Theoretical analysis of policies to improve the recruitment and retention of rural physicians.

The lack of success in resolving the shortage of rural physicians in Organisation for Economic Cooperation and Development countries has been attributed to the weakness of implemented policies. This research examines the theoretical plausibility of policies to improve the recruitment and retention of rural physicians, first, by modelling the policies; and then, by describing how they might achieve their intended outcome based on a theoretical analysis. A theory-driven method relying on published research and expert analysis is used. A conceptual model is created to represent the policies and their underlying assumptions. Then, the functional mechanism of the policies is defined. This research demonstrates that financial, educational and tailored interventions might improve rural physician recruitment and retention, but that regulatory interventions are unlikely to do this. The majority of the policies implemented in Organisation for Economic Cooperation and Development countries are therefore theoretically plausible.

Strategic analysis of interventions to reduce physician shortages in rural regions.

INTRODUCTION: Physician shortages in rural regions of OECD countries has led to the development of regulatory, financial, educational and tailored interventions designed to reduce physician shortages. Studies evaluating these interventions report weak or inconclusive results. The objective of this research is to examine the strategic relevance of the interventions by identifying and prioritizing the determinants of physician shortages and analyzing the interventions based on their ability to target the determinants. METHODS: First, the determinants of physician shortages were identified and categorized using Mays et al's 2005 method for reviewing qualitative literature. Second, the determinants were prioritized based on importance, severity and solvability, using Lehmann et al's multilevel categorization of factors affecting attraction and retention. Third, the interventions were analyzed based on their ability to target the determinants through a document analysis as descriptive commentary from a policy analysis perspective. RESULTS: Three individual and 10 contextual (work, rural or international context) determinants of physician shortages were identified. Non-rural background, inadequate training and inadequate incentive structure were prioritized as level 1. Lack of professional support, poor work infrastructure and personal interests were prioritized as level 2. Poor rural infrastructure, inadequate supply planning and cultural difference were prioritized as level 3. Non-minority background, geography and climate, global migration and aging population were prioritized as level 4. Establishing rural medical schools targets the greatest number of priority determinants, followed by financial interventions targeting practicing physicians and non-traditional health services delivery strategies. Curriculum changes, professional support strategies, selective admission to medical schools, financially targeting student physicians and coercive regulatory measures follow. Community support strategies target the fewest number of determinants and trickle-down economic regulation targets none. CONCLUSION: Strategic analysis demonstrates that most interventions designed to reduce physician shortages in rural regions are strategically relevant because they address the priority determinants of physician shortages. A link is established between the determinants of physician shortages and the interventions, thereby addressing an important concern expressed in the literature. An original contribution is made to health human resources literature by relying on established theoretical frameworks to achieve a strategic analysis of the interventions.

Scope of Nursing Practice in a Tertiary Pediatric Setting: Associations With Nurse and Job Characteristics and Job Satisfaction.

PURPOSE: While professional nursing, like other health professions, has a recognized educational base and a legal scope of practice that is remarkably consistent across societies, there are important variations even within the same institution or organization in the extent to which professional nurses engage in the full range of activities for which they are qualified. There has been limited study of enacted (actual) scope of nursing practice (ESOP) or of its impacts on nurse job outcomes, such as job satisfaction. The aim of this study is to measure ESOP, as well as its predictors and impact on job satisfaction, in a specialty university-affiliated tertiary referral center in one of the few remaining jurisdictions outside the United States that continue to educate registered nurses at multiple educational levels. METHODS: This was a correlational cross-sectional design using structural equation modeling. Self-administered questionnaires were completed by 301 registered nurses holding permanent positions in specific clinical areas for 6 months or longer in a pediatric hospital in the province of Quebec, Canada. FINDINGS: ESOP or actual scope of practice was low-on average, nurses applied the range of skills within their theoretical scopes of practice only occasionally or "less than frequently" in their daily work (3.21 out of a possible 6 points). ESOP was strongly related to decision latitude (ß = 0.319; p  = .012), role ambiguity (ß = 0.297; p  = .011), and role overload (ß  =  0.201; p  = .012). The personal characteristics that exerted the greatest direct influence on ESOP were education level (ß  =  0.128; p  = .015) and growth need strength (ß  =  0.151; p  = .008). Results also showed that ESOP exerts a direct positive influence on nurses' job satisfaction (ß  =  0.118; p  = .006). Structural equation modeling analyses revealed a good fit of the data to the hypothesized conceptual model (χ²/df ratio index =  1.68, root mean square error of approximation  =  0.049, confirmatory fit index  =  0.985). CONCLUSIONS: Specific aspects of nurses' jobs are closely related to ESOP. ESOP is limited by certain job and personal characteristics and appears to affect nurses' job satisfaction. CLINICAL RELEVANCE: Results suggest that ESOP might be improved by adjusting nursing job characteristics and practice environments and that expanding ESOP increases nurse job satisfaction and may improve other health system outcomes as well.

