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1.
J Am Geriatr Soc ; 69(4): 850-860, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33577714

RESUMO

BACKGROUND/OBJECTIVES: Regulatory oversight has been a central strategy to assure nursing home quality of care for decades. In response to COVID-19, traditional elements of oversight that relate to resident care have been curtailed in favor of implementing limited infection control surveys and targeted complaint investigations. We seek to describe the state of nursing home oversight during the pandemic to facilitate a discussion of whether and how these activities should be altered going forward. DESIGN AND SETTING: In a retrospective study, we describe national oversight activities in January-June 2020 and compare these activities to the same time period from 2019. We also examine state-level oversight activities during the peak months of the pandemic. PARTICIPANTS: United States nursing homes. DATA: Publicly available Quality, Certification, and Oversight Reports (QCOR) data from the Centers for Medicare and Medicaid Services (CMS). MEASUREMENTS: Number of standard, complaint, and onsite infection surveys, number of deficiencies from standard and complaint surveys, number of citations by deficiency tag, and number and amount of civil monetary penalties. RESULTS: The number of standard and complaint surveys declined considerably in the second quarter of 2020 relative to the same time frame in 2019. Deficiency citations generally decreased to near zero by April 2020 with the exception of infection prevention and control deficiencies and citations for failure to report COVID-19 data to the national health safety network. Related enforcement actions were down considerably in 2020, relative to 2019. CONCLUSION: In the months since COVID-19 first impacted nursing homes, regulatory oversight efforts have fallen off considerably. While CMS implemented universal infection control surveys and targeted complaint investigations, other routine aspects of oversight dropped in light of justifiable limits on nursing home entry. Going forward, we must develop policies that allow regulators to balance the demands of the pandemic while fulfilling their responsibilities effectively.


Assuntos
Centers for Medicare and Medicaid Services, U.S./estatística & dados numéricos , Controle de Infecções , Notificação de Abuso , Casas de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Idoso , Certificação/normas , Feminino , Regulamentação Governamental , Humanos , Estudos Retrospectivos , Estados Unidos
2.
J Surg Res ; 262: 240-243, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33549329

RESUMO

As the SARS-COV-2 pandemic created the need for social distancing and the implementation of nonessential travel bans, residency and fellowship programs have moved toward a web-based virtual process for applicant interviews. As part of the Society of Asian Academic Surgeons 5th Annual Meeting, an expert panel was convened to provide guidance for prospective applicants who are new to the process. This article provides perspectives from applicants who have successfully navigated the surgical subspecialty fellowship process, as well as program leadership who have held virtual interviews.


Assuntos
/prevenção & controle , Cirurgia Geral/educação , Internato e Residência/organização & administração , Seleção de Pessoal/métodos , Comunicação por Videoconferência/organização & administração , /epidemiologia , Certificação/organização & administração , Certificação/normas , Docentes/psicologia , Docentes/normas , Bolsas de Estudo/organização & administração , Bolsas de Estudo/normas , Humanos , Internato e Residência/normas , Liderança , Pandemias/prevenção & controle , Seleção de Pessoal/organização & administração , Seleção de Pessoal/normas , Conselhos de Especialidade Profissional , Cirurgiões/psicologia , Cirurgiões/normas
4.
Am J Surg ; 221(2): 388-393, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33341234

RESUMO

BACKGROUND: Competency-based medical education requires evaluations of residents' performances of tasks of the discipline (ie. entrustable professional activities (EPAs)). Using neurosurgical Faculty perspectives, this study investigated whether a sample of neurosurgical EPAs accurately reflected the expectations of general neurosurgical practice. METHOD: A questionnaire was sent to all Canadian neurosurgery Faculty using a SurveyMonkey® platform. RESULTS: The proportion of respondents who believed the EPAs were representative of general neurosurgery competences varied significantly across all EPAs [47%-100%] (p < 0.0001). For 9/15 proposed EPAs, ≥75% agreed they were appropriate for general neurosurgery training and expected residents to attain the highest standard of performance. However, a range of 27-53% of the respondents felt the other six EPAs would be more appropriate for fellowship training and thus, require a lower standard of performance from graduating residents. CONCLUSION: The shift towards subspecialization in neurosurgery has implications for curriculum design, delivery and certification of graduating residents.


