Planning skills play a key role in higher developmental processes. The Tower of London test not only measures planning skills, but also the ability to execute plans. Yoga practices aim to bring about higher development. Can a Yoga-based education system be shown to meet this challenge?This study was aimed at comparing a Modern Education System (MES) with the ancient Yoga-based system of education, the Gurukula Education System (GES), in developing planning skills.Forty-nine boys with ages ranging from 11 to 13 years were selected from each of two residential schools, one MES and the other GES, providing similar ambience and daily routines. The boys were matched for age and socio-economic status. The GES educational program is based around integrated yoga modules while the MES provides a conventional modern education program. Planning and executive abilities were assessed using the Tower of London test at the start and the end of an academic year.P < 0.001 significance level.Within groups, the pre-post test differences were significant for both groups. However, the between-groups results showed improvement in the GES group compared to the MES group at a The study suggests that whereas both MES and GES Yoga-based education improve planning and execution skills in school boys, GES is more effective of the two systems. It is important for India to enhance national levels of achievement in education by improving its system of modern education, including increasing levels of academic achievement and decreasing levels of stress and hypertension among students. This paper is the first in a series of four, which examine the traditional Gurukula Education System (GES) for ways in which its practices might contribute advantageously to the Modern Education System (MES). The concern of this first paper is with the development of planning abilities associated with self-reliant, successful persons.The GES is a Vedic system of learning, which includes many yogic practices. It is time-tested and has been preserved for several millennia in an unbroken tradition. In the Indian tradition, it is believed that GES brings great benefits to society, including improvements in cognitive and higher mental abilities. AlthoughOutside the context of education, studies have been conducted on many different yogic practices. These include asanas, pranayama, Vedic chanting, and meditation, and reveal that such techniques can be used as intervention to enhance cognitive abilities such as attention, concentration, and visuKadambini used the same Tower of London test on 30 school students in an RCT  design to assess the effects of a short-term intervention of a nine day period practising yoga lifestyle including intensive yoga practice. The yogaPlanning has been defined as identification and organization of the steps and elements needed to carry out an intention or achieve a goal. It is a one year Yoga intervention on boys in a GES school compared to a matched control group of boys in a MES school.The Tower of London test is a standardized test for measuring planning ability. The testTwo residential schools, one MES and the other GES providing similar ambience and daily routines, were chosen. Both the residential schools had similar natural surroundings with an atmosphere congenial for learning. Out of the 110 students in the Yoga-based boys' Gurukula (GES) and 500 students studying in the MES, a group of 49 healthy boys between 11 and 13 years of age from each school, were one-to-one matched for age, family circumstances and socio-economic background.The boys' health status was assessed by a doctor based on their personal history and a general clinical examination. Those having congenital defects or taking medication known to affect planning or cognitive abilities were excluded from the study. The students in the GES school were all freshers and had received a modern education similar to the MES school until that time, when being interested in GES, they had chosen the Gurukula school. An independent samples‘t’-test on the baseline data showed no significant differences (P > 0.05) between the two groups for any of the demographic parameters. The demographic data for the two groups are presented in Shallice's Tower of London test was used to assess planning abilities and execution skills. The ToweThe measure of planning time assesses planning skill. The essence of planning is to see how to attain a goal through a series of intermediate steps. The subject plans in advance the complete sequence of moves required to solve the problem. In order to do so, the subject considers the consequences of various courses of action. Goal setMeasuring execution time not only assesses motor skill but also the planning ability. This is because new decisions can occur during execution. Planning ability not only sets goals, but also monitors performance to reach a goal and make corrections to the chosen course, in order to ensure that the goal is attained. In carryAssessing the number of moves evaluates perfection of planning. If planning has not been perfect, the number of moves increases. This is also a measure of brain function. Imaging studies have found that more efficient planning involving