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Background

"Integrative health care" has become a common term to describe teams of health care providers working together to provide patient care. However this term has not been well-defined and likely means many different things to different people. The purpose of this paper is to develop a conceptual framework for describing, comparing and evaluating different forms of team-oriented health care practices that have evolved in Western health care systems.

Discussion

Seven different models of team-oriented health care practice are illustrated in this paper: parallel, consultative, collaborative, coordinated, multidisciplinary, interdisciplinary and integrative. Each of these models occupies a position along the proposed continuum from the non-integrative to fully integrative approach they take to patient care. The framework is developed around four key components of integrative health care practice: philosophy/values; structure, process and outcomes.

Summary

This framework can be used by patients and health care practitioners to determine what styles of practice meet their needs and by policy makers, healthcare managers and researchers to document the evolution of team practices over time. This framework may also facilitate exploration of the relationship between different practice models and health outcomes.

Context

Inteprofessional collaboration (IPC) between biomedically trained doctors (BMD) and traditional, complementary and alternative medicine practitioners (TCAMP) is an essential element in the development of successful integrative healthcare (IHC) services. This systematic review aims to identify organizational strategies that would facilitate this process.

Methods

We searched 4 international databases for qualitative studies on the theme of BMD-TCAMP IPC, supplemented with a purposive search of 31 health services and TCAM journals. Methodological quality of included studies was assessed using published checklist. Results of each included study were synthesized using a framework approach, with reference to the Structuration Model of Collaboration.

Findings

Thirty-seven studies of acceptable quality were included. The main driver for developing integrative healthcare was the demand for holistic care from patients. Integration can best be led by those trained in both paradigms. Bridge-building activities, positive promotion of partnership and co-location of practices are also beneficial for creating bonding between team members. In order to empower the participation of TCAMP, the perceived power differentials need to be reduced. Also, resources should be committed to supporting team building, collaborative initiatives and greater patient access. Leadership and funding from central authorities are needed to promote the use of condition-specific referral protocols and shared electronic health records. More mature IHC programs usually formalize their evaluation process around outcomes that are recognized both by BMD and TCAMP.

Conclusions

The major themes emerging from our review suggest that successful collaborative relationships between BMD and TCAMP are similar to those between other health professionals, and interventions which improve the effectiveness of joint working in other healthcare teams with may well be transferable to promote better partnership between the paradigms. However, striking a balance between the different practices and preserving the epistemological stance of TCAM will remain the greatest challenge in successful integration.

BACKGROUND. A four-partner, non-fundholding, urban practice with 6000 patients has since September 1991 worked closely with nine complementary practitioners working part time on a private, fee-paying basis. AIM. This study set out to describe and evaluate a model of integrating complementary practitioners into the primary health care team. METHOD. A description of the model operating in the practice was compiled. Qualitative analysis was carried out of semistructured interviews with all members of the primary health care team using the method of a cooperative enquiry. Retrospective quantitative data on patients attending complementary practitioners were also examined. RESULTS. The model allowed patients to refer themselves or be referred by a team member, encouraged communication between team members, and did not require any specific funding. After two years the model had been largely successful in preventing conflict over power, control and decision making; had maintained commitment to the idea of integrating complementary and allopathic medicine; and was self-funding. However, despite varied mechanisms set up to share knowledge and ideology, the rate of change in this area was slower than expected and referral rates were varied. The dilemma of charging patients for complementary medicine in an environment where health care is free emerged as a major concern among the doctors and practice staff. CONCLUSION. The method of cooperative inquiry allowed the whole team to gain an understanding of other viewpoints and to use the research to tackle the problems raised. This model could be adopted and used by any enthusiastic general practice.

The co-occurrence of mental health and substance use disorders is becoming increasingly recognized as a single problem, and professionals recognize that both should be addressed at the same time. Medical best practices recommend integrated treatment. However, criticisms have arisen, particularly concerning the difficulty of implementing integrated teams in specific health-care contexts and the appropriateness of the proposed model for certain populations. Using logic analysis, we identify the key clinical and organizational factors that contribute to successful implementation. Building on both the professional and organizational literatures on integrated services, we propose a conceptual model that makes it possible to analyze integration processes and places integrated treatment within an interpretative framework. Using this model, it becomes possible to identify key factors necessary to support service integration, and suggest new models of practice adapted to particular contexts.