Assuntos
Competência Clínica/normas , Educação Baseada em Competências/normas , Internato e Residência/normas , Neurocirurgiões/educação , Neurocirurgia/educação , Canadá , Certificação/normas , Currículo/normas , Docentes de Medicina/estatística & dados numéricos , Humanos , Internato e Residência/métodos , Neurocirurgiões/normas , Neurocirurgia/normas , Inquéritos e Questionários/estatística & dados numéricos
5.
Methodist Debakey Cardiovasc J ; 16(3): 199-204, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33133355

RESUMO

Americans expect their doctors to have the competence to deliver high-quality care and expect safeguards to be in place that assure their doctors are competent. However, competence requires knowledge, and people have trouble assessing their own knowledge and level of competence. Because external assessment is required, several organizations have taken on the roles of defining and assuring medical competence. For example, professional organizations such as the American College of Cardiology (ACC) have developed consensus documents that define core competencies for cardiologists. External organizations such as the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine (ABIM) have defined training requirements for cardiologists, and the ABIM has developed a process to certify that physicians maintain their competence, although the process has generated considerable criticism from the profession. Recently, the ACC and ABIM have worked together to make the certification process less onerous and more meaningful. This paper provides a brief summary of the history and ongoing efforts to assure the competence of cardiologists.


Assuntos
Acreditação , Cardiologistas/educação , Cardiologia/educação , Certificação , Competência Clínica , Educação de Pós-Graduação em Medicina , Acreditação/normas , Cardiologistas/normas , Cardiologia/normas , Certificação/normas , Competência Clínica/normas , Currículo , Educação de Pós-Graduação em Medicina/normas , Humanos
6.
Anesth Analg ; 131(5): 1412-1418, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079864

RESUMO

In 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate an Objective Structured Clinical Examination (OSCE) into its initial certification examination system. Previously, the ABA's staged examination system consisted of 2 written examinations (the BASIC and ADVANCED examinations) and the Standardized Oral Examination (SOE). The OSCE and the existing SOE are now 2 separate components of the APPLIED Examination. This report presents the results of the first-year OSCE administration. A total of 1410 candidates took both the OSCE and the SOE in 2018. Candidate performance approximated a normal distribution for both the OSCE and the SOE, and was not associated with the timing of the examination, including day of the week, morning versus afternoon session, and order of the OSCE and the SOE. Practice-based Learning and Improvement was the most difficult station, while Application of Ultrasonography was the least difficult. The correlation coefficient between SOE and OSCE scores was 0.35 ([95% confidence interval {CI}, 0.30-0.39]; P < .001). Scores for the written ADVANCED Examination were modestly correlated with scores for the SOE (r = 0.29 [95% CI, 0.25-0.34]; P < .001) and the OSCE (r = 0.15 [95% CI, 0.10-0.20]; P < .001). Most of the candidates who failed the SOE passed the OSCE, and most of the candidates who failed the OSCE passed the SOE. Of the 1410 candidates, 77 (5.5%) failed the OSCE, 155 (11.0%) failed the SOE, and 25 (1.8%) failed both. Thus, 207 (14.7%) failed at least 1 component of the APPLIED Examination. Adding an OSCE to a board certification examination system is feasible. Preliminary evidence indicates that the OSCE measures aspects of candidate abilities distinct from those measured by other examinations used for initial board certification.


