The power of nursing peer review.

This article describes how an integrated healthcare system created a nursing peer-review structure to empower nurses to make practice changes and enhance professional accountability. A nursing peer-review committee and tools supporting the process were developed and implemented.

A critical review of Dr. Charles S. Greene's article titled "Managing the Care of Patients with Temporomandibular Disorders: a new Guideline for Care" and a revision of the American Association for Dental Research's 1996 policy statement on temporomandibular disorders, approved by the AADR Council in March 2010, published in the Journal of the American Dental Association September 2010.

Dr. Charles Greene's article, "Managing the Care of Patients with TMDs A New Guideline for Care," and the American Association for Dental Research's (AADR) 2010 Policy Statement on Temporomandibular Disorders, published in the Journal of the American Dental Association (JADA) September 2010, are reviewed in detail. The concept that all temporomandibular disorders (TMDs) should be lumped into one policy statement for care is inappropriate. TMDs are a collection of disorders that are treated differently, and the concept that TMDs must only be managed within a biopsychosocial model of care is inappropriate. TMDs are usually a musculoskeletal orthopedic disorder, as defined by the AADR. TMD orthopedic care that is peer-reviewed and evidence-based is available and appropriate for some TMDs. Organized dentistry, including the American Dental Association, and mainstream texts on TMDs, support the use of orthopedics in the treatment of some TMDs. TMDs are not psychological or social disorders. Informed consent requires that alternative care is discussed with patients. Standard of care is a legal concept that is usually decided by a court of law and not decided by a policy statement, position paper, guidelines or parameters of care handed down by professional organizations. The 2010 AADR Policy Statement on TMD is not the standard of care in the United States. Whether a patient needs care for a TMD is not decided by a diagnostic test, but by whether the patient has significant pain, dysfunction and/or a negative change in quality of life from a TMD and they want care. Some TMDs need timely invasive and irreversible care.

Reviewing and reflecting on practice: the midwives experiences of credentialling.

RESEARCH QUESTION: What are the experiences of midwives working in midwifery-led models of care in NSW who undertake the credentialling process? BACKGROUND: In 2005, the NSW Health Department issued a directive requiring midwives who worked in midwifery-led models of care to undergo a process known as credentialling. Credentialling involved a four-step process: self-assessment, face-to-face panel review of midwifery practice, assessment of emergency management skills and discussion of a case study from practice. METHOD: A descriptive exploratory study examined the experiences of the midwives who undertook the credentialling process in NSW. Data were collected through in-depth, semi-structured interviews with 12 midwives who had experienced credentialling and analysed using descriptive and thematic analysis. FINDINGS: The themes were preparing for credentialling; doing credentialling; achieving credentialling; valuing credentialling; and, improving credentialling. Initially, the midwives were self-focused in their understanding and impressions of the value of credentialling. There were a number of contentions including seeing credentialling as another 'hoop to jump through' or a need to 'tick the box' and not as a framework for practice. Some viewed it as a necessary move to increase professionalism and facilitate practice review. Others felt they were being unfairly targeted as not all midwives were expected to undertake it. The midwives were cognisant of the need for a process that encouraged responsibility for ongoing professional development and continuing competence and believed the process would be useful in promoting deeper reflection on practice. IMPLICATIONS FOR PRACTICE: Credentialling was recognised as being valuable for all midwives to undertake as it encourages both a review of, and reflection on, practice. The process has further developed into Midwifery Practice Review (MPR) and is administered by the national professional association for midwifery.

