Systems of service: reflections on the moral foundations of improvement

Providing clinical care is above all a service; in that sense, the medical profession aspires to Aristotelian phronesis, or prudence—being ‘capable of action with regard to things that are good and bad for man.’ This intense commitment to service encourages healthcare providers to gravitate towards one or another epistemology as their preferred moral pathway to better care. One such epistemology, the ‘snail’ perspective, places particular value on knowing whether newly devised clinical interventions are both effective and safe before applying them, mainly through rigorous experimental (deductive) studies, which contribute to the body of established scientific knowledge (episteme). Another (the ‘evangelist’ perspective) places particular value on the experiential learning gained from applying new clinical interventions, which contributes to professional know-how (techne). From the ‘snail’ point of view, implementing clinical interventions before their efficacy and safety are rigorously established is morally suspect because it can result in ineffective, wasteful and potentially harmful actions. Conversely, from the ‘evangelist’ point of view, demanding ‘hard’ proof of efficacy and safety before implementing every intervention is morally suspect because it can delay and obstruct the on-the-ground learning seen as being urgently needed to fix ineffective, inefficient and sometimes dangerous existing clinical practices. Two different moral syndromes—sets of interlocked values—underlie these perspectives; both are arguably essential for better care. Although it is not clear how best to leverage their combined strengths, a true symbiotic relationship between the two appears to be developing, one that leaves the two syndromes intact but softens their epistemological edges and supports active, close, respectful interaction between them

Multidisciplinary centres for safety and quality improvement: learning from climate change science

Effective improvement and research rely on sustained multidisciplinary collaboration, but few examples are available of centres with the broad range of disciplines and practical experience that are needed to sustain long-term improvement in healthcare quality and safety. In a number of respects, the parlous state of the quality and safety of medical care resembles the problem of climate change. Both constitute a profoundly serious man-made threat to the public good which have until recently been both ignored and denied but are increasingly being recognised, taken seriously and acted on. Among the most interesting and important responses to the challenge of climate change has been the creation of Centres of Climate Change in which experts from multiple diverse disciplines are brought together to tackle the problem. Such centres, while science-based, express their vision in solid pragmatic terms and embrace policy, public engagement and education as essential components of that vision. Cross-discipline collaboration has unfortunately not achieved the same effectiveness or visibility in healthcare quality and safety as it has in the area of climate change. The authors argue that there is a need to create multidisciplinary centres in healthcare to accelerate the improvement of safety and quality, and provide the necessary theoretical and empirical foundations. Such centres would draw on disciplines such as epidemiology, statistics and relevant clinical disciplines but equally from psychology, engineering, ergonomics, sociology, economics, organisational development in addition to engaging with patients and citizens and leaders with practical experience of improvement in the field. In this paper, we address some of the pragmatic challenges of creating such centres and consider how the right groups and networks of researchers and practitioners might be assembled

Health sciences librarians in academic libraries: a brief review of their developing role

Information relating to health has been gathered since ancient times. Physicians often gathered their own books which were sometimes donated to create early medical libraries. The explosion of information, the demands of qualification accrediting bodies and technological developments have also helped to promote the work of health libraries. The professionalisation of health occupations has tended to move their library support from hospitals into academic settings. Librarians are increasingly concerned with promoting their services and teaching patrons to use library resources. While some health sciences librarians see the availability of health information on the internet as a threat, to those that can see ways to exploit it, it may serve to enhance their role

Medicare Payment and Hospital Provision of Outpatient Care to the Uninsured

Objective. To describe the amount of hospital outpatient care provided to the uninsured and its association with Medicare payment rate cuts following the implementation of Medicare\u27s Outpatient Prospective Payment System. Data Sources/Study Setting. We use hospital outpatient discharge records from Florida from 1997 through 2008. Study Design. We estimate multivariate regression models of hospital outpatient care provided to the uninsured in separate samples of nonprofit and for-profit hospitals. Principal Findings. Hospital outpatient departments provide significant amounts of care to the uninsured. As Medicare payment rates fall, total charges and the share of charges for outpatient visits by the uninsured decrease at nonprofit hospitals. At for-profit hospitals, the share of outpatient care provided to uninsured patients increases, but there is no significant change in the number of uninsured discharges. Conclusions. Nonprofit and for-profit hospitals respond differently to reductions in Medicare payments; thus, studies of the impact of legislated Medicare payment cuts on care of the uninsured should account for differences in hospital ownership in communities. Given that outpatient care to the uninsured includes preventive and diagnostic care procedures, reductions in this care following payment cuts may adversely affect long-run health and health care costs in communities dominated by nonprofit hospitals