Team analysis and team development are important instruments of organizational development and quality management. They contribute to team optimization in medical rehabilitation. Team analysis allows assessment of strengths and weaknesses of teams, resulting in possible recommendations for team development. So far there are only a few empirical studies and little practical experience analyzing multiprofessional teams in the health care field and inpatient medical rehabilitation in particular. This article presents team analyses performed on twelve multiprofessional medical rehabilitation teams in Germany and corresponding recommendations for team development.

A heuristic model of team analysis and team development was designed for this purpose. The model comprises the following parameters: input (team structure), process (teamwork) and output (team success). Variables to measure these parameters were derived from team performance models and known weaknesses of teams in medical care. Team analyses were conducted by administering a semi-standardized interview form and a short questionnaire to the head physicians of participating clinics while a survey was administered to all members of the rehabilitation team.

The results of the team analyses suggested the use of team development measures on each team. The teams were classified into three categories by their need for team development (low, medium and high). Furthermore five modules of team development could be generated from the results of the team analyses: (1) executive coaching, (2) communication training, (3) changing attitude towards teamwork, (4) task-oriented team development, and (5) training on socio-integrative aspects of teamwork. Some of these modules are important constituents of quality management programs. Team development can facilitate quality management programs, particularly with regard to process and output relating to leadership and staff. The study shows, that there is a basic, yet variable need of team analysis and team development in the medical rehabilitation facilities.

Background

In health care, many organizations are working on quality improvement and/or innovation of their care practices. Although the effectiveness of improvement processes has been studied extensively, little attention has been given to sustainability of the changed work practices after implementation. The objective of this study is to develop a theoretical framework and measurement instrument for sustainability. To this end sustainability is conceptualized with two dimensions: routinization and institutionalization.

Methods

The exploratory methodological design consisted of three phases: a) framework development; b) instrument development; and c) field testing in former improvement teams in a quality improvement program for health care (N teams = 63, N individual = 112). Data were collected not until at least one year had passed after implementation.

Underlying constructs and their interrelations were explored using Structural Equation Modeling and Principal Component Analyses. Internal consistency was computed with Cronbach's alpha coefficient. A long and a short version of the instrument are proposed.

Results

The χ2- difference test of the -2 Log Likelihood estimates demonstrated that the hierarchical two factor model with routinization and institutionalization as separate constructs showed a better fit than the one factor model (p < .01). Secondly, construct validity of the instrument was strong as indicated by the high factor loadings of the items. Finally, the internal consistency of the subscales was good.

Conclusions

The theoretical framework offers a valuable starting point for the analysis of sustainability on the level of actual changed work practices. Even though the two dimensions routinization and institutionalization are related, they are clearly distinguishable and each has distinct value in the discussion of sustainability. Finally, the subscales conformed to psychometric properties defined in literature. The instrument can be used in the evaluation of improvement projects.

Background

Integrative health care (IHC) has become a popular term used in practice and research to define the blending of complementary and alternative medicine (CAM) and conventional care as an innovative approach to health care delivery.

Purpose and objectives

To conduct a bibliometric analysis to develop a better understanding of the evolution of the concept of IHC in the CAM field.

Methods

All articles on IHC published between 1915 and 2008 indexed in the ISI web of knowledge database were retrieved. Title and abstract review were conducted to determine eligibility. Inclusion criteria included a research report and integration of CAM and conventional therapies. A second review of the full papers will be conducted to determine the final article sample, which will be analyzed using a rigorous bibliometric analysis approach.

Results

Three thousand and five articles were retrieved and 35% met the inclusion criteria in the first screening round. Descriptive and relational bibliometric indicators will be presented, including the volume of research by year, keywords used, impact of the publication and collaboration amongst researchers.

Discussion and conclusion

Application of a bibliometric analysis allows for a broad and focused overview of the IHC literature within its historical and cultural context, and evaluation of the research output and its impact.

Background

Redesigning care has been proposed as a lever for improving chronic illness care. Within primary care, diabetes care is the most widespread example of restructured integrated care. Our goal was to assess to what extent important aspects of restructured care such as multidisciplinary teamwork and different types of organizational culture are associated with high quality diabetes care in small office-based general practices.

