Patterns for collaborative work in health care teams

Objective

The problem of designing and managing teams of workers that can collaborate working together towards common goals is a challenging one. Incomplete or ambiguous specification of responsibilities and accountabilities, lack of continuity in teams working in shifts, inefficient organization of teams due to lack of information about workers’ competences and lack of clarity to determine if the work is delegated or assigned are examples of important problems related to collaborative work in healthcare teams. Here we address these problems by specifying goal-based patterns for abstracting the delegation and assignment of services. The proposed patterns should provide generic and reusable solutions and be flexible enough to be customizable at run time to the particular context of execution. Most importantly the patterns should support a mechanism for detecting abnormal events (exceptions) and for transferring responsibility and accountability for recovering from exceptions to the appropriate actor.

Method

To provide a generic solution to the problematic issues arising from collaborative work in teams of health workers we start from definitions of standard terms relevant for team work: competence, responsibility, and accountability. We make explicit the properties satisfied by service assignment and delegation in terms of competences, responsibilities, and accountability in normal scenarios and abnormal situations that require the enactment of recovery strategies. Based on these definitions we specify (1) a basic terminology, (2) design patterns for service assignment and delegation (with and without supervision), and (3) an exception manager for detecting and recovering from exceptions. We use a formal framework to specify design patterns and exceptions.

Results

We have proved using Owicki-Gries Theory that the proposed patterns satisfy the properties that characterize service assignment and delegation in terms of competence, responsibility and accountability in normal and abnormal (exceptional) scenarios. We show that although abstract, the proposed patterns can be instantiated in an executable COGENT prototype, and can be mapped into the Tallis tool that enacts PROforma language specifications of medical guidelines.

Conclusions

The proposed patterns are generic and abstract enough to capture the normal and abnormal scenarios of assignment and delegation of tasks in collaborative work in health care teams.     

Exploring attitudes,beliefs, and communication preferences of Latino community members regarding BRCA1/2 mutation testing and preventive strategies

PurposeTo inform development of a culturally sensitive hereditary breast and ovarian cancer communication initiative and related clinical genetic services.MethodsFive focus groups were conducted with 51 female and male Latinos. Educational materials were designed to communicate information about hereditary breast or ovarian cancer and availability of relevant clinical services or prevention strategies. Focus groups explored participants' knowledge, attitudes, and beliefs about hereditary breast and ovarian cancer, BRCA1/2 testing, and communication preferences for hereditary breast and ovarian cancer health messages.ResultsOverall, awareness of familial breast and ovarian cancer and availability of genetic risk assessment was low. Once informed, participants held favorable attitudes toward risk assessment and counseling services. Critical themes of the research highlighted the need to provide bilingual media products and use of a variety of strategies to increase awareness about hereditary cancer risk and availability of clinical genetic services. Important barriers were identified regarding family cancer history communication and cancer prevention services. Strategies were suggested for communicating cancer genetic information to increase awareness and overcome these barriers; these included both targeted and tailored approaches.ConclusionThis research suggests that cancer genetic communication efforts should consider community and cultural perspectives as well as health care access issues before widespread implementation.     

Identifying mental health services in clinical genetic settings

The purpose of this study was to examine the mental health needs of individuals at risk for adult onset hereditary disorder (AOHD) from the perspective of their genetic service providers, as it is unknown to what extent psychosocial services are required and being met. A mail-out survey was sent to 281 providers on the membership lists of the Canadian Association of Genetic Counsellors and the Canadian College of Medical Geneticists. The survey assessed psychosocial issues that were most commonly observed by geneticists, genetic counsellors (GCs), and nurses as well as availability and types of psychosocial services offered. Of the 129 respondents, half of genetic service providers reported observing signs of depression and anxiety, while 44% noted patients' concerns regarding relationships with family and friends. In terms of providing counselling to patients, as the level of psychological risk increased, confidence in dealing with these issues decreased. In addition, significantly more GCs reported that further training in psychosocial issues would be most beneficial to them if resources were available. As a feature of patient care, it is recommended that gene-based predictive testing include an integrative model of psychosocial services as well as training for genetic service providers in specific areas of AOHD mental health.     