fewer moves is associated with increased activation of the left prefrontal cortex.One-to-one matching of students was done under the guidance of a statistician. Demographic data were collected by trained persons not involved in the design of the study. The Tower of London test assessments were carried out under the guidance of a psychologist, by trained persons who had not been involved in the selection process, and who did not know the design of the study. No teacher at either school was involved in making the assessments. There were no interactions between the GES and MES schools as they were in different locations more than 100 kilometers apart. Furthermore, no one at either school knew the identity of the other school.The GES School used an educational program which integrated yoga practices, while the MES provided a conventional modern education program. The GES program included yogic postures (asanas), voluntary regulated breathing (pranayama), meditation (dhyana), recitation of mantras (japa), yogic prayers, worship (puja) and Yogic games (team games played on Yogic principles). In contrast, the MES program included physical exercises, mathematical puzzles, music, prayer and normal sports. The daily routines of the two schools are shown in The pre- data of the two groups were compared using an Independent Samples ‘t’ test. The Kolmogorov test of normality showed that the pre- data were not normally distributed, as would be expected, because the Tower of London test has distinct minima but no upper limits. Hence, nonparametric tests were used in the analysis. Within groups, the pre-post data were analyzed using the Wilcoxon Signed Ranks Test, while between groups the pre-post data were analyzed using the Mann-Whitney U Test. SPSS 10.0 was used for analysis.The results of tests are summarized in P < 0.005, Mann-Whitney U test).The Mann-Whitney U Test used to compare results between the two groups, showed significant differences on three of the four subscales of planning, execution, and mean time, and only one of the subscales of number of moves. In all cases, it was the smaller number of moves that were significant. Between-groups results showed that the greater improvement in GES compared to the MES group was significant in trial four of the planning time, trials two, three and four of execution time, and in trial two in the number of moves , Bhajans (harmonious songs of expansion and surrender), and Yogic games have the element of speed and stimulation; but their objective is also mental calmness and peace. This is because, although they start with speed-related stimulation, they end in a state of relaxation and silence. That may be why the comparative results were initially significant, but why as the number of moves increased, they gradually decreased to insignificance at five moves. It would appear that although the GES group could execute their plans more quickly, they were reduced to almost the same speed as the MES group when they had to think about complicated tasks.This suggests that the GES group were better able to visualize their plan and hold it in mind. Interestingly, such an improved ability to hold an idea in the mind is a well-known result of the practice of Transcendental Meditation (TM). TM has been shown in several studies to strongly improve the property of field independence where a particular property or pattern has to be identified against a confusing background.With regard to Execution Time, increased alertness may also be expected to improve performance. In particular, in trials with 2, 3 and 4 moves, the GES group perceived wrong moves quickly and were able to make the correct move without much delay. In addition, the task cannot be achieved efficiently without growth of the Supervisory Attentional System (S.A.S.), which contains the general programming or planning systems that operate on schemas in every domain. The data suggest that the S.A.S. is more developed by the GES curriculum.et al.[Earlier studies of the Tower of London test by Manjunath et al. and Kadaet al. comparedIt is pertinent to compare these results with those found for various kinds of meditation. Several studies have shown that the practice of the Transcendental Meditation technique produces a state of restful alertness, which enhances cognitive and functional abilities. A positrAlthough the Tower of London test is now used to study planning ability in normal persons, ShalliceSingle photon emission computerized tomography (SPECT) has shown that the level of regional cerebral blood flow increases in the left prefrontal cortex in normal persons during Tower of London test performance. Improvemet al., planning during the Tower of London test activates a wide network consisting of the dorsal prefrontal cortex, premotor and parietal cortex, and the cerebellum.[According to Morris rebellum. The assorebellum. suggestsrebellum. both theWhile the strength of the study could have been enhanced by an RCT design, the practical limitations of such trials are obvious. Individual component analysis of different practices such as meditation, pranayama or chanting might throw more light on the mechanisms whereby GES generates more benefits than MES.


