Changes In Care Policy Research Articles

A Spotlight on Strategies for Increasing Safety Reporting in Nursing Education

Health care policy changes have ripple effects that touch many different areas of the health care arena. Quality and safety are at the forefront of this discussion. In health care institutions, error reporting is expected to monitor and improve patient safety. Procedures are in place for reporting errors. However, multiple barriers lead to low use of reporting methods. Creating a reporting system that leads to transparency could positively affect the health care system. Introducing nurses to error reporting at the beginning of their educational experience could lead to a reduction in barriers to error reporting and promote error reporting. This article discusses strategies to increase error and near-miss reporting in a school of nursing.

The physician assistant workforce in Indiana: Preparing to meet future health care needs

This study identifies baseline demographic and descriptive statistics for physician assistants (PAs) in Indiana from 1978 to 2010. Data were obtained from Indiana Professional Licensing Agency applications, the Indiana State Department of Health, and PA educational programs. Descriptive statistics were used to characterize the PA workforce as well as their supervising physicians. Most PAs working in Indiana were born and educated outside the state. Of those educated in Indiana, 77% obtained an initial license in Indiana; as of May 2010, 62% were still licensed in the state. In the past 8 years, Indiana had a 97% increase in active licensed PAs. Only 24% of PAs work in primary care; 92% work in metropolitan areas. For 40 years, PAs have increasingly worked in areas that are medically underserved or experiencing a shortage of health professionals. However, the overall numbers of PAs working in those areas remain low. More PAs in Indiana are practicing in medical specialties than in primary care. As health care policy and regulatory changes evolve, future studies will be needed to understand the impact on the health care workforce of Indiana PAs. This study will serve as a baseline for those studies.

Self-care and end of life care—patients’ and carers’ experience a qualitative study utilising serial triangulated interviews

This study aimed to understand patient and carer experiences of end of life care and to explore how patients care for themselves at the end of life in Scotland. (1) From the perspectives of patients and carers, what are their experience of advanced cancer and end of life care? (2) What self-care strategies enable patient and carers to cope with their end of life care? This paper reports a qualitative study using in-depth, unstructured serial interviews involving collaboration with and participation of people affected by advanced cancer. The study was a 2-year, three-phase study with multiple methods of data collection. The study was conducted in the Highlands and West of Scotland including rural, remote and socially deprived areas. Patient experience data were collected from 20 patients as well as their main carer and the health professional who they perceived had given them the most support. Triangulating data in this way allowed the totality of the patient experience to be captured. A total of 71 interviews were conducted. Data were analysed both within and across cases using framework analysis with the aid of QSR NVIVO 7. Maintaining normality and preparing for death were the two most important areas, for the patients in the study, as far as their self-care was concerned. Patients wished support that enabled them to maintain their independence and remain at home. People managed their illness both physically and emotionally; managing and adjusting to their lack of independence and keeping control were keys to most participants. Self-care is important to this group of people. People receiving end of life care want to and are able to engage in research. The findings are timely and relevant to current changes in palliative care policy and practice.

Economic impact of juvenile idiopathic arthritis and familial Mediterranean fever.

The aim of the study was to determine the economical impact of juvenile idiopathic arthritis (JIA) and familial Mediterranean fever (FMF) in Turkey. A total of 100 patients (69 F/31 M) with JIA and 100 with FMF (68 F/32 F) who were consecutively seen in the outpatient clinic of the pediatric rheumatology department at Cerrahpasa Medical School between August 2008 and January 2009 were studied. Cost data were collected through a questionnaire filled out by the parents. The mean age (JIA: 11 ± 5 years; FMF:12 ± 4 years) and mean disease duration (JIA:5 ± 3 years; FMF: 4 ± 3 years) of the patients were similar. JIA patients were assigned to 5 subtypes (polyarticular: n = 45, oligoarticular: n = 30, systemic onset: n = 13, psoriatic: n = 6, and enthesopathy-related JIA: n = 6). Forty-nine percent of the patients with JIA were treated with anti-TNF drugs and 61% with DMARDs. All patients with FMF were using colchicine. The total annual cost of JIA (€3,994 ± 4,101) was considerably higher than that of FMF (€162 ± 77) (P < 0.001). Medication fee was the major determinant of total costs in both diseases constituting 85% in JIA and 39% in FMF. Among the subtypes of JIA, total annual costs were the highest among patients with polyarticular type (€6,045 ± 4,078). Medications especially anti-TNF drugs were the major contributor among all determinants of costs in JIA. The low costs of health care system and prominent changes in the health care policies for the last 5 years in Turkey might have played role in our findings.

