SF) is the gold standard for measuring facility readiness globally and endorsed by the World Health Organization. The presence of tracer items classifies facilities' readiness to manage basic emergencies. However, research suggests the SF may be an incomplete indicator. The Clinical Cascades (CC) have emerged as a clinically-oriented alternative to measuring readiness. The purpose of this study is to determine Amhara's clinical readiness and quantify the relationship between SF and CC estimates of readiness. Data were collected in May 2021via Open Data Kit (ODK) and KoBo Toolbox. We surveyed 20 hospitals across three levels of the health system. Commodities were used to create measures of SF-readiness (e.g., % tracers) and CC-readiness. We calculated differences in SF and CC estimates and calculated readiness loss across six emergencies and 3 stages of care in the cascades. The overall SF estimate for all six obstetric emergencies was 29.6% greater than the estimates using the CC. Consistent with global patterns, hospitals were more prepared to provide medical management (70.0% ready) compared to manual procedures (56.7% ready). The SF overestimate was greater for manual procedures 33.8% overall for retained placenta and incomplete abortion) and less for medical treatments (25.3%). Hospitals were least prepared to manage retained placentas (30.0% of facilities were ready at treatment and 0.0% were ready at monitor and modify) and most prepared to manage hypertensive emergencies (85.0% of facilities were ready at the treatment stage). When including protocols in the analysis, no facilities were ready to monitor and modify the initial therapy when clinically indicated for 3 common emergencies-sepsis, post-partum hemorrhage and retained placentas. We identified a significant discrepancy between SF and CC readiness classifications. Those facilities that fall within this discrepancy are unprepared to manage common obstetric emergencies, and employees in supply management may have difficulty identify the need. Future research should explore the possibility of modifying the SF or replacing it with a new readiness measurement.

Changes in Posttraumatic Growth After a Virtual Contemplative Intervention During the COVID-19 Pandemic.

OBJECTIVE: The aim of this study was to describe the effects of an intervention called "Compassion & Growth Workshops" on reported posttraumatic growth (PTG) using the Posttraumatic Growth Inventory-Expanded (PTGI-X). BACKGROUND: Few studies measure the impact of interventions, such as contemplative practices, on nurse PTG. METHODS: We delivered a series of three 2-hour microretreats to nurses and advanced practice nurses and measured their impact on PTG scores. Using multivariate logistic regression, we identified cofactors predictive of 25% overall improvement on the PTGI-X. RESULTS: Overall PTG increased among participants, with the greatest improvement in relating to others, new possibilities, and personal strength. Posttraumatic growth improved as workshop attendance increased; nurses providing direct patient care also benefitted the most. CONCLUSIONS: Contemplative interventions can substantively improve PTG. This may be particularly relevant for coping with COVID pandemic stress among nurses on the frontlines and for healthcare leaders seeking to strengthen psychological support within their teams and reform the workplace environment.

Creation of a globally informed and locally relevant KMC implementation model for population-impact in Amhara, Ethiopia.

AIM: As part of a multi-country implementation trial, we tested a regionally specific model of kangaroo mother care (KMC). Effective KMC was defined as ≥8 h of newborn-caregiver skin-to-skin contact daily plus exclusive breast feeding. The study was designed to achieve ≥80+% effective KMC coverage at the population level. METHODS: The Amhara KMC model was designed using global evidence, formative research in the region and input from government officials, clinicians, newborn families and global scientists. We optimised the initial model using continuous quality improvement with process feedback, outcome measurement and collaborative re-design. Outcomes from the evaluation period are reported. RESULTS: At discharge, the final model resulted in a median of 16 h per day of skin-to-skin contact with 63% effective KMC coverage. Fifty-three percent sustained effective KMC to 7 days post-discharge. CONCLUSIONS: It is possible to achieve high coverage (63%), high-quality KMC at public hospitals without prior KMC services using government-owned, multisectoral collaborative design. Targeted co-design, real-time data and customisation of KMC interventions with input from impacted stakeholders was critical in achieving high coverage and sustained quality.

Using clinical cascades to measure health facilities' obstetric emergency readiness: testing the cascade model using cross-sectional facility data in East Africa.