While quality of care is a major concern in the western world, not many studies investigate this topic in low-income countries. Even less is known about the quality of care in humanitarian aid settings, where additional challenges from natural or manmade disasters contribute to additional challenges. This study tried to address this gap by introducing a new approach to systematically measure quality of care in a project of Médecins Sans Frontières (MSF) in Agok area, between South Sudan and Sudan. Our objective was to obtain a valid snapshot of quality of care for a MSF project in three weeks that has the potential to serve as a baseline for quality improvement strategies. The evaluation followed a cross-sectional study design to assess structural, process and outcome quality according to Donabedian's criteria of quality of care. A bundle of well-established methods for collection of quantitative and qualitative data was used to assess the project by following a triangulated mixed-methods approach. Mean structural quality scored 73% of expected performance level and mean process quality 59%. The overall mortality rate for the hospital was 3.6%. On average, less complicated cases got a better level of care than patients who were seriously ill. Significant motivational issues were discovered in staff interviews potentially affecting quality of care. The tool appeared to be quick, feasible and effective in judging quality of care in the selected project. To tap the whole potential of the approach a re-evaluation should be carried out to assess the effectiveness of implemented improvement strategies in Agok. To confirm the usefulness of the approach, more studies are needed covering the variety of different humanitarian aid settings. Quality of care seems to be not only difficult to define but also not easy to measure. In the Western world, the assessment of quality in health care has nevertheless become a routine. To a lesser extent, quality of care is measured in developing countries also, but when it comes to humanitarian aid settings, difficulties deriving from disaster settings seem to hinder effective evaluations of quality of care .Many non-governmental organisations around the world have realised the urgent need for measuring and improving quality of care in humanitarian aid projects; Médecins Sans Frontières (MSF), which provides emergency medical assistance to populations in danger in more than 60 countries, is one of them. Because MSF is constantly making efforts to improve quality of care in their projects, they agreed to conduct a pilot study in one of their programmes to demonstrate that quality of care can be measured effectively and comprehensively with this new approach in the context of humanitarian aid. The project chosen was situated in Agok, Abyei area, a disputed zone between the Republic of the Sudan and the Republic of South Sudan.The issue of low performance in health care in developing countries is widespread, and strategies for improvement face complex difficulties on implementation . While eProceeding from the situation in developing countries to humanitarian aid contexts, even less is known about quality of care. This is not to say that quality of care is not evaluated in those settings. Crisp  even argUnfortunately, it seems to be crucial, especially in humanitarian aid situations, to be able to come to sound decisions as fast as possible. To be forced to decide in spite of a severe lack of data is part of the daily frustration of health care workers in emergency settings . HoweverOne way to make sure that patients get the care they need and the most effective treatment possible in the given context is the introduction and use of clinical guidelines, which are seen in the literature as an important link between scientific evidence and clinical practice . It has Today, many observers see health care in South Sudan as being at crossroads . After aIn Agok, like in other parts of (South) Sudan, only a low percentage of the population has access to health care. According to country reports of MSF, which has been working in Sudan since 1983, there is a lack of access to safe drinking water, especially during the rainy season, and access to and use of latrines is low. The public health services are facing chronic malfunction with low coverage in terms of primary and secondary health care, lack of skilled human resources as well as shortages of drugs, vaccines, and material supplies. The level of care at public health structures is basic at best and hygiene standards are very low.Since August 2008, the medical programme of MSF-Switzerland in Agok offers primary and secondary health care, fixed outreach site, and mobile clinics as well as emergency interventions to an estimated population of 100,000 people. Services include in- and outpatient departments, comprising mother and child health with ante- and post-natal care, vaccinations, nutritional support, communicable disease intervention, community health care, trauma, surgical and referral services. Specific health needs such as tuberculosis (TB) and outbreak responses are also addressed. In 2012, 91 beds were provided in Agok hospital – 26 beds in the Inpatient Department (IPD), 36 beds in the Inpatient Therapeutic Feeding Centre (ITFC), 15 beds in Maternity, 8 beds in Surgical/Recovery, and 6 beds in TB Department.see supplemental file 1). Structural, and outcome quality of the project was evaluated according to Donabedian's criteria of quality of care . To measure the quality of health care performance, the catalogue of indicators served as the expected performance level (EPL) against which the actual performance level (APL) was being compared. For the purpose of quantitative analysis, each indicator was labelled with a value from 0 to 2 points, where 0 points meant not performed according to standard, 1 point meant not fully performed according to standard, and 2 points stood for performance according to the MSF standard. Each performance, including