Assuntos
Anestesiologia/normas , Certificação/normas , Avaliação Educacional , Competência Clínica , Comunicação , Humanos , Internato e Residência , Aprendizagem , Papel Profissional , Melhoria de Qualidade , Conselhos de Especialidade Profissional , Ultrassonografia , Estados Unidos
7.
J Am Board Fam Med ; 33(Supplement): S1-S9, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32928942

RESUMO

Family Medicine was a child of the 1960s. Triggered by compelling social need for care outside of large hospitals, Family Medicine emphasized access to personal physicians based in the community. As a protest movement, the ABFP required ongoing recertification for all Diplomates, with both independent examination and chart audit. Fifty years later, society and health care have changed dramatically, and it is time again to consider how Board Certification must respond to those change. We propose three interlocking arguments. First, even before COVID-19, health and health care have been in a time of fundamental transformation. Second, given the role Board Certification plays in supporting improvement of healthcare, Board Certification itself must respond to these changes. Third, to move forward, ABFM and the wider Board community must address a series of wicked problems - i.e., problems which are both complex-with many root causes-and complicated- in which interventions create new problems. The wicked problems confronting board certification include: 1) combining summative and formative assessment, 2) improving quality improvement and 3) reaffirming the social contract and professionalism and its assessment.


Assuntos
Certificação/normas , Competência Clínica/normas , Medicina de Família e Comunidade/normas , Melhoria de Qualidade , Certificação/métodos , Certificação/tendências , Medicina de Família e Comunidade/educação , Medicina de Família e Comunidade/tendências , Humanos , Estados Unidos
8.
Vasc Endovascular Surg ; 54(8): 692-696, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32787694

RESUMO

OBJECTIVES: Penetrating abdominal aortic injury (PAAI) is a highly acute injury requiring prompt surgical management. When compared to surgeons at level-II trauma centers, surgeons at level-I trauma centers are more likely to take in-house call, and may more often be available within 15 minutes of patient arrival. Thus, we hypothesized that level-I trauma centers would have a lower mortality rate than level-II trauma centers in patients with PAAI. METHODS: We queried the Trauma Quality Improvement Program database for patients with PAAI, and compared patients treated at American College of Surgeons (ACS)-verified level-I centers to those treated at ACS level-II centers. RESULTS: PAAI was identified in 292 patients treated at level-I centers and 86 patients treated at level-II centers. Patients treated at the 2 center types had similar median age, injury severity scores and prevalence of diabetes, hypertension, and smoking (p > 0.05). There was no difference in the frequency of additional intra-abdominal vascular injuries (p > 0.05). Median time to hemorrhage control (level-I: 40.8 vs level-II: 49.2 minutes, p = 0.21) was similar between hospitals at the 2 trauma center levels. We found no difference in the total hospital length of stay or post-operative complications (p > 0.05). When controlling for covariates, we found no difference in the risk of mortality between ACS verified level-I and level-II trauma centers (OR:1.01, CI:0.28-2.64, p = 0.99). CONCLUSION: Though the majority of PAAIs are treated at level-I trauma centers, we found no difference in the time to hemorrhage control, or the risk of mortality in those treated at level-I centers when compared to those treated at level-II trauma centers. This finding reinforces the ACS-verification process, which strives to achieve similar outcomes between level-I and level-II centers.


Assuntos
Traumatismos Abdominais/cirurgia , Aorta Abdominal/cirurgia , Certificação/normas , Técnicas Hemostáticas/normas , Centros de Traumatologia/normas , Procedimentos Cirúrgicos Vasculares/normas , Lesões do Sistema Vascular/cirurgia , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/diagnóstico por imagem , Traumatismos Abdominais/mortalidade , Adolescente , Adulto , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/lesões , Bases de Dados Factuais , Feminino , Técnicas Hemostáticas/efeitos adversos , Técnicas Hemostáticas/mortalidade , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Indicadores de Qualidade em Assistência à Saúde/normas , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/mortalidade , Adulto Jovem
10.
Nurs Outlook ; 68(4): 385-387, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32593461