Japanese Structure Survey of Radiation Oncology in 2007 with Special Reference to Designated Cancer Care Hospitals

The structure of radiation oncology in designated cancer care hospitals in Japan was investigated in terms of equipment, personnel, patient load, and geographic distribution. The effect of changes in the health care policy in Japan on radiotherapy structure was also examined. The Japanese Society of Therapeutic Radiology and Oncology surveyed the national structure of radiation oncology in 2007. The structures of 349 designated cancer care hospitals and 372 other radiotherapy facilities were compared. Respective findings for equipment and personnel at designated cancer care hospitals and other facilities included the following: linear accelerators/facility: 1.3 and 1.0; annual patients/linear accelerator: 296.5 and 175.0; and annual patient load/full-time equivalent radiation oncologist was 237.0 and 273.3, respectively. Geographically, the number of designated cancer care hospitals was associated with population size. The structure of radiation oncology in Japan in terms of equipment, especially for designated cancer care hospitals, was as mature as that in European countries and the United States, even though the medical costs in relation to GDP in Japan are lower. There is still a shortage of manpower. The survey data proved to be important to fully understand the radiation oncology medical care system in Japan.

A traveling team concept to expedite the transfer and management of unstable patients in cardiopulmonary shock

Emergent mechanical support with transfer of patients in acute cardiopulmonary shock to specialty centers for definitive management is often required at non-transplant centers. An alternative approach to the traditional "hub and spoke" model is presented. A team of health care specialists from our hospital is deployed to the community hospital for stabilization, possible implantation, and transfer of patients to our tertiary care facility. Patient assessment can be made with intervention, allowing stabilization and safe transfer by our team to our institution. This method provides tertiary level care at the referring hospital and may improve survival for a sub-set of patients in the community hospital setting.

Long-term Care in South Korea—Migrant Care Workers and Transnational Social Welfare

AbstractIn this paper, we examine the issue of international migration of care labour using the case of the changing profile of the South Korean long-term care workforce. Based on analysis of care and immigration policy changes and empirical data gathered from interviews, we present the construction of hierarchical categories of care workers according to workers' immigration status and qualification level, in South Korea's shifting institutional care sectors. We further discuss the development of a system of transnational social welfare, relying on Korean-Chinese migrant care workers in the area where public care services are not delivered and care labour is unregulated.

Investing in our future: Unrealized opportunities for funding graduate psychology training.

Changes in the health care environment have brought challenges and opportunities to the field of psychology. Practitioners have been successful in modifying service models to absorb losses of financial support for behavioral health care, due to managed care and public policy changes, while simultaneously managing the growing need for these services. However, in this reactive mode of responding to evolutions in the health care system, the field of psychology has at times lost sight of the long-term vision required to promote psychology's inclusion in the health care system of the future. In particular, a focus on training psychologists and ensuring the availability of funding to support these activities must be a priority in planning for the future. This article provides an overview of federal programs that currently offer funding for psychology training, as well as other opportunities for federal funding that have been unrealized. Details regarding advocacy efforts that were required to secure available sources of funding are given, followed by consideration of strategies for taking advantage of existing resources and prioritizing advocacy for additional funding. Funding for psychology training provides an avenue for increasing the number of well-trained psychologists who can serve patients' mental and behavioral health needs and thereby improve health outcomes. Moreover, capitalizing on available funding opportunities for psychology training and promoting efforts to expand these opportunities will help ensure that the field of psychology is positioned to remain an important contributor to the health care system of the future.