Contributing causes to adverse events in home care and potential interventions to reduce their incidence.

The increasing complexity of home care services, pressures to discharge patients quicker, and the growing vulnerabilities of home care clients all contribute to adverse events in home care. In this article, home care staff in six programs analyzed 27 fall- and medication-related events. Classification of contributing causes indicates that patient and environmental factors were common in fall events, while organization and management factors along with patient, task, team, and individual factors were common in medication-related events. Home care settings create specific challenges in identifying and mitigating risks. Some factors, such as variations in home environments, are difficult to address. However, changing care coordination structures and communication methods could ameliorate other factors, including poor communications among staff and limited team and cross-sector communication and coordination. Ensuring that medication ordering and administration processes are optimized for home environments would also contribute to safer care.

Associations between patient factors and adverse events in the home care setting: a secondary data analysis of two canadian adverse event studies.

BACKGROUND: Early identification of patients at who have a higher risk for the occurrence of harm can provide patient safety improvement opportunities. Patient factors contribute to adverse event occurrence. The study aim was to identify a single, parsimonious model of home care patient factors that, regardless of location and differences in home care program management and design factors, could provide a means of locating patients at higher and lower risk of harm. METHODS: Split modeling using secondary analyses of data from two recent Canadian home care patient safety studies was undertaken. Patient factors from the Minimum Data Set Resident Assessment Instrument (RAI) for Home Care and diagnoses consistent with ICD-10 and RAI-Mental Health assessment were used. Continuous and categorical measures of factors were considered. Adverse events were defined using World Health Organization taxonomy and measured on a dichotomous yes/no scale. Patient factors significantly associated (Pearson's Chi Square, p ≤ .05) with the occurrence of adverse events in both earlier studies were entered in forward selection regression analyses to locate factors predictive of adverse event occurrence. RESULTS: Instrumental activities of daily living dependency and escalating co-morbidity counts are associated with patient vulnerability to adverse events. CONCLUSIONS: Instrumental activities of daily living dependency and burden of illness, both easily identifiable early in the episode of care, are significantly associated with the risk of adverse event occurrence, however there is regional variability in the relationships.

Association of Nursing Overtime, Nurse Staffing, and Unit Occupancy with Health Care-Associated Infections in the NICU.

Objective This study aims to assess the association of nursing overtime, nurse staffing, and unit occupancy with health care-associated infections (HCAIs) in the neonatal intensive care unit (NICU). Study Design A 2-year retrospective cohort study was conducted for 2,236 infants admitted in a Canadian tertiary care, 51-bed NICU. Daily administrative data were obtained from the database "Logibec" and combined to the patient outcomes database. Median values for the nursing overtime hours/total hours worked ratio, the available to recommended nurse staffing ratio, and the unit occupancy rate over 3-day periods before HCAI were compared with days that did not precede infections. Adjusted odds ratios (aOR) that control for the latter factors and unit risk factors were also computed. Results A total of 122 (5%) infants developed a HCAI. The odds of having HCAI were higher on days that were preceded by a high nursing overtime ratio (aOR, 1.70; 95% confidence interval [95% CI], 1.05-2.75, quartile [Q]4 vs. Q1). High unit occupancy rates were not associated with increased odds of infection (aOR, 0.85; 95% CI, 0.47-1.51, Q4 vs. Q1) nor were higher available/recommended nurse ratios (aOR, 1.16; 95% CI, 0.67-1.99, Q4 vs. Q1). Conclusion Nursing overtime is associated with higher odds of HCAI in the NICU.