RESUMO

Nurse practitioner (NP) employment in specialty practice areas, such as subspecialty ambulatory practices and inpatient units is growing substantially. The Consensus Model provides guidelines to help states aligning NP education and certification with specialty practice area. Despite expansion of the Consensus Model, significant misalignment exists between specialty NPs' education, certification, and practice location. Therefore, further implementation of the Consensus Model across states could have significant impact on health systems and NPs working in specialty settings. More than 10 years after its introduction, it is time to evaluate the policy and practice implications of the Consensus Model. Important next steps include examination of the impact of the Consensus Model and how to help health systems with alignment when and if the Model is more widely implemented.


Assuntos
Certificação/estatística & dados numéricos , Consenso , Emprego/estatística & dados numéricos , Profissionais de Enfermagem/educação , Profissionais de Enfermagem/normas , Padrões de Prática em Enfermagem/estatística & dados numéricos , Padrões de Prática em Enfermagem/normas , Adulto , Certificação/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Enfermagem , Estados Unidos
13.
PLoS One ; 15(5): e0231073, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32365128

RESUMO

The Marine Stewardship Council (MSC) sets a standard by which sustainable fisheries can be assessed and eco-certified. It is one of the oldest and most well-known fisheries certifications, and an estimated 15% of global fish catch is MSC-certified. While the MSC is increasingly recognized by decision-makers as an indicator for fishery success, it is also criticized for weak standards and overly-lenient third-party certifiers. This gap between the standard's reputation and its actual implementation could be a result of how the MSC markets and promotes its brand. Here we classify MSC-certified fisheries by gear type (i.e. active vs. passive) as well as by length of the vessels involved (i.e. large scale vs. small scale; with the division between the two occurring at 12 m in overall length). We compared the MSC-certified fisheries (until 31 December 2017) to 399 photographs the MSC used in promotional materials since 2009. Results show that fisheries involving small-scale vessels and passive gears were disproportionately represented in promotional materials: 64% of promotional photographs were of passive gears, although only 40% of MSC-certified fisheries and 17% of the overall catch were caught by passive gears from 2009-2017. Similarly, 49% of the photographs featured small-scale vessels, although just 20% of MSC-certified fisheries and 7% of the overall MSC-certified catch used small-scale vessels from 2009 to 2017. The MSC disproportionately features photographs of small-scale fisheries although the catch it certifies is overwhelmingly from industrial fisheries.


Assuntos
Publicidade , Certificação , Conservação dos Recursos Naturais/métodos , Pesqueiros , Indústria Alimentícia , Alimentos Marinhos/provisão & distribução , Publicidade/classificação , Publicidade/métodos , Publicidade/normas , Animais , Certificação/organização & administração , Certificação/normas , Eficiência Organizacional , Pesqueiros/classificação , Pesqueiros/organização & administração , Pesqueiros/normas , Peixes/fisiologia , Indústria Alimentícia/classificação , Indústria Alimentícia/instrumentação , Indústria Alimentícia/organização & administração , Indústria Alimentícia/normas , Afiliação Institucional/organização & administração , Afiliação Institucional/normas , Alimentos Marinhos/classificação , Conselhos de Especialidade Profissional/organização & administração , Conselhos de Especialidade Profissional/normas
14.
Tunis Med ; 98(2): 99-109, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32395798

