In-kind incentives and health worker performance: Experimental evidence from El Salvador

We experimentally evaluated the effects of in-kind team incentives on health worker performance in El Salvador, with 38 out of 75 community health teams randomly assigned to performance incentives over a 12-month period. All teams received monitoring, performance feedback and recognition for their achievements allowing us to isolate the effect of the incentive. While both treatment and control groups exhibit improvements in performance measures over time, the in-kind incentives generated significant improvements in community outreach, quality of care, timeliness of care, and utilization of maternal and child health services after 12 months. Gains were largest for teams at the bottom and top of the baseline performance distribution. We find no evidence of results being driven by changes in reporting or by shifting away effort from non-contracted outcomes. These results suggest that in-kind team incentives may be a viable alternative to monetary or individual incentives in certain contexts.     

糖尿病足患者三级甲等医院专业诊疗中心就诊前的诊治状况及影响因素分析

背景与目的:糖尿病足(DF)是糖尿病患者致残、致死的主要原因之一,而早期诊断和规范治疗不仅可提高疗效、促进溃疡愈合,也是保肢和节省医疗费用的有效途径。本研究探讨DF患者在具有专业DF多学科诊疗团队的三级甲等医院就诊前的诊治现状及相关因素,为DF的规范化诊疗提供相关依据。方法:于2017年10月-11月期间,采用随机整群抽样法,抽取湖南、浙江、上海、四川、广东、河北、黑龙江、澳门的13家具有专业DF诊疗中心的三级甲等医院共326例Wagner 1~5级DF患者行问卷调查与足部检查,以患者就诊于三级甲等医院前伤口清洗液的选择和伤口用药情况为指标评估治疗的规范性,分析可能影响其治疗规范性的因素。结果:在326例DF患者中,误诊率为25.8%,治疗不规范率为72.7%。单因素分析结果显示,患者治疗的规范性与清创人、就诊医院级别、敷料应用人、院前诊治地点、并发症个数和清创地点有关(均P<0.05);Logistic多元回归分析结果表明,医院分级和敷料应用人是DF治疗规范率的独立影响因素(均P<0.05),其中三级医院DF治疗规范率是一级医院的6.707倍,且明显优于二级医院,敷料应用人为伤口/造口治疗师的DF治疗规范率是敷料应用人为患者本人的24.117倍,且明显优于敷料应用人为医生和护士。结论:DF患者在进入具有专业DF多学科诊疗团队的三级甲等医院前存在较多的误诊和治疗不规范的现象。因此,需进一步加强对基层医院医务人员DF多学科规范化诊治的培训,尤其应重视伤口/造口治疗师的培养;完善基层医疗机构和三级医院DF患者双向转诊的标准;鼓励患者主动就医,以减少误诊和不规范诊治现象的发生。     

Analysis of verbal communication during teaching in the operating room and the potentials for surgical training

BACKGROUND: Verbal communication in the operating room during surgical procedures affects team performance, reflects individual skills, and is related to the complexity of the operation process. During the procedural training of surgeons (residents), feedback and guidance is given through verbal communication. A classification method based on structural analysis of the contents was developed to analyze verbal communication. This study aimed to evaluate whether a classification method for the contents of verbal communication in the operating room could provide insight into the teaching processes. METHODS: Eight laparoscopic cholecystectomies were videotaped. Two entire cholecystectomies and the dissection phase of six additional procedures were analyzed by categorization of the communication in terms of type (4 categories: commanding, explaining, questioning, and miscellaneous) and content (9 categories: operation method, location, direction, instrument handling, visualization, anatomy and pathology, general, private, undefinable). The operation was divided into six phases: start, dissection, clipping, separating, control, closing. RESULTS: Classification of the communication during two entire procedures showed that each phase of the operation was dominated by different kinds of communication. A high percentage of explaining anatomy and pathology was found throughout the whole procedure except for the control and closing phases. In the dissection phases, 60% of verbal communication concerned explaining. These explaining communication events were divided as follows: 27% operation method, 19% anatomy and pathology, 25% location (positioning of the instrument-tissue interaction), 15% direction (direction of tissue manipulation), 11% instrument handling, and 3% other nonclassified instructions. CONCLUSION: The proposed classification method is feasible for analyzing verbal communication during surgical procedures. Communication content objectively reflects the interaction between surgeon and resident. This information can potentially be used to specify training needs, and may contribute to the evaluation of different training methods.     