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

BACKGROUND: Despite extensive ongoing quality improvement (QI) efforts, substantial variation existed in hospital standardized mortality ratios (HSMRs) across hospitals in Kaiser Permanente, an integrated health care delivery system. In 2008, Kaiser Permanente developed an efficient and effective method for investigating hospital-level mortality to identify patterns of potential harm. METHODS: The standardized multidisciplinary mortality review process incorporates the Institute for Healthcare Improvement Global Trigger Tools and 2x2 Mortality Matrix, elements of the United Kingdom's National Health Service (NHS) 3x2 matrix, and two groups of questions to "deep dive" into issues of preventable harm and the use of appropriate care settings. Between April 2008 and November 2009, multidisciplinary teams conducted mortality reviews of the 50 most recent inpatient deaths at 11 hospitals in Kaiser Permanente's Southern California region. An electronic chart abstraction tool facilitated rapid analysis of data. De-identified patient narratives portrayed trends and issues from a patient-centered perspective. RESULTS: Ten categories of harm in inpatient deaths were identified, including failure to rescue, to plan, and to communicate; harm that occurred before hospitalization; medication-related events; surgical or procedural-related harm; hospital-acquired infection and pressure ulcers; falls; and "other." Senior leaders at the study hospitals identified 36 quality improvement goals in response. CONCLUSIONS: The mortality review process, which included quantitative data from structured chart abstraction and qualitative description of harm events, efficiently gathered important information on patterns of mortality that was not otherwise available, enabling hospitals to identify trends and focus improvement efforts.

Yoga for arthritis: a scoping review.

This article reviews the existing literature on using yoga for arthritis. It includes peer-reviewed research from clinical trials (published from 1980 to 2010) that used yoga as an intervention for arthritis and reported quantitative findings. Eleven studies were identified, including 4 randomized controlled trials (RCTs) and 4 non-RCTs. All trials were small and control groups varied. No adverse events were reported, and attrition was comparable or better than that typical for exercise interventions. Evidence was strongest for reduced disease symptoms (tender/swollen joints, pain) and disability and for improved self-efficacy and mental health. Interventions, research methods, and disease diagnoses were heterogeneous.

Infusing evidence-based practice into interdisciplinary perinatal morbidity and mortality conferences.

Incorporating evidence-based practice into the hospital setting has been a challenge but is needed to deliver quality healthcare. Interdisciplinary morbidity and mortality conferences are used to discuss perinatal and neonatal care issues with high-risk and low-frequency cases, such as fetal demise, maternal death, or identified areas for improvement. By involving an interdisciplinary team to review the patient's case, a more holistic perspective of the patient's care will be achieved. The purpose of this article is to demonstrate how nurses can be an essential part of the interdisciplinary morbidity and mortality conferences and how to infuse evidence-based practice into the conference. A perinatal morbidity and mortality conference will be described to illustrate how one maternal-neonatal department brought medicine and nursing together to review care.

Professional regulation in nursing. Part 1: an introduction.

The preceding articles in this series have addressed the issues that surround the legal principle of owing a duty of care to people. The articles discussed the underlying concept of the application of 'standards' to a nurse's duty to people. Nurses owe to their patients and clients a duty that is underpinned not only by law (or legal principles) but also by reference to a more overtly political understanding. The purpose of this cluster of articles is try to identify how the Government has achieved its purpose of increasing the protection of the public (its underlying rationale for the changes brought to the health care professions). It is intended to approach this subject in a two-fold way: first, a descriptive perusal of government literature will be undertaken; second, in an chronological way, the responses from the health profession's regulatory bodies will be elucidated by way of analysis.

Developing a review process for Australian midwives: a report of the midwifery practice review project process.

OBJECTIVE: To develop a formal, robust and transparent process that supports and enables midwives to reflect on their own midwifery practice in relation to recognised professional standards and to identify, prioritise and act upon individual professional development and learning needs for the provision of safe, high quality care to women and their families within the full scope of midwifery practice. This process was part of a national project commissioned by the Australian College of Midwives and funded by the Australian Council for Safety and Quality in Health Care and is part of the Continuing Professional Development, MidPLUS program developed by the Australian College of Midwives. APPROACH: A multi-method, staged approach was used to develop the national Midwifery Practice Review process. Data to inform the development of the Midwifery Practice Review process was collected through a literature review, workshop consultations, written submissions and the pilot testing of a draft process. Finally, a national training workshop was undertaken to train reviewers to carry out reviews and to ensure the final process was validated and was feasible and acceptable to midwives and consumers. SETTING: Maternity care settings in each state and territory throughout Australia. PARTICIPANTS: Midwives, other health professionals and consumers of midwifery care. FINDINGS: The Midwifery Practice Review process was developed through research and national consultation prior to being validated in practice. KEY CONCLUSIONS: The Midwifery Practice Review process is currently being implemented and evaluated in Australia. IMPLICATIONS FOR PRACTICE: The Midwifery Practice Review Project established a national validated process for assessing the ongoing competence of midwives. The resulting program helps to reinforce responsibility and accountability in the provision of quality midwifery care through safe and effective practice.

