Project to improve storage, access and incorporation of advance care plans in a regional Australian hospital.

PROBLEM: Despite acknowledged benefits, the impact of advance care planning on usual care is inconsistent. DESIGN: Quality improvement study. SETTING: A Western Australian regional hospital. KEY MEASURES FOR IMPROVEMENT: This project aimed to create a system for storing, accessing and incorporating advance care planning documents in clinical care. STRATEGIES FOR CHANGE: Interventions over 18 months addressed four areas: medical records processes for receiving and processing advance care planning documents; information technology solutions for electronic storage and alerts; clerical staff duties in regards advance care planning documents; and clinician education. EFFECTS OF CHANGE: There was a 12-fold increase in advance care planning documents stored electronically and 100% of audited notes had correct filing of advance care planning documents with an alert in place at follow-up audit. Clinician recognition of the presence of an advance care planning document improved. Detailed examples of interventions are described. LESSONS LEARNT: Repeated exposure to different forms of advance care planning education, in conjunction with simple but effective system changes can make a difference in changing established hospital practice. Final impact of these changes on end-of-life care requires further audit.

Outsourcing your medical practice call center: how to choose a vendor to ensure regulatory compliance.

Medical practices receive hundreds if not thousands of calls every week from patients, payers, pharmacies, and others. Outsourcing call centers can be a smart move to improve efficiency, lower costs, improve customer care, ensure proper payer management, and ensure regulatory compliance. This article discusses how to know when it's time to move to an outsourced call center, the benefits of making the move, how to choose the right call center, and how to make the transition. It also provides tips on how to manage the call center to ensure the objectives are being met.

Which factors predict the time spent answering queries to a drug information centre?

OBJECTIVE: To develop a model based upon factors able to predict the time spent answering drug-related queries to Norwegian drug information centres (DICs). SETTING AND METHOD: Drug-related queries received at 5 DICs in Norway from March to May 2007 were randomly assigned to 20 employees until each of them had answered a minimum of five queries. The employees reported the number of drugs involved, the type of literature search performed, and whether the queries were considered judgmental or not, using a specifically developed scoring system. MAIN OUTCOME MEASURES: The scores of these three factors were added together to define a workload score for each query. Workload and its individual factors were subsequently related to the measured time spent answering the queries by simple or multiple linear regression analyses. RESULTS: Ninety-six query/answer pairs were analyzed. Workload significantly predicted the time spent answering the queries (adjusted R (2) = 0.22, P < 0.001). Literature search was the individual factor best predicting the time spent answering the queries (adjusted R(2) = 0.17, P < 0.001), and this variable also contributed the most in the multiple regression analyses. CONCLUSION: The most important workload factor predicting the time spent handling the queries in this study was the type of literature search that had to be performed. The categorisation of queries as judgmental or not, also affected the time spent answering the queries. The number of drugs involved did not significantly influence the time spent answering drug information queries.

Patient Advice and Liaison Services: results of an audit survey in England.

OBJECTIVE: To assess the extent national standards for Patient Advice and Liaison Services (PALS) were achieved across England. CONTEXT: PALS are an important element of patient and public involvement strategy in England. Seven national standards for PALS were identified. Previous research has not assessed PALS across all trust types in England. DESIGN: Audit survey as part of a mixed method 'realistic evaluation' in which regularities of context, mechanism and outcome are hypothesized and tested. SETTING AND PARTICIPANTS: PALS based in 570 NHS trusts in England between October and December 2005. MAIN OUTCOME MEASURES: Self reported achievement against PALS national standards. RESULTS: Three hundred and thirty-six valid responses were received, a response rate of 65%. However because some PALS serve more than one trust, this represents an estimated 76% of trusts. Overall, PALS rated themselves highly against all the standards, though somewhat less highly against standard 2 (seamlessness across health and social care) and standard 6 (acting as a catalyst for culture change). There was a wide range of responses with regard to PALS budget, staffing and activity levels, and statistically significant associations between levels of funding and staffing and higher levels of performance. CONCLUSIONS: The overall response rate was good so there can be a high degree of confidence in the reliability of the results. The results indicate the challenging context in which PALS are operating. Although the majority of PALS are single trust PALS, there is a high degree of variation in key mechanism factors such as budget and staffing.

Patient safety in after-hours telephone medicine.

