The Charter on Professionalism for Health Care Organizations.

In 2002, the Physician Charter on Medical Professionalism was published to provide physicians with guidance for decision making in a rapidly changing environment. Feedback from physicians indicated that they were unable to fully live up to the principles in the 2002 charter partly because of their employing or affiliated health care organizations. A multistakeholder group has developed a Charter on Professionalism for Health Care Organizations, which may provide more guidance than charters for individual disciplines, given the current structure of health care delivery systems.This article contains the Charter on Professionalism for Health Care Organizations, as well as the process and rationale for its development. For hospitals and hospital systems to effectively care for patients, maintain a healthy workforce, and improve the health of populations, they must attend to the four domains addressed by the Charter: patient partnerships, organizational culture, community partnerships, and operations and business practices. Impacting the social determinants of health will require collaboration among health care organizations, government, and communities.Transitioning to the model hospital described by the Charter will challenge historical roles and assumptions of both its leadership and staff. While the Charter is aspirational, it also outlines specific institutional behaviors that will benefit both patients and workers. Lastly, this article considers obstacles to implementing the Charter and explores avenues to facilitate its dissemination.

Fidelity to the healing relationship: a medical student's challenge to contemporary bioethics and prescription for medical practice.

As a medical  student, I observed that different physicians had strikingly different attitudes and approaches when caring for patients. The care of one patient in particular continues to challenge my understanding of illness and moral responsibility in the practice of medicine. In this paper, I illustrate the care of this patient in order to evaluate the dominant ethics I was taught in medical school, in theory and in practice, and argue neither principlism nor the ethics of care fully captures the moral responsibility of physicians. Emphasising fidelity to the healing relationship, a core principle derived from Pellegrino's virtue theory, I conclude that this approach to clinical ethics fully explains physician responsibility. Pellegrino deconstructs the practice of medicine to clarify the moral event within the clinical encounter and offers a sufficiently useful and justified approach to patient care.

Clinic-based versus outsourced implementation of a diabetes health literacy intervention.

BACKGROUND: We compared two implementation approaches for a health literacy diabetes intervention designed for community health centers. METHODS: A quasi-experimental, clinic-randomized evaluation was conducted at six community health centers from rural, suburban, and urban locations in Missouri between August 2008 and January 2010. In all, 486 adult patients with type 2 diabetes mellitus participated. Clinics were set up to implement either: 1) a clinic-based approach that involved practice re-design to routinely provide brief diabetes education and counseling services, set action-plans, and perform follow-up without additional financial resources [CARVE-IN]; or 2) an outsourced approach where clinics referred patients to a telephone-based diabetes educator for the same services [CARVE-OUT]. The fidelity of each intervention was determined by the number of contacts with patients, self-report of services received, and patient satisfaction. Intervention effectiveness was investigated by assessing patient knowledge, self-efficacy, health behaviors, and clinical outcomes. RESULTS: Carve-out patients received on average 4.3 contacts (SD = 2.2) from the telephone-based diabetes educator versus 1.7 contacts (SD = 2.0) from the clinic nurse in the carve-in arm (p < 0.001). They were also more likely to recall setting action plans and rated the process more positively than carve-in patients (p < 0.001). Few differences in diabetes knowledge, self-efficacy, or health behaviors were found between the two approaches. However, clinical outcomes did vary in multivariable analyses; carve-out patients had a lower HbA1c (ß = -0.31, 95 % CI -0.56 to -0.06, p = 0.02), systolic blood pressure (ß = -3.65, 95 % CI -6.39 to -0.90, p = 0.01), and low-density lipoprotein (LDL) cholesterol (ß = -7.96, 95 % CI -10.08 to -5.83, p < 0.001) at 6 months. CONCLUSION: An outsourced diabetes education and counseling approach for community health centers appears more feasible than clinic-based models. Patients receiving the carve-out strategy also demonstrated better clinical outcomes compared to those receiving the carve-in approach. Study limitations and unclear causal mechanisms explaining change in patient behavior suggest that further research is needed.

Telehealth ethics.

The ethical implications of telehealth go well beyond providers' obligations to ensure privacy and confidentiality. The ethical conundrum of telehealth realizes the uniquely positive impact that telehealth can have on patients, providers, and clinical outcomes, as well as the potential for harm and abuse that may ensue. This article explores telehealth as one of many evolving information technologies that have ethical questions extending well beyond the confines of privacy and confidentiality. Providers and systems who utilize telehealth should also consider how it influences relationships with patients, access to healthcare, capacity for equitable treatment, cost, and quality of life. The ability to respond to these concerns will be important to the future development and deployment of this important technology as one means by which to improve access and quality of healthcare for all members of our society.

