Changing Physicians' Practices

Greco, Peter M.; Eisenberg, John M.

doi:10.1056/nejm199310213291714

Cited by 866 publications

(473 citation statements)

References 39 publications

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“…Previous process improvement initiatives have clearly demonstrated the importance of strong local champions for the success of the interventions. 29 The nurse champions in our project identified the need for reeducation, particularly during the first 3 months of implementation of the algorithm. This training information was easily relayed through huddles, staff meetings, and 1-on-1 sessions.…”

Section: Discussionmentioning

confidence: 99%

Improving Family Satisfaction and Participation in Decision Making in an Intensive Care Unit

Huffines

Johnson

Naranjo

et al. 2013

Critical Care Nurse

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Background Survey data revealed that families of patients in a surgical intensive care unit were not satisfied with their participation in decision making or with how well the multidisciplinary team worked together. Objectives To develop and implement an evidence-based communication algorithm and evaluate its effect in improving satisfaction among patients’ families. Methods A multidisciplinary team developed an algorithm that included bundles of communication interventions at 24, 72, and 96 hours after admission to the unit. The algorithm included clinical triggers, which if present escalated the algorithm. A pre-post design using process improvement methods was used to compare families’ satisfaction scores before and after implementation of the algorithm. Results Satisfaction scores for participation in decision making (45% vs 68%; z = −2.62, P = .009) and how well the health care team worked together (64% vs 83%; z = −2.10, P = .04) improved significantly after implementation. Conclusions Use of an evidence-based structured communication algorithm may be a way to improve satisfaction of families of intensive care patients with their participation in decision making and their perception of how well the unit’s team works together.

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Section: Discussionmentioning

confidence: 99%

Improving Family Satisfaction and Participation in Decision Making in an Intensive Care Unit

Huffines

Johnson

Naranjo

et al. 2013

Critical Care Nurse

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“…However, it is extremely difficult to alter physicians' practice styles. 30 Second, early specialty consultation might be encouraged. Knowledge increases rapidly, and tends to be adopted first by specialists.…”

Section: Discussionmentioning

confidence: 99%

Differences in generalist and specialist physicians’ knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure

et al. 1997

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OBJECTIVE:To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication. DESIGN:Survey of a national systematic sample of physicians. PARTICIPANTS:Five hundred family practitioners, 500 general internists, and 500 cardiologists. MEASUREMENTS AND MAIN RESULTS:Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently ( p Յ .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%); and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely ( p Յ .05) to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less (43% vs 15%). he appropriate role of generalist and specialist physicians in the care of patients is controversial. 1 It is generally assumed that the sickest, most complicated patients, as well as patients with rare disorders, benefit most from specialty care. However, the majority of patients with chronic diseases such as heart failure, diabetes, or chronic obstructive pulmonary disease initially are not severely ill, and are therefore first seen by the generalist physician. The most cost-effective threshold for specialty referral and the optimal mix of generalist and specialist care remain unknown. 2 Congestive heart failure is an ideal model to study variation in physicians' practice patterns among patients with chronic disease. This syndrome is common and presently the domain of both generalist and specialist physicians. Advances in cardiac transplantation and hemodynamically titrated therapy have made some of the sickest patients clear candidates for referral to cardiologists. 3 Recently, however, multicenter trials of angiotensin-converting enzyme (ACE) inhibitors have modified the standard of treatment for a broad range of patients with heart failure. 4 These medications have been found to decrease mortality in patients with chronic heart failure and ejection fractions of 0.35 or less, 5 decrease...

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“…Riccucci 2005), and tend to be individualistic in their practice and attitude towards integration (Shortell et al 2000). Furthermore, the status, power, and expertise of the medical profession mean that any set of organizational reforms requires the compliance of physicians for its effectiveness (Greco and Eisenberg 1993;Shortell et al 1998). This is arguably all the more so in the NHS, where in contrast to the relative erosion of medical power and autonomy in the US (Hafferty and Light 1995), physicians have retained an authority that gives them power of veto over NHS administrators in regard of any organizational reconfigurations that they do not welcome (Harrison et al 1992;Bate 2000).…”

Section: Network and Leadership: Obstacles And Impedimentsmentioning

confidence: 99%

Leadership, Service Reform, and Public-Service Networks: The Case of Cancer-Genetics Pilots in the English NHS

Martin

Currie

Finn

2008

Journal of Public Administration Research and Theory

107

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In attempting to reform public services, governments worldwide have sought to effect change through policies aimed at both transforming structures of public service provision and facilitating the agency of public servants working within these. Various obstacles have been found, however, to impede the effectiveness of such efforts. In this paper, the authors examine the role of organizational networks and distributed leadership-two prominent policies aimed at structure and agency respectively-in the establishment and consolidation of service reform in the English National Health Service. Using a comparative case-study approach, they contrast the trajectories of two attempts to introduce and gain acceptance for service reform, noting important differences of context, process and outcome between the sites. The findings indicate the importance of dispersed, as well as distributed, leadership in achieving change in a networked public-service setting. Effective leaders may indeed achieve change through the structures and processes of the network. However, the coexistence alongside the network of other organizational forms constrains the ability of leaders to achieve change without complementary action beyond the boundaries of the network.

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Changing Physicians' Practices

Cited by 866 publications

References 39 publications

Improving Family Satisfaction and Participation in Decision Making in an Intensive Care Unit

Improving Family Satisfaction and Participation in Decision Making in an Intensive Care Unit

Differences in generalist and specialist physicians’ knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure

Leadership, Service Reform, and Public-Service Networks: The Case of Cancer-Genetics Pilots in the English NHS

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