availability, was graded on these values by comparing the actual performance to the agreed-upon standard from guidelines. Outcome data of the project was assembled from routine MSF databases and reports. Collection and processing of data was observed to estimate the soundness of the available outcome data.The method originates from a hospital assessment tool published by Bosse et al. in 2011 . The eva of care  with a f of care : observa of care , using ssee supplemental file 3)Semi-structured interviews completed data collection for the quantitative items. Three sets of interview guides were used and sampling for interviews also followed an opportunity sampling approach according to the availability of the researcher, suitable candidates, and the translator. Four interviews were conducted with project managers on different levels, 9 with health care workers, and 10 with patients after they were discharged. For qualitative analysis, open-ended interview questions were designed to find out reasons for the quantitative findings as well as levels of motivation and satisfaction. In the quantitative part of the staff interviews, knowledge according to MSF treatment guidelines was assessed using simple questions directly related to the daily work of the individual care provider. All interview candidates were carefully informed and patients signed a written consent before participating in the interview. Participants were both men and women, all older than 21 years and all contractually capable. For all patients and some staff who did not speak English, interviews were translated from Arabic or Dinka into English and back. For validation, they were later compared with the translation of an independent translator. Interviews were conducted in English .Due to the unsolved political situation in the Abyei area, no relevant authorities were in place to apply for ethical clearance locally. As most parts of the evaluation is considered as internal assessment of a MSF programme, only the interviews with patients could raise ethical questions. To address this issue as carefully as possible, informed written and signed consent from all patients was obtained, all the while being aware of the special vulnerable population in humanitarian aid settings . Particin corresponds to the number of different key procedures for process quality results; how many times a key procedure could have been observed varied from 1 to 5. n for structural quality results present the number of key items checked.At the end of the assessment, supervisors in Agok and coordinators in Juba were confronted with raw data highlighting the strength and weaknesses of the project and making suggestions for possible improvement strategies. Performance from each department and patients’ perceptions were presented, guarding the anonymity of the interviewed individual. Management in the Agok project, coordinators in Juba, and those at the MSF-Switzerland Headquarters in Geneva were provided with a detailed report shortly after the evaluation of the project. This report provided a comprehensive snapshot of all measured aspects related to quality of care in the project and made several detailed suggestions for improvement. Only some selected results are shown here as an example; percentages of performance levels combine the results from observations and file review presented as means and corresponding standard deviations. n=273, SD±7%) of EPL, and mean process quality reached 59% . The overall mortality rate for the hospital was 3.6% in 2011. Structural quality was impaired by the storage condition of drugs and equipment on wards, missing supplies in some departments, and poor cleaning of low risk areas like ‘normal’ wards. Process quality for supportive departments (laboratory and pharmacy) scored 86%  of EPL while clinical areas showed more deficiencies  and the OT , scores for process quality were better than for ‘normal’ wards like the Inpatient Department .The observational checklists for structural and process quality assessment, as well as the checklists for patient file review provided detailed quantitative results. Mean structural quality for all assessed areas of the project scored 73% . On average, less complicated cases  got a better level of care 79%  than patients who were seriously ill, e.g. in a coma . General nursing care procedures scored 54%  and hygiene procedures marked 41%  of EPL. Specialised care like treatment of sick neonates, that was performed on a maternity ward, showed the most shortcomings with a score of 33% .The best process quality was assessed for supportive departments, such as the laboratory , but still was below the expected standard. Departments that were no longer based in tents, as the construction of permanent buildings was on-going, obtained better results. This fuels the hope that when construction is finalised, structural quality will improve in the near future. A minimum level of structural quality is needed to provide a meaningful level of care . This esTo measure a considerably low level of process quality did not come as a surprise. Perception on quality of care by key informants matched with these findings and results from a district hospital in Tanzania, evaluated with a parallel approach showed similar scores . In spitProcess quality was significantly influenced through the performance quality of the individual health worker. At the same time, in interviews, no member of staff made the link between his own performance and overall quality of care. The best level of care was observed for patients without risk factors and non-emergencies, such as patients who came because of uncomplicated malaria. Key procedures, which included continuous monitoring, the care for sick neonates, or postoperative care, showed a severe lack of continuous high-level performance. Unfortunately, it is these complicated and more severe cases that need the medical attention of a secondary health care facility like the Agok hospital.If there is a general feeling in a