Comorbidity: Coexisting substance use and mental disorders in young people

Young people with comorbid disorders (coexisting mental health and substance use disorders) present with particular issues that can be difficult for service providers, and for the community as a whole, to respond to. They tend to fall between the cracks of mental health services and substance use services, with the outcome often being ineffective treatment, or no treatment at all, for the young people concerned, and increasing conflict, ideological clashes and blame between agencies. There is urgent need for better communication and development of protocols between mental health services and substance use services for young people; both need to recognise and respect their differing expertise, develop coordinated treatment plans and convey this information to the wider helping services sector. Cross-training is necessary for professionals in the mental health and substance use fields.     

Patients’ expectations for and experiences with primary healthcare services received from a patient centered medical home

ObjectiveExpectations for and experiences with healthcare services are summarized for 1143 patients receiving care in a statewide demonstration of Patient Centered Medical Homes (PCMH).MethodsPatients were recruited from 91 primary care clinics for semi-structured interviews to determine what patients expect, what they plan to do and how they intend to execute their plans in partnership with their healthcare team.ResultsThe majority (78%) of patients defined the patient-team partnership as a collaborative and problem-solving effort. Overall, 68% defined responsibility for own health as a personal responsibility; 55% defined listening to patient’s concerns and answering questions as a responsibility of their healthcare team. Diet and exercise came up most frequently whether as a personal responsibility, issues for receiving additional help from their clinic, or plans for personal change.ConclusionPatients’ preferred a collaborative, problem-solving healthcare team partnership but also had boundaries for what additional services they wanted from this team.Practice Implications: Patients’ expectations for a collaborative partnership, acceptance of personal responsibility and interest in diet and exercise expands opportunities for patient education and teamwork. Clinics’ engagement with broader resources would be needed to address patients’ many and varied challenges to taking care of their health.     

Outcomes of a randomised controlled trial of a complex genetic counselling intervention to improve family communication

When an inherited genetic condition is diagnosed in an individual it has implications for other family members. Privacy legislation and ethical considerations can restrict health professionals from communicating directly with other family members, and so it is frequently the responsibility of the first person in a family to receive the diagnosis (the proband) to share this news. Communication of genetic information is challenging and many at-risk family members remain unaware of important information that may be relevant to their or their children''s health. We conducted a randomised controlled trial in six public hospitals to assess whether a specifically designed telephone counselling intervention improved family communication about a new genetic diagnosis. Ninety-five probands/parents of probands were recruited from genetics clinics and randomised to the intervention or control group. The primary outcome measure was the difference between the proportion of at-risk relatives who contacted genetics services for information and/or genetic testing. Audit of the family genetic file after 18 months revealed that 25.6% of intervention group relatives compared with 20.9% of control group relatives made contact with genetic services (adjusted odds ratio (OR) 1.30, 95% confidence interval 0.70–2.42, P=0.40). Although no major difference was detected overall between the intervention and control groups, there was more contact in the intervention group where the genetic condition conferred a high risk to offspring (adjusted OR 24.0, 95% confidence interval 3.4–168.5, P=0.001). The increasing sophistication and scope of genetic testing makes it imperative for health professionals to consider additional ways of supporting families in communicating genetic information.     