Methods

We conducted cross-sectional analyses of data from 83 health care professionals involved in diabetes care from 30 primary care practices in the Netherlands, with a total of 752 diabetes mellitus type II patients participating in an improvement study. We used self-reported measures of team climate (Team Climate Inventory) and organizational culture (Competing Values Framework), and measures of quality of diabetes care and clinical patient characteristics from medical records and self-report. We conducted multivariate analyses of the relationship between culture, climate and HbA1c, total cholesterol, systolic blood pressure and a sum score on process indicators for the quality of diabetes care, adjusting for potential patient- and practice level confounders and practice-level clustering.

Results

A strong group culture was negatively associated to the quality of diabetes care provided to patients (β = -0.04; p = 0.04), whereas a more 'balanced culture' was positively associated to diabetes care quality (β = 5.97; p = 0.03). No associations were found between organizational culture, team climate and clinical patient outcomes.

Conclusion

Although some significant associations were found between high quality diabetes care in general practice and different organizational cultures, relations were rather marginal. Variation in clinical patient outcomes could not be attributed to organizational culture or teamwork. This study therefore contributes to the discussion about the legitimacy of the widespread idea that aspects of redesigning care such as teamwork and culture can contribute to higher quality of care. Future research should preferably combine quantitative and qualitative methods, focus on possible mediating or moderating factors and explore the use of instruments more sensitive to measure such complex constructs in small office-based practices.

This paper explores the factors that influence the persistence of unsafe practice in an interprofessional team setting in health care, towards the development of a descriptive theoretical model for analyzing problematic practice routines. Using data collected during a mixed method interview study of 28 members of an operating room team, participants' approaches to unsafe practice were analyzed using the following three theoretical models from organizational and cognitive psychology: Reason's theory of “vulnerable system syndrome”, Tucker and Edmondson's concept of first and second order problem solving, and Amalberti's model of practice migration. These three theoretical approaches provide a critical insight into key trends in the interview data, including team members' definition of error as the breaching of standards of practice, nurses' sense of scope of practice as a constraint on their reporting behaviours, and participants' reports of the forces influencing tacit agreements to work around safety regulations. However, the relational factors underlying unsafe practice routines are poorly accounted for in these theoretical approaches. Incorporating an additional theoretical construct such as “relational coordination” to account for the emotional human features of team practice would provide a more comprehensive theoretical approach for use in exploring unsafe practice routines and the forces that sustain them in healthcare team settings.

Over the last few years, there has been increased awareness and use of complementary/alternative therapies (CAM) in many countries without the health care infrastructure to support it. The National Centre for Complementary and Alternative Medicine referred to the combining of mainstream medical therapies and CAM as integrative medicine. The creation of integrative health care teams will definitely result in redefining roles, but more importantly in a change in how services are delivered. The purpose of this paper is to describe a model of the necessary health care agency resources to support an integrative practice model. A logic model is used to depict the findings of a review of current evidence. Logic models are designed to show relationships between the goals of a program or initiative, the resources to achieve desired outputs and the activities that lead to outcomes. The four major resource categories necessary for implementing integrative care are within the domains of a) professional and research development, b) health human resource planning, c) regulation and legislation and d) practice and management in clinical areas. It was concluded that the system outcomes from activities within these resource categories should lead to freedom of choice in health care; a culturally sensitive health care system and a broader spectrum of services for achieving public health goals.

Introduction

Primary health care in The Netherlands evolves from small general practices to multidisciplinary teams. Research on the effects on outcomes of organization of primary care is hardly available.

Aims

Develop a conceptual model to be able to systematically arrange empirical evidence on the effects of different types of organizations of integrated (primary) care.

Methods

During an expert meeting of directors of health centres we identified essential elements which they consider important for integrated primary care. Based on the outcomes of the meeting we designed a first draft of the conceptual model and completed it, based on literature.

Results and Conclusion

Based on an inventory and analysis of different definitions of primary care and integrated care, we formulated a definition of integrated primary care: ‘The smooth process of assistance and care provided by multiple disciplines within Primary Care, experienced by citizens’. The developed conceptual model contains elements to enable the delivery of integrated primary care (such as culture, professional competences, relationships and network system) and factors that affect the fluent process (such as subsequent financing, organization, ICT, legislation and regulations).

