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Ohrling M, Tolf S, Solberg-Carlsson K, Brommels M. That's how it should work: the perceptions of a senior management on the value of decentralisation in a service delivery organisation. J Health Organ Manag 2021; ahead-of-print. [PMID: 33905183 DOI: 10.1108/jhom-12-2020-0474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Decentralisation in health care has been proposed as a way to make services more responsive to local needs and by that improve patient care. This study analyses how the senior management team conceptualised and implemented a decentralised management model within a large public health care delivery organisation. DESIGN/METHODOLOGY/APPROACH Data from in-depth interviews with a senior management team were used in a directed content analysis. Underlying assumptions and activities in the decentralisation process are presented in the logic model and scrutinised in an a priori logic analysis using relevant scientific literature. FINDINGS The study found support in the scientific literature for the underlying assumptions that increased responsibility will empower managers as clinical directors know their local prerequisites best and are able to adapt to patient needs. Top management should function like an air traffic control tower, trust and loyalty improve managerial capacity, increased managerial skills release creativity and engagement and a system perspective will support collaboration and learning. ORIGINALITY/VALUE To the authors' knowledge this is the first a priori logic analysis of a decentralised management model in a healthcare delivery organisation in primary and community care. It shows that the activities consist with underlying assumptions, supported by evidence, and timely planned give managers decision space and ability to use their delegated authority, not disregarding accountability and fostering necessary organisational and individual capacities to avoid suboptimisation.
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Affiliation(s)
- Mikael Ohrling
- SLSO, Region Stockholm, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Sara Tolf
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Karin Solberg-Carlsson
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Mats Brommels
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
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Storkholm MH, Mazzocato P, Savage C. Make it complicated: a qualitative study utilizing a complexity framework to explain improvement in health care. BMC Health Serv Res 2019; 19:842. [PMID: 31727069 PMCID: PMC6857274 DOI: 10.1186/s12913-019-4705-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/31/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Successful application of Quality Improvement (QI) methods is challenging, and awareness of the role context plays has increased. Complexity science has been advocated as a way to inform change efforts. However, empirical support is scarce, and it is still difficult to grasp the practical implications for QI interventions. The aim of this study was to use a complexity-based leadership framework to explain how managers in a clinical department addressed external requirements to cut costs without compromising patient outcomes and experience. METHODS Explanatory case study design of a Danish OB/GYN department tasked to improve efficiency. Data came from documents, 30 interviews, and 250 h of observations over 3 years. A Complexity Analysis Framework that combined two complexity-based leadership frameworks was developed to analyze all changes implemented to reduce cost, while maintaining clinical quality. RESULTS Managers reframed the efficiency requirement as an opportunity for quality improvement. Multiple simple, complicated, and complex situations were addressed with an adaptive approach to quality improvement. Changes were made to clinical pathways for individual conditions (n = 37), multiple conditions (n = 7), and at the organizational level (n = 9). At the organizational level, changes addressed referral practice, physical space in the department, flow and capacity, discharge speed, and managerial support. Managers shared responsibility with staff; together they took a "professional path" and systematically analyzed each clinical pathway through process mapping, attentive to patterns that emerged, before deciding on the next steps, such as a engaging in a complex process of probing - the iterative development and testing of new responses. CONCLUSIONS Quality improvement efforts could benefit from an understanding of the importance of learning and sharing responsibility to deal with the co-existing degrees of contextual complexity in modern health care. By "making things complicated" through a systematic analysis that engages staff in an open and reflective dialog, clinical praxis and established organizational structures can be questioned and improved. The Complexity Analysis Framework could then help managers to identify improvement opportunities, know when to implement technical solutions, and when to keep abreast of emerging patterns and allow appropriate responses to complex challenges to evolve.