Some in Saskatchewan Find The Cochrane Library Useful after Promotion, Access and Training Efforts

A review of:&#x0D; Forbes, Dorothy, Christine Neilson, Janet Bangma, Jennifer Forbes, Daniel Fuller, and Shari Furniss. “Saskatchewan Residents’ Use of The Cochrane Library.” Partnership: the Canadian Journal of Library and Information Practice and Research 2.2 (2007). &#x0D; &#x0D; Objective – To evaluate the use of The Cochrane Library by librarians, health care providers and consumers in the Canadian province of Saskatchewan. &#x0D; &#x0D; Design – Volunteer telephone interviews and surveys of training participants at multiple time points; usage statistics. &#x0D; &#x0D; Setting – Saskatchewan. &#x0D; &#x0D; Subjects – Ninety-four volunteers participated in the study. Participants were self-selected from approximately 300 health practitioners and 100 public library staff attending training sessions, located primarily in rural areas. The majority of public library staff who attended training sessions were not professional librarians, although 31.5% of the study participants were librarians. Nurses made up the next largest group (16.3%), followed by therapists (7.6%), library support staff (5.4%), pharmacists (4.3%), physicians (3.3%), other health care providers (20.7%), and other (9.8%). Most were 40-65 years of age (71.6%) and female (92.4%).&#x0D; &#x0D; Methods – Forty-six training sessions were provided upon request between October 2004 and December 2006. Attendees were invited to participate in the study. Telephone interviews were conducted at three, six, nine, and twelve months following training sessions. Demographic information and data on the use of and satisfaction with The Cochrane Library were collected. Additionally, monthly statistics were tracked by Wiley-Blackwell for user sessions, number of searches, and the number of full-text articles and abstracts visited. &#x0D; &#x0D; Main Results – Telephone interviews revealed that 65.2% of participants had accessed The Cochrane Library at three months; 64.2% had at six months. At nine months access dropped to 45.2%. At twelve months only 27.4% of participants reported using the resource. Of those who used The Cochrane Library, 16.4% reported at the three-month interview that it was not helpful. This number decreased at six months (11.6%), nine months (7.7%) and twelve months (11.8%). 57.5% of respondents claimed to have learned something from The Cochrane Library, although a few (11.1%) reported that the information found had no impact. Others reported that the knowledge gained confirmed their beliefs (26.1%) and/or helped in decision-making (32.6%). No time points were reported for the data collected about the use and helpfulness of information found in The Cochrane Library. Three-year data from Wiley-Blackwell showed that The Cochrane Database of Systematic Reviews was most frequently accessed (abstracts=26,016; full texts=15,934). The Cochrane Central Register was accessed 5,640 times and Database of Abstracts of Reviews of Effects was accessed 1,612 times. Periods of low usage corresponded with summer and Christmas breaks. The type of search strategy used was tracked; the authors note that an emphasis on MeSH during training between October 2004 and December 2006 corresponded with the higher number of MeSH searches during the same time period. Participants reported using The Cochrane Library in response to patron requests, to prepare educational materials, and to support health care policy and practice changes. Reasons for not using The Cochrane Library included lack of time, limited access to the Internet, forgetting how to find and use the Web site, and disappointment with the content.&#x0D; &#x0D; Conclusion – Since the fall of 2004, The Cochrane Library has been promoted and made available free of charge to all Saskatchewan residents. Usage fluctuates during the year, with less use during the summer and winter holidays; it is reasonable to presume that students use The Cochrane Library during the academic school year. Most telephone interviewees who used The Cochrane Library reported that it was somewhat to very helpful; this number increased slightly over time while the number of respondents who used the resource fell measurably over twelve months. In other words, those who continued to use The Cochrane Library over time were more likely to report a higher level of satisfaction with the resource. Interviews indicated how librarians used The Cochrane Library, why they do or do not use the resource, and their level of satisfaction. The study revealed less about how others, such as practitioners or consumers, use the resource. Based on the limits of the telephone interviews, follow-up studies should try to capture more detailed usage data to describe the attributes of those who do and do not use The Cochrane Library. The authors note that additional data collected through online surveys or the Wiley-Blackwell website could help determine how to sustain use of the resource.