OBJECTIVES: This study analyzed our family medicine department's after-hours telephone medicine systems at an academic health center from a patient safety perspective. The research questions were (1) What are the threats to patient safety associated with after-hours telephone medicine and (2) What kinds of errors are made during after-hours telephone medicine? METHODS: Subjects were patients at the University of Kentucky family medicine practice who called in to the after-hours answering service. Telephone interviews were conducted with 64 patients over 10 weeks. During the interviews, patients described their telephone medicine experience, identified any problems, and reported potential or actual harm (patient-identified threats to patient safety). Two registered nurses and one physician analyzed the patient narratives to identify threats to patient safety (medical personnel-identified threats to patient safety). RESULTS: Sixty-three analyzable patient interviews identified four instances (6%) of temporary physical harm. Two separate after-hours calls (3%) involved four medical errors with potentially serious consequences to patient safety (wrong dose, serious illness not ruled out). Fourteen calls (22%) involved events that could have threatened patient safety. CONCLUSIONS: Situations that threaten patient safety occur frequently in telephone medicine. Although this study is too small to draw strong conclusions, it suggests that there are risks to patient safety associated with after-hours telephone medicine.

The Call-Centre: a child welfare liaison program with immigrant serving agencies.

Alberta, Canada, welcomed nearly 16,000 landed immigrants in 2003, of whom more than half came to the Calgary area. Approximately 200,000 immigrants of various ethnic and cultural groups now live in the region. Many of these new arrivals have no natural support networks while struggling with language, cultural, and economic barriers. Recognizing these difficulties, the Calgary and Area Child and Family Services Authority (CFSA) joined with several Immigrant Serving Agencies to develop guidelines and procedures to direct staff working with diverse cultures, including the Call-Centre pilot project, which provided CFSA staff with a one-stop telephone contact for information about an immigrant or refugee family, their culture, and available culturally-appropriate resources. The Call-Centre, which is currently being evaluated by researchers at the University of Calgary, will gradually expand to all CFSA sites in the region. This article describes the Call-Centre and the first phase of the evaluation.

[The 'Beijing clinical database' on severe acute respiratory syndrome patients: its design, process, quality control and evaluation].

OBJECTIVE: To develop a large database on clinical presentation, treatment and prognosis of all clinical diagnosed severe acute respiratory syndrome (SARS) cases in Beijing during the 2003 "crisis", in order to conduct further clinical studies. METHODS: The database was designed by specialists, under the organization of the Beijing Commanding Center for SARS Treatment and Cure, including 686 data items in six sub-databases: primary medical-care seeking, vital signs, common symptoms and signs, treatment, laboratory and auxiliary test, and cost. All hospitals having received SARS inpatients were involved in the project. Clinical data was transferred and coded by trained doctors and data entry was carried out by trained nurses, according to a uniformed protocol. A series of procedures had been taken before the database was finally established which included programmed logic checking, digit-by-digit check on 5% random sample, data linkage for transferred cases, coding of characterized information, database structure standardization, case reviewe by computer program according to SARS Clinical Diagnosis Criteria issued by the Ministry of Health, and exclusion of unqualified patients. RESULTS: The database involved 2148 probable SARS cases in accordant with the clinical diagnosis criteria, including 1291 with complete records. All cases and record-complete cases showed an almost identical distribution in sex, age, occupation, residence areas and time of onset. The completion rate of data was not significantly different between the two groups except for some items on primary medical-care seeking. Specifically, the data completion rate was 73% - 100% in primary medical-care seeking, 90% in common symptoms and signs, 100% for treatment, 98% for temperature, 90% for pulse, 100% for outcomes and 98% for costs in hospital. CONCLUSION: The number of cases collected in the Beijing Clinical Database of SARS Patients was fairly complete. Cases with complete records showed that they could serve as excellent representatives of all cases. The completeness of data was quite satisfactory with primary clinical items which allowed for further clinical studies.

Bioethics in Germany: debates and infrastructure.

In Germany the public awareness on ethical problems of the application of medicine and life sciences on human beings is very high. It can be observed that German Society is rather sensitive concerning bioethical issues. Politics supports this attitude. Many articles in professional journals as well as in newspapers cover bioethical issues. Conferences and workshops on a professional and an educational level deal with topics on ethics of life sciences and ethics in general. Moreover, in the case of bioethics many different disciplines contribute with relevant considerations to the process of opinion and judgment formation. This paper summarizes the main ethical and legal debates on bioethical issues in Germany, specifies the focus of leading German centres of bioethics and biolaw, and explains the tasks, services and networking of the German Reference Centre for Ethics in the Life Sciences (DRZE) which was founded by the Federal Government.

Evaluation activities to strengthen an injury prevention resource center for urban families.

The Johns Hopkins Children's Safety Center (CSC) is a unique health care provider and patient education resource that elevates the attention injury prevention receives in a medical setting and reduces barriers to injury prevention experienced by low-income, urban families, the Center's priority population. This article describes the CSC's development, implementation, and selected elements of its evaluation. Because evaluation has played an important role in the CSC from its inception through its implementation and sustainability, three evaluation activities are described: process evaluation to monitor activity, impact evaluation to understand its effects on parents' safety behaviors, and qualitative interviews with CSC visitors and non-visitors to enhance services. Implications of each evaluation activity are described and recommendations are made for strengthening the CSC.