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Affiliation(s)
- Marie Höjriis Storkholm
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Pamela Mazzocato
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
| | - Carl Savage
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
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Harnett PJ, Kennelly S, Williams P. A 10 Step Framework to Implement Integrated Care for Older Persons. AGEING INTERNATIONAL 2019. [DOI: 10.1007/s12126-019-09349-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Budrevičiūtė A, Kalėdienė R, Petrauskienė J. Priorities in effective management of primary health care institutions in Lithuania: Perspectives of managers of public and private primary health care institutions. PLoS One 2018; 13:e0209816. [PMID: 30596741 PMCID: PMC6312249 DOI: 10.1371/journal.pone.0209816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/12/2018] [Indexed: 11/19/2022] Open
Abstract
Background Primary health care institutions are looking for opportunities to create value for patients and to increase the competitiveness of the health care institution. Determination of competitive priorities for creation of value for patients in the management of primary health care institutions allows improving competitiveness and achieving a competitive advantage in the market. The aim of the study To determine the priorities in the management of public and private primary health care institutions by using the focus group discussion method with managers. Methods The study was exploratory with intention to find a ground for a management theory and to be the root for the development of health care reform in Lithuania. Focus group discussions were held in 10 Lithuanian counties; 10 focus group sessions were carried out. A total of 48 primary health care executives were interviewed. The participants of this qualitative study were given 8 questions related to value creation of the primary health care institution to patients and rise in competitiveness. The main question of the focus group discussion was “What are the main priorities of management of primary health care institution?” The criteria of data collection based on the deep understanding of the phenomenon and the richness of data expressed by participants of the research. Results Qualitative research showed that the priorities of management of primary health care institutions were work management of an organization; human resources management; patient management; and health policy decision making. The participants of focus groups pointed out that effective work of primary health care institutions is ensured by the model of management, doctor-patient communication, quality and timely delivery of health care services, and financial resources. The major decisions involving the management of patients were as follows: meeting patients’ expectations, quality and timely satisfaction of patients’ needs, effective solution of patients’ problems, patient-centered services, patient satisfaction, and communication with the patient. Accessibility to services, quality, geographical accessibility, disease prevention, strengthening of patients’ health and adequate funding were mentioned as the priorities of health policy.
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Affiliation(s)
- Aida Budrevičiūtė
- Department of Health Management, Faculty of Public Health, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
- * E-mail:
| | - Ramunė Kalėdienė
- Department of Health Management, Faculty of Public Health, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jadvyga Petrauskienė
- Department of Health Management, Faculty of Public Health, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Harnett PJ. Improvement attributes in healthcare: implications for integrated care. Int J Health Care Qual Assur 2018; 31:214-227. [PMID: 29687756 DOI: 10.1108/ijhcqa-07-2016-0097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Healthcare quality improvement is a key concern for policy makers, regulators, carers and service users. Despite a contemporary consensus among policy makers that integrated care represents a means to substantially improve service outcomes, progress has been slow. Difficulties achieving sustained improvement at scale imply that methods employed are not sufficient and that healthcare improvement attributes may be different when compared to prior reference domains. The purpose of this paper is to examine and synthesise key improvement attributes relevant to a complex healthcare change process, specifically integrated care. Design/methodology/approach This study is based on an integrative literature review on systemic improvement in healthcare. Findings A central theme emerging from the literature review indicates that implementing systemic change needs to address the relationship between vision, methods and participant social dynamics. Practical implications Accommodating personal and professional network dynamics is required for systemic improvement, especially among high autonomy individuals. This reinforces the need to recognise the change process as taking place in a complex adaptive system where personal/professional purpose/meaning is central to the process. Originality/value Shared personal/professional narratives are insufficiently recognised as a powerful change force, under-represented in linear and rational empirical improvement approaches.
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Affiliation(s)
- Patrick John Harnett
- National Integrated Care Programme, Older Persons, Social Care Division, Health Service Executive, Dublin, Ireland
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Pype P, Krystallidou D, Deveugele M, Mertens F, Rubinelli S, Devisch I. Healthcare teams as complex adaptive systems: Focus on interpersonal interaction. PATIENT EDUCATION AND COUNSELING 2017; 100:2028-2034. [PMID: 28687278 DOI: 10.1016/j.pec.2017.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 06/11/2017] [Accepted: 06/24/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The aim of this study is to test the feasibility of a tool to objectify the functioning of healthcare teams operating in the complexity zone, and to evaluate its usefulness in identifying areas for team quality improvement. METHODS We distributed The Complex Adaptive Leadership (CAL™) Organisational Capability Questionnaire (OCQ) to all members of one palliative care team (n=15) and to palliative care physicians in Flanders, Belgium (n=15). Group discussions were held on feasibility aspects and on the low scoring topics. Data was analysed calculating descriptive statistics (sum score, mean and standard deviation). The one sample T-Test was used to detect differences within each group. RESULTS Both groups of participants reached mean scores ranging from good to excellent. The one sample T test showed statistically significant differences between participants' sum scores within each group (p<0,001). Group discussion led to suggestions for quality improvement e.g. enhanced feedback strategies between team members. CONCLUSION The questionnaire used in our study shows to be a feasible and useful instrument for the evaluation of the palliative care teams' day-to-day operations and to identify areas for quality improvement. PRACTICAL IMPLICATIONS The CAL™OCQ is a promising instrument to evaluate any healthcare team functioning. A group discussion on the questionnaire scores can serve as a starting point to identify targets for quality improvement initiatives.
