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BACKGROUND There is a paucity of data or publications in the literature on best practices for opening a new Mohs surgery unit. OBJECTIVE The goal of this article is to be a "how to" guide for starting a Mohs and dermatologic surgery practice. MATERIALS AND METHODS Two academic Mohs surgeons share their personal experiences and data from the literature. RESULTS Topics discussed include picking a location and identifying space, equipment, staffing, regulatory practices, policies and procedures, marketing and outreach, patient experience, building culture, clinic efficiency, and vision. CONCLUSION Although opening a new Mohs surgery unit is challenging, it can be rewarding to have the opportunity to develop best practices and systems that create a wonderful working environment and allow for exceptional care of patients.

Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment or by leading to unnecessary or harmful treatment.The aim of the study was to investigate the relationship between patient safety culture, health information technology (IT) implementation, and the frequency of problems that could lead to diagnostic errors in the medical office setting, such as unavailable test results, unavailable medical records, or unpursued abnormal results.We used survey data from 925 medical offices nationwide that voluntarily submitted results to the 2012 Agency for Healthcare Research and Quality Medical Office Surveys on Patient Safety Culture database. At the office level, we ran a multivariate regression model to estimate the effect of culture on problem frequency while controlling for office-reported implementation levels of health IT, office characteristics such as the number of locations, and survey characteristics such as the percent of respondents that were physicians.The most frequent problem was "results from a lab or imaging test were not available when needed"; across 925 offices, the average was 15% reporting that it happened daily or weekly. Higher overall culture scores were significantly associated with fewer occurrences of each problem assessed. Compared with offices with completed health IT implementation, offices in the process of health IT implementation had higher frequency of problems.This study offers insight into how patient safety culture and health IT implementation in medical offices can influence the frequency of breakdowns in processes of care, thereby identifying potential vulnerabilities that can increase diagnostic errors.

Background Implantation failure remains a mystery since decades. This procedure needs a “top quality embryo” and a “normal” uterine cavity. To assess uterine cavity before first in vitro fertilization (IVF), many diagnostic tools could be used. Hysteroscopy remains the gold standard to diagnose and treat intra-uterine anomalies. However, it is not clearly recommanded to offer an office hysteroscopy before first IVF when transvaginal ultrasound (TVUS) and hysterosalpingography (HSG) were normal. Purpose This study aimed to assess the role of office hysteroscopy before first IVF when no intra-uterine anomalies are suspected. Basic procedures We conducted a randomized controlled trial including 171 women scheduled for their first IVF. Women were assigned to either Group I: office hysteroscopy before IVF or Group II: immediate IVF. We included women aged less than 40 years, having regular cycles, FSH levels less than10UI/l, antral follicular count ≥12, normal TVUS and HSG. Their body mass index (BMI) ranged from 19 to 30 kg/m2. We excluded patients known having severe endometriosis, polycystic ovarian syndrome (PCOS) and oocyte receivers. The primary outcome were livebirth rate and clinical pregnancy rate. Main fundings Between january 2016 and september 2017, we randomly assigned 171 women to either Group I (n = 84) or Group II (n = 87). Hysteroscopy was done in the mid-follicular phase immediately before IVF. Baseline characteristics and IVF features were comparable between groups except for the IVF protocol. Live birth rate was 23,9% in Group I versus 19,3% in Group II. (p = 0,607). Clinical Pregnancy rate was 32,4% in Group I versus 21,7% in Group II. (p = 0,326). No statistical significance was observed for neither miscarriage rate nor multiple pregnancy rate. Hysteroscopy showed 30% unsuspected intra-uterine anomalies: 11 intra-uterine adhesions, 7 polyps, 7 clinical endometritis and one fibroid print. Therapeutic hysteroscopy was done only for 6 intra-uterine adhesions and 3 polyps. Other anomalies did not require operative hysteroscopy. Visual analog score during hysteroscopy was 4,69 +/-2,892. 5 women (6%) of Group I experienced discomfort during diagnostic hysteroscopy. Only one patient had vagal syncope. No further complications were observed. Principal conclusions Office hysteroscopy before first IVF seems not improve IVF results. Minimal intra-uterine anomalies not diagnosed by transvaginal ultrasound and hysterosalpingography do not seem to reduce IVF results.