The application of remote monitoring to improve health outcomes to a rural area.

The objective of this study was to evaluate the impact of remote monitoring home telehealth on client and provider satisfaction, clinical outcomes, and cost. The project design was a pragmatic evaluation of the technology in a real-world setting at an operational scale rather than a controlled clinical trial. Patients receiving monitoring were selected by the home health agency, and a random sample of other agency clients was selected for comparative purposes. Data were collected on additional costs and benefits associated with home telehealth monitoring. Quantitative and qualitative data suggest that when remote monitoring telehealth technology was utilized in the home-care setting, both clients and providers were very satisfied with services; they felt it was easy to communicate, and that the technology was convenient and user friendly. Clients also felt that home telehealth technology had a very positive impact on the provider-client relationship and improved care. The study also suggests that home care monitoring reduces hospitalizations and decreases personnel expenses. This preliminary study provides evidence as to the value of remote monitoring home telehealth in the delivery of services to home care populations. It also provides evidence as to the positive impact that this form of technology may have on healthcare systems, provider and client satisfaction, and on the relationships that form between providers and clients.

Achieving a high-performance health care system with universal access: what the United States can learn from other countries.

This position paper concerns improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it with health care in other countries. The concluding section proposes lessons that the United States can learn from these countries and recommendations for achieving a high-performance health care system in the United States. The articles are based on a position paper developed by the American College of Physicians' Health and Public Policy Committee. This policy paper (not included in this article) also provides a detailed analysis of health care systems in 12 other industrialized countries. Although we can learn much from other health systems, the College recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. This caution notwithstanding, we have identified several approaches that have worked well for countries like ours and could probably be adapted to the unique circumstances in the United States.

The burden of caregiving at the end-of-life.

Nonprofessional caregiving is crucial to effective end-of-life care for patients who wish to die at home. The burden of caregiving may lead to physical illness, emotional distress, financial hardship, and early mortality in the caregiver. Unmet caregiver needs have historically been poorly recognized and incompletely studied. Early recognition of caregiver distress, validation of the caregiver role, and effective communication by physicians may ease the burden of caregiving and help to secure a trusting partnership between the physician and the patient-caregiver unit at the end of life.

Caregiving near the end of life: unmet needs and potential solutions.

OBJECTIVE: A key aspect of the role of clinicians caring for patients in the setting of advanced illness focuses on attending to the needs of informal caregivers during the end-of-life period. The purpose of this study was twofold: (1) to complement and enrich existing quantitative findings regarding caregiver burden near the end of life, and (2) to identify potential solutions to caregivers' unmet needs in an effort to assist clinicians in the development of clinical interventions. METHODS: This qualitative study, using focus groups and content analysis of transcripts, was conducted in a comprehensive cancer center in Washington, DC. Seven focus groups were held: three with recently bereaved caregivers and four with active caregivers of patients with metastatic cancer and an expected survival of 6 to 12 months. RESULTS: Data were stratified into two broad categories: (1) general problems and (2) behaviors/activities that were helpful/would have been helpful in alleviating these problems. Within each of these two categories, five subcategories emerged: medical care (including provision of information, coordination of care, bedside manner, satisfaction with care), quality of life (including well-being, role adjustments), help from others (including practical assistance, social support), positives of caregiving, and unsolicited themes (including job flexibility, impact of the disease on the family, informational needs, relationship with patient). SIGNIFICANCE OF RESULTS: Results suggest caregivers may benefit from more information about patient prognosis and hospice, attention to quality-of-life issues, and enhanced, direct communication with clinicians. Although information of this nature is likely to be known to palliative care clinicians, the specific details and verbal insights provided by caregivers give an important voice to existing quantitative data and may provide more detailed information to assist palliative care clinicians seeking to develop interventions to meet caregiver needs during the period near the end of life.

A needs assessment study for the Missouri Tele-hospice Project.

Hospice care focuses on palliation and the relief of suffering aiming to improve the quality of patients' last days. Telemedicine is considered to be a tool that can address challenges such as staff shortage, funding limitations and limited access to services in rural areas. Hospice services via telemedicine can be delivered directly into a patient's home by utilizing videoconferencing technology. The Missouri Telehospice Project aims to investigate the impact of a telehospice model on satisfaction with delivered care, caregiver burden, crisis prevention rates and overall cost of delivered care. Five urban and rural hospice agencies in Missouri are participating. A needs assessment study was conducted where hospice staff members responded to a set of questions within focus group and interview sessions providing feedback about the design, type of technology, frequency of usage and perceived impact on quality of hospice care.