Ethical,social, and cultural issues related to clinical genetic testing and counseling in low- and middle-income countries: a systematic review

PurposeWe performed a systematic review of the ethical, social, and cultural issues associated with delivery of genetic services in low- and middle-income countries (LMICs).MethodsWe searched 11 databases for studies addressing ethical, social, and/or cultural issues associated with clinical genetic testing and/or counselling performed in LMICs. Narrative synthesis was employed to analyze findings, and resultant themes were mapped onto the social ecological model (PROSPERO #CRD42016042894).ResultsAfter reviewing 13,308 articles, 192 met inclusion criteria. Nine themes emerged: (1) genetic counseling has a tendency of being directive, (2) genetic services have psychosocial consequences that require improved support, (3) medical genetics training is inadequate, (4) genetic services are difficult to access, (5) social determinants affect uptake and understanding of genetic services, (6) social stigma is often associated with genetic disease, (7) family values are at risk of disruption by genetic services, (8) religious principles pose barriers to acceptability and utilization of genetic services, and (9) cultural beliefs and practices influence uptake of information and understanding of genetic disease.ConclusionWe identified a number of complex and interrelated ethical, cultural, and social issues with implications implications for further development of genetic services in LMICs.     

Don't Mourn: Organize. Reviving Mental Health Services Research for Healthcare Quality Improvement

The structure, organization, management, and design of the mental health system are changing profoundly as new healthcare policies reshape its configurations. This special issue is a call to action for the mental health services research field. The articles represent an important attempt to identify specific concepts, constructs, and findings from psychosocial treatment research about fidelity and integrity of treatment and align them with healthcare quality. However, the current structure and processes for deriving quality indicators place other demands on the extant research base. These will challenge this migration unless changes are made in leadership around consistent measurement strategies, payment mechanisms to support quality, and attention to technological infrastructure development. The mental health services research field should be proactive. Pediatric issues need special attention, especially as applied to community‐based services for children and their families.     

Genetic services

This is a time of unprecedented increase in knowledge about the genetic basis of disease against a background of rapidly changing technology. Advances happen quickly, with the new knowledge rapidly becoming relevant to services for patients, and hence there is an increasing demand for, and expectation of, genetic services. This brings a challenge for health services worldwide to keep pace with the expectations of their populations. There is also a need for public and professional education and dialogue to dispel some of the hype and myths about what can be achieved. It should not be forgotten that any services must be provided and developed within a broad ethical framework. A statement from a WHO expert consultation (1) concluded that 'Genetic advances will only be acceptable if their application is carried out ethically, with due regard to autonomy, justice, education and the beliefs and resources of each nation and community'. That so many public bodies have commented on genetic services and their associated ethical, legal and social issues emphasizes not only the importance of this area in health care, but also that the wider issues are of great importance in democratic societies. The aim of this paper is to review the current situation in the provision of genetic services, to examine the drivers for change, to speculate on the likely need for future services and to suggest models for the development of such services. Pharmacogenetics and the determination of genetic factors indicating susceptibility to infection will not be discussed since these have been the subject of several recent excellent reviews (2, 3). Genetic services have been defined as health measures implemented to help people with a genetic disadvantage and their families to live and reproduce as normally as possible (4). Broadly they can be divided into those services which target whole populations with a view to identifying those at increased risk; and those which focus on the needs of families which are affected by a genetic disorder or who perceive themselves to be at increased risk.     

Being homeless and the use and nonuse of services: a qualitative study

Eight homeless people were interviewed about their experiences of health and social services. Three themes emerged: responsibility, identity, and feeling trapped. Although some felt they were responsible for their own situation and avoided help, most turned to formal channels for help, but professionals were often seen as offering unwanted labels and as being rule bound. In contrast, peers were considered more understanding but colluded with their problems. Participants also expressed feeling trapped within the homeless system. Therefore, by locating responsibility for change with others, they were left feeling stigmatized, but by turning to their peers, their situation remained the same. © 2011 Wiley Periodicals, Inc.     