Recently, due to the coronavirus pandemic, many guidelines and anti-contagion strategies continue to report unclear information about the persistence of coronavirus disease 2019 (COVID-19) in the environment. This certainly generates insecurity and fear in people, with an important psychological component that is not to be underestimated at this stage of the pandemic. The purpose of this article is to highlight all the sources currently present in the literature concerning the persistence of the different coronaviruses in the environment as well as in medical and dental settings. As this was a current study, there are still not many sources in the literature, and scientific strategies are moving towards therapy and diagnosis, rather than knowing the characteristics of the virus. Such an article could be an aid to summarize virus features and formulate new guidelines and anti-spread strategies.

Supplemental digital content is available in the text., Objective The aim of the study was to examine whether miscarriage treatment–related morbidities and adverse events vary across facility types. Methods A retrospective cohort study compared miscarriage treatment–related morbidities and adverse events across hospitals, ambulatory surgery centers (ASCs), and office-based settings. Data on women who had miscarriage treatment between 2011 and 2014 and were continuously enrolled in their insurance plan for at least 1 year before and at least 6 weeks after treatment were obtained from a large national private insurance claims database. The main outcome was miscarriage treatment–related morbidities and adverse events occurring within 6 weeks of miscarriage treatment. Secondary outcomes were major events and infections. Results A total of 97,374 miscarriage treatments met inclusion criteria. Most (75%) were provided in hospitals, 10% ASCs, and 15% office-based settings. A total of 9.3% had miscarriage treatment–related events, 1.0% major events, and 1.5% infections. In adjusted analyses, there were fewer events in ASCs (6.5%) than office-based settings (9.4%) and hospitals (9.6%), but no significant difference between office-based settings and hospitals. There were no significant differences in major events between ASCs (0.7%) and office-based settings (0.8%), but more in hospitals (1.1%) than ASCs and office-based settings. There were fewer infections in ASCs (0.9%) than office-based settings (1.2%) and more in hospitals (1.6%) than ASCs and office-based settings. In analyses stratified by miscarriage treatment type, the difference between ASCs and office-based settings was no longer significant for miscarriages treated with procedures. Conclusions Although there seem to be slightly more events in hospitals than ASCs or office-based settings, findings do not support limiting miscarriage treatment to particular settings.

INTRODUCTION Measuring patient experience is key when assessing quality of care but can be biased: A perceptual bias occurs when renovations of the interior design of a general practitioner (GP) office improves how patients assessed quality of care. The aim was to assess the length of perceptual bias and if it could be reproduced after a second renovation. METHODS A GP office with 2 GPs in Switzerland was renovated twice within 3 years. We assessed patient experience at baseline, 2 months and 14 months after the first and 3 months after the second renovation. Each time, we invited a sample of 180 consecutive patients that anonymously graded patient experience in 4 domains: appearance of the office; qualities of medical assistants and GPs; and general satisfaction. We compared crude mean scores per domain from baseline until follow-up. In a multivariate model, we adjusted for patient's age, gender and for how long patients had been their GP. RESULTS At baseline, patients aged 60.9 (17.7) years, 52% females. After the first renovation, we found a regression to the baseline level of patient experience after 14 months except for appearance of the office (p1 year that improves how patients rate quality of care. This bias could be reproduced after a second renovation strengthening a possible causal relationship. These findings imply to appropriately time measurement of patient experience to at least one year after interior renovation of GP practices to avoid environmental changes influences the estimates when measuring patient experience.

Objective: This study investigates effects of the newly built nonpatient-related buildings of a large university medical center on staff perceptions and whether the design objectives were achieved. Background: The medical center is gradually renewing its hospital building area of 200,000 m.2 This redevelopment is carefully planned and because lessons learned can guide design decisions of the next phase, the medical center is keen to evaluate the performance of the new buildings. Method: A pre- and post-study with a control group was conducted. Prior to the move to the new buildings an occupancy evaluation was carried out in the old setting ( n = 729) (pre-study). Post occupation of the new buildings another occupancy evaluation (post-study) was carried out in the new setting (intervention group) and again in some old settings (control group) ( n = 664). The occupancy evaluation consisted of an online survey that measured the perceived performance of different aspects of the building. Longitudinal multilevel analysis was used to compare the performance of the old buildings with the new buildings. Results: Significant improvements were found in indoor climate, perceived safety, working environment, well-being, facilities, sustainability, and overall satisfaction. Commitment to the employer, working atmosphere, orientation, work performance, and knowledge sharing did not improve. The results were interpreted by relating them to specific design choices. Conclusion: We showed that it is possible to measure the performance improvements of a complex intervention being a new building design and validate design decisions. A focused design process aiming for a safe, pleasant and sustainable building resulted in actual improvements in some of the related performance measures.