RESUMO

INTRODUCTION: A Certificate of Specialization (C2S) in research methodology and scientific communication was established at the Faculty of Medicine of Bejaia (Algeria), for the benefit of university hospital teachers, in 2018. The objective of this study was to evaluate the impact of a clinical certifying-research training program on the acquisition of fundamental knowledge for the conduct of health research projects in its three conceptual, operational and editorial phases. METHODS: This training took place during three face-to-face seminars (a total of 12 teaching days), in the form of lectures and workshops by eight lecturers, with a final exam and a thesis dissertation project. The data were collected through Pre- and post-tests which were distributed before and after each seminar while the questionnaire was administered by the end of the training in order to assess the whole course of this training. The knowledge assessment grids were composed of 20 items for each of the first two seminars and 12 items for the third seminar. According to the categories of the Likert scale, these items were weighted from 1 to 5 points, an overall score for the 52 items of 260 points. RESULTS: A total of 38 candidates (selected from 140 applications) attended this training with an overall presenteeism rate of 93%. The differential scores ("pre-test" and "post-test") of progression of knowledge were successively 60%, 49% and 42% in the three seminars. Out of a total of 260 points, the overall learning score of all three seminars increased from an average of 119 points ± 8.66 to 180 points ± 15.87 (p <10-7), with a differential score of 51.6%. CONCLUSION: The evaluation of the C2S clinical research program of the Bejaia Faculty of Medicine documented the significant evolution of knowledge of research methodology and scientific writing tools. The continuity of this training and its generalization to the Maghreb faculties of health sciences are highly recommended, for the improvement of scientific production in Algeria and the Great Maghreb.


Assuntos
Pesquisa Biomédica/educação , Certificação , Currículo/normas , Docentes de Medicina , Capacitação de Professores/normas , Redação/normas , Argélia , Atitude do Pessoal de Saúde , Certificação/normas , Educação Médica/normas , Docentes de Medicina/educação , Docentes de Medicina/normas , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Aprendizagem , Inquéritos e Questionários
16.
Ann R Coll Surg Engl ; 102(6): 437-441, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32374217

RESUMO

INTRODUCTION: In the UK, general surgeons must demonstrate competency in emergency general surgery before obtaining a certificate of completion of training. Subsequently, many consultants develop focused elective specialist interests which may not mirror the breadth of procedures encountered during emergency practice. Recent National Emergency Laparotomy Audit analysis found that declared surgeon special interest impacted emergency laparotomy outcomes, which has implications for emergency general surgery service configuration. We sought to establish whether local declared surgeon special interest impacts emergency laparotomy outcomes. METHODS: Adult patients having emergency laparotomy were identified from our prospective National Emergency Laparotomy Audit database from May 2016 to May 2019 and categorised as colorectal or oesophagogastric according to operative procedure. Outcomes included 30-day mortality, return to theatre and length of stay. Binomial logistic regression was used to identify any association between declared consultant specialist interest and outcomes. RESULTS: Of 600 laparotomies, 358 (58.6%) were classifiable as specialist procedures: 287 (80%) colorectal and 71 (20%) oesophagogastric. Discordance between declared specialty and operation undertaken occurred in 25% of procedures. For colorectal emergency laparotomy, there was an increased risk of 30-day mortality when performed by a non-colorectal consultant (unadjusted odds ratio 2.34; 95% confidence interval 1.10-5.00; p = 0.003); however, when adjusted for confounders within multivariate analysis declared surgeon specialty had no impact on mortality, return to theatre or length of stay. CONCLUSION: Surgeon-declared specialty does not impact emergency laparotomy outcomes in this cohort of undifferentiated emergency laparotomies. This may reflect the on-call structure at Birmingham Heartlands Hospital, where a colorectal and oesophagogastric consultant are paired on call and provide cross-cover when needed.


Assuntos
Competência Clínica/normas , Tratamento de Emergência/estatística & dados numéricos , Gastroenteropatias/cirurgia , Laparotomia/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Idoso , Certificação/normas , Competência Clínica/estatística & dados numéricos , Colo/cirurgia , Consultores/estatística & dados numéricos , Estado Terminal/mortalidade , Estado Terminal/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Esôfago/cirurgia , Feminino , Gastroenteropatias/mortalidade , Cirurgia Geral/organização & administração , Cirurgia Geral/normas , Mortalidade Hospitalar , Humanos , Laparotomia/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Reto/cirurgia , Reoperação/estatística & dados numéricos , Estômago/cirurgia , Cirurgiões/organização & administração , Cirurgiões/normas , Resultado do Tratamento
17.
Nurs Outlook ; 68(4): 484-493, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32359922