Cooperative uses grant to evaluate quality plan.

Ease of access as well as extensive electronic sharing of information characterize the program. Physicians receive incentives based on measures of productivity, cost, and quality. The model covers range of care, from primary care and prevention to palliation/hospice.

Moving forward? Complementary and alternative practitioners seeking self-regulation.

Complementary and alternative medicine (CAM) occupations continue to struggle towards achieving professional status, especially in the form of statutory regulation. Many consider professional status a worthwhile goal for CAM occupations, yet it is a process fraught with tensions. In this paper we present in-depth interview data from the leaders of three CAM groups (naturopaths, traditional Chinese medicine practitioners acupuncturists, and homeopaths) in Ontario, Canada that demonstrate four main strategies used by these groups to professionalize. The strategies discussed are related to how the knowledge base of each group is organised and transmitted. These strategies include: improving educational standards, improving practice standards, engaging in peer-reviewed research and increasing group cohesion. At the core of these strategies is the demarcation of who is qualified to practice, and a signalling to 'outsiders', such as medicine and the government, that practitioners are qualified and legitimate. Across the three groups, the leaders referred to the inclusion of medical science as a basis for distinguishing between 'science' and 'non-science' as well as who should practice and who should not. We highlight how internal battles over the infusion of medical science into the knowledge base are part of the process for establishing legitimacy for the three CAM groups in our study. We end with a brief discussion of the implications of these internal battles over medical science knowledge for the future of CAM groups.

The evidence base for complementary and alternative medicine: methods of Evidence Mapping with application to CAM.

BACKGROUND: There is widespread concern regarding the adequacy of evidence for specific practices under the rubric of "complementary and alternative medicine" (CAM). OBJECTIVE: To map the evidence pertaining to many commonly used CAM practices. DESIGN: In 2000, the Yale Prevention Research Center was funded by the Centers for Disease Control and Prevention to conduct a "systematic review" of the evidence underlying CAM. The investigative team, working in collaboration with CAM practitioners, developed a systematic and replicable 9-step process termed evidence mapping. The process stipulates means for specifying the boundaries of the subject to be mapped in MeSH terms, and the characteristics used to situate retrieved articles in the overall map of evidence. SETTING: Yale Prevention Research Center, Derby, CT. RESULTS: Steps completed thus far have led to the identification of over 4,000 papers distributed across 207 condition-treatment pairs. Of these pairs, 58% (n = 121) have been studied with one or more RCTs (1,070 total RCTs), and 23% (n = 47) have been the subject of one or more meta-analyses (86 total meta-analyses). Thirty-seven condition/treatment pairs (18%) had no identifiable supporting studies. CONCLUSIONS: The novel methods of evidence mapping reported are useful and practical in characterizing the extent, distribution, and methodologic quality of research pertaining to a broad topic in medicine. Applied to CAM, they suggest that summary judgments about the quantity or quality of underlying evidence are overly simplistic.

Report of the mid-term review of Victoria's Maternity Services Program.

Substantial State Government funding has been committed in Victoria for the enhancement of maternity services. The funding is intended to improve the quality of care for women and meet consumer expectations for choice and continuity of care in maternity services. This paper reports on a mid-term review (the 'Review') of the Victorian Maternity Services Program, which was conducted by the authors on behalf of the Victorian Department of Human Services. Documentary analysis was conducted for the review, and workshops and key informant interviews were held throughout Victoria with midwives, medical staff and Department of Human Services staff. The Review found that there had been many gains as a result of the Maternity Services Program and identified directions for further development. Issues of change and facilitators of change processes in maternity services are highlighted in this article.