Investigating risk exposure in e-health systems

PURPOSE: Health managers, administrators and health practitioners now face new challenges due to the increasing dependency being placed on electronic health information systems. This paper focuses on Electronic Health Records for determining the critical attributes for e-health system development. The proposed QUiPS model aims to provide a framework for building trustworthy solutions by identifying the pertinent issues needed to determine the risk exposure with a given system. APPROACH: To produce dependable, low risk and viable IT solutions, each critical attribute needs to be specifically addressed and prioritized. It is shown how these attributes possess a number of interdependencies making the analysis and prioritization tasks complex and hence, in practice, often incomplete. Two Australian case studies are presented that access enterprise level applications of live health records where these risk based techniques have been applied. RESULTS: The value and the shortcomings of taking a risk based approach to developing and deploying electronic health information systems that are safe and secure, is evaluated. The case studies presented indicate that traditional methods used to derive the requirements are often inadequate and the risks that are faced in ensuring a safe and secure system are highly application dependent and dynamic. CONCLUSIONS: Convergence towards a viable universal solution for our electronic health records is not imminent and trust in e-health is fragile. Policies that data custodians follow need to be flexible and updated on a regular basis. Technological solutions are at best a stop gap to avoid the common hazards associated with access control and secure messaging. A wider range of analysis techniques to determine the key issues for a dependable health information system can derive longer term sustainable solutions.     

Developing a stroke intervention program: What do people at risk of stroke want?

OBJECTIVE: There is currently little research examining what individuals who are at risk of a stroke want from an invention program. In order to increase the usefulness of such programs, qualitative research methods were used explore invention design issues such as factors affecting accessibility of programs and preferred health information sources. METHODS: Thirty people, each with at least one stroke risk factor, participated in one of eight focus groups. RESULTS: Broad support was indicated for our proposed intervention. Participants perceived the value and likely success of such a program enhanced if it: (a) was integrated with, and supported by, other respected health services; (b) included social components (particularly important to women); (c) produced long-term benefits; and (d) included information that was personally relevant and practical in terms of implementing change. Three reasons emerged for continuing stroke education campaigns as a component of intervention programs; these were: (a) a lack of awareness among some participants of gaps in their stroke knowledge; (b) participants' explicit requests for specific rather than general information; and (c) the apparent failure of some participants to self-identify as at risk. CONCLUSION: This study yielded a number of important design considerations that should be taken into account when developing stroke intervention programs. PRACTICE IMPLICATIONS: We discuss ways of maximising the personal relevance of stroke prevention information along theoretically important dimensions, and consumers' recommendations for the design and delivery of stroke intervention programs.     

Increased male responsibility and participation: a key to improving the reproductive health

This article examines the role of male responsibility and participation in the enhancement of reproductive health in India. Men are recognized to be responsible for the large proportion of reproductive ill health suffered by their female partners. Lack of knowledge, nonavailability of acceptable contraceptives and lack of services with quality of care deter men from sharing the responsibility in reproductive health matters. Misinformation regarding male sexuality and limited availability of scientific data contributed men's less involvement in reproductive health. Thus, various strategies are implemented to increase men's awareness of reproductive health and the accessibility of products and services. These strategies include: 1) increasing contraceptive options for men; 2) supporting women's contraceptive use; 3) improving sexual behavior and safe sex practices; and 4) narrowing the gender gap for better fertility control. Moreover, extensive research is required in order to understand men's perceptions and needs about fertility regulation and sexual behavior as well as services development.     

Antivirals in medical biodefense

The viruses historically implicated or currently considered as candidates for misuse in bioterrorist events are poxviruses, filoviruses, bunyaviruses, orthomyxoviruses, paramyxoviruses and a number of arboviruses causing encephalitis, including alpha- and flaviviruses. All these viruses are of concern for public health services when they occur in natural outbreaks or emerge in unvaccinated populations. Recent events and intelligence reports point to a growing risk of dangerous biological agents being used for nefarious purposes. Public health responses effective in natural outbreaks of infectious disease may not be sufficient to deal with the severe consequences of a deliberate release of such agents. One important aspect of countermeasures against viral biothreat agents are the antiviral treatment options available for use in post-exposure prophylaxis. These issues were adressed by the organizers of the 16th Medical Biodefense Conference, held in Munich in 2018, in a special session on the development of drugs to treat infections with viruses currently perceived as a threat to societies or associated with a potential for misuse as biothreat agents. This review will outline the state-of-the-art methods in antivirals research discussed and provide an overview of antiviral compounds in the pipeline that are already approved for use or still under development.