Discussion

Debate the model with participants of the conference to determine whether the model will be sufficient.

Background

Quality of care in general practice may be affected by the team climate perceived by its health and non-health professionals. Better team working is thought to lead to higher effectiveness and quality of care. However, there is limited evidence available on what affects team functioning and its relationship with quality of care in general practice. This study aimed to explore individual and practice factors that were associated with team climate, and to explore the relationship between team climate and quality of care.

Methods

Cross sectional survey of a convenience sample of 14 general practices and their staff in South Tyneside in the northeast of England. Team climate was measured using the short version of Team Climate Inventory (TCI) questionnaire. Practice characteristics were collected during a structured interview with practice managers. Quality was measured using the practice Quality and Outcome Framework (QOF) scores.

Results

General Practitioners (GP) had a higher team climate scores compared to other professionals. Individual's gender and tenure, and number of GPs in the practice were significantly predictors of a higher team climate. There was no significant correlation between mean practice team climate scores (or subscales) with QOF scores.

Conclusion

The absence of a relationship between a measure of team climate and quality of care in this exploratory study may be due to a number of methodological problems. Further research is required to explore how to best measure team functioning and its relationship with quality of care.

Objectives

This study describes complementary and alternative medicine (CAM) use among rural older adults with diabetes, delineates the relationship of health self-management predictors to CAM therapy use, and furthers conceptual development of CAM use within a health self-management framework.

Methods

Survey interview data were collected from a random sample of 701 community dwelling African American, Native American, and White elders residing in two rural North Carolina counties. We summarize CAM use for general use and for diabetes care and use multiple logistic modeling to estimate the effects of health self-management predictors on use of CAM therapies.

Results

The majority of respondents used some form of CAM for general purpose, whereas far fewer used CAM for diabetes care. The most widely used CAM categories were food home remedies, other home remedies, and vitamins. The following health self-management predictors were related to the use of different categories of CAM therapies: personal characteristics (ethnicity), health status (number of health conditions), personal resources (education), and financial resources (economic status).

Discussion

CAM is a widely used component of health self-management among rural among older adults with diabetes. Research on CAM use will benefit from theory that considers the specific behavior and cognitive characteristics of CAM therapies.

BACKGROUND

The Chronic Care Model (CCM) is a multidimensional framework designed to improve care for patients with chronic health conditions. The model strives for productive interactions between informed, activated patients and proactive practice teams, resulting in better clinical outcomes and greater satisfaction. While measures for improving care may be clear, measures of residents’ competency to provide chronic care do not exist. This report describes the process used to develop educational measures and results from CCM settings that used them to monitor curricular innovations.

SUBJECTS

Twenty-six academic health care teams participating in the national and California Academic Chronic Care Collaboratives.

METHOD

Using successive discussion groups and surveys, participants engaged in an iterative process to identify desirable and feasible educational measures for curricula that addressed educational objectives linked to the CCM. The measures were designed to facilitate residency programs’ abilities to address new accreditation requirements and tested with teams actively engaged in redesigning educational programs.

ANALYSIS

Field notes from each discussion and lists from work groups were synthesized using the CCM framework. Descriptive statistics were used to report survey results and measurement performance.

RESULTS

Work groups generated educational objectives and 17 associated measurements. Seventeen (65%) teams provided feasibility and desirability ratings for the 17 measures. Two process measures were selected for use by all teams. Teams reported variable success using the measures. Several teams reported use of additional measures, suggesting more extensive curricular change.

CONCLUSION

Using an iterative process in collaboration with program participants, we successfully defined a set of feasible and desirable education measures for academic health care teams using the CCM. These were used variably to measure the results of curricular changes, while simultaneously addressing requirements for residency accreditation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-010-1358-1) contains supplementary material, which is available to authorized users.