OBJECTIVES: Globally, hundreds of women die daily from preventable pregnancy-related causes, with the greatest burden in sub-Saharan Africa. Five key emergencies-bleeding, infections, high blood pressure, delivery complications and unsafe abortions-account for nearly 75% of these obstetric deaths. Skilled clinicians with strategic supplies could prevent most deaths. In this study, we (1) measured facility readiness to manage common obstetric emergencies using the clinical cascades and signal function tracers; (2) compared these readiness estimates by facility characteristics; and (3) measured cascading drop-offs in resources. DESIGN: A facility-based cross-sectional analysis of resources for common obstetric emergencies. SETTING: Data were collected in 2016 from 23 hospitals (10 designated comprehensive emergency obstetric care (CEmOC) facilities) in Migori County, western Kenya, and Busoga Region, eastern Uganda, in the Preterm Birth Initiative study in East Africa. Baseline data were used to estimate a facility's readiness to manage common obstetric emergencies using signal function tracers and the clinical cascade model. We compared emergency readiness using the proportion of facilities with tracers (signal functions) and the proportion with resources for identifying and treating the emergency (cascade stages 1 and 2). RESULTS: The signal functions overestimated practical emergency readiness by 23 percentage points across five emergencies. Only 42% of CEmOC-designated facilities could perform basic emergency obstetric care. Across the three stages of care (identify, treat and monitor-modify) for five emergencies, there was a 28% pooled mean drop-off in readiness. Across emergencies, the largest drop-off occurred in the treatment stage. Patterns of drop-off remained largely consistent across facility characteristics. CONCLUSIONS: Accurate measurement of obstetric emergency readiness is a prerequisite for strengthening facilities' capacity to manage common emergencies. The cascades offer stepwise, emergency-specific readiness estimates designed to guide targeted maternal survival policies and programmes. TRIAL REGISTRATION NUMBER: NCT03112018.

Using Routinely Collected Electronic Health Record Data to Predict Readmission and Target Care Coordination.

ABSTRACT: Patients with chronic renal failure (CRF) are at high risk of being readmitted to hospitals within 30 days. Routinely collected electronic health record (EHR) data may enable hospitals to predict CRF readmission and target interventions to increase quality and reduce readmissions. We compared the ability of manually extracted variables to predict readmission compared with EHR-based prediction using multivariate logistic regression on 1 year of admission data from an academic medical center. Categorizing three routinely collected variables (creatinine, B-type natriuretic peptide, and length of stay) increased readmission prediction by 30% compared with paper-based methods as measured by C-statistic (AUC). Marginal effects analysis using the final multivariate model provided patient-specific risk scores from 0% to 44.3%. These findings support the use of routinely collected EHR data for effectively stratifying readmission risk for patients with CRF. Generic readmission risk tools may be evidence-based but are designed for general populations and may not account for unique traits of specific patient populations-such as those with CRF. Routinely collected EHR data are a rapid, more efficient strategy for risk stratifying and strategically targeting care. Earlier risk stratification and reallocation of clinician effort may reduce readmissions. Testing this risk model in additional populations and settings is warranted.

Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study.

OBJECTIVES: Kangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage. DESIGN: This study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge. PARTICIPANTS: 3804 infants of birth weight under 2000 g who survived the first 3 days, were available in the study area and whose mother resided in the study area. MAIN OUTCOME MEASURES: The primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7 days postdischarge. RESULTS: Key barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%-86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7 days postdischarge, KMC was provided to 53%-65% of infants in all sites, except Oromia (38%) and Karnataka (36%). CONCLUSIONS: This study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers' conviction that KMC is the standard of care, women's and families' acceptance of KMC, and changes in infrastructure, policy, skills and practice. TRIAL REGISTRATION NUMBERS: ISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

Toolkit for Best Practice Use of Electronic Health Record Data in Quality Improvement.

This project piloted an educational intervention focused on use and management of EHR data by Doctor of Nursing Practice students in quality improvement initiatives. Recommendations from academic and clinical nursing promote the integration of EHR data findings into practice. Nursing's general lack of understanding about how to use and manage data is a barrier to using EHR data to guide quality improvement initiatives. Doctor of Nursing Practice students at a hospital-affiliated university participated in a pre-test, training, and post-test through an online learning management system. Training content and assessments focused on data and planning for its use in quality improvement initiatives. Sixteen students experienced a median of 17.6% increase in scores after completing the post-test. There was a statistically significant increase in scores between the pre-test and post-test (P = .0006). These results suggest educational content included in the Doctor of Nursing Practice Quality Improvement Toolkit increases knowledge about use and management of EHR data. Future considerations include use for educating a variety of students and healthcare staff.