     

Hospital services for patients with acute stroke in Ireland: the Volunteer Stroke Scheme survey of consultant opinion

A national postal survey of hospital based consultants with responsibility for acute care of stroke admissions was performed in November, December 1998. Of 162 survey forms, 140 (86.4%) were returned representing consultants working in all 38 acute general hospitals (total 10,067 hospital beds) of whom 135 indicated that stroke patients were admitted under their care. Patients were admitted under 11 different subspeciality groups to various medical and surgical wards. Only 18.5% of consultants worked in hospitals where there was a physician/neurologist with specific responsibility for stroke, whilst only 19.5% were aware of a policy in their hospital for implementation of minimum standards of care for stroke patients or a recent audit of stroke care (9%). A substantial number of hospitals in certain health board areas have no access to a consultant led rehabilitation unit within their own health board area whilst 18/38 hospitals have no on-site CT brain scanning. Despite the proven value of organised hospital stroke care, this survey documents major deficiencies in this country. We suggest that each health board would review its services to include in each hospital a consultant physician with special responsibility for co-ordination and development of appropriately staffed and funded stroke services.     

Expanding the space: inclusion of most-at-risk populations in HIV prevention, treatment, and care services

The provision of appropriate HIV prevention, treatment, and care services for most-at-risk populations (MARP) will challenge many health care systems. For people who sell sex or inject drugs and for men who have sex with men, stigma, discrimination, and criminalization can limit access to care, inhibit service uptake, and reduce the disclosure of risks. Several models for provision of HIV services to MARP may address these issues. We discuss integrated models, stand-alone services, and hybrid models, which may be appropriate for some MARP in some settings. Both public health and human rights frameworks concur that those at greatest risk should have expanded access to services.     

Providing Interdisciplinary Geriatric Team Care: What Does It Really Take?

We concur with Speer and Schneider's arguments (2003 ; this issue) that more psychologists should offer mental health services to older adults and that the primary care system is a good focus of such efforts. Three issues deserve more prominence in their review. First, their argument that older adults are averse to mental health services seems incorrect, given research indicating that older adults prefer psychotherapy to medication for treatment of depression. Second, psychologists working in primary care need to be aware of new Current Procedural Terminology (CPT) codes that allow documentation of psychological work in medical settings. Third, Speer and Schneider allude to interdisciplinary team functioning, but provide little information about models of team care or issues in developing a well-functioning interdisciplinary team; this commentary expands on those topics.     

Multicentre derivation and validation of a simple predictive index for healthcare-associated Clostridium difficile infection

ObjectivesClostridium difficile infection (CDI) is the most common cause of healthcare-associated infections in the United States. Despite well-established risk factors, little research has focused on use of these variables to identify a patient population at high risk for CDI to target with primary prevention strategies. A predictive index for healthcare-associated CDI could improve clinical care and guide research for primary prevention trials. Our objective was to develop a predictive index to identify patients at high risk for healthcare-associated CDI.MethodsWe performed a secondary database analysis in a five-hospital health system in Houston, Texas. Our cohort consisted of 97 130 hospitalized patients admitted for more than 48 hours between October 2014 and September 2016. The derivation cohort consisted of the initial 80% of admissions (75 545 patients), with the remainder being used in the validation cohort.ResultsCDI rates in the derivation and validation cohorts were 1.55% and 1.43%, respectively. Thirty-day predictors of CDI were increased number of high-risk antibiotics, Charlson comorbidity index score, age and receipt of a proton pump inhibitor. These variables were incorporated into a simple risk index with a score range of 0 to 10. The final model demonstrated good discrimination and calibration with the observed CDI incidence ranging from 0.1% to 20.4%.ConclusionsWe developed a predictive index for 30-day risk of healthcare-associated CDI using readily available and clinically useful variables. This simple predictive risk index may be used to improve clinical decision making and resource allocation for CDI stewardship initiatives, and guide research design.