A consistent theme running through the healthcare debate is the need for new care models that include collaborative, team-based care. There is also growing recognition that interprofessional education is critical to achieving collaborative, patient-centered care. Not unlike conventional, biomedical professions, CAM (complementary and alternative medicine) professions have also educated students in silos with little interaction between various disciplines. Northwestern Health Sciences University, under their NIH NCCAM-funded R-25 grant, is breaking new ground in requiring that their students in chiropractic, massage, and OAM complete a common course in evidence informed practice. A previous Explore column described the core competencies that the students are required to achieve. This column focuses on the practicalities and challenges of offering a course to students enrolled in three different degree programs. Perhaps it will stimulate readers to consider how we might achieve interprofessional education that brings together all health professional students, biomedical and CAM.

Introduction

More than 50% of the People with Multiple Sclerosis (PwMS) in Denmark have used complementary and alternative medicine (CAM). The majority of these combine CAM and conventional treatment, and from 2004 to 2010 the Danish Multiple Sclerosis Society conducted a research project with the purpose of investigating and testing models for cooperation between conventional and complementary practitioners.

Theory

Five health care providers and five CAM practitioners were set up to work together from 2004 to 2010 in developing and offering integrated treatment to 200 PwMS at a Danish MS Hospital. The investigation of the collaborative process between practitioners has been based on theories of epistemic cultures as well as learning theories, focusing on interdisciplinary development.

Methods

Empirical material consists of individual interviews with practitioners, a group interview with practitioners, a group interview with professional staff at the Danish MS Hospital, interviews with patients as well as written responses from the practitioners.

Results and conclusions

The six-year cooperation among the practitioners documented mutual inspiration and learning within the team, as well as numerous basic challenges involved in developing interdisciplinary treatment for PwMS. Cooperation between researchers and the treatment team resulted in the development of four interdisciplinary models, which describe the potentials and barriers in relation to various types of collaboration.

Discussions

In many cases, integrating CAM and conventional treatment providers is seen as an ideal. This paper points out the importance of not overlooking the opportunities, values and the potential inherent in a pluralistic ideal in terms of the patients’ own active efforts and the dynamism that can arise when the patient becomes a co-informant, co-coordinator and/or co-integrator.

Over a two year period an inner city primary health care team constructed a manifesto which defined the common aims and objectives of the team. The statement was not comprehensive, but it served a variety of purposes. Audit was made explicit and a framework was provided for the team's annual report. The manifesto has proved useful for trainees and other new members of staff. It has given the team a sense of direction, and it is hoped that it will foster teamwork through team members feeling that they have 'ownership' of the plan. The manifesto was conceived in advance of the government's white paper and new contract for general practitioners. It addresses the perceived health needs of the practice population in a practical way. Other primary health care teams may wish to adapt or use the framework of the manifesto to produce their own version.

Purpose

Conceptual frameworks for primary care have evolved over the last 40 years, yet little attention has been paid to the environmental, structural and organizational factors that facilitate or moderate service delivery. Since primary care is now of more interest to policy makers, it is important that they have a comprehensive and balanced conceptual framework to facilitate their understanding and appreciation. We present a conceptual framework for primary care originally developed to guide the measurement of the performance of primary care organizations within the context of a large mixed-method evaluation of four types of models of primary care in Ontario, Canada.

Methods

The framework was developed following an iterative process that combined expert consultation and group meetings with a narrative review of existing frameworks, as well as trends in health management and organizational theory.

Results

Our conceptual framework for primary care has two domains: structural and performance. The structural domain describes the health care system, practice context and organization of the practice in which any primary care organization operates. The performance domain includes features of health care service delivery and technical quality of clinical care.

Conclusion

As primary care evolves through demonstration projects and reformed delivery models, it is important to evaluate its structural and organizational features as these are likely to have a significant impact on performance.

The role of general practitioners is changing and expanding. Doctors have more control over the treatment received by their patients but remain largely unaccountable to the public and management. This article proposes an organisational model for integrating primary and secondary care which retains the advantages of fund-holding while giving management control over overall strategy. It proposes that general practitioners control funds for all primary and secondary care. Secondary care will be contracted through a joint team of managers and an elected general practice executive committee. A new health care purchasing authority will contract for primary services with individual practices or primary care provider units. General practitioners will have local contracts reflecting their desire to provide an expanded range of services and the needs of the community.

