The engagement chasm: Time for competency-based training in employee engagement for healthcare and beyond.

BACKGROUND: Employee disengagement in healthcare and business is currently at unexceptionally high levels worldwide. Disengagement negatively impacts productivity, profitability, efficiency (waste reduction), innovation, quality, customer satisfaction and experience, staff well-being, safety, mortality, staff attendance, and turnover. Despite its serious detrimental impacts, no dedicated competency-based training curriculum exists for engagement as a competency. OBJECTIVE: To develop a competency-based educational curriculum for an Engagement Competency. METHODS: A curricular roadmap comprising the following steps was observed 1. Identifying the desired outcomes needed of trainees. These must help fulfill all the Q12 Gallup survey engagement items. 2. Explicitly defining the required Competencies, Entrustable Professional Activities, and Milestones, 3. Selecting the educational activities, and instructional methods, 4. Selecting the tools to assess progress along the milestones, and finally, 5. Designing an evaluation system to assess the outcomes of the engagement competency program. RESULTS: We developed an Engagement Competency Framework with 7 Entrustable Professional activities "rationally and practically" arranged. These are: Envision E1, Embrace E2, Empower E3, Enlighten E4, Empathize E5, Energize E6, and Evaluate E7 (the 7Es). CONCLUSION: The unfortunate global issue of disengagement in healthcare and in the business arena may be practically tackled by introducing Engagement Competency and training. It should be compulsory for all in the "leadership role". Such training may lead to remarkable performance improvement and a happier, more prosperous, and safer world.

Clinical Practice Guidelines in an Era of Accountability, Saudi Arabia: A Call for Action.

INTRODUCTION: Clinical Practice Guidelines (CPGs) development and implementation in the Kingdom of Saudi Arabia are suboptimal. The Kingdom's Vision 2030 envisages a transformational change to achieve an effective, integrated, value-based ecosystem focused on patient health. OBJECTIVES: This study aimed to develop a CPG appraisal tool that will support the realization of the Kingdom's Vision 2030 through the development of high-quality and highly implementable CPGs. To maximize its impact, all vital healthcare paradigms, such as systems thinking, value-based healthcare, and information technology, will robustly be incorporated in the tool. METHODS: The Saudi Health Council through its National Center of Evidence-Based Medicine (NCEBM) embarked on a program to develop this appraisal tool. A taskforce of experts was selected based on their experience in evidence-based practice and training. The task force, through a methodology of extensive literature review, deliberation, outside experts' feedback, and Delphi and consensus voting, developed a prototype appraisal tool that was named the Holistic Appraisal Tool for CPGs (HAT-CPG). RESULTS: The HAT-CPG was developed comprising three sections: an initial basic information section, an internal validity section, and an external validity section with a total of 13 section items and 73 reporting elements. CONCLUSION: It is envisaged that the Holistic Appraisal Tool will support CPG developers and users in Saudi Arabia in realizing the objectives for which it was developed.

A Systems Thinking approach for the creation of effective competency-based medical education programs.

Successful and sustainable implementation of Competency-based Medical Education (CBME) programs is a significant and daunting challenge facing medical education worldwide. Our manuscript endorses for the first time, Systems Thinking as a concept for transforming and redesigning CBME programs employing the full 7-system elements as advocated by the Biomatrix Systems Theory. The majority of internationally recommended actions and processes for such an endeavor are highlighted, each within its system element. New innovative ideas such as having competency-structured clinical training activities as well as re-writing medical textbooks following a novel competency-based roadmap for their disease monographs etc. are also highlighted. Furthermore, the need for innovative partnerships as well as novel medical rotations that may facilitate the creation of "master clinicians" are also stressed.

The wisdom in ISCHEMIA.

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) study was published recently demonstrating that over a period of 3.3 years a routine invasive approach along with optimised medical therapy (OMT) was not superior to OMT alone in patients with stable coronary artery disease and at least moderate to severe ischemia. Considerable interest and discussion have emerged over the applicability of the trial to real-world settings and the limitations of the trial. Given the fact that no clinical trial will ever be designed that will be perfect, it is important to prise out the pearls that the findings reveal and not interpret the findings as either positive or negative towards one approach or the other.

Perception of the role of inhaled corticosteroids and factors affecting compliance among asthmatic adult patients.

