Responsible Practice or Restricted Practice? an Empirical Study of the Use of Clinical Guidelines in Medical Negligence Litigation.

In medical negligence litigation, the standard for breach of duty is measured against the Bolam test which reflects accepted practice. Despite protracted debate and common law development, the Bolam standard remains the touchstone for litigation in this area. Clinical guidelines (CGs) are statements based upon best available medical evidence and are designed to facilitate clinical decision-making to optimise outcomes thereby reflecting expected practice. Nevertheless, there is little research that considers how CGs engage in litigation and their influence on judicial reasoning. Given the increasing pressures on the NHS amid rising costs of litigation, these are important issues. This study provides an original contribution to the literature on CGs in determining breach of duty in law. Using a mixed methods' approach, data from multiple sources have been gathered and analysed to assess the use of CGs by lawyers and the courts thereby adding to the discourse on the judicial shift away from deference to Bolam. It concludes by offering a conceptual basis for the use of CGs within a framework for reasonableness and promotes their principled use while avoiding constraints on expert testimony, experience, and exercise of clinical discretion. This study has relevance for academics, legal and medical practitioners, and policy makers.

Intervening to enhance collaboration in translational research: A relational coordination approach.

INTRODUCTION: A core challenge of a multidisciplinary and multi-organizational translational research enterprise such as a Clinical and Translational Research Award (CTSA) is coordinating and integrating the work of individuals, workgroups, and organizations accustomed to working independently and autonomously. Tufts Clinical and Translational Science Institute (CTSI) undertook and studied a multifacted intervention to address this challenge and to create a culture of systems thinking, process awareness, responsive to others' needs, and shared decision-making. INTERVENTION: The intervention, based on relational coordination, included 1) relational interventions, in three staff retreats and a diagnostic survey to provide feedback on the current quality of relational coordination, and 2) structural interventions, in the launching of five new cross-functional teams with regular meeting structures. METHODS: A mixed-methods evaluation yielded quantitative data via two types of team surveys and qualitative data via interviews and meeting observations. RESULTS: The findings suggest that interventions to improve relational coordination are feasible for CTSAs, including good fidelity to the model and staff/physician engagement. Survey and interview data suggest model improvements in coordination and alignment. Further research about their optimal design is warranted.

DEVO-(WO) MAN? A MOVE IN RESPECT OF PERSONAL SOVEREIGNTY AND DECISION-MAKING IN HEALTH CARE? Anita Border v Lewisham and Greenwich NHS Trust [2015] EWCA Civ 8.

This case commentary discusses a recent case concerning the determination of acceptable clinical practice. It critically examines two particular elements of the judgment-the method for the determination of acceptable clinical practice including the impact (if any) of the Bolitho exception. It then moves on to considering the importance of consent as a pre-requisite for medical treatment and the interplay of negligence and battery in this area. It concludes by examining the possibility that the courts in England and Wales might be entering an era of judicial assertiveness in the regulation of clinical practice.

Teamwork methods for accountable care: relational coordination and TeamSTEPPS®.

BACKGROUND: To deliver greater value in the accountable care context, the Institute of Medicine argues for a culture of teamwork at multiple levels--across professional and organizational siloes and with patients and their families and communities. The logic of performance improvement is that data are needed to target interventions and to assess their impact. We argue that efforts to build teamwork will benefit from teamwork measures that provide diagnostic information regarding the current state and teamwork interventions that can respond to the opportunities identified in the current state. PURPOSE: We identify teamwork measures and teamwork interventions that are validated and that can work across multiple levels of teamwork. We propose specific ways to combine them for optimal effectiveness. APPROACH: We review measures of teamwork documented by Valentine, Nembhard, and Edmondson and select those that they identified as satisfying the four criteria for psychometric validation and as being unbounded and therefore able to measure teamwork across multiple levels. We then consider teamwork interventions that are widely used in the U.S. health care context, are well validated based on their association with outcomes, and are capable of working at multiple levels of teamwork. We select the top candidate in each category and propose ways to combine them for optimal effectiveness. FINDINGS: We find relational coordination is a validated multilevel teamwork measure and TeamSTEPPS® is a validated multilevel teamwork intervention and propose specific ways for the relational coordination measure to enhance the TeamSTEPPS intervention. PRACTICAL IMPLICATIONS: Health care systems and change agents seeking to respond to the challenges of accountable care can use TeamSTEPPS as a validated multilevel teamwork intervention methodology, enhanced by relational coordination as a validated multilevel teamwork measure with diagnostic capacity to pinpoint opportunities for improving teamwork along specific dimensions (e.g., shared knowledge, timely communication) and in specific role relationships (e.g., nurse/medical assistant, emergency unit/medical unit, primary care/specialty care).

Pathways of health technology diffusion: the United States and low-income countries.

In the United States, the complex process of getting health care technologies into practice takes place in a competitive health system that is driven by technological innovation. Federal, state, and local governments' roles in the diffusion process are limited. In low-income countries, where competitive markets are not as prominent, diffusing medical innovations requires an alternative understanding of how new technologies are adopted. This paper describes how, in low-income countries, the lack of functioning markets serves as a barrier to the transfer of necessary health technologies, and why governments must act as stewards in promoting technologies there.