project that quality of care might be low, it is in many cases structural quality that gets the most attention . This waAdherence to guidelines was a major aspect for the measurement of process quality in this study. As the results suggest, adherence to guidelines had room for improvement in the Agok project. Among other reasons, clinical guidelines have been introduced to reduce errors in medicine, and it is well known that medical errors are not a problem of developing countries alone . One wayIn Agok, many different aspects impaired the performance level of quality of care. The perception that salaries were low compared to a workload that was perceived as being too heavy, combined with a low guideline-knowledge of health workers contributed to the measured results. The problem is known for its complexity: ‘measurable improvements in the quality of delivered care and reductions in medical errors have been variable and modest in most cases. Multiple barriers to the implementation of patient safety and error reduction initiatives have been identified in the literature’ . One wayOutcome in terms of morbidity and mortality in the hospital could not be compared to local data, due to the collapse of public health services in the Abyei area. Generally, the usefulness of outcome data as quality indicators for humanitarian settings seems questionable and there is an on-going debate mainly because compounding factors are extremely difficult to control.Nevertheless, especially for comparison over time, outcome quality was not neglected. Hospital outcome data was listed whenever available, but their interpretation remains difficult.The bundle of methods used in Agok appeared to be quick, feasible, and effective in judging quality of care in the selected project. After the assessment, a comprehensive picture of quality of care in the project could be presented, showing detailed strength and weaknesses. Reasons for the encountered situation could also be offered to explain some of the findings by showing knowledge, motivation, and attitude of health workers. Recommendations were presented, derived from measured priorities, showing ways for improvement whenever possible and appropriate.Whether this way of evaluating humanitarian aid settings becomes an effective tool cannot be answered at this stage. At the moment, the results can serve as a baseline for improvement measures; they can help to prioritise problems and to allocate resources. To tap the whole potential of this approach, re-evaluations should be planned to assess the effectiveness of implemented improvement measures in Agok. Aiming for a long-term strategy to manage quality of care in Agok and other humanitarian aid projects, implementation of a quality improvement circle and training for self-evaluation with the tool should be aimed for.As the set-up, scope, and context of humanitarian aid settings differ a lot, other situations need to be investigated to reach conclusive judgements about the effectiveness of this approach. However, the study could demonstrate that quality of care in humanitarian aid can be evaluated in a way that results can have the potential to help programme managers to implement improvement measures.According to our experience, it does not seem to be too complicated to measure quality of care effectively in the field. Quite certainly, there are no valid reasons to exclude beneficiaries in humanitarian aid programmes from systematically evaluated health care any longer.


Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally.To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care.The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians – 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans.The vast majority of respondents (87%) felt that the monitoring of quality was important and two-thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71%) supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification . At the same time, support for the program was widespread even among physicians who are young, board-certified in family medicine, and salaried.Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems.The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified. Health care systems around the world are increasingly making use of monitoring and reporting systems as a key tool for improving quality of care, and use of these systems is expected to grow further in the years ahead ,2. The sIsrael's National Health Insurance (NHI) Law entitles all persons residing in the State of Israel to a broad package of health care benefits including hospital care, community-based services, and pharmaceuticals. Each resident is free to choose from among four non-profit, competing health plans. The plans are required to provide all members with the full range of benefits prescribed by the NHI law and, in return, receive a capitation payment from the government .a They focus on the areas of immunizations, early detection of cancer, diabetes care,b asthma, and cardiovascular care. All four health plans participate in the program and they receive financial support from the government to help defray the costs of monitoring and reporting on the quality indicators. However, the program does not offer financial incentives for high performance (P4P) to either health plans or individual physicians.In 2000, Israel initiated a program to monitor the quality of the community-based services provided by the health plans. It is currently operated by the Ministry of Health as a national program under the auspices of the Israel National Institute for Health Policy. At present, approximately 40 quality indicators are used by the national program.Two of the plans had actually begun independent quality monitoring programs prior to the initiation of the national program, and they subsequently integrated the two efforts. As a result, all the plans utilize the full set of indicators specified by the national program, and two of the plans also utilize a limited number of additional