OBJECTIVE: To examine the patient characteristics linked with reduced adherence to inhaled corticosteroids (ICS) use. METHODS: A prospective study of adult asthmatic patients who were prescribed with ICS and are under regular follow-up at the pulmonary outpatient clinics between June 1st, and December 31st, 2001, at King Fahad National Guard Hospital in Riyadh. All patients underwent structured interviews with an investigator. RESULTS: Included in the study were 334 patients. Thirty eight percent (38%) of the patients reported irregular use of ICS. Factors associated with irregular ICS use were a negative perception of the role of ICS (p=0.03) and less than high school education (p=0.03). Almost 50% (169/334) of all patients had concerns regarding ICS safety resulting in reduced willingness to use them. These concerns were again significantly related to the level of education and the patient's attitude to ICS. Among the most common fears hindering regular ICS use were their potential to lead to addiction (60%) and worry from steroid side effects (41%). CONCLUSION: The result of this study raises the importance of patient's education and the importance of treatment of those involved in asthma care to educate the patient and discuss with them the role of asthma medications, particularly ICS, and to correct common fears and misconceptions.

The demographic and clinical characteristics of leprosy in Saudi Arabia.

Leprosy is a chronic disease caused by Mycobacterium leprae. Although the occurrence of leprosy has declined in Saudi Arabia, it has not yet been eradicated. To our knowledge, this descriptive retrospective study is the first to assess the clinical presentation of leprosy at the time of diagnosis in Saudi Arabia. All study subjects were leprosy patients admitted to Ibn Sina hospital, the only referral hospital for leprosy in Saudi Arabia, between January 2000 and May 2012. A total of 164 subjects, the majority of whom (65%) were between 21 and 50 years of age, were included, and the male-to-female ratio was 2.8:1. Of these 164 patients, 63% were Saudis, and 77% of all admitted patients were from the western region. Lepromatous leprosy was observed most frequently (33%), and 31% of cases had a positive history of close contact with leprosy. At the time of diagnosis, 84% of all subjects presented with skin manifestation. The prevalence of neurological deficit at the time of diagnosis was 87%. Erythema nodosum leprosum (E.N.L.) developed in only 10% of all subjects. Further studies are needed to determine the clinical characteristics pertaining to each type of leprosy in the region, and training courses in caring for and diagnosing patients with leprosy should be organized for health workers.

Competency-structured case discussion in the morning meeting: enhancing CanMEDS integration in daily practice.

Outcome-focused, competency-based educational curricula have become the norm in residency training programs. The Canadian Medical Education Directives for Specialists (CanMEDS) framework is one example of such a curriculum. However, models for incorporating all the competencies in everyday clinical practice have been difficult to accomplish. In this manuscript, a CanMEDS, competency-structured, acute case discussion in a regular morning meeting was undertaken. All the diagnostic and therapeutic interventions were explicitly organized and discussed under their respective CanMEDS competency headings. Post exercise, the majority of residents felt that they were more competent in all the competencies and indicated their willingness to continue having similarly structured acute case discussions in the future.

Implementation of the national asthma management guidelines in the emergency department.

OBJECTIVE: The national protocol for asthma management was released in 1995. There has been no national investigation to compare the actual care delivered at the Emergency Department to those recommended by these guidelines: To compare the documented management of acute bronchial asthma at the Emergency Room (ER) with the Saudi National Guidelines METHODS: Retrospective analyses of a total of 150 ER records, of patients with a diagnosis of asthma over a one year period (January through to December 2000), at King Abdul-Aziz Medical City, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. Documentation of the history, indices of severity, treatment given, pre-discharge assessment and prescriptions were compared to the nationally recommended management. RESULTS: History of the present attack, its duration, frequency of b-agonist use and nocturnal symptoms were documented in less than 50% of patients. Previous ER visits and hospitalization, peak flow rate and accessory muscle use were similarly recorded in less than 50% of patients whereas intensive care unit admission and intubation were documented in less than 15% of asthmatics. Steroids were given to only 46% of patients with acute asthma who visited the Emergency Department. Pre-discharge clinical assessment and peak flow readings were documented in 48% and 29%. Only 64% of patients were given a follow up appointment. CONCLUSION: The documented treatment of patients with an acute asthmatic episode at the ER varies significantly from what is recommended by the National and International Asthma Management Guidelines. Failure to implement Asthma Guidelines probably results in an inadequate care of asthmatic patients and raises the urgent need for a National Physician Asthma Education Program.