Requisitos uniformes para originais submetidos a Revistas Biomédicas

Um pequeno grupo de editores de revistas da área médica reuniu-se informalmente em Vancouver, Colúmbia Britânica, em 1978, para estabelecer diretrizes para o formato dos originais submetidos a suas revistas. Esse grupo ficou conhecido como o Grupo de Vancouver. Seus requisitos para apresentação de originais, que incluíam os formatos de referências bibliográficas desenvolvidos pela Biblioteca Nacional de Medicina (National Library of Medicine - NLM), foram publicados pela primeira vez em 1979. O Grupo de Vancouver se expandiu e evoluiu para o Comitê Internacional de Editores de Revistas Médicas (International Committee of Medical Journal Editors - ICMJE), que se reúne anualmente. Gradualmente, este comitê vem ampliando seus alvos de atenção. O comitê produziu quatro edições prévias dos requisitos uniformes. Ao longo dos anos, surgiram questões que vão além da preparação dos originais. Algumas delas são tratadas agora nos requisitos uniformes; outras são contempladas em pareceres separados. Cada parecer foi publicado em uma revista científica; todos estão reproduzidos no final deste artigo

Dopamine, affordance and active inference.

The role of dopamine in behaviour and decision-making is often cast in terms of reinforcement learning and optimal decision theory. Here, we present an alternative view that frames the physiology of dopamine in terms of Bayes-optimal behaviour. In this account, dopamine controls the precision or salience of (external or internal) cues that engender action. In other words, dopamine balances bottom-up sensory information and top-down prior beliefs when making hierarchical inferences (predictions) about cues that have affordance. In this paper, we focus on the consequences of changing tonic levels of dopamine firing using simulations of cued sequential movements. Crucially, the predictions driving movements are based upon a hierarchical generative model that infers the context in which movements are made. This means that we can confuse agents by changing the context (order) in which cues are presented. These simulations provide a (Bayes-optimal) model of contextual uncertainty and set switching that can be quantified in terms of behavioural and electrophysiological responses. Furthermore, one can simulate dopaminergic lesions (by changing the precision of prediction errors) to produce pathological behaviours that are reminiscent of those seen in neurological disorders such as Parkinson's disease. We use these simulations to demonstrate how a single functional role for dopamine at the synaptic level can manifest in different ways at the behavioural level

Understanding contexts: how explanatory theories can help

Abstract Objective To rethink the nature and roles of context in ways that help improvers implement effective, sustained improvement interventions in healthcare quality and safety. Design Critical analysis of existing concepts of context; synthesis of those concepts into a framework for the construction of explanatory theories of human environments, including healthcare systems. Data sources Published literature in improvement science, as well as in social, organization, and management sciences. Relevant content was sought by iteratively building searches from reference lists in relevant documents. Results Scientific thought is represented in both causal and explanatory theories. Explanatory theories are multi-variable constructs used to make sense of complex events and situations; they include basic operating principles of explanation, most importantly: transferring new meaning to complex and confusing phenomena; separating out individual components of an event or situation; unifying the components into a coherent construct (model); and adapting that construct to fit its intended uses. Contexts of human activities can be usefully represented as explanatory theories of peoples’ environments; they are valuable to the extent they can be translated into practical changes in behaviors. Healthcare systems are among the most complex human environments known. Although no single explanatory theory adequately represents those environments, multiple mature theories of human action, taken together, can usually make sense of them. Current mature theories of context include static models, universal-plus-variable models, activity theory and related models, and the FITT framework (Fit between Individuals, Tasks, and Technologies). Explanatory theories represent contexts most effectively when they include basic explanatory principles. Conclusions Healthcare systems can usefully be represented in explanatory theories. Improvement interventions in healthcare quality and safety are most likely to bring about intended and sustained changes when improvers use explanatory theories to align interventions with the host systems into which they are being introduced