A Gram-positive, oxidase- and catalase-positive, strictly aerobic and motile bacterium, designated WS 4626T, was isolated from a medical practice. Spherical endospores were formed terminally in swollen rods. The genomic DNA G+C content was 37.1 mol%. Cells contained iso-C15 : 0, anteiso-C15 : 0, iso-C17 : 1ω10c, anteiso-C17 : 0 and iso-C17 : 0 as the predominant cellular fatty acids and MK-7 and MK-6 as the major isoprenoid quinones. The major polar lipids were diphosphatidylglycerol, phosphatidylethanolamine and phosphatidylglycerol, the cell-wall peptidoglycan was type A4α, l-Lys-d-Asp and the major cell-wall sugar was xylose. The closest phylogenetic relatives were Lysinibacillus xylanilyticus XDB9T (96.7 % 16S rRNA gene sequence similarity) and Lysinibacillus odysseyi 34hs-1T (96.5 %). DNA–DNA relatedness between the isolate and L. odysseyi DSM 18869T was very low (6 %). On the basis of the data presented, strain WS 4626T represents a novel species of the genus Lysinibacillus , for which the name Lysinibacillus meyeri sp. nov. is proposed. The type strain is WS 4626T ( = DSM 25057T = LMG 26643T).

This study investigated the role of non-traditional locations in the decision to vaccinate for seasonal flu. We measured individuals’ preferred location for seasonal flu vaccination by examining the National H1N1 Flu Survey (NHFS) conducted from late 2009 to early 2010. Our econometric model estimated the probabilities of possible choices by varying individual characteristics, and predicted the way in which the probabilities are expected to change given the specific covariates of interest. From this estimation, we observed that non-traditional locations significantly influenced the vaccination of certain individuals, such as those who are high-income, educated, White, employed, and living in a metropolitan statistical area (MSA), by increasing the coverage. Thus, based on the empirical evidence, our study suggested that supporting non-traditional locations for vaccination could be effective in increasing vaccination coverage.

Background People with disabilities report physical barriers in doctors' offices that affect the quality of care. Whether most or few doctors' offices are accessible is not known. We address this gap with data on 2389 primary care provider facilities. Objectives The analysis seeks to describe overall primary care office physical accessibility and identify (1) in which areas offices meet access criteria, (2) which accessibility criteria are most often not met, and (3) whether there are urban/non-urban differences. Methods Reviewers rated medical offices using a 55-item instrument that assessed parking, exterior access, building entrance, interior public spaces, doctor's office interior, and the presence of accessible exam equipment. Five health plans that serve California Medicaid patients conducted reviews of providers signed with their plans. Data from the plans were merged, coded, and a descriptive analysis conducted. Results An accessible weight scale was present in 3.6% and a height adjustable examination table in 8.4% of the sites. Other high prevalence access barriers were in bathrooms and examination rooms. Parking, exterior access, building access, and interior public spaces generally met the access criteria, except for van accessible parking. Conclusions These findings provide a base for quantitative expectations about accessibility nationwide, and indicate significant barriers exist. They show it is possible to conduct a large number of accessibility site reviews, providing one model to meet the Affordable Care Act requirement for provider accessibility information. Physical access is important as it may affect the quality of care and willingness of patients to engage in preventive care.