The Call for Global Health Research Mentorship for Doctorally Prepared Nurses in Low- and Middle-Income Countries.

Limited research about nursing mentorship in low- and middle-income countries (LMICs) is holding science back. This article describes the strengths and challenges associated with global health research mentorship for doctorally prepared nurses whose scholarship focuses on LMICs. Using reflexive narrative accounts from current and former nurse mentors and nurse mentees who participated in a NIH-funded global health doctoral research program, emerging themes revealed the perspectives of mentors and mentees, producing a global health mentoring model for nursing research mentorship relevant to LMICs. Identified themes, which applied across roles and primary affiliations, included 1) collaborative mentor-mentee relationships and 2) enthusiasm for global health nursing. Our global health nursing research mentor-mentee interaction systems conceptual model focuses on nursing science mentoring in LMICs incorporating interpersonal, institutional, and cultural factors. We describe successful components of global nurse researcher mentorship and summarize directions for future research in the field. Our model can be used to create more effective mentee-centered mentoring for nurses or health professionals conducting global research. To advance science, we encourage doctorally prepared nurses to support mentee-centered research mentorship experiences that are sensitive to the unique needs of interdisciplinary global health scholarship.

Valent USA LLC strategies, innovations, and collaborations to deal with herbicide resistance and achieve sustainability.

In conjunction with our parent company Sumitomo Chemical, Valent USA LLC continues to research, develop, and steward products that assist growers in the management of existing and emerging weed resistance issues in their fields. The knowledge gained through collaboration with universities and industry stakeholders in how to effectively manage and prevent the spread of herbicide-resistant weeds is being incorporated into the development and stewardship of our products. Valent demonstrates our commitment to herbicide stewardship by developing products which incorporate multiple-effective modes of action using flumioxazin as a foundational component for preemergence residual weed control. © 2021 Society of Chemical Industry.

Collaborative Development and Implementation of a Video-Based Curriculum Expansion to Improve Refugee Women's Birth Experiences in the United States.

Many refugee and immigrant women in the United States experience cultural and language barriers when seeking pregnancy-related medical care. Such barriers may delay needed care and adversely impact birth outcomes. Embrace Refugee Birth Support (Embrace) in Clarkston, Georgia, supports pregnant refugee women by offering birth education classes in the women's primary languages. Our academic-practice partnership designed and implemented a series of birth education videos for Embrace participants. Based on input from former participants, the partnership team created video scenarios that could be embedded into Embrace's existing didactic curriculum. The videos addressed common challenges and learning needs identified by previous participants. All videos were filmed in the participant's primary languages (Swahili and Kinyarwanda) and featured actual Embrace graduates who spoke the languages. Then, Embrace trainers used the video scenarios to augment teaching on birth preparedness and foster participant discussion during class sessions. After implementation, a focus group with participants in the video-expanded class reported the videos were well received, understood, and practically related to their pregnancy needs. Overall, participants reported that video scenarios were an important part of their learning and skill development, as well as a positive experience. Embrace has plans to continue creating native language educational videos for additional languages and birth-related topics. The academic partner's attempts to measure video impact with standardized quantitative instruments at baseline were terminated. The substantive revisions in data collection strategies highlight the need for cross-cultural flexibility and the potential for unforeseen barriers when using quantitative research tools among non-English-speaking participants.

Neonatal care and community-level treatment seeking for possible severe bacterial infection (PSBI) in Amhara, Ethiopia.