Education and Role Title as Predictors of Enacted (Actual) Scope of Practice in Generalist Nurses in a Pediatric Academic Health Sciences Center.

OBJECTIVE: The aim of this study is to document the enacted (actual) scope of practice (SOP) of nurses in pediatric settings in relation to education level and position. BACKGROUND: Baccalaureate-prepared staff nurses routinely carry out only a fraction of the activities essential for quality of care and patient safety they have been educated for. A direct care nurse clinician role exists for nurses with bachelor's degrees in Quebec, Canada. METHOD: Survey of 301 nurses in a pediatric university hospital in Quebec was conducted. RESULTS: Enacted (actual) SOP for baccalaureate-educated nurses was significantly broader than that of nurses with junior college diplomas and nurse clinicians (baccalaureate-educated) carried out complex activities more frequently. CONCLUSION: The creation of job titling and role descriptions that reflect the upper range of nursing competencies could be an important tool for promoting broadened SOP for baccalaureate nurses.

The safety at home study: an evidence base for policy and practice change.

This paper explores the policies and practices that are needed to improve the safety of home care in light of the most recent evidence about home care safety in Canada. Four areas for policy and practice change are addressed: 1) the promotion of effective communication processes in home care through cross-sector collaboration, case management and technology innovations; 2) screening for safety risk factors; 3) standardizing care processes, packaging and equipment; and 4) supporting family/caregivers and strengthening clients' ability to engage in therapeutic self-care. Evidence-based strategies for change are presented within the context of the evidence about home care safety issues.

Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study.

BACKGROUND: Home care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario. METHODS: A retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences. RESULTS: The study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death. CONCLUSIONS: Our study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.

Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals.

OBJECTIVE: To examine the associations of four distinct nursing care organizational models with patient safety outcomes. DESIGN: Cross-sectional correlational study. Using a standardized protocol, patients' records were screened retrospectively to detect occurrences of patient safety-related events. Binary logistic regression was used to assess the associations of those events with four nursing care organizational models. SETTING: Twenty-two medical units in 11 hospitals in Quebec, Canada, were clustered into 4 nursing care organizational models: 2 professional models and 2 functional models. PARTICIPANTS: Two thousand six hundred and ninety-nine were patients hospitalized for at least 48 h on the selected units. MAIN OUTCOME MEASURE: Composite of six safety-related events widely-considered sensitive to nursing care: medication administration errors, falls, pneumonia, urinary tract infection, unjustified restraints and pressure ulcers. Events were ultimately sorted into two categories: events 'without major' consequences for patients and events 'with' consequences. RESULTS: After controlling for patient characteristics, patient risk of experiencing one or more events (of any severity) and of experiencing an event with consequences was significantly lower, by factors of 25-52%, in both professional models than in the functional models. Event rates for both functional models were statistically indistinguishable from each other. CONCLUSIONS: Data suggest that nursing care organizational models characterized by contrasting staffing, work environment and innovation characteristics may be associated with differential risk for hospitalized patients. The two professional models, which draw mainly on registered nurses (RNs) to deliver nursing services and reflect stronger support for nurses' professional practice, were associated with lower risks than are the two functional models.

Association of nurse staffing and unit occupancy with mortality and morbidity among very preterm infants: a multicentre study.