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Affiliation(s)
- Peter Pype
- Department of Family Medicine and Primary Health Care, University Hospital - 6K3, Ghent University, De Pintelaan 185, B-9000 Gent, End-of-Life Care Research Group, VUB & Ghent University, Belgium.
| | - Demi Krystallidou
- Faculty of Arts (Sint Andries Campus), Sint Andriesstraat 2, B-2000 Antwerp, Belgium.
| | - Myriam Deveugele
- Department of Family Medicine and Primary Health Care, University Hospital - 6K3, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium.
| | - Fien Mertens
- Department of Family Medicine and Primary Health Care, University Hospital - 6K3, Ghent University, De Pintelaan 185, B-9000 Gent, Belgium.
| | - Sara Rubinelli
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne\and Swiss Paraplegic Research, Nottwil, Guido Zäch Strasse 4, 6207 Nottwil, Switzerland.
| | - Ignaas Devisch
- Department of Family Medicine and Primary Health Care, University Hospital - 6K3, Ghent University-Artevelde University College, De Pintelaan 185, B-9000 Gent, Belgium.
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Skela-Savič B, Macrae R, Lillo-Crespo M, Rooney KD. The development of a consensus definition for healthcare improvement science (HIS) in seven European countries: A consensus methods approach. Zdr Varst 2017; 56:82-90. [PMID: 28289467 PMCID: PMC5329771 DOI: 10.1515/sjph-2017-0011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 08/29/2016] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION There is a limited body of research in the field of healthcare improvement science (HIS). Quality improvement and 'change making' should become an intrinsic part of everyone's job, every day in all parts of the healthcare system. The lack of theoretical grounding may partly explain the minimal transfer of health research into health policy. METHODS This article seeks to present the development of the definition for healthcare improvement science. A consensus method approach was adopted with a two-stage Delphi process, expert panel and consensus group techniques. A total of 18 participants were involved in the expert panel and consensus group, and 153 answers were analysed as a part of the Delphi survey. Participants were researchers, educators and healthcare professionals from Scotland, Slovenia, Spain, Italy, England, Poland, and Romania. RESULTS A high level of consensus was achieved for the broad definition in the 2nd Delphi iteration (86%). The final definition was agreed on by the consensus group: 'Healthcare improvement science is the generation of knowledge to cultivate change and deliver person-centred care that is safe, effective, efficient, equitable and timely. It improves patient outcomes, health system performance and population health.' CONCLUSIONS The process of developing a consensus definition revealed different understandings of healthcare improvement science between the participants. Having a shared consensus definition of healthcare improvement science is an important step forward, bringing about a common understanding in order to advance the professional education and practice of healthcare improvement science.
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Affiliation(s)
| | - Rhoda Macrae
- Institute of Care and Practice Improvement, School of Health, Nursing and Midwifery, University of the West of Scotland, Hamilton, ML3OBA, Scotland
| | - Manuel Lillo-Crespo
- Faculty of Health Sciences, University of Alicante, Spain, Carretera de San Vicente del Raspeig s/n 03690 San Vicente del Raspeig, Alicante, Spain
| | - Kevin D Rooney
- Institute of Care and Practice Improvement, School of Health, Nursing and Midwifery, University of the West of Scotland, Hamilton, ML3OBA, Scotland; Anaesthesia & Intensive Care Medicine, Royal Alexandra Hospital, Corsebar Road, Paisley, PA2 9PN, Scotland
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van der Biezen M, Derckx E, Wensing M, Laurant M. Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: a qualitative study. BMC FAMILY PRACTICE 2017; 18:16. [PMID: 28173766 PMCID: PMC5297134 DOI: 10.1186/s12875-017-0587-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Due to the increasing demand on primary care, it is not only debated whether there are enough general practitioners (GPs) to comply with these demands but also whether specific tasks can be performed by other care providers. Although changing the workforce skill mix care by employing Physician Assistants (PAs) and Nurse Practitioners (NPs) has proven to be both effective and safe, the implementation of those professionals differs widely between and within countries. To support policy making regarding PAs/NPs in primary care, the aim of this study is to provide insight into factors influencing the decision of GPs and managers to train and employ a PA/NP within their organisation. METHODS A qualitative study was conducted in 2014 in which 7 managers of out-of-hours primary care services and 32 GPs who owned a general practice were interviewed. Three main topic areas were covered in the interviews: the decision-making process in the organisation, considerations and arguments to train and employ a PA/NP, and the tasks and responsibilities of a PA/NP. RESULTS Employment of PAs/NPs in out-of-hours services was intended to substitute care for minor ailments in order to decrease GPs' caseload or to increase service capacity. Mangers formulated long-term planning and role definitions when changing workforce skill mix. Lastly, out-of-hours services experienced difficulties with creating team support among their members regarding the employment of PAs/NPs. In general practices during office hours, GPs indented both substitution and supplementation for minor ailments and/or target populations through changing the skill mix. Supplementation was aimed at improving quality of care and extending the range of services to patients. The decision-making in general practices was accompanied with little planning and role definition. The willingness to employ PAs/NPs was highly influenced by an employees' motivation to start the master's programme and GPs' prior experience with PAs/NPs. Knowledge about the PA/NP profession and legislations was often lacking. CONCLUSIONS Role standardisations, long-term political planning and support from professional associations are needed to support policy makers in implementing skill mix in primary care.