Health Care Utilization, Access, and Expenditures for Infants and Young Children With Special Health Care Needs

Special health care needs in the very young are on the rise. Understanding how health care systems provide service for these children is essential. We report on the prevalence of infants and young children with special health care needs (IYCSHCN), and delineate their access to health care, utilization, expenditures, and the financial impact on families. Using data from the 2001 and 2002 Medical Expenditure Panel Survey, we performed statistical analysis on the prevalence, demographics, utilization rates, expenditures, and out-of-pocket expenses for IYCSHCN to determine the impact on families, medical systems, and health care providers. An estimated 2.6 million children younger than 6 in the United States have special health care needs. These children have greater health care service needs as demonstrated by significantly higher utilization rates for all services. Although IYCSHCN were more likely to have a usual source of care, they were more likely than other children to have access issues. As expected, health care expenditures were markedly higher for IYCSHCN ($2923 per year) than those of their healthy peers ($770 per year). Families of IYCSHCN disproportionately felt the financial burden of health care, with more than 10% of families reporting out-of-pocket health care expenditures above $500 annually. The burden of disease and health care expenditures for families of IYCSHCN is substantial. Certain characteristics, such as having insurance, help protect families from high out-of-pocket expenses. Individuals who provide health care and educational services should be aware of the financial impact of service utilization and the issues faced by families in terms of access to care and out-of-pocket expenses. Health care policy changes may be necessary to ensure that needed care for IYCSHCN is accessible and affordable.

Coyuntura crítica y cambio institucional en salud: Argentina en los años '40

The 1940s witnessed deep changes in Argentina health care policies. This summary presents the proposal led in Santa Fe by Abelardo Yrigoyen Freyre, minister of Public Health and Labor between 1941 and 1943. This article emphasizes the need to deepen the study of both national and provincial processes of institutional change, starting from uniform concepts and categories, so as to enhance history's explanation capability through comparative analyses.

PP_010: Health Care Utilization, Access, and Expenditures for Infants and Young Children With Special Health Care Needs

Special health care needs in the very young are on the rise. Understanding how health care systems provide service for these children is essential. We report on the prevalence of infants and young children with special health care needs (IYCSHCN), and delineate their access to health care, utilization, expenditures, and the financial impact on families. Using data from the 2001 and 2002 Medical Expenditure Panel Survey, we performed statistical analysis on the prevalence, demographics, utilization rates, expenditures, and out-of-pocket expenses for IYCSHCN to determine the impact on families, medical systems, and health care providers. An estimated 2.6 million children younger than 6 in the United States have special health care needs. These children have greater health care service needs as demonstrated by significantly higher utilization rates for all services. Although IYCSHCN were more likely to have a usual source of care, they were more likely than other children to have access issues. As expected, health care expenditures were markedly higher for IYCSHCN ($2923 per year) than those of their healthy peers ($770 per year). Families of IYCSHCN disproportionately felt the financial burden of health care, with more than 10% of families reporting out-of-pocket health care expenditures above $500 annually. The burden of disease and health care expenditures for families of IYCSHCN is substantial. Certain characteristics, such as having insurance, help protect families from high out-of-pocket expenses. Individuals who provide health care and educational services should be aware of the financial impact of service utilization and the issues faced by families in terms of access to care and out-of-pocket expenses. Health care policy changes may be necessary to ensure that needed care for IYCSHCN is accessible and affordable.