Clinical significance of performing immunohistochemistry on cases with a previous diagnosis of cancer coming to a national comprehensive cancer center for treatment or second opinion.

Immunohistochemistry (IHC) is an important adjunctive test in diagnostic surgical pathology. We studied the clinical significance and outcomes in performing IHC on cases with a previous diagnosis of cancer who are coming to the Fox Chase Cancer Center (FCCC), a National Cancer Institute designated National Comprehensive Cancer Center (NCCC), for treatment and/or second opinion. We reviewed all the outside surgical pathology slide review cases seen at the FCCC for 1998 and 1999 in which IHC was performed. Cases were divided into the following: confirmation of outside diagnoses without and with prior IHC performed by the outside institution (groups A and B, respectively) and cases with a significant change in diagnosis without and with prior IHC performed by the outside institution (groups C and D, respectively). During 1998 and 1999, 6678 slide review cases were reviewed at the FCCC with an overall significant change in diagnosis in 213 cases (3.2%). IHC was performed on 186 of 6678 (2.7%) slide review cases with confirmation of the outside diagnosis in 152 (81.7%) cases and a significant change in diagnosis in 34 (18.3%) cases. Patient follow-up was obtained in 32 of 34 (94.1%) cases with a significant change in diagnosis (groups C and D), which confirmed the correctness of our diagnosis in 26 of 27 cases (96%; in five cases follow-up was inconclusive). We repeated the identical antibodies performed by the outside institutions in group D (37 antibodies) and group B (133 antibodies) with different results in 48.6% and 13.5%, respectively (overall nonconcordance 21.2%). In group D additional antibody tests beyond that performed by the outside institution were needed in 88.8% of cases to make a change of diagnosis. In the setting of a NCCC, reperforming and/or performing IHC on cases with a previous diagnosis of cancer is not a duplication of effort or misuse of resources. Repeating and/or performing IHC in this setting is important in the care and management of patients with cancer.

Assessing efficacy of complementary medicine: adding qualitative research methods to the "Gold Standard".

Randomized controlled trials (RCTs) have an important place in the assessment of the efficacy of complementary and alternative medicine (CAM). However, they address only one, limited, question, namely whether an intervention has-statistically-an effect. They do not address why the intervention works, how participants are experiencing the intervention, and/or how they give meaning to these experiences. Therefore, we argue that the addition of qualitative research methods to RCTs can greatly enhance understanding of CAM interventions. Qualitative research can assist in understanding the meaning of an intervention to patients as well as patients' beliefs about the treatment and expectations of the outcome. Qualitative research also assists in understanding the impact of the context and the process of the intervention. Finally, qualitative research is helpful in developing appropriate outcome measures for CAM interventions. Greater understanding of CAM interventions has the potential to improve health care delivery.

An economic analysis of midwifery training programmes in South Kalimantan, Indonesia.

In order to improve the knowledge and skills of midwives at health facilities and those based in villages in South Kalimantan, Indonesia, three in-service training programmes were carried out during 1995-98. A scheme used for both facility and village midwives included training at training centres, peer review and continuing education. One restricted to village midwives involved an internship programme in district hospitals. The incremental cost-effectiveness of these programmes was assessed from the standpoint of the health care provider. It was estimated that the first scheme could be expanded to increase the number of competent midwives based in facilities and villages in South Kalimantan by 1% at incremental costs of US$ 764.6 and US$ 1175.7 respectively, and that replication beyond South Kalimantan could increase the number of competent midwives based in facilities and villages by 1% at incremental costs of US$ 1225.5 and US$ 1786.4 per midwife respectively. It was also estimated that the number of competent village midwives could be increased by 1% at an incremental cost of US$ 898.1 per intern if replicated elsewhere, and at a cost of US$ 146.2 per intern for expanding the scheme in South Kalimantan. It was not clear whether the training programmes were more or less cost-effective than other safe motherhood interventions because the nature of the outcome measures hindered comparison.