In the present study, the amounts of medical waste materials, sharps, liquid waste, hazardous waste, household waste and recyclables generated from 375 healthcare services including private hospitals, state hospitals, university hospitals, private medical centres, dialysis centres, cottage hospitals and private dentist surgeries were determined, and the relation between the amount of the waste and the bed capacities, inpatient and outpatient numbers were evaluated. The amount of regulated medical waste corresponded to 28.8% of the total waste streams collected from the healthcare services, and the major producers were private hospitals. The major producers of hazardous waste were state hospitals with a generation rate of 57.9%. The main results of the study indicate that the quantities of the waste streams generated from healthcare services in accordance with the outpatient number gave more appropriate results than the other evaluation methods. Furthermore, evaluation based on the bed capacities gave reasonable results except for recyclables and hazardous waste. As a result of the evaluation of the medical waste generation rate with bed capacities, the generation rate was determined as 2.11 ± 3.83 kg bed-1 day-1 and this rate was 1.45 ± 9.84 kg outpatient-1 day-1 for the evaluation by outpatient numbers. The observed significant P values (P > 0.05) indicate that the evaluation of the waste streams in healthcare services based upon outpatient numbers did not show any reasonable change according to service category.

Healthcare providers continue to seek improved methods for preventing, detecting and treating diseases that affect human survival and quality of life. At the same time, there will always be financial constraints because of limited societal resources. Many of the discussions on how to provide economically sound solutions to this challenge have not fully engaged the input of clinicians in the field. The purpose of this review is to increase economic knowledge for clinicians. We cover healthcare cost elements and methods used to assign value to a health outcome. We outline the challenges in conducting economic studies in the field of infectious diseases. Finally, we discuss the meaning of efficiency from multiple perspectives, and how the concept of economic externalities applies to infectious diseases.

Background: The aim of this study was to provide inter-laboratory imprecision comparisons of different groups of diagnostic systems as well as a comparison of professional laboratories with medical offices performance on the basis of 88,429 glucose results obtained in external quality assessment (EQA) schemes organized by three European EQA centers between 1996 and 2007. Methods: A simple, non-parametrical statistical model suited to all EQA results, including outliers, was used to calculate yearly and global performance. Results: The best performance was obtained from professional laboratories with a group of three diagnostic systems – Hitachi, Integra, and Vitros, followed by Cobas Mira, and finally by Reflotron. For medical offices, the best performance was achieved with the Cobas Mira diagnostic systems, followed by the Reflotron, SpotChem, and Vitros DT60 diagnostic systems. A slight but overall improvement in performance over time was observed for most diagnostic devices. Conclusions: The analysis of glucose EQA results collected over a 12-year period showed that professional laboratories obtained better performances than medical offices, and that a general improvement in yearly performance was observed for both types of laboratories. Clin Chem Lab Med 2010;48:1255–62.

Background Health care infrastructure constitutes a major component of the structural quality of a health system. Infrastructural deficiencies of health services are reported in literature and research. A number of instruments exist for the assessment of infrastructure. However, no easy-to-use instruments to assess health facility infrastructure in developing countries are available. Present tools are not applicable for a rapid assessment by health facility staff. Therefore, health information systems lack data on facility infrastructure. Methods A rapid assessment tool for the infrastructure of primary health care facilities was developed by the authors and pilot-tested in Tanzania. The tool measures the quality of all infrastructural components comprehensively and with high standardization. Ratings use a 2-1-0 scheme which is frequently used in Tanzanian health care services. Infrastructural indicators and indices are obtained from the assessment and serve for reporting and tracing of interventions. The tool was pilot-tested in Tanga Region (Tanzania). Results The pilot test covered seven primary care facilities in the range between dispensary and district hospital. The assessment encompassed the facilities as entities as well as 42 facility buildings and 80 pieces of technical medical equipment. A full assessment of facility infrastructure was undertaken by health care professionals while the rapid assessment was performed by facility staff. Serious infrastructural deficiencies were revealed. The rapid assessment tool proved a reliable instrument of routine data collection by health facility staff. Conclusions The authors recommend integrating the rapid assessment tool in the health information systems of developing countries. Health authorities in a decentralized health system are thus enabled to detect infrastructural deficiencies and trace the effects of interventions. The tool can lay the data foundation for district facility infrastructure management. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0838-8) contains supplementary material, which is available to authorized users.