OBJECTIVE: In a healthcare system with finite resources, hospital organisational factors may contribute to patient outcomes. We aimed to assess the association of nurse staffing and neonatal intensive care unit (NICU) occupancy with outcomes of preterm infants born <33 weeks' gestation. DESIGN: Retrospective cohort study. SETTING: Four level III NICUs. PATIENTS: Infants born 23-32 weeks' gestation 2015-2018. MAIN OUTCOME MEASURES: Nursing provision ratios (nursing hours worked/recommended nursing hours based on patient acuity categories) and unit occupancy rates were averaged for the first shift, 24 hours and 7 days of admission of each infant. Primary outcome was mortality/morbidity (bronchopulmonary dysplasia, severe neurological injury, retinopathy of prematurity, necrotising enterocolitis and nosocomial infection). ORs for association of exposure with outcomes were estimated using generalised linear mixed models adjusted for confounders. RESULTS: Among 1870 included infants, 823 (44%) had mortality/morbidity. Median nursing provision ratio was 1.03 (IQR 0.89-1.22) and median unit occupancy was 89% (IQR 82-94). In the first 24 hours of admission, higher nursing provision ratio was associated with lower odds of mortality/morbidity (OR 0.93, 95% CI 0.89 to 0.98), and higher unit occupancy was associated with higher odds of mortality/morbidity (OR 1.19, 95% CI 1.04 to 1.36). In causal mediation analysis, nursing provision ratios mediated 47% of the association between occupancy and outcomes. CONCLUSIONS: NICU occupancy is associated with mortality/morbidity among very preterm infants and may reflect lack of adequate resources in periods of high activity. Interventions aimed at reducing occupancy and maintaining adequate resources need to be considered as strategies to improve patient outcomes.

A taxonomy of nursing care organization models in hospitals.

BACKGROUND: Over the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features. METHODS: This study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units' profile data. RESULTS: The study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses' professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses' perceptions that the practice environment is less supportive of their professional work. CONCLUSIONS: This study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an "ideal" nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.

Measuring actual scope of nursing practice: a new tool for nurse leaders.

OBJECTIVE: : This project describes the development and testing of the actual scope of nursing practice questionnaire. BACKGROUND: : Underutilization of the skill sets of registered nurses (RNs) is a widespread concern. Cost-effective, safe, and efficient care requires support by management to facilitate the implementation of nursing practice at the full scope. METHODS: : Literature review, expert consultation, and face validity testing were used in item development. The instrument was tested with 285 nurses in 22 medical units in 11 hospitals in Canada. RESULTS: : The 26-item, 6-dimension questionnaire demonstrated validity and reliability. The responses suggest that nurses practice at less than their optimal scope, with key dimensions of professional practice being implemented infrequently. CONCLUSIONS: : This instrument can help nurse leaders increase the effective use of RN time in carrying out the full scope of their professional practice.

Impact of a multipronged education strategy on antibiotic prescribing in Quebec, Canada.

BACKGROUND: Antibiotic overuse and resistance have become a major threat in the last 2 decades. Many programs tried to optimize antibiotic consumption in the inpatient setting, but the outpatient environment that represents the bulk of antibiotic use has been challenging. Following a significant rise of Clostridium difficile infections, all the health care stakeholders in the province of Quebec, Canada initiated a global education program targeting physicians and pharmacists. METHODS: A bundle approach was used; 11 user-friendly guidelines were produced by a group of experts and sent to all physicians and pharmacists in Quebec in January 2005. Downloadable versions of guidelines were posted on a dedicated Web site. They were promoted by professional organizations, universities, and experts during educational events, and there was strong acceptance by the pharmaceutical industry with a willingness to follow the recommendations in their marketing. The Intercontinental Medical Statistics (IMS) database was used to analyze and compare Quebec's total outpatient prescriptions per 1000 inhabitants with those in the other Canadian provinces for 2 time periods: preintervention (January 2003 to December 2004), and postintervention (February 2005 to December 2007). RESULTS: In 2004, antibiotic consumption per capita was 23.3% higher in Canada generally than in Quebec. After the guidelines dissemination, the gap between Quebec and the other Canadian provinces increased by 4.1 prescriptions/1000 inhabitants (P = .0002), and the trend persisted 36 months later. Antibiotic costs fell $134.5/1000 inhabitants in Quebec compared with the rest of Canada (P = .054). CONCLUSIONS: The implementation of guidelines significantly reduced antibiotic prescriptions in Quebec compared with the rest of the country, and there was a strong trend toward significant cost reduction.

Physician, heal thyself: Survey of users of the Quebec Physicians Health Program.

