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					Human Resource Chapter

     Eyerusalem (yerus) Negussie,
   HIV/AIDS department, WHO/Geneva,
            Major areas
 Staffing requirements: number and building the
  skill and knowledge of care providers, who for
  which service

 Task shifting for basic primary care and HIV

 Workplace health and safety for health
 Basic and additional staffing for primary health centres

 Catchment population: for small (< 7000) and big
  (7000-20,000) health centres

 Expected case load:

Expected number of patients =

estimated adult HIV prevalence X Catchment popn/2
              Basic staffing
Small health centres   1 cleaner

2 nurses               1 watchman
Large health centres   2 cleaners

1 clinical officer     1 watchman

5 nurses

1 pharmacy tech

1 laboratory tech
 Additional staff for HIV care
Expected # of   Additional clinical   Additional support
patients        staff required        staff required

< 100           none                  1-2 lay providers

1001-250        1                     1 clerk/triage officer

                                      2 lay counsellors
251-500         1-2                   1 clerk/triage officer

                                      3 lay counsellors
                      Who for what
 Head HIV clinical provider

 Clinical provider

 Clerk

 Counsellor

 Community health worker

 Laboratory staff

 Pharmacy staff

 Cleaning staff and watchmen
2 nurses             Both trained IMCI, IMAI acute care, care for
                     pregnant women

1 clinical officer   trained IMCI, IMAI acute care, IMPAC
5 nurses             2 trained IMCI

                     2 trained IMAI acute care

                     1 trained in care for pregnant women
1 pharmacy tech      Supply management

1 laboratory tech Laboratory skills
             Task shifting
 Within clinical staff

 To lay providers

 Systematic with the help of evidence

 Role of PLHIV in health service provision
      Clinical mentoring
 New sites require one mentoring visit every month
  for the first 6 months, followed by 1 visit every 2-3

 Each mentoring visit requires at least one day

 The clinical team should be prepared for these
  visit by blocking the dates and selecting cases for
   Safety of health personnel
TB infection control in the health care

Occupational HIV exposure
    didn‟t follow guidelines
                      Access: many names, many
                      places to find, web and print
                      Consistency: experts still
                      Applicability: different
                      patients, settings, values
                      Practicality: correct targets
                      for primary care?
Do Guidelines Follow Guidelines?

  279 guidelines, 69 developers „85-‟97
  Overall adherence to standards 43%
      Identify & summarize evidence        34%
      Formulation of recommendation        46%
  No difference by source of guidelines
      Specialty societies, gov‟t agencies, etc.
  Improvement 1985 -> 1997: 37% -> 50%
Guidelines Can Work

  Leeds Effective Health Care Rpt 1994
    81/87 change practice, 12/17 change outcome

    Effective when

       Account for local circumstances
       Active dissemination and implementation
       Reinforced by patient specific reminders
       Intended users included in process
  Grimshaw 2004 Effect of Guideline Implementation
    235 studies, 73% multifaceted interventions

    Majority observed modest improvement in process

    3 w/ EB-guideline; little cost info; few pt outcome
Putting EBM to Use in Practice

   Beyond the 1-on-1 patient encounter
      quality committees, etc - time for EBM
   Delegate: others help find and organize
      Librarians, patients, staff: changing role of MD
   Organize: high quality online sources
      E-journals, EBM resources, MEDLINE
   Use Web to store and organize
      bookmarks, bulletin board on web, intranet
   Incorporate into decision support tools
      checklists, order sets, reminders
Evidence Based Approach
Steps in EBM paradigm

  Ask - recognize need for information
  Access - choose and use best source
  Appraise - assess validity of reports
  Apply - to patient, setting, local factors
  Assess - impact on important outcomes
Step 1: Ask
Recognize Information Need

  Background or foreground question?
      textbooks vs current literature
  Well-formulated question
      Patient
      Condition
      Intervention
      Outcome
  Questions about policy issues: effectiveness
  vs. feasibility, affordability, trade-offs
Step 2: Access
Locating guidelines on internet

   General search engines
   Hospital or health system web pages
   Government agencies
   Professional societies
General Search Engines
Unique term “Ottawa Ankle”
General Search Engines
Unique term “JNC 7”
Hospital Intranet Guidelines
You‟ve Got to Know Where To Look
Hospital Intranet Guidelines
Lots of Stuff Hidden Behind Link
Government Agencies
CDC guidelines STD treatment
Government Agencies
Asthma guidelines at NHLBI
Professional Societies
A guideline by any other name
Professional Societies
Another Name for Guideline
Professional Societies
Cardiology Pocket Guides
AHRQ Guidelines Clearinghouse
Publication type: guideline
Guideline or Practice Guideline
Step 3: Appraise
Evidence Based Medicine Approach

  Evidence Component          Advice Component
  Bottom line               Precise instructions
  Valid                     Local relevance
      comprehensive        Local expertise, values,
      systematic           economics, expertise
       methods driven
                            Flow charts, algorithms,
  Important                 with grades of
  Current                   recommendation
  Broad expertise
  Uses Levels of Evidence
Step 3: Appraisal
Use the JAMA Users‟ guides

  Objective: problem,     Values: whose values?
  patients, clinicians,   Benefits, Harms and
  reason                  Costs:
  Options: practice       Recommendations:
  options considered      Brief and specific list
  Outcomes: health and    Validation: testing,
  economic outcomes       external comparison
  Evidence: methods to    Sponsors: development,
  gather, select,         funding, endorsement
Step 3: Appraisal
Other Approaches

  Guidelines Clearinghouse table
      incorporates Users‟ Guide criteria
  SIGN Tool
Step 4

Apply to Patient Care
Treatment:              Patient Care

Myth     Organization
                         Diagnosis     Scientific


Treatment:Coexisting         Patient Care
                              Problem          Patient
             Conditions                      Preferences

Reality     Organization
                              Diagnosis        Scientific

                              Treatment     Social   Factors

           Local Practices
                              Problem         Experience
Apply to Decisions
Individual vs Population

"While the individual man is an insoluble
puzzle, in the aggregate he becomes a
mathematical certainty. You can, for
example, never foretell what any one man
will do, but you can say with precision what
an average number will be up to."
                      -Sherlock Holmes to Watson
                             -The Sign of the Four
Step 4: Apply Revisited
Integrate into practice

   Store and organize for later use
      Your bookmarks on web
      Personal web based bulletin board
      Clinic or hospital intranet
   Integrate into clinical process
      Checklists and order sets - paper or electronic
      Integrated decision support in EMR
Using the Internet
Your Favorites, Available Everywhere
Endocarditis Prophylaxis
Summarized for Quick Reference
Ottowa Ankle Rules
Just the Facts, Man
Health System Intranet Guidelines
Integrated Decision Support
Paper checklists & order sets
Integrated Decision Support
Integrated into EMR or POE
Integrated Decision Support
Results of a randomized trial

  Established EMR in teaching hospital
  Integrated local P&T recommendations
  System suggests “corollary orders”
  30 weeks, 7,394 orders, 2,181 pts, 89 MDs
  At order: 46% adherence vs 27% in controls
  Hosp stay: 51% adherence vs 35% in
Disseminating Innovations

 1. Find sound            5. Trust and enable
    innovations               reinvention
                                New ideas from outside
 2. Find and support            New processes from inside
    innovators                  Celebrate reinvention

 3. Invest in early       6. Create slack for change
    adopters              7. Lead by example
 4. Make early adopters
Questions and Discussion

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