Proper cleaning of surgical instruments prior to sterilization is an essential objective in the surgical setting. Testing for the presence of adenosine triphosphate (ATP) on a cleaned instrument can help determine if it meets cleanliness requirements for sterilization. A program was piloted in our facility by using a commercial ATP testing system. In this article, our experience with the evaluation of available ATP testing systems, the implementation processes we used, and conclusions drawn from our procedures and results are described.

As rural community hospitals continue their transition of health care delivery to predominantly outpatient and ambulatory services, many factors are being considered in design, planning, and operations to enact this change both efficiently and effectively. The following examines strategies that allow these changes to be incorporated successfully while maintaining the flexibility for the continued transition that these organizations will experience in the future.

It has recently been found that several resident and office buildings in Taiwan were constructed with 60Co-contaminated reinforcing steel bar (rebar). Both governmental officials and the residents of such buildings have been concerned about this finding. In order to respond to the situation, the government has adopted a number of remedial measures, including full-scale radiation survey, dose evaluation and physical examinations of residents. This article presents three methods for evaluating the dose equivalents of the residents living in the contaminated rebar buildings by means of gamma-ray survey, necklace-type thermoluminescence dosimeters (TLDs) and the human lymphocyte chromosome aberration analyses. The results reveal that the dose evaluation by gamma-ray survey is rather conservative. Generally for the residents whose annual dose equivalents are greater than 5 mSv (0.5 rem) by gamma-ray survey, the dose equivalents from necklace-type TLDs are only within the range of 20 to 50% of the evaluated values mentioned above. For chromosome analyses, at least 500 lymphocyte cells were scored and analyzed for each resident. Most of the chromosome analysis data show that the dose equivalents received by residents are lower than the detection limit of the method (100 mSv) and quite different from the estimated dose obtained from either gamma-ray survey or necklace-type TLD measurements.

Health Secretary, Andrew Lansley, has announced that, as part of the new 'healthcare landscape', NHS Property Services (PropCo), which will be owned by the Department of Health (DH), will take ownership of existing primary care trust (PCT) estate not transferred to community care providers. The new company is expected to take over assets owned by PCTs such as offices and health centres, community hospitals, and clinics. Peter Wearmouth, a former chief executive of NHS Estates, and DH policy director on construction, property, and facilities management, who is now a director of Health Solutions at design, infrastructure, management, real estate, and outsourcing solutions specialist, Capita Symonds, considers the implications.

'Estates as the enabler' was the title of an interesting debate session on the morning of the second day of November's Healthcare Estates conference, in which participants focussed on what part healthcare buildings and other 'built assets' would play in a future UK care landscape potentially quite different from that of today. HEJ editor Jonathan Baillie reports.

Few studies analyze cross-reactivity between lipid transfer proteins (LTP) from a large spectrum of botanically unrelated plant-derived foods using routine diagnostic tests.To assess the clinical usefulness of currently available in vivo and in vitro tests in LTP-hypersensitive patients.An in vitro and in vivo study was performed of 15 peach-allergic adults monosensitized to LTP in order to analyze their allergy and hypersensitivity to apple, hazelnut, walnut, peanut, soybean, lentil, maize, celery, carrot, banana, melon, tomato, kiwi, buckwheat, and sunflower, poppy, mustard, and sesame seeds.The study revealed that 8, 7, 10, 5, 3, 2, 1, 1, and 1 patients were allergic to apple, hazelnut, walnut, peanut, tomato, kiwi, melon, lentil, and maize, respectively. Immunoglobulin (Ig) E levels for peach were strongly associated with the total number of offending foods other than peach and with levels of IgE specific for all the study foods except carrot. Both in vivo and in vitro tests showed excellent sensitivity and negative predictive value, but poor specificity and positive predictive value. Sensitized but tolerant patients showed lower IgE levels than those with a history of local or systemic symptoms, although the difference between the 3 subsets was not statistically significant.This study confirms that peach is the primary sensitizer to LTP and that the level of IgE to peach LTP is the main factor associated with cross-reactivity (and clinical allergy) to non-Rosaceae foods. Clinically irrelevant sensitization is common in LTP-hypersensitive patients, and positive in vivo and/or in vitro test results are of little help in detecting potential clinical reactors.

The William Beaumont Imaging Center is designed to bridge the gap between conventional and totally digital imaging technology. Reverse capacity and flexibility are designed into the building and it's systems to facilitate the transition at minimal cost and disruption to daily operations.