OBJECTIVE: To document the opinions of the users of the Quebec Physicians Health Program (QPHP) about the services they received. DESIGN: Mailed questionnaire. SETTING: Quebec. PARTICIPANTS: A total of 126 physicians who used QPHP services between 1999 and 2004. MAIN OUTCOME MEASURES: Users' overall rating of the QPHP services, their opinions about the program, and whether their situations improved as a result of accessing QPHP services. RESULTS: Ninety-two of the 126 physicians surveyed returned their completed questionnaires, providing a response rate of 73%. Most respondents thought that the QPHP services were good or excellent (90%), most would use the program again (86%) or recommend it (96%), and most thought the Quebec physician associations and the Collège des médecins du Québec should continue funding the QPHP (97%). Most respondents thought the service confidentiality was excellent (84%), as was staff professionalism (82%), and 62% thought the quality of the services they were referred to was excellent. However, only 57% believed their situations had improved with the help of the QPHP. CONCLUSION: The QPHP received good marks from its users. Given the effects of physician burnout on patients and on the health care system, it is not only a personal problem, but also a collective problem. Thus, actions are needed not only to set up programs like the QPHP for those suffering from burnout, but also to prevent these types of problems. Because family physicians are likely to be the first ones consulted by their physician patients in distress, they play a key role in acknowledging these problems and referring those colleagues to the appropriate help programs when needed.

Strengthening collaborations at the public health system-academic interface: a call to action.

In Canada and globally, the COVID-19 pandemic has highlighted the importance of reliable and responsive public health systems. The pandemic has required decisive leadership and collaboration across all sectors of society informed by the best available evidence. In this commentary, we argue that in order to create a robust public health system equipped to address current and future public health challenges, we must prioritize and invest in stronger relationships between public health practice and academia. We briefly review key recommendations following the SARS outbreak, particularly those calling for stronger linkages between public health academia and practice settings in Canada. We then propose key actions for strengthening these linkages. Echoing other COVID-19-related calls, which request long-term reinvestment in public health education and training, we recommend the following actions: (1) Improve collaboration between education programs and public health agencies to address system needs (e.g., surge capacity) and persisting health inequities; (2) Fund a pan-Canadian public health training initiative that builds on a renewed set of public health competencies to address priority training needs (e.g., equity-oriented leadership); and (3) Prepare a cadre of certified public health leaders who can progress along public health career pathways, including those already in practice.

RéSUMé: Au Canada et ailleurs dans le monde, la pandémie de COVID-19 a montré qu'il est important d'avoir des systèmes de santé publique fiables et réactifs. La pandémie nécessite un leadership décisif et une collaboration entre tous les secteurs de la société, éclairés par les meilleures preuves disponibles. Dans ce commentaire, nous faisons valoir que pour créer un système de santé publique robuste capable de relever les défis actuels et futurs, il faut privilégier des liens plus forts entre les praticiens de la santé publique et les milieux universitaires et y consacrer les investissements nécessaires. Nous passons brièvement en revue les principales recommandations qui ont suivi la crise du SRAS, en particulier celles qui réclamaient le renforcement des liens entre les facultés de santé publique et les milieux de pratique au Canada. Nous proposons ensuite des mesures clés pour renforcer ces liens. Faisant écho à d'autres appels à l'action liés à la COVID-19, qui préconisent un réinvestissement à long terme dans l'enseignement et la formation en santé publique, nous recommandons les mesures suivantes: 1) Améliorer la collaboration entre les programmes d'enseignement et les organismes de santé publique pour aborder les besoins des systèmes (p. ex. leur capacité d'appoint) et les inégalités persistantes en santé; 2) Financer une initiative pancanadienne de formation en santé publique qui s'appuie sur un ensemble renouvelé de compétences en santé publique pour répondre aux besoins prioritaires en matière de formation (p. ex. le leadership axé sur l'équité); et 3) Préparer un groupe de dirigeants de santé publique agréés pouvant progresser dans les carrières de la santé publique, y compris des personnes qui exercent déjà la profession.

The nature of safety problems among Canadian homecare clients: evidence from the RAI-HC reporting system.