Quality Summit Puts Premium on Staff Retention

WASHINGTON — The workforce shortage in long-term care is not simply an issue of recruitment, but perhaps more importantly it is an issue of retention, according to Robyn Stone, Dr.P.H. “We are facing significant shortages, so we want to worry about recruitment, but—as providers—our focus should be [on] retention,” she said. The executive director and CEO of the International Longevity Center in Washington spoke recently during the kickoff of the Quality Summit, the national campaign to advance excellence in America's nursing homes. AMDA is one of the organizations to help lead this campaign. “Many people have been spending the past decade working on staffing issues,” Dr. Stone said. However, “I believe there is a disconnect between recognizing the need to invest in our workforce—nursing, physicians, medical directors, therapists, and administrators—and actually doing something.” Dr. Stone said the fact that “we don't have a comprehensive strategy at a policy level or practice level” poses a significant problem. She added that many people in the provider sector think they are investing in staff by holding ‘in services’ and spending money on training. However, she noted that “your entire infrastructure has to be about the people who work there—how information flows, how the organization is structured, how people get clinical, administrative, and leadership [skills] training, and what they do with this information when they come back to the facility.” While there is no panacea to solve staffing shortages and turnover in long-term care, Dr. Stone emphasized that there are answers and they aren't as complicated as people might think. “It is about what you do every day. You need to go back and look at the infrastructure and supports you have in place. You need to address how training is used and spread throughout the organization,” she observed. “It's not rocket science. It's what every good employer needs to do.” The “Advancing Excellence” campaign hopes to unveil and share best practices in staff retention and recruitment. Dr. Stone noted that there already are some useful models in existence. For example, she pointed to Better Jobs Better Care, a 4-year, $15.5 million research and demonstration program that seeks to achieve changes in long-term care policy and practice to reduce high vacancy and turnover rates among direct-care staff. The project will test new approaches to providing a more stable and qualified staff and will systematically evaluate what works best to achieve this objective. “We need to look at models that are most successful and how they involve staff, including front-line caregivers,” said Dr. Stone. She added that these models need to employ evidence-based practices that staff use because they are “empowered to do so.” While Quality Improvement Organizations (QIOs) can be effective partners in improving staff quality, Dr. Stone emphasized that the facilities themselves need to make the changes. “QIOs can't do this. Instead, things happen because people do it. Staff have to observe and document better, catch things earlier, communicate more effectively, and so on.” Providers play a key role in improving staffing in long-term care, Dr. Stone observed. She said, “good providers recognize caregivers, listen to them, and treat them with respect. Teamwork is a common concept, and most facilities aim for this; but it is really hard to get people working together effectively as a team and to keep this momentum going.”

Child Care in Poland before, during, and after the Transition: Still a Women's Business

This article gives a historical overview of changes in child care policies in Poland and analyzes their influence on gender equality/inequality over the last period. Under the Communist regime, these policies were subordinated to economic interests and characterized by contradictory trends. The measures enforced during this period in the field of public child care facilities and of child care leave reveal that, despite a progressive constitution, Polish women were treated as second-class citizens. However, even a market economy and massive privatizations have reinforced this trend. Women are still seen primarily as mothers and suffer discrimination in the labor market. In order to meet the conditions of integration into the European Union, a more egalitarian framework was adopted, but at the same time, the Polish state made drastic cuts in welfare expenditures. Thus, the family allowances look more like a “safety net” for the poorest than a real family-policy system. Collective care institutions progressively disappear: today, they cover only 2 percent of children under the age of three. This affects women first of all, as they are held responsible for taking care of children. The weight of the Church and the traditional point of view concerning women’s place in society brake any movement of emancipation, and most women still consider that their main duty lies in their role as mothers.

Comparison of Home versus Physical Therapy-Supervised Rehabilitation Programs after Anterior Cruciate Ligament Reconstruction

Background Because of health care funding and policy changes, there is a need to examine the effects of an evolution toward patient-directed (ie, home-based) rehabilitation programs on clinical outcomes of patients undergoing anterior cruciate ligament reconstruction. Hypothesis There will be no difference in the effectiveness of a home-based rehabilitation program and a standard physical therapy-supervised rehabilitation program in patients 3 months after nonacute anterior cruciate ligament reconstruction with bone-patellar tendon-bone grafts. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods There were 145 patients (16-59 years) who attended a presurgery education class. Home-based patients attended 4 physical therapy sessions, and physical therapy-supervised patients attended 17 physical therapy sessions over the first 12 weeks after surgery. All patients followed the same standardized rehabilitation program. Study outcome measures included active-assisted knee flexion and passive knee extension range of motion, knee range of motion during walking, KT computerized arthrometer results, and isokinetic quadriceps and hamstrings strength. Patient outcomes were dichotomized as either clinically acceptable or unacceptable. Rehabilitation programs were compared by the proportion of acceptable patients in each group. Results The home-based group had a significantly higher percentage of patients with acceptable flexion and extension range of motion compared to the standard physical therapy group (flexion, 67% vs 47%; extension, 97% vs 83%). There were no significant differences between the groups in range of motion during walking, ligament laxity, and strength. Conclusion A structured, minimally supervised rehabilitation program was more effective in achieving acceptable knee range of motion in the first 3 months after anterior cruciate ligament reconstruction than a standard physical therapy-based program. Clinical Relevance Recreational athletes undergoing nonacute anterior cruciate ligament reconstruction can successfully reach acceptable rehabilitation goals in the first 3 months after surgery with a limited number of purposeful physical therapy education sessions, allowing recreational athletes more flexibility when integrating the necessary postoperative rehabilitation into their daily activities.