Background

Knowledge translation (KT) is an imperative in order to implement research-based and contextualized practices that can answer the numerous challenges of complex health problems. The Chronic Care Model (CCM) provides a conceptual framework to guide the implementation process in chronic care. Yet, organizations aiming to improve chronic care require an adequate level of organizational readiness (OR) for KT. Available instruments on organizational readiness for change (ORC) have shown limited validity, and are not tailored or adapted to specific phases of the knowledge-to-action (KTA) process. We aim to develop an evidence-based, comprehensive, and valid instrument to measure OR for KT in healthcare. The OR for KT instrument will be based on core concepts retrieved from existing literature and validated by a Delphi study. We will specifically test the instrument in chronic care that is of an increasing importance for the health system.

Methods

Phase one: We will conduct a systematic review of the theories and instruments assessing ORC in healthcare. The retained theoretical information will be synthesized in a conceptual map. A bibliography and database of ORC instruments will be prepared after appraisal of their psychometric properties according to the standards for educational and psychological testing. An online Delphi study will be carried out among decision makers and knowledge users across Canada to assess the importance of these concepts and measures at different steps in the KTA process in chronic care.

Phase two: A final OR for KT instrument will be developed and validated both in French and in English and tested in chronic disease management to measure OR for KT regarding the adoption of comprehensive, patient-centered, and system-based CCMs.

Discussion

This study provides a comprehensive synthesis of current knowledge on explanatory models and instruments assessing OR for KT. Moreover, this project aims to create more consensus on the theoretical underpinnings and the instrumentation of OR for KT in chronic care. The final product--a comprehensive and valid OR for KT instrument--will provide the chronic care settings with an instrument to assess their readiness to implement evidence-based chronic care.

Background:

The integration of the contact lens (CL) practice with the VISION 2020 initiative is important. We assessed the facilities at the private CL clinics of Muscat. Accordingly, we suggested the appropriate eye care for CL wearers in Oman.

Study Design:

This was a descriptive study.

Materials and Methods:

This study was conducted between May and July 2006. A team of optometrists and health inspectors visited clinics and collected information about the infrastructure, available human resources, and materials used in the CL practice. We used a pre-tested close-ended questionnaire to collect responses of the practitioners and observations of the field staff.

Statistical Method:

Univariate parametric type of analysis.

Results:

The team visited 67 CL clinics and interviewed 75 CL practitioners. Proper hand washing facility was available at 61 clinics. Thirty-nine practitioners had >10 years of experience in dispensing contact lenses. Only 13 clinics had a bio-microscope. None of the clinics had legal documents signed by both providers and end users of the contact lens.

Conclusions:

Contact lens has received less attention in areas outside the developed world. The CL practice in the private sectors of Oman needs to be strengthened. Minimum standards, standard operating procedures for CL practice, and its periodic supervision would be useful.

Objective

Recommendations to use integrated models for health behavior change abound, however, the translation to practice has been poor. We used stimulated reflections of primary care physicians and nurse practitioners to generate insights about current practices and opportunities for changing how health behavior advice is addressed.

Method

Twenty-one community practicing primary care clinicians invited to a nationally sponsored practice-based research network conference on promotion of healthy behaviors were asked to record aspects of health behaviors they addressed during a day of outpatient visits. In response to 8 questions, clinicians reflected insights which were then analyzed by a multidisciplinary team to identify over-arching themes.

Results

Health behavior discussions are initiated and carried out predominantly by the clinician. These discussions occur primarily during health care maintenance visits or visits in which presenting complaints or chronic illnesses can be linked to health behaviors. Clinicians' reflections on viable opportunities for change include different modes of patient education materials such as web-based materials. Suprisingly infrequent were solutions outside of the clinical encounter or strategies that engage other staff or other community partners.

Conclusion

Implementation of the integrated care model as an opportunity to enhance health promotion seems far from the current realities and future vision of even motivated network-based clinicians.

Background

All sectors in health care are being asked to focus on the knowledge-to-practice gap, or knowledge translation, to increase service effectiveness. A social interaction approach to knowledge translation assumes that research evidence becomes integrated with previously held knowledge, and practitioners build on and co-create knowledge through mutual interactions. Knowledge translation strategies for public health have not provided anticipated positive changes in evidence-based practice, possibly due in part to a narrow conceptualization of knowledge. More work is needed to understand the role of tacit knowledge in decision-making and practice. This pilot study examined how health practitioners applied tacit knowledge in public health program planning and implementation.

