Guide Point-of-Care Testing: Performance Improvement and Evidence-Based Outcomes (Medical Psychiatry)

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Medication with food: What does it really mean? Before you go! Sign up today! Yemen Zambia Zimbabwe. Toggle navigation. Click Here to Login. News Off the Charts Insights Blog. Infection Control Wellness Research Professionalism Search for: Advanced Search. Current Issue. Digital Edition. Author Guidelines. Submit an Article. Send a Letter to the Editor. Editorial Advisory Board. Clinical Topics.

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Quantitative studies typically involve scientific methodology to determine appropriate sample size, various designs to control for potential errors during data collection, and rigorous statistical analysis of the data. Qualitative studies tend to explore life experiences to give them meaning. Cultivate a spirit of inquiry.

Ask a burning clinical question. Collect the most relevant and best evidence. Critically appraise the evidence. Evaluate the practice decision or change. Disseminate EBP results. Hierarchy of evidence In searching for the best available evidence, nurses must understand that a hierarchy exists with regard to the level and strength of evidence. Indeed, rigorous measurement of value outcomes and costs is perhaps the single most important step in improving health care. Wherever we see systematic measurement of results in health care—no matter what the country—we see those results improve.

Yet the reality is that the great majority of health care providers and insurers fail to track either outcomes or costs by medical condition for individual patients.

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That surprising truth goes a long way toward explaining why decades of health care reform have not changed the trajectory of value in the system. When outcomes measurement is done, it rarely goes beyond tracking a few areas, such as mortality and safety. HEDIS the Healthcare Effectiveness Data and Information Set scores consist entirely of process measures as well as easy-to-measure clinical indicators that fall well short of actual outcomes. For diabetes, for example, providers measure the reliability of their LDL cholesterol checks and hemoglobin A1c levels, even though what really matters to patients is whether they are likely to lose their vision, need dialysis, have a heart attack or stroke, or undergo an amputation.

Few health care organizations yet measure how their diabetic patients fare on all the outcomes that matter. The only true measures of quality are the outcomes that matter to patients. And when those outcomes are collected and reported publicly, providers face tremendous pressure—and strong incentives—to improve and to adopt best practices, with resulting improvements in outcomes. Take, for example, the Fertility Clinic Success Rate and Certification Act of , which mandated that all clinics performing assisted reproductive technology procedures, notably in vitro fertilization, provide their live birth rates and other metrics to the Centers for Disease Control.

After the CDC began publicly reporting those data, in , improvements in the field were rapidly adopted, and success rates for all clinics, large and small, have steadily improved. Since public reporting of clinic performance began, in , in vitro fertilization success rates have climbed steadily across all clinics as process improvements have spread. Outcomes should be measured by medical condition such as diabetes , not by specialty podiatry or intervention eye examination.

The outcomes that matter to patients for a particular medical condition fall into three tiers. Tier 1 involves the health status achieved. In measuring quality of care, providers tend to focus on only what they directly control or easily measured clinical indicators. However, measuring the full set of outcomes that matter to patients by condition is essential in meeting their needs. And when outcomes are measured comprehensively, results invariably improve.

Survival Example: Hip Replacement. Disutility of care or treatment process for instance, diagnostic errors, ineffective care, treatment-related discomfort, complications, adverse effects. Tier 2 outcomes relate to the nature of the care cycle and recovery. The level of discomfort during care and how long it takes to return to normal activities also matter greatly to patients.

Significant delays before seeing a specialist for a potentially ominous complaint can cause unnecessary anxiety, while delays in commencing treatment prolong the return to normal life. Even when functional outcomes are equivalent, patients whose care process is timely and free of chaos, confusion, and unnecessary setbacks experience much better care than those who encounter delays and problems along the way.

Tier 3 outcomes relate to the sustainability of health. It is also one of the most powerful vehicles for lowering health care costs. If Tier 1 functional outcomes improve, costs invariably go down. If any Tier 2 or 3 outcomes improve, costs invariably go down. By failing to consistently measure the outcomes that matter, we lose perhaps our most powerful lever for cost reduction. Over the past half dozen years, a growing array of providers have begun to embrace true outcome measurement.

Many of the leaders have seen their reputations—and market share—improve as a result. A welcomed competition is emerging to be the most comprehensive and transparent provider in measuring outcomes. The Cleveland Clinic is one such pioneer, first publishing its mortality data on cardiac surgery and subsequently mandating outcomes measurement across the entire organization. The range of outcomes measured remains limited, but the Clinic is expanding its efforts, and other organizations are following suit.