BACKGROUND: In Ethiopia, neonatal mortality accounts for approximately 54% of under-five deaths with the majority of these deaths driven by infections. Possible Severe Bacterial Infection (PSBI) in neonates is a syndromic diagnosis that non-clinical health care providers use to identify and treat newborns with signs of sepsis. In low- and middle-income countries, referral to a hospital may not be feasible due to transportation, distance or finances. Growing evidence suggests health extension workers (HEWs) can identify and manage PSBI at the community level when referral to a hospital is not possible. However, community-based PSBI care strategies have not been widely scaled-up. This study aims to understand general determinants of household-level care as well as household care seeking and decision-making strategies for neonatal PSBI symptoms. METHODS: We conducted eleven focus group discussions (FGDs) to explore illness recognition and care seeking intentions from four rural kebeles in Amhara, Ethiopia. FGDs were conducted among mothers, fathers and households with recruitment stratified among households that have had a newborn with at least one symptom of PSBI (Symptomatic Group), and households that have had a newborn regardless of the child's health status (Community Group). Data were thematically analyzed using MAXQDA software. RESULTS: Mothers were described as primary caretakers of the newborn and were often appreciated for making decisions for treatment, even when the father was not present. Type of care accessed was often dependent on conceptualization of the illness as simple or complex. When symptoms were not relieved with clinical care, or treatments at facilities were perceived as ineffective, alternative methods were sought. Most participants identified the health center as a reliable facility. While designed to be the first point of access for primary care, health posts were not mentioned as locations where families seek clinical treatment. CONCLUSIONS: This study describes socio-contextual drivers for PSBI treatment at the community level. Future programming should consider the role community members have in planning interventions to increase demand for neonatal care at primary facilities. Encouragement of health post utilization could further allow for heightened accessibility-acceptability of a simplified PSBI regimen.

Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation.

INTRODUCTION: Kangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it. METHODS AND ANALYSIS: This implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: 'pre-KMC facility'-to maximise the number of newborns getting to a facility that provides KMC; 'KMC facility'-for initiation and maintenance of KMC; and 'post-KMC facility'-for continuation of KMC at home. Stable infants with birth weight<2000 g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24 hours and will be measured at discharge from the KMC facility and 7 days after hospital discharge. ETHICS AND DISSEMINATION: Ethics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination. STUDY STATUS: WHO approved protocol: V.4-12 May 2016-Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019. TRIAL REGISTRATION NUMBER: Community Empowerment Laboratory, Uttar Pradesh, India (ISRCTN12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

Clinical cascades as a novel way to assess physical readiness of facilities for the care of small and sick neonates in Kenya and Uganda.

BACKGROUND: Globally, there were 2.7 million neonatal deaths in 2015. Significant mortality reduction could be achieved by improving care in low- and middle-income countries (LMIC), where the majority of deaths occur. Determining the physical readiness of facilities to identify and manage complications is an essential component of strategies to reduce neonatal mortality. METHODS: We developed clinical cascades for 6 common neonatal conditions then utilized these to assess 23 health facilities in Kenya and Uganda at 2 time-points in 2016 and 2017. We calculated changes in resource availability over time by facility using McNemar's test. We estimated mean readiness and loss of readiness for the 6 conditions and 3 stages of care (identification, treatment, monitoring-modifying treatment). We estimated overall mean readiness and readiness loss across all conditions and stages. Finally, we compared readiness of facilities with a newborn special care unit (NSCU) to those without using the two-sample test of proportions. RESULTS: The cascade model estimated mean readiness of 26.3-26.6% across the 3 stages for all conditions. Mean readiness ranged from 11.6% (respiratory distress-apnea) to 47.8% (essential newborn care) across both time-points. The model estimated overall mean readiness loss of 30.4-31.9%. There was mild to moderate variability in the timing of readiness loss, with the majority occurring in the identification stage. Overall mean readiness was higher among facilities with a NSCU (36.8%) compared to those without (20.0%). CONCLUSION: The cascade model provides a novel approach to quantitatively assess physical readiness for neonatal care. Among 23 facilities in Kenya and Uganda, we identified a consistent pattern of 30-32% readiness loss across cascades and stages. This aggregate measure could be used to monitor and compare readiness at the facility-, health system-, or national-level. Estimates of readiness and loss of readiness may help guide strategies to improve care, prioritize resources, and promote neonatal survival in LMICs.

Leveraging Graduate Academic-Practice Partnerships to Transform Health System Outcomes.