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Affiliation(s)
- Mieke van der Biezen
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands.
| | - Emmy Derckx
- Foundation for Development of Quality Care in General Practice, Tilburgseweg-West 100, Eindhoven, 5652 NP, The Netherlands
| | - Michel Wensing
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands.,Department of General Practice and Health Services Research, Heidelberg University, INF- Marsilius Arkaden, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany
| | - Miranda Laurant
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands.,HAN University of Applied Sciences, Faculty of Health and Social Studies, P.O. Box 6960, Nijmegen, 6503 GL, The Netherlands
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Copelli FHDS, Oliveira RJTD, Oliveira CMSD, Meirelles BHS, Melo ALSFD, Magalhães ALP. O pensamento complexo e suas repercussões na gestão em enfermagem e saúde. AQUICHAN 2016. [DOI: 10.5294/aqui.2016.16.4.8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objetivo: evidenciar el conocimiento científico sobre la teoría de la complejidad en las publicaciones científicas sobre gestión en enfermería y salud. Método: revisión integrativa que se realizó en mayo del 2014, en las bases de datos LILACS, BDENF y PubMed por medio de la combinación de las siguientes palabras clave: teoría de la complejidad, pensamiento complejo, Edgar Morin, enfermeros, enfermería, organización, administración, gestión y gerencia. Se incluyeron diez artículos, publicados entre 2004 y 2013. Resultados: se evidenció el crecimiento de la producción científica sobre el pensamiento complejo en la gestión de enfermería y salud. Todos eran artículos originales; siete de abordaje cualitativo. Interpretación: se construyeron dos categorías temáticas: “Pensamiento complejo que sostiene las prácticas de la gerencia del cuidado” y “Administración compleja en la perspectiva de las organizaciones de enfermería y salud”. Conclusiones: el pensamiento complejo es un paradigma relacionado a la integralidad, multidisciplinariedad, atención a las redes de apoyo y articulación de los saberes. Se ha usado como modelo de gestión en organizaciones vivas e imprevisibles para promover la organización de los sistemas complejos adaptativos. Este estudio contribuye con la aproximación del referencial de la complejidad con los conceptos de gestión en enfermería y salud, dando mayor visibilidad para futuras publicaciones.
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Kristensen N, Nymann C, Konradsen H. Implementing research results in clinical practice- the experiences of healthcare professionals. BMC Health Serv Res 2016; 16:48. [PMID: 26860594 PMCID: PMC4748469 DOI: 10.1186/s12913-016-1292-y] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 02/05/2016] [Indexed: 11/10/2022] Open
Abstract
Background In healthcare research, results diffuse only slowly into clinical practice, and there is a need to bridge the gap between research and practice. This study elucidates how healthcare professionals in a hospital setting experience working with the implementation of research results. Method A descriptive design was chosen. During 2014, 12 interviews were carried out with healthcare professionals representing different roles in the implementation process, based on semi-structured interview guidelines. The analysis was guided by a directed content analysis approach. Results The initial implementation was non-formalized. In the decision-making and management process, the pattern among nurses and doctors, respectively, was found to be different. While nurses’ decisions tended to be problem-oriented and managed on a person-driven basis, doctors’ decisions were consensus-oriented and managed by autonomy. All, however, experienced a knowledge-based execution of the research results, as the implementation process ended. Conclusion The results illuminate the challenges involved in closing the evidence-practice gap, and may add to the growing body of knowledge on which basis actions can be taken to ensure the best care and treatment available actually reaches the patient. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1292-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Camilla Nymann
- Gentofte Hospital, Kildegårdsvej 28, 2900, Hellerup, Denmark.
| | - Hanne Konradsen
- Gentofte Hospital, Kildegårdsvej 28, 2900, Hellerup, Denmark
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Scott I, Phelps G, Dalton S. Arise the systems physician. Intern Med J 2014; 44:1251-6. [DOI: 10.1111/imj.12608] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 09/28/2014] [Indexed: 11/28/2022]
Affiliation(s)
- I. Scott
- Department of Internal Medicine and Clinical Epidemiology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - G. Phelps
- Internal Medicine; Ballarat Health Services; Ballarat Victoria Australia
| | - S. Dalton
- Department of Health; The Clinical Excellence Commission; Sydney New South Wales Australia
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