Educating Physical Therapists in Womenʼs Health: Recommendations for Professional (Entry-Level) and Postprofessional Curricula

Background and Purpose. Managing conditions unique to and more prevalent in women is an emerging trend in care. The key purposes of this study were to determine (1) practice patterns and emphasis of physical therapists, (2) how and to what extent physical therapists were educated about health, ( 3) curricular content deemed important in preparing practicing and professional (entry-level) physical therapists, and (4) by what means therapists may be interested in furthering their knowledge of health. Subjects and Methods. Subjects were a random sample (N = 1,021) of members of the Section on Women's Health of the American Physical Therapy Association who completed a survey on their practice emphasis, educational preparation in health, and opinions regarding content that should be taught at the professional and postprofessional levels in physical therapist education programs. Results. Thirty-seven percent of the subjects (n=347), representing 48 states, responded. A majority of respondents (n=204) reported that up to 25% of their practice involved treating specific issues and most had received minimal academic education specific to health. Examples of curricular content recommended for entry into the profession included osteoporosis, musculoskeletal conditions, obstetrics, and urogenital concerns, while pathology, pelvic floor assessment/treatment, endocrinology, and gynecology were recommended for the postprofessional level. Of the 347 who responded, practitioners' preference for postprofessional education was via continuing education (n=229) or certificate programs (n=227). Discussion and Conclusion. As physical therapist education program curricula evolve in response to degree advances and changes in care policy, educators can use this information to strengthen both professional and postprofessional curricula in health. Key Words: Women's health, Physical therapist education, Curriculum. INTRODUCTION Women's has become a national focus influencing everything from National Institutes of Health policy1 to nutrition options and vitamin supplements. Despite this interest, topics have been reported to be underrepresented in both professional and postprofessional physical therapist education programs.2,3 In 1979, Frahm wrote exposure to the OB/GYN area is noticeably sparse in the American physical therapy school curriculum.4 And now, over 25 years later, there is some question about the degree to which topics are being taught in physical therapist education programs today. According to A Normative Model of Physical Therapist Professional Education, professional physical therapist education programs should graduate students who are sensitive to individual and cultural differences when engaged in physical therapy practice, research, and education.5 To effectively compare the effects of sex on diagnosis, prognosis, health, and wellness, physical therapist education needs to expand the traditional medical view of women's health which typically includes reproductive issues in adolescent girls and adult women.6,7 Instead, physical therapist educators should take steps to account for the broad spectrum of concerns throughout the lifespan and the relative differences between men and women in terms of behaviors, morbidity, disability, and mortality. Additional considerations may also need to be made regarding the demographic, social, cultural, and political influences on a woman's and her approach to care.7-11 Unfortunately, there is little evidence on the current status of content in physical therapy curricula. Therefore, the current study was developed to address the following purposes: (1) to determine practice patterns and practice emphasis of a national sample of physical therapists, (2) to determine how and to what extent these physical therapists were educated about issues, (3) to identify important curricular topics in preparing both practicing (postprofessional) and professional (entry-level) physical therapists to address care needs unique to women, and (4) to determine whether, and by what means, physical therapists were interested in advancing their knowledge of health. …

Facilitating EMS Turnaround Intervals at Hospitals in the Face of Receiving Facility Overcrowding