Work environment characteristics associated with quality of care in Dutch nursing homes: A cross-sectional study

BackgroundA lack of relationship between direct care staffing levels and quality of care, as found in prior studies, underscores the importance of considering the quality of the work environment instead of only considering staff ratios. Only a few studies, however, have combined direct care staffing with work environment characteristics when assessing the relationship with quality of care in nursing homes.ObjectivesTo examine the relationship between direct care staffing levels, work environment characteristics and perceived quality of care in Dutch nursing homes.DesignCross-sectional, observational study in cooperation with the Dutch Prevalence Measurement of Care Problems.Settings: Twenty-four somatic and 31 psychogeriatric wards from 21 nursing homes in the Netherlands.Participants: Forty-one ward managers and 274 staff members (registered nurses or certified nurse assistants) from the 55 participating wards.MethodsWard rosters were discussed with managers to obtain an insight into direct care staffing levels (i.e, total direct care staff hours per resident per day). Participating staff members completed a questionnaire on work environment characteristics (i.e., ward culture, team climate, communication and coordination, role model availability, and multidisciplinary collaboration) and they rated the quality of care in their ward.Data were analyzed using multilevel linear regression analyses (random intercept). Separate analyses were conducted for somatic and psychogeriatric wards.ResultsIn general, staff members were satisfied with the quality of care in their wards. Staff members from psychogeriatric wards scored higher on the statement ‘In the event that a family member had to be admitted to a nursing home now, I would recommend this ward’. A better team climate was related to better perceived quality of care in both ward types (p ≤ 0.020). In somatic wards, there was a positive association between multidisciplinary collaboration and agreement by staff of ward recommendation for a family member (p = 0.028). In psychogeriatric wards, a lower score on market culture (p = 0.019), better communication/coordination (p = 0.018) and a higher rating for multidisciplinary collaboration (p = 0.003) were significantly associated with a higher grade for overall quality of care. Total direct care staffing, adhocracy culture, hierarchy culture, as well as role model availability were not significantly related to quality of care.ConclusionsOur findings suggest that team climate may be an important factor to consider when trying to improve quality of care. Generating more evidence on which work environment characteristics actually lead to better quality of care is needed.     

基于团队文化建设的急诊护士核心能力培训模式的建立

目的探讨基于团队文化建设的急诊护士核心能力培训模式的建立与实施效果。方法选取2014年01-12月参加常规急诊护士核心能力培训方案进行培训的24名就职于江苏大学附属医院急诊科护士作为对照组,对培训结果进行分析,找出培训中存在的不足并进行分析。选取2015年1-12月参加团队文化建设融入在急诊护士核心能力培训方案培训的24名就职于江苏大学附属医院急诊科护士作为观察组;对两组护士的一般自我效能感量表、中国注册护士核心能力量表、护理工作满意度量表测量结果进行对比分析。结果经培训后,观察组在护士核心能力、一般自我效能感、工作满意度三方面得分高于对照组,差异均有统计学意义(P0.05)。结论基于团队文化建设的急诊护士核心能力培训模式更有利于护士核心能力的提高,有利于增强护士自身效能感与工作满意度的提高,值得推广。     

End-of-life care for older people in subacute care: A retrospective clinical audit

Background

With an ageing population and chronic illness the leading cause of death, challenges exist in meeting the healthcare needs of older people. For older people, care may be provided in subacute care services where, although the focus is on rehabilitation and optimisation of functioning, many older people will die.