Academic and clinical site partnerships are not new. However, many of these have not resulted in graduates of nursing education programs who are prepared to fulfill their full potential as newly employed professionals. This article describes an education program for Doctorate of Nursing Practice (DNP) students in which the students, under the close supervision of academic faculty, utilize their statistical analyses and complex system coursework to study and address "wicked" problems faced by health care organizations. This partnership between academia and practice is benefitting practice partners, students, and patients.

Measuring movement towards improved emergency obstetric care in rural Kenya with implementation of the PRONTO simulation and team training program.

As the proportion of facility-based births increases, so does the need to ensure that mothers and their newborns receive quality care. Developing facility-oriented obstetric and neonatal training programs grounded in principles of teamwork utilizing simulation-based training for emergency response is an important strategy for improving the quality care. This study uses 3 dimensions of the Kirkpatrick Model to measure the impact of PRONTO International (PRONTO) simulation-based training as part of the Linda Afya ya Mama na Mtoto (LAMMP, Protect the Health of mother and child) in Kenya. Changes in knowledge of obstetric and neonatal emergency response, self-efficacy, and teamwork were analyzed using longitudinal, fixed-effects, linear regression models. Participants from 26 facilities participated in the training between 2013 and 2014. The results demonstrate improvements in knowledge, self-efficacy, and teamwork self-assessment. When comparing pre-Module I scores with post-training scores, improvements range from 9 to 24 percentage points (p values < .0001 to .026). Compared to baseline, post-Module I and post-Module II (3 months later) scores in these domains were similar. The intervention not only improved participant teamwork skills, obstetric and neonatal knowledge, and self-efficacy but also fostered sustained changes at 3 months. The proportion of facilities achieving self-defined strategic goals was high: 95.8% of the 192 strategic goals. Participants rated the PRONTO intervention as extremely useful, with an overall score of 1.4 out of 5 (1, extremely useful; 5, not at all useful). Evaluation of how these improvements affect maternal and perinatal clinical outcomes is forthcoming.

Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness.

BACKGROUND: Globally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model. OBJECTIVE-METHOD: We compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial. FINDINGS: Although most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%. SIGNIFICANCE: Comparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade's intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted.

Are CNM-Attended Births in Texas Hospitals Underreported?

INTRODUCTION: Accurate data on the number of births attended by certified nurse-midwives and certified midwives (CNMs/CMs) are required to establish the public health benefits attributed to the midwifery model of care and the role of CNMs/CMs in the US health care system. However, the number of CNM/CM-attended births may be underreported in birth certificate data. The purpose of this project was to estimate the number of births CNM practices attended in Texas hospitals in 2014 and to describe Texas CNMs' knowledge about their hospitals' policies on naming CNMs as birth attendants. METHODS: CNMs from Texas practices employing CNMs completed a survey. Descriptive statistics were used to summarize respondent data. These results were used to impute data for practices that did not respond to the survey so that total estimates for the state could be calculated. RESULTS: CNM-attended hospital births in Texas in 2014 may be underreported by 65%. Most CNMs (90%) keep records of births attended, but only 19% of practices receive facility reports with the births CNMs in the practice attended. DISCUSSION: CNMs/CMs need to regularly verify that they are being named as the provider on birth certificates for births they attend and work with advocacy groups, hospital administrators, physicians, legislators, and policy makers to improve the accuracy of birth certificate data.

The development and implementation of a strategic and tactical planning framework at Mayo Clinic Arizona.

This article describes the Mayo Arizona process for developing an information technology strategic plan. The background of organizational events that gave rise to this strategic planning process is presented. A cross-functional team of key IT stakeholders was convened; the team used a facilitated process to derive a pro forma set of IT strategic objectives from the larger organization's emerging strategic plan. A broad set of leadership interviews was conducted to further identify detailed objectives that would confirm, complement, or conflict with the "strawperson." The IT strategic objectives then were refined and published by the organization. The article also describes the annual process of reviewing the IT strategic plan and translating it to a set of tactical objectives. This includes the committee structure for project prioritization, which is guided by the IT strategic plan. The outcome of the prioritization process is a five-year IT tactical plan, which is used to communicate the IT action plan for achievement of the strategic objectives. The strategic and tactical plans have resulted in stronger ownership and advocacy of IT activities by organizational leadership and a clearer view of the impact of technology on the organization's strategic plan.