The escalating national problem of oversaturated hospital beds andemergency departments (EDs) has resulted in serious operational impediments within patient-receiving facilities. It has also had a growing impact on the 9-1-1 emergency care system. Beyond the long-standing difficulties arising from ambulance diversion practices, many emergency medical services (EMS) crews are now finding themselves detained in EDs for protracted periods, unable to transfer care of their transported patients to ED staff members. Key factors have included a lack of beds or stretcher space, and, in some cases, EMS personnel are used transiently for ED patient care services. In other circumstances, ED staff members no longer prioritize rapid turnaround of EMS-transported patients because of the increasing volume andacuity of patients already in their care. The resulting detention of EMS crews confounds concurrent ambulance availability problems, creates concrete risks for delayed EMS responses to impending critical cases, andincurs regulatory jeopardy for hospitals. Communities should take appropriate steps to ensure that delivery intervals (time elapsing from entry into the hospital to physical transfer of patient care to ED staff) remain extremely brief (less than a few minutes) andthat they rarely exceed 10 minutes. While recognizing that the root causes of these issues will require far-reaching national health care policy changes, EMS andlocal government officials should still maintain ongoing dialogues with hospital chief administrators to mitigate this mutual crisis of escalating service demands. Federal andstate health officials should also play an active role in monitoring progress andcompliance.

The resident 80-hour work week: how has it affected surgical specialties?

To identify strategies employed by surgical departments to address recently implemented resident duty hour regulations, and to assess resident and faculty acceptance of these changes. Attendees to the 2003 Residency Program Coordinator/Administrator Workshop for sub-specialties (Denver, CO) were surveyed. The study population included 46 respondents spanning 9 surgical sub-specialties. Forty-eight percent of programs instituted at least 1 administrative change specifically to comply with duty hour regulations. The most commonly employed strategies were the hiring of nurse practitioners or physician assistants (30%) and the use of Internet-based software to track resident duty hours (30%). Other changes included giving call responsibilities to residents on research rotations (19%), institution of home-call (13%), and assignment of a night-float resident (11%). Perceptions of program coordinators indicated that junior residents and junior faculty accepted changes better than did senior residents and senior faculty (P=.025). The resident 80-hour work week is a major health care policy change that has required academic sub-specialty departments to make significant alterations in their administrative structure. Further study is necessary to determine how these changes affect both quality of training and patient care in the short and long term.

Future Challenges: Changing Health Care Delivery and Advancing Patient Care

Our current health care system involves multidisciplinary groups of practitioners who function as freestanding silos and in which a “team” approach means an awareness and tolerance of other disciplines as patients are handed from one practitioner to another. Pharmacy has advanced from clinical pharmacy through pharmaceutical care to the dawning of medication therapy management services. With each step pharmacy has become more focused on direct patient care. As technology and technicians improve the dispensing process and as electronic databases evolve, the pharmacist will increasingly be positioned to be more available and better equipped to provide direct patient care and medication therapy management services. Over the next decade, I see pharmacy and other health care providers moving to an interdisciplinary team approach in which decisions are made by consensus and through which each discipline has an equal opportunity for input.1 To accommodate such a change, I envision a new health care delivery model based on the following components: n Wellness and prevention services as the entry point into the system. n An interdisciplinary delivery model with providers having shared borders (a model in which our professional boundaries become blurred or overlap, and health care professionals share a common knowledge base, a common professional interest, and an instinct to help the patient). n “Physician extenders” providing disease and medication management services using evidenced-based medicine. n Systems that are outcomes driven and outcomes justified. n A broader acceptance and use of complementary and alternative medicine within the delivery model. All of the above components are evolving or already exist in the current environment. The challenge to the system is to integrate them into successful delivery models. The challenge to the pharmacist is to identify, embrace, Future Challenges: Changing Health Care Delivery and Advancing Patient Care and drive their evolving roles within this new health care delivery model.

Ethical Issues in Emergency Preparedness and Response for Health Professionals

Health care policy changes are needed to minimize the risk to physicians responding to public health emergencies and aid in their longer-term responsibility of protecting and promoting the nation's health. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.