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We describe a process for assisting seriously ill patients and their caregivers in prioritizing their preferences for care during advanced illness. Thirty-two seriously ill patients and their caregivers participated in seven 90-minute focus groups conducted cross-sectionally in Denver, Colorado; San Francisco, California; and Washington State. Fourteen expert-defined end-of-life quality indicators were presented to each group, and quantitative unweighted rankings were obtained through patient and caregiver preferences. Aggregated weightings were used to rank the top five quality measures for exploration of open-ended questions. Pain management was the most important quality indicator among all three groups. Overlap in preferences were found for at least two of the groups for symptom management, monitoring medical issues, advance care preferences and assessment of family and caregiver involvement. Caregivers were more focused on bereavement support. Variation in preferences for end-of-life care by patients and their caregivers reflects the need to understand the individual decision-making regarding end-of-life care. Quality improvement activities are beginning to address these needs. [ABSTRACT FROM AUTHOR]

The Ceasefire Oregon gun turn in program was initiated to educate the community regarding violence through a gun turn-in program with voluntary surrender of firearms, educational efforts about violence, and institution of public safety policies. The community board of directors was composed of multiple community leadership organizations. A multi-intervention education, outreach and media program consisting of distribution of brochures, presentations, school education programs, and workshops was implemented throughout the year in addition to the gun turn-in program held in May for two days. A survey was administered to participants in the program at the turn-in sites. The cumulative total for guns turned in years 1994 to 1999 was 4,345. Half of the respondents reported possession of a gun at home. The most common reasons for participating in the gun turn in were obtaining gift certificates and not wanting the gun any more. A successful community grassroots program, Ceasefire Oregon has shown sustainability over six years with increased participation secondary to education, advertising and incentives. Community and statewide efforts can assist with building the infrastructure for programs, however more tools for quantitative performance program evaluation would facilitate measuring the impact on the community. [ABSTRACT FROM AUTHOR]

This article demonstrates the value of using benchmark patient satisfaction data for Medicaid program quality improvement. The authors compare surveys of Maryland Medicaid and federal employees in Maryland, utilizing the latter as an external benchmark. Unadjusted and adjusted analyses found a significantly lower percentage of Medicaid than federal respondents rated telephone access excellent, very good, or good, whereas more Medicaid respondents rated advice on prevention and choice of primary care doctor highly. Patient satisfaction external benchmark data provide managed care organizations (MCOs) and state policy makers with goals to improve quality and standards to measure care objectively in vulnerable populations. [ABSTRACT FROM AUTHOR]

As care for HIV/AIDS becomes more concentrated within specific providers and organisations, it would be useful to have indicators to describe the quality of care. This paper reviews concepts related to quality of care, and practical issues including sampling and risk adjustment. Indicators can be collected using a combination of administrative, chart review and survey data to reflect clinical, patient and societal perspectives. We suggest that for adults with HIV/AIDS, indicators might include measures of health status and patient satisfaction, and essential care processes. Health status measures could include CD4+ T-lymphocyte count and HIV-RNA, progression to AIDS, symptom scores, health-related quality of life scores, patient utility and disability days. Essential care processes could include receipt of acceptable antiretroviral treatment, CD4+ and HIV-RNA monitoring, screening for opportunistic infections, prophylaxis against Pneumocystis carinii pneumonia, handling of symptoms and pneumococcal vaccination. For those at increased risk for HIV, potential indicators include screening for HIV risk behaviours and HIV testing. Data from indicators such as these could be used by individuals to select among providers, purchasers of care to select among health plans and payors to hold provider groups accountable. In addition, data could be used by groups of providers to improve the quality of care. [ABSTRACT FROM AUTHOR]