This paper focuses on Montreal's Drummond Medical Building (1929), designed by the well-known architectural firm of NobbsHyde, as a case study of the new typology that emerged in urban Canada in the 1920s: a modern, purpose-built high-rise for healthcare professionals, with elevators, telephones, indoor parking, and retail shops, located in an upscale commercial district. What role did medical high-rises play in the practice of modern medicine? We speculate that these clinics marked the end of the house-office era across Canada, centralizing the practice of healthcare professionals. This CIHR-funded project illustrates complex social and physical networks among architects and doctors, drawing attention to the importance of studying architecture as a technology in the history of modern medicine.

When leasing office space, physicians should determine the effective lease rate (ELR) for each building they are considering before making a selection. The ELR is based on a number of factors, including building quality, building location, basic form of lease agreement, rent escalators and add-on factors in the lease, tenant improvement allowance, method of square footage measurement, quality of building management, and other variables. The ELR enables prospective physician tenants to accurately compare lease rates being quoted by building owners and to make leasing decisions based on objective criteria.

Background and aims Physician reimbursement for services and thus income are largely determined by the Medicare Resource-Based Relative Value Scale. Patients’ assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients’ valuation of health-care services to Medicare’s relative value unit (RVU) assessments and to discover patients’ perceptions about the relative differences in incomes across physician specialties. Design Cross-sectional survey. Participants and setting Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. Methods Data collection included the use of a visual analog ‘value scale’ wherein participants assigned value to 10 specific physician-dependent health-care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the abovementioned services. Comparisons of (i) the ‘patient valuation RVUs’ with actual Medicare RVUs, and (ii) patients’ estimations of physician income with actual income were explored using t-tests. Outcomes Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P

When used effectively for strategic purposes, a successful MOB will: Align physicians with the hospital. Increase ancillary utilization, improving the hospital's bottom line Support physician recruitment. Allow the hospital to reallocate capital for operational needs. Improve the hospital's image. Expand the hospital's geographical market share. Enhance physicians' revenue.

Physician groups now face a dynamic medical real estate market that can provide an attractive alternative to self-owned and self-financed outpatient facilities and medical office buildings. The ownership and financing options available to physicians and physician groups considering the development of new medical projects have expanded greatly over the past few years and are likely to continue to evolve in the foreseeable future. This changing environment, driven by new sources of institutional capital and the emergence of qualified developers, has led to a more competitive market for physicians and groups seeking real estate capital partners, and physicians are starting to take advantage of it. Physicians and groups have embraced third-party ownership and management of real estate, because it can preserve capital resources and minimizes risk. These groups are using third parties to develop and own new medical real estate projects. This article describes medical real estate project development alternatives, the attributes and concerns of developers, typical transaction terms, and a recommended process for physicians and groups to select the best real estate development partner.

Mounting evidence indicates that buildings can be a significant cause of human illness and environmental degradation. According to the United States (US) Environmental Protection Agency, indoor air pollution is one of the top five environmental risks to public health in the US. This may be related, to a large extent, to the fact that US citizens spend as much as 95% of their time indoors. Health care leaders, designers, and architects, recognizing the connection between health and the buildings in which much time is spent, are engaging in sustainable design and construction for healthy, ‘green’ buildings. The purpose of this article is to assist nurses in understanding the impact that unhealthy buildings can have on nurses and nursing practice and to provide tools and resources to assist nurses in transforming the health care industry with the goal of creating healing environments and reducing the negative environmental impact of the health care industry. First definitions, current initiatives, and motivations related to sustainable designs will be presented. Next sustainable health care design strategies, such as site planning, clean transportation, water conservation, healthy materials selection, indoor environmental quality, and also the benefits of sustainable design will be discussed. The article will conclude by sharing a variety of resources nurses can use to create healing environments in health care settings.

When entering into office-space lease agreements with hospitals, physician practice administrators need to pay close attention to the federal antikick-back statute and the Stark law. Compliance with these regulations calls for adherence to fair market value and commercial reasonableness--blurry terms open to interpretation. This article provides you with a framework for defining fair market value and commercial reasonableness in regard to real-estate transactions with hospitals.