Knowledge translation through clinical pathways: principles for practical development and successful use.

Proper implementation of guidelines is clearly associated with better medical outcomes. Success of guidelines' implementation depends on the tools used to accomplish it. Clinical pathways, also known as Integrated Care Pathways, represent one such tool that clearly promotes the implementation of guidelines and research evidence into clinical practice. They also encourage multidisciplinary teamwork, help in staff education, and aid in clinical research and audit. Additionally, they help in cutting hospital care costs. Important steps for a successful pathway development and implementation include getting leadership support, involving relevant people, selecting the right area of practice, using multiple implementation strategies and regularly assessing and monitoring pathway implementation.

Cognitive schemes and strategies in diagnostic and therapeutic decision making: a primer for trainees.

Unlike novices, expert clinicians develop refined schemes and strategies that predictably allow them to provide a better quality, prompt and less error-prone patient care input. Empowering novices with cognitive aids or mental schemes as early as possible in their clinical career may significantly improve their critical thinking, problem-solving and decision-making skills. These cognitive aids may also improve trainees' use of evidence-based medicine in addition to reducing their diagnostic errors and improving their therapeutic care inputs.

Models for enhancing competency-based training and contextual clinical decision making.

BACKGROUND: In the era of quality care, competency and outcome-based education, new models of teaching and resident staff training are greatly needed. These should be based on adult learning principles and allow for high-quality, patient-centred, evidence-based care. CONTEXT: Three areas that need restructuring with specific conceptual frameworks to allow for seamless competency-based training, and also to assist in putting the decision-making process in context, are: case or topic presentation; diagnostic labelling; and immediate interventions for front-line caregivers. INNOVATION: Three models are proposed: the competency-structured presentation (CSP) model; the bedside clinical diagnosis, etiological cause and severity score diagnostic labelling (BESD) model; and the symptomatic, supportive, specific, specialty and site of care (5S) model. IMPLICATIONS: The models listed above may assist in the following domains of patient care. In a competency-structured presentation, the CSP model formalises case presentations and discussions in a competency-based structure, thereby supporting the development of a competency-focused thought process for patient care. The BESD and 5S models improve the understanding of patient problems within the appropriate context, and thus assists in achieving the following quality outcomes. The BESD model promotes better diagnostic labelling, thereby assisting in implementing individualised, evidence-based interventions. The 5S model promotes the cognitive conceptualisation of medical management, which will aid a more comprehensive, patient-centred, multidisciplinary care input, thereby reducing process errors and improving outcomes.

Status epilepticus and cardiopulmonary arrest in a patient with carbon monoxide poisoning with full recovery after using a neuroprotective strategy: a case report.

INTRODUCTION: Carbon monoxide poisoning can be associated with life-threatening complications, including significant and disabling cardiovascular and neurological sequelae. CASE PRESENTATION: We report a case of carbon monoxide poisoning in a 25-year-old Saudi woman who presented to our facility with status epilepticus and cardiopulmonary arrest. Her carboxyhemoglobin level was 21.4 percent. She made a full recovery after we utilized a neuroprotective strategy and normobaric oxygen therapy, with no delayed neurological sequelae. CONCLUSIONS: Brain protective modalities are very important for the treatment of complicated cases of carbon monoxide poisoning when they present with neurological toxicities or cardiac arrest. They can be adjunctive to normobaric oxygen therapy when the use of hyperbaric oxygen is not feasible.

Hypokalaemia and refractory asystole complicating diabetic ketoacidosis, lessons for prevention.

We report a unique case of diabetic ketoacidosis in which a relatively low potassium level on admission was associated with consequent life-threatening and refractory arrhythmia secondary to inappropriate use of intravenous insulin and bicarbonate therapy. The latter was reversed by rapid bolus potassium injection. Although we do not advocate this approach in every case, we emphasise that a bolus injection of potassium may be life saving in such cases. The lessons from this case have led to multidisciplinary meetings and modification of the institute's diabetic ketoacidosis clinical pathway.