Methods

This study used a narrative approach, where teams from two public health units in Ontario, Canada were conveniently selected. Respondents participated in individual interviews and focus groups at each site. Questions were designed to understand the role of tacit knowledge as it related to the program planning process. Data were analyzed through a combination of content analysis and thematic comparison.

Results

The findings highlighted two major aspects of knowledge that arose: the use of tacit knowledge and the integration of tacit and explicit knowledge. Tacit knowledge included: past experiences, organization-specific knowledge, community contextual knowledge, and the recognition of the tacit knowledge of others. Explicit knowledge included: research literature, the Internet, popular magazines, formal assessments (surveys and interviews), legislation and regulations. Participants sometimes deliberately combined tacit and explicit knowledge sources in planning.

Conclusions

This pilot demonstrated that front-line public health workers draw upon both tacit knowledge and explicit knowledge in their everyday lived reality. Further, tacit knowledge plays an important role in practitioners' interpretation and implementation of explicit research findings. This indicates a need to broaden the scope of knowledge translation to include other forms of knowledge beyond explicit knowledge acquired through research. Strategies that recognize and support the use of tacit knowledge, such as communities of practice or networks, may be important components of a comprehensive approach to knowledge translation. This study provides support for further investigation of the role of tacit knowledge in the planning and delivery of effective public health services.

We describe here the use of a conceptual framework for implementing and disseminating in a Health Maintenance Organization an evidence-based model of well-child care (WCC) that includes developmental and preventive services recommended by the American Academy of Pediatrics. Twenty-first Century WCC is a parent-centered, team-based, primary care model that combines online previsit assessments—completed by parents and caregivers regarding clinic-based weight, growth, and development assessments—with vaccinations and anticipatory guidance. Nurses, nurse practitioners, developmental specialists, and pediatricians all play roles in the WCC model. Patient and clinician interaction, health records, and resources are all facilitated through a Web-based diagnostic, management, tracking, and resource information tool. Implementation and dissemination concepts and their attendant practices and tools can reliably be used to augment strategic decisions about how to best disseminate and implement innovations in health care delivery. Unlike innovations that are embedded only in technical systems, validated models of team-based health care have multiple components that must be made compatible with complex sociotechnical systems. Interpersonal communication, work, coordination, and judgment are key processes that affect implementation quality. Implementation can involve tailoring to a particular site and customizing either the model or the organizational context to accommodate it.

Background

There has been a marked increase in the use of complementary and alternative medicine (CAM) in recent years worldwide. In Germany, apart from 'Heilpraktiker' (= state-licensed, non-medical CAM practitioners), some general practitioners (GPs) provide CAM in their practices. This paper aims to explore the attitudes of GPs about the role of CAM in Germany, in relation to the healthcare system, quality of care, medical education and research. Furthermore, experiences of GPs integrating CAM in their daily practice were explored.

Methods

Using a qualitative methodological approach 3 focus groups with a convenience sample of 17 GPs were conducted. The discussions were transcribed verbatim and analysed using qualitative content analysis.

Results

The majority of the participating GPs had integrated one or more CAM therapies into their every-day practice. Four key themes were identified based on the topics covered in the focus groups: the role of CAM within the German healthcare system, quality of care, education and research. Within the theme 'role of CAM within the healthcare system' there were five categories: integration of CAM, CAM in the Statutory Health Insurance, modernisation of the Statutory Health Insurance Act, individual healthcare services and 'Heilpraktiker'. Regarding quality of care there were two broad groups of GPs: those who thought patients would benefit from standardizing CAM and those who feared that quality control would interfere with the individual approach of CAM. The main issues identified relating to research and education were the need for the development of alternative research strategies and the low quality of existing CAM education respectively.

Conclusion

The majority of the participating GPs considered CAM as a reasonable complementary approach within primary care. The study increased our understanding of GPs attitudes about the role of CAM within the German healthcare system and the use of 'Heilpraktiker' as a competing CAM-provider. It seems to be a need for increased funding for research, better education and remuneration by the Statutory Health Insurance in order to improve access to 'Integrative medicine' in Germany.