At the individual IPU level, numerous providers are beginning efforts. Providers are improving their understanding of what outcomes to measure and how to collect, analyze, and report outcomes data. For example, some of our colleagues at Partners HealthCare in Boston are testing innovative technologies such as tablet computers, web portals, and telephonic interactive systems for collecting outcomes data from patients after cardiac surgery or as they live with chronic conditions such as diabetes.

Outcomes are also starting to be incorporated in real time into the process of care, allowing providers to track progress as they interact with patients. To accelerate comprehensive and standardized outcome measurement on a global basis, we recently cofounded the International Consortium for Health Outcomes Measurement. ICHOM develops minimum outcome sets by medical condition, drawing on international registries and provider best practices.

It brings together clinical leaders from around the world to develop standard outcome sets, while also gathering and disseminating best practices in outcomes data collection, verification, and reporting. Just as railroads converged on standard track widths and the telecommunications industry on standards to allow data exchange, health care providers globally should consistently measure outcomes by condition to enable universal comparison and stimulate rapid improvement.

For a field in which high cost is an overarching problem, the absence of accurate cost information in health care is nothing short of astounding. Few clinicians have any knowledge of what each component of care costs, much less how costs relate to the outcomes achieved. In most health care organizations there is virtually no accurate information on the cost of the full cycle of care for a patient with a particular medical condition.

Instead, most hospital cost-accounting systems are department-based, not patient-based, and designed for billing of transactions reimbursed under fee-for-service contracts. In a world where fees just keep going up, that makes sense. Existing systems are also fine for overall department budgeting, but they provide only crude and misleading estimates of actual costs of service for individual patients and conditions.

For example, cost allocations are often based on charges, not actual costs. As health care providers come under increasing pressure to lower costs and report outcomes, the existing systems are wholly inadequate. Existing costing systems are fine for overall department budgeting, but they provide only crude and misleading estimates of actual costs of service for individual patients and conditions. To determine value, providers must measure costs at the medical condition level, tracking the expenses involved in treating the condition over the full cycle of care.

Then the cost of caring for a condition can be compared with the outcomes achieved. While rarely used in health care to date, it is beginning to spread. Where TDABC is being applied, it is helping providers find numerous ways to substantially reduce costs without negatively affecting outcomes and sometimes even improving them. In light of those cost differences, focusing the time of the most expensive staff members on work that utilizes their full skill set is hugely important.

Without understanding the true costs of care for patient conditions, much less how costs are related to outcomes, health care organizations are flying blind in deciding how to improve processes and redesign care. Clinicians and administrators battle over arbitrary cuts, rather than working together to improve the value of care.

Neither of the dominant payment models in health care—global capitation and fee-for-service—directly rewards improving the value of care. It also decouples payment from what providers can directly control.

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Fee-for-service couples payment to something providers can control—how many of their services, such as MRI scans, they provide—but not to the overall cost or the outcomes. Providers are rewarded for increasing volume, but that does not necessarily increase value. The payment approach best aligned with value is a bundled payment that covers the full care cycle for acute medical conditions, the overall care for chronic conditions for a defined period usually a year , or primary and preventive care for a defined patient population healthy children, for instance.

Well-designed bundled payments directly encourage teamwork and high-value care. Payment is tied to overall care for a patient with a particular medical condition, aligning payment with what the team can control. Providers benefit from improving efficiency while maintaining or improving outcomes. Sound bundled payment models should include: severity adjustments or eligibility only for qualifying patients; care guarantees that hold the provider responsible for avoidable complications, such as infections after surgery; stop-loss provisions that mitigate the risk of unusually high-cost events; and mandatory outcomes reporting.

Governments, insurers, and health systems in multiple countries are moving to adopt bundled payment approaches. For example, the Stockholm County Council initiated such a program in for all total hip and knee replacements for relatively healthy patients.

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The result was lower costs, higher patient satisfaction, and improvement in some outcomes. In Germany, bundled payments for hospital inpatient care—combining all physician fees and other costs, unlike payment models in the U. Among the features of the German system are care guarantees under which the hospital bears responsibility for the cost of rehospitalization related to the original care. Here, mandatory outcomes reporting has combined with bundles to reinforce team care, speed diffusion of innovation, and rapidly improve outcomes.

Providers that adopted bundle approaches early benefitted. Employers are also embracing bundled payments. The hospitals are reimbursed for the care with a single bundled payment that includes all physician and hospital costs associated with both inpatient and outpatient pre- and post-operative care. Employees bear no out-of-pocket costs for their care—travel, lodging, and meals for the patient and a caregiver are provided—as long as the surgery is performed at one of the centers of excellence.