RESUMO

BACKGROUND: Definitions of nursing certification are lacking in the research literature and research on certification in nursing is remarkably limited. METHODS: A six-stage scoping review framework was used to identify the nature, extent, and range of certification within the nursing literature. FINDINGS: Thirty-six articles were included in this scoping review. Most originated in the United States (89%), were classified as research articles (56%), and used a quantitative approach (90%). The majority focused on initial certification (50%), and written examination was the most prevalent approach to certification (39%). Missing and incomplete data were prevalent. DISCUSSION: The overall lack of nursing certification origin, focus, methodological rigor, and clear certification mastery criteria have hindered meaningful study of the relationship between nursing certification and patient outcomes. Common data elements, reporting standards, and observational studies linking common data elements and patient outcomes could guide future research and improve the transparency of certification processes and reporting.


Assuntos
Certificação/estatística & dados numéricos , Certificação/normas , Competência Clínica/estatística & dados numéricos , Competência Clínica/normas , Guias como Assunto , Recursos Humanos de Enfermagem/estatística & dados numéricos , Recursos Humanos de Enfermagem/normas , Adulto , Canadá , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
18.
Eur J Surg Oncol ; 46(4 Pt B): 717-736, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32075718

RESUMO

The Breast Surgery theoretical and practical knowledge curriculum comprehensively describes the knowledge and skills expected of a fully trained breast surgeon practicing in the European Union and European Economic Area (EEA). It forms part of a range of factors that contribute to the delivery of high quality cancer care. It has been developed by a panel of experts from across Europe and has been validated by professional breast surgery societies in Europe. The curriculum maps closely to the syllabus of the Union of European Medical Specialists (UEMS) Breast Surgery Exam, the UK FRCS (breast specialist interest) curriculum and other professional standards across Europe and globally (USA Society of Surgical Oncology, SSO). It is envisioned that this will serve as the basis for breast surgery training, examination and accreditation across Europe to harmonise and raise standards as breast surgery develops as a separate discipline from its parent specialties (general surgery, gynaecology, surgical oncology and plastic surgery). The curriculum is not static but will be revised and updated by the curriculum development group of the European Breast Surgical Oncology Certification group (BRESO) every 2 years.


Assuntos
Doenças Mamárias/diagnóstico , Doenças Mamárias/terapia , Currículo/normas , Oncologia Cirúrgica/educação , Oncologia Cirúrgica/normas , Mama/anatomia & histologia , Mama/fisiologia , Mama/cirurgia , Doenças Mamárias/fisiopatologia , Certificação/métodos , Certificação/normas , Competência Clínica/normas , Educação Médica/normas , Europa (Continente) , Bolsas de Estudo/normas , Humanos , Internato e Residência/normas
20.
Crit Care Nurs Clin North Am ; 32(1): 109-119, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32014157

RESUMO

Many academic and community hospitals have obtained, or are considering obtaining, stroke center certification. Participation in structured quality improvement programs that also incorporate an objective assessment has been shown to improve outcomes and foster team building. Although obtaining certification can be challenging and costly, it can provide a framework to ensure hospitals deliver high- level, evidence-based stroke care. For the intensive care unit nurse, awareness and participation in the certification programs process is an important part of professional nursing practice.


Assuntos
Certificação , Enfermagem de Cuidados Críticos/normas , Medicina Baseada em Evidências/normas , Hospitais/normas , Melhoria de Qualidade , Acidente Vascular Cerebral/diagnóstico , Certificação/economia , Certificação/normas , Competência Clínica , Humanos , Melhoria de Qualidade/organização & administração , Melhoria de Qualidade/normas , Fatores de Tempo
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