AIM(S): The purpose of this study was to identify the nature of patient safety problems among Canadian homecare (HC) clients, using data collected through the RAI-HC((c)) assessment instrument. BACKGROUND: Problems of patient safety have been well documented in hospitals. However, we have very limited data about patient safety problems among HC clients. METHOD(S): The study methodology involved a secondary analysis of data collected through the Canadian home care reporting system. The study sample consisted of all HC clients who qualified to receive a RAI-HC assessment from Ontario, Nova Scotia and Winnipeg Regional Health Authority for the 2003-2007 reporting period. There were a total of 238 958 cases available for analysis; 205 953 from Ontario, 26 751 from Nova Scotia and 6254 from Winnipeg Regional Health Authority. RESULTS: New fall (11%), unintended weight loss (9%), new emergency room (ER) visits (7%) and new hospital visits (8%) were the most prevalent potential adverse events identified in our study. A small proportion of the HC clients experienced a new urinary tract infection (2%). CONCLUSION(S): Understanding clients' risk profiles is foundational to effective patient care management. IMPLICATIONS FOR NURSING MANAGEMENT: We need to begin to develop evidence about best practices for ameliorating safety risk.

Cross-generational comparison of dispensed pharmacotherapy for depression.

PURPOSE: The purpose of this paper is to compare predictors of receipt of recommended first-line pharmacotherapy in three generational cohorts of patients with new episode depression. DESIGN/METHODOLOGY/APPROACH: This retrospective database cohort study included adolescent, adult and senior Quebec Public Prescription Drug Insurance Plan beneficiaries with new episode depression, who were diagnosed by primary care physicians or psychiatrists (October 2000 to March 2001) and received pharmacotherapy. Receipt of recommended first-line pharmacotherapy, based on the first psychoactive medication dispensed following the depression diagnosis, was defined according to Canadian guidelines. FINDINGS: Receipt of first-line pharmacotherapy was documented in 52 percent, 71 percent and 50 percent of adolescents, adults and seniors, respectively. Among adolescents and seniors, diagnosis by a psychiatrist was associated with a lower likelihood of receipt of recommended pharmacotherapy. Adolescent females and senior males were more likely and adults with comorbidity were less likely to receive recommended pharmacotherapy. For all age groups, having a physician who both diagnosed the depression and prescribed the initial pharmacotherapy was associated with an increased likelihood of receiving recommended pharmacotherapy. Relational continuity of care influenced receipt of recommended first-line pharmacotherapy. Gender differences in treatment were found in adolescents and seniors. ORIGINALITY/VALUE: This paper identifies predictors of receipt of recommended first-line pharmacotherapy in three generational cohorts of patients with new episode depression.

A typology of mentally disordered users of resources for homeless people: towards better planning of mental health services.

The aim of this study is to describe distinct typologies among mentally ill users of resources for homeless people, in order to inform the targeted development of mental health services to address their varied needs. Data came from a survey of clientele of resources for homeless persons in Montreal and Quebec (N = 757) and this study includes the 369 people from this sample who met DSM-IV criteria for serious mental disorders at any point in their lifetime. A hierarchical logistic regression analysis was run with mental health service utilization in the past 12 months (dependent variable), and variables from Pescosolido's Model (independent variables). Cluster analysis identified six types of homeless persons with mental disorders: women; men with schizophrenia; previously depressed or alcoholic men; men with current depressive disorders; men with comorbidity; and men who were previously homeless. Results are discussed concerning the mental health service use, and needs of these different groups.

TOCSIN: a proposed dashboard of indicators to control healthcare-associated infections.

Healthcare-associated infections (HAIs) constitute a major safety problem. Healthcare managers need complete and valid information to fight against these infections. The purpose of this study was to develop a dashboard of indicators to help healthcare managers monitor HAIs. A pilot testing approach was used that was composed of the following steps: literature review, consultation with infection control experts and healthcare managers, operationalization of selected indicators, data collection from six Quebec hospital complexes to test the feasibility of the selected indicators and results dissemination. The literature review identified 299 possible indicators. After consulting infection control experts and healthcare managers and having collected data in the hospitals, a proposed dashboard was created that includes 97 indicators divided in three categories (structure, process and outcome) and grouped in 22 themes. The proposed indicators are both scientifically valid and administratively feasible. However, many healthcare facilities need additional financial resources and expertise to measure these indicators and manage the information they will generate.