The program is in its infancy, but expectations are that Walmart and other large employers will expand such programs to improve value for their employees, and will step up the incentives for employees to use them. Sophisticated employers have learned that they must move beyond cost containment and health promotion measures, such as co-pays and on-site health and wellness facilities, and become a greater force in rewarding high-value providers with more patients.

As bundled payment models proliferate, the way in which care is delivered will be transformed. For example, many hospitals routinely have patients return to see the cardiac surgeon six to eight weeks after surgery, but out-of-town visits seem difficult to justify for patients with no obvious complications. In deciding to drop those visits, clinicians realized that maybe local patients do not need routine postoperative visits either.

Providers remain nervous about bundled payments, citing concerns that patient heterogeneity might not be fully reflected in reimbursements, and that the lack of accurate cost data at the condition level could create financial exposure. Those concerns are legitimate, but they are present in any reimbursement model. Providers will adopt bundles as a tool to grow volume and improve value.

A large and growing proportion of health care is provided by multisite health care delivery organizations. Those proportions are even higher today. Unfortunately, most multisite organizations are not true delivery systems, at least thus far, but loose confederations of largely stand-alone units that often duplicate services. There are huge opportunities for improving value as providers integrate systems to eliminate the fragmentation and duplication of care and to optimize the types of care delivered in each location.

To achieve true system integration, organizations must grapple with four related sets of choices: defining the scope of services, concentrating volume in fewer locations, choosing the right location for each service line, and integrating care for patients across locations. Is relocating service lines on the table? A starting point for system integration is determining the overall scope of services a provider can effectively deliver—and reducing or eliminating service lines where they cannot realistically achieve high value.

For community providers, this may mean exiting or establishing partnerships in complex service lines, such as cardiac surgery or care for rare cancers. For academic medical centers, which have more heavily resourced facilities and staff, this may mean minimizing routine service lines and creating partnerships or affiliations with lower-cost community providers in those fields.

Although limiting the range of service lines offered has traditionally been an unnatural act in health care—where organizations strive to do everything for everyone—the move to a value-based delivery system will require those kinds of choices. Second, providers should concentrate the care for each of the conditions they do treat in fewer locations. Concentrating volume is essential if integrated practice units are to form and measurement is to improve.

Numerous studies confirm that volume in a particular medical condition matters for value. Providers with significant experience in treating a given condition have better outcomes, and costs improve as well. Patients, then, are often much better off traveling longer distance to obtain care at locations where there are teams with deep experience in their condition.

That often means driving past the closest hospitals. Organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow. Concentrating volume is among the most difficult steps for many organizations, because it can threaten both prestige and physician turf.

Yet the benefits of concentration can be game-changing. In , the city of London set out to improve survival and prospects for stroke patients by ensuring that patients were cared for by true IPUs—dedicated, state-of-the-art teams and facilities including neurologists who were expert in the care of stroke. These were called hyper-acute stroke units, or HASUs. At the time, there were too many hospitals providing acute stroke care in London 32 of them to allow any to amass a high volume. UCL Partners, a delivery system comprising six well-known teaching hospitals that serve North Central London, had two hospitals providing stroke care—University College London Hospital and the Royal Free Hospital—located less than three miles apart.

University College was selected to house the new stroke unit. Neurologists at Royal Free began practicing at University College, and a Royal Free neurologist was appointed as the overall leader of the stroke program. These steps sent a strong message that UCL Partners was ready to concentrate volume to improve value.

Thus, a multifaceted intervention including a variety of active strategies was used [ 3 ], which previously has been reported to be more effective than passive strategies or just the use of feed-back or audit [ 38 ]. Shortell et al. Our implementation program included all of these dimensions.

The Strategy for Value Transformation

The standard of care is not the same as the quality of care. The quality of care provided by the clinician may be below, equal to, or even above the acceptable standard of care. Practice parameters are strategies for patient management, designed to assist health care professionals in clinical decision-making. The practice parameters describe the generally accepted practices, but are not intended to define a standard of care. The intentions with the quality indicators as presented in the clinical guidelines were to represent ideal practice.

Thus, they could be used to measure deficiencies between current practice and ideal practice as defined in the guidelines, which would indicate an area for intervention. These practice parameters reflect the state of knowledge at the time of development of the guidelines, and most certainly need to be regularly updated. Psychiatric disorders are of great importance in public health. Depression is now the fourth-leading cause of the global disease burden and the leading cause of disability worldwide. Depression is the most important risk factor for suicide, which is among the top three causes of death in young people ages 15 to 35 [ 40 ].