Objective: To explore the attitudes and experiences of abused women to identify characteristics that helped or hindered abuse disclosure to clinicians and to determine how women viewed potential interventions to improve detection and treatment in a medical setting.Design: Focus group data conducted and analyzed with qualitative methodology.Setting: Three community-based mental health centers and one women's shelter.Participants: Twenty-one women in group therapy for domestic violence.Main Results: Eighteen (86%) of the 21 women had seen their "regular doctor" in the prior year; only 1 in 3 had discussed the abuse with the clinician. The major discussion themes were medical problems that were exacerbated with abuse, lack of ability to access medical care due to abuser interference, emotional attitudes about abuse that acted as barriers to disclosure, clinician characteristics that helped or hindered disclosure, and treatment experiences and preferences. Women described how their medical problems began or worsened during the abusive period. one in three women described how abusers blocked them from receiving medical care. Women reported intense shame about the abuse and described their self-denial of abuse. Women stated they were inclined to discuss abuse if they felt the clinician was perceived to be caring, was easy to talk to, had a protective manner, or if the clinician offered a follow-up visit. There was no consistent clinician gender preference among the women. One in four women had received psychotropic medication for problems associated with abuse. Many feared addiction, or a loss of alertness, increasing their risk for more abuse.Conclusions: Many abused women experience worsening health and seek medical care; most do not volunteer a history of violence even to their regular clinicians. Many of the barriers to disclosure of abuse could be overcome by a physician's knowledge of the link between abuse and medical illness, an understanding of the women's emotions about abuse, and her treatment preferences. [ABSTRACT FROM AUTHOR]

Purpose: To explore patient preferences to aid in the development of quality measures to assess quality of health care for people living with human immunodeficiency virus/acquired immunodeficiency disease (HIV/AIDS)., Method: This study involved three 2-hour focus groups with 29 people living with HIV/AIDS in Portland, Oregon, and San Francisco, California. Eighteen quality of care indicators for HIV/AIDS health care were presented to each group and quantitative rankings were obtained. Aggregated weightings were used to rank and prioritize the quality measures for further exploration., Results: Participants identified 38 themes relevant to high-quality care for HIV/AIDS. Patients ranked the following candidate measures most important: effective relationship with provider, prevention of opportunistic infections, involvement in care and treatment decisions, being offered antiretroviral treatment, and access to health care services. We observed attitudinal differences among focus group participants that corresponded to gender and race/ethnicity., Conclusion: Participants favored quality information that rated the experience of care and outcome measures including indicators of access to services, standard treatments, and competence of the providers. Patient perspectives can inform the development of quality measures that are meaningful to consumers and can assist in the design of services that meet patients' demographic and socioeconomic needs.

Objective: To explore the attitudes and experiences of abused women to identify characteristics that helped or hindered abuse disclosure to clinicians and to determine how women viewed potential interventions to improve detection and treatment in a medical setting., Design: Focus group data conducted and analyzed with qualitative methodology., Setting: Three community-based mental health centers and one women's shelter., Participants: Twenty-one women in group therapy for domestic violence., Main Results: Eighteen (86%) of the 21 women had seen their "regular doctor" in the prior year; only 1 in 3 had discussed the abuse with the clinician. The major discussion themes were medical problems that were exacerbated with abuse, lack of ability to access medical care due to abuser interference, emotional attitudes about abuse that acted as barriers to disclosure, clinician characteristics that helped or hindered disclosure, and treatment experiences and preferences. Women described how their medical problems began or worsened during the abusive period. one in three women described how abusers blocked them from receiving medical care. Women reported intense shame about the abuse and described their self-denial of abuse. Women stated they were inclined to discuss abuse if they felt the clinician was perceived to be caring, was easy to talk to, had a protective manner, or if the clinician offered a follow-up visit. There was no consistent clinician gender preference among the women. One in four women had received psychotropic medication for problems associated with abuse. Many feared addiction, or a loss of alertness, increasing their risk for more abuse., Conclusions: Many abused women experience worsening health and seek medical care; most do not volunteer a history of violence even to their regular clinicians. Many of the barriers to disclosure of abuse could be overcome by a physician's knowledge of the link between abuse and medical illness, an understanding of the women's emotions about abuse, and her treatment preferences.

The second of a two-part article dealing with an effective employee separation process and its maximization as a management tool through interview feedback.

The successful achievement of change has become a hallmark of the effective medical group manager. In the face of the inevitability of change, as dictated by the rapidly progressing healthcare industry and business environment, every manager must take a firm grip on the change process. The author presents an in-depth analysis of change, including a point-by-point description of the process and discussion of technical and systematic preparation, proper presentation and implementation, anticipation of personnel and priority problems, and behavioral implications. Out of this multitude of considerations comes a collection of wisdoms regarding the change process that will be useful to every manager as he implements change and prepares his organization for the future.