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Depression seriously reduces the quality of life for individuals and their families, and often aggravates the outcome of other physical health problems. Because depression is highly treatable, and currently undertreated, it is an appropriate focus for improvement of the treatment by implementing available evidenced-based clinical guidelines. Guideline implementation studies in the care of psychiatric disorders are lacking, but a review by Weingartner of clinical guidelines in chronic medical diseases has stressed the importance of multifaceted interventions [ 41 ].

A comparable conclusion that multiple strategies seem to be most effective is presented in a systematic meta-review by Francke [ 16 ]. There were some limitations in the present study. Firstly, although both intervention and control clinics were randomly assigned, all had volunteered to participate, and therefore probably were more motivated to change. Secondly, given the fact that clinical practice change is a complex phenomenon dependent on local context, results from one particular setting can be generalised only with great caution [ 42 ].

Our study had a cluster design where patients were nested within their health care providers, and the health care providers were nested within their clinics. While the clustering at the provider level was properly addressed in our analyses, due to the low number of participating clinics it was not possible to fit a three-level model.

Therefore, we could not investigate the possible role of clinic level covariates, and the lack of controlling for autocorrelation within clinics might inflate somewhat the standard error of our estimates. Addressing local needs when implementing clinical guidelines is important in closing the gap between research and practice. The need to adapt implementation efforts to local circumstances has been shown to be valuable [ 43 ].

Adequate funding is needed to train the staff in the intervention techniques, establish protocols, and support evaluation of the outcome. Further research is needed on practical frameworks to facilitate the implementation of intervention in mental health care settings. A large number of factors determine whether or not implementation will be successful and all factors cannot be addressed within one theory or model of change. Further studies are needed to examine our implementation approach with reference to theories about the implementation of change.

The strength of the present study is that it is, to our knowledge, the first one to assess the long-term effects of implementation of psychiatric guidelines. This study suggested that the compliance to clinical guidelines, for treatment of depression and suicidal behaviour, was implemented and sustained over a two-year period after an active implementation.

Quality indicators were helpful tools in the implementation process as well as in the evaluation.

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Thus, supported local implementation based on local organisation theory may be a strategy for narrowing the gap between evidence-based care and current practice. Grol R, Grimshaw J: From best evidence to best practice: effective implementation of change in patients' care. Health Technol Assess. BMC health services research. The Medical journal of Australia. Int J Qual Health Care. Barosi G: Strategies for dissemination and implementation of guidelines. Neurol Sci. Grol R: Successes and failures in the implementation of evidence-based guidelines for clinical practice. Medical care. BMJ Clinical research ed. Eur Psychiatry. Davis D: Continuing education, guideline implementation, and the emerging transdisciplinary field of knowledge translation. J Contin Educ Health Prof. Br J Psychiatry. Michie S, Johnston M: Changing clinical behaviour by making guidelines specific.

Implement Sci. Weinmann S, Koesters M, Becker T: Effects of implementation of psychiatric guidelines on provider performance and patient outcome: systematic review. Acta Psychiatr Scand. BMC Psychiatry. Jt Comm J Qual Improv. Garvin D: Learning in action: a guide to putting the learning organization to work. World Health Organization: International statistical classification of diseases and related health problems, Tenth Revision. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. Nordstrom G, Gardulf A: Nursing documentation in patient records.

Scand J Caring Sci. Linden M, Schotte K: A randomized controlled clinical trial comparing "guideline exposed" and "guideline naive" physicians in respect to dosage selection and treatment outcome with doxepin in depressive disorders. Journal of evaluation in clinical practice. International journal of integrated care. Hermann RC, Palmer RH: Common ground: a framework for selecting core quality measures for mental health and substance abuse care. Psychiatric services Washington, DC. Holsapple CW: Handbook on knowledge management 1: Knowledge matters.

Garside P: Organisational context for quality: lessons from the fields of organisational development and change management. Qual Health Care. Health affairs Project Hope. The Milbank quarterly. Meta-analysis of published reports. Beyond performance gaps. J Gen Intern Med. Download references. Correspondence to Tord Forsner. All authors participated in interpretation of the results. TF drafted the manuscript and all other authors provided critical revision of the draft for important intellectual content. All authors read and approved the final manuscript.

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This article is published under license to BioMed Central Ltd. Reprints and Permissions. Search all BMC articles Search. Abstract Background The gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Methods Six psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. Results The documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics.

Conclusions Compliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. Open Peer Review reports. Background Transferring research results into routine clinical practice is complicated; several studies have described implementation difficulties and the complexity of achieving performance change in health care [ 1 , 2 ]. Methods Implementation of psychiatric guidelines in Stockholm In Stockholm county, Sweden, a series of regional clinical guidelines regarding psychiatric disorders has been published and disseminated since [ 20 , 21 ].