indicators.The Israeli quality monitoring program drew heavily on the U.S. system for monitoring quality in health plans (HEDIS), in terms of both approach and specific measures. The unique features of the Israeli system include its coverage of the entire population, the extensive reliance on electronic health records, and a focus on a limited number of clinical areas . A recenWhile the support of front-line health care providers is a prerequisite for the success of quality improvement efforts, we know of only a few studies of practitioners' attitudes to, and perceptions of, quality monitoring systems. Almost all of them were qualitative and based on semi-structured interviews of a restricted number of practitioners. For example, a qualitative study of the attitudes of Canadian family physicians to accountability for quality revealed that they viewed the private feedback they received as a necessary part of medical professionalism; however, they were reluctant to share this feedback with patients . A qualiOther studies have focused on doctors' attitudes to practice support provided by health plans – an issue that is clearly related to quality monitoring, albeit not identical to it ,9,11. FoThe objective of this study is to assess how Israeli primary care physicians experience and rate health-plan efforts to track and improve the quality of care. It was motivated, in part, by the need of Israeli policymakers to understand how the country succeeds in improving quality of community care and whether physician opposition constitutes a salient risk to the program. Prior to this study there were anecdotal and journalistic reports of opposition to the program among some primary care physicians . These rIt was not possible for Israeli policymakers to rely solely on studies from abroad, in part because of the paucity of relevant quantitative studies. Moreover, there are significant differences in the organization of community care and in the quality monitoring programs between the U.S., Canada, and the UK on the one hand and Israel on the other, which preclude assuming that findings from one country are directly applicable to another. Therefore, we surveyed a national representative sample of Israeli primary care physicians who are front-line participants in the monitoring system with the objective of assessing how they experience and rate health-plan efforts to track and improve the quality of care.c As almost all quality indicators pertain to adult care, we excluded pediatricians. We also excluded physicians who do not have responsibility for the quality of care for a panel of patients: consultants, physicians who engaged mainly in administrative or managerial work, junior residents, retired physicians, and temporary replacements. The study team estimated that, at the time of the study, approximately 4,400 Israeli physicians met these criteria.dThe study population consisted of a stratified random sample of primary care physicians employed by the health plans. Physicians were included irrespective of whether they worked full time or part time, and whether they worked on a salaried basis or as independent contractors.e were randomly sampled – 250 from each of the four health plans. Of these, 884 met the study criteria. Pediatricians were generally excluded prior to sampling the 250 physicians from each plan. In contrast, physicians lacking responsibility for a panel of patients were only identified (and hence excluded from the study) at the time that they were contacted by project staff.Altogether, 1,000 physiciansThe survey was conducted between August and December 2010. Physicians were approached by mail with an explanation of the objectives of the survey and given the opportunity to refuse to participate. A week later, they were mailed the questionnaire and provided with a choice of responding by mail, e-mail, or telephone. About half responded by mail (53%), about a third used the telephone (33%), and the remaining 14% responded by e-mail.f The main reasons for non-response were refusal to participate in the survey (15%) and failure to locate (7%).g605 of the physicians who met the study criteria – 69% of the sample – completed the questionnaire.h so that the results would more accurately reflect the national study population. The weighting also took into account the relationship between the sampling probability and the number of health plans where each physician worked .iThe data were weighted to reflect the differences among the health plans in sampling ratios and response rates,The main topics covered in the questionnaire were: (a) the doctors' experiences with the program; (b) their assessment of its impact on their work, patient care, and their relationship with their patients, their colleagues, and their health plans; (c) their perceptions of the quality indicators and their definitions; (d) how the physicians are using the information gathered through the program; (e) their difficulties and concerns regarding the quality assurance program; (f) their satisfaction with the program and their desires regarding its future; (g) their suggestions for improving the program; and (h) their personal and professional characteristics.Decisions regarding the choice of topics, as well as the choice of specific questions and their formulation, were made through an iterative process involving the study team and the project steering committee, which consisted of many of Israel's leading experts on the quality monitoring system. While several questions were taken from other surveys  and adapted to meet the needs of this study, most of the questions were developed specifically for this study. The full questionnaire was piloted on a random sample of 10 primary care physicians and those questions found to be poorly understood were either modified or removed.The final questionnaire included approximately 70 items. Many, though not all, of the questions that explored the extent of key phenomena used a six-point scale ranging from "not at all" to "very great". Generally speaking, in the tables and charts that follow we present the full distributions, while the text highlights the percentage of respondents who used the two high-end categories: "great" or "very great".The questionnaire addressed the physicians' experience with the quality monitoring effort that they experienced in their health plans, and did not distinguish between the indicators common to all the plans as part of the national program and the additional indicators employed in two of the plans.This paper focuses on the findings for the physician population as a whole. In addition, various analyses were carried out to explore differences among various physician subgroups. These bivariate and multivariate analyses made use of the complex samples option of the Statistical Package for the Social Sciences (SPSS), Version 13. To analyze the responses to the open-ended questions, we used the SPSS facility that permits coding of multiple responses and quantitative assessment of the frequency of each response. Non-responses to the closed-ended questions were treated as missing values.jAs indicated in Table The study team compared the characteristics of the respondents and the study population for Israel’s largest health plan, which accounts for about half of the physician population. The two were found to be very similar with regard to sex and whether they worked as independent contractors; the sample had a slightly higher concentration of young physicians up to age 44 (33% in the sample vs. 21% in the population) and board-certified specialists (73% vs. 60%). Similar comparisons were not carried out in the other three plans due to lack of available data on the physician population meeting study criteria.The vast majority of respondents (87%) felt that the monitoring of quality was either important (50%) or very important (37%). Two-thirds of the respondents (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great or very great extent. Almost three-quarters of respondents (71%) supported continuation of the program in an unqualified manner, and another 11% supported its continuation in part or under certain conditions.There was widespread support of the monitoring program's choice of broad clinical areas, with 76% indicating that the areas were chosen appropriately to a great or very great extent. There was also a fair amount of support for the way the specific indictors had been defined, with 60% indicating that they were appropriately defined to a great or very great extent.At the same time, about a third of respondents recommended that some of the specific indicators needed to be modified to a great or very great extent Table . Ten perAn overwhelming majority of the respondents (83%) agreed that patients' psycho-socioeconomic determinants affect clinical outcomes. A very large majority also felt that the use of the indicators should take into account the patients' psychosocial status 91%), socioeconomic status (73%), and general health (92%) to a great or very great extent  had received explanations about the quality indicators from their health plans, and about two-thirds of that group thought that these explanations were adequate. Similarly, about half of the respondents (55%) indicated that they had received training from the plans on how to improve performance, and about two-thirds of that group found the training adequate. Half the respondents (50%) indicated that the health plans were doing everything they could to help physicians improve performance to a great or very great extent, and another 27% indicated that they did so to a moderate extent.Almost all of the physicians (91%) reported that they received computerized reminders when they saw patients for whom the quality indicators suggested that additional health care was needed. Similarly, about three-quarters of the physicians (76%) reported that they periodically received a list of patients who had not been given the required checks or treatment.k; 42% indicated that they could do so to a great or very great extent, 33% indicated the ability to do so to a moderate extent, and 25% indicated that they could so only to a minor/very minor extent or not at all. At the same time, 37% of respondents indicated that the monitoring led to clinically unnecessary tests or treatments to a great or very great extent.There was a great deal of diversity in the extent to which respondents felt that the health plans were allowing them to deviate from the protocols embedded in the quality indicators in those cases where it made sense clinically to do soAbout half of the physicians (47%) felt that the program enhanced teamwork in the health plan to a great or very great extent Table . As manylThere was a great deal of variety in the extent to which respondents endorsed the statement "Doctors help one another with suggestions on how to improve performance on the indicators"; 29% indicated that they do so to a great or very great extent, 29% indicated that they do so to a moderate extent, and 42% indicated that they do so to a minor/very minor extent or not at all Table .lAbout half of the respondents (53%) felt their relationships with patients had improved as a result of the program, about two-fifths (38%) reported no change, and the remaining 9% felt that the relationship had deteriorated.About two-thirds of the physicians who had received computerized reminders about patients who failed to adhere to quality standards stated that the reminders helped them provide better care to a great or very great extent.Approximately two-thirds of our respondents (64%) reported that they generally begin an encounter by focusing on the patient's complaints , and another 30% reported that they sometimes did so. Regarding the patient encounter as a whole, approximately one-third of the physicians (35%) claimed that adherence to quality standards distracted them from other clinical issues to a great or very great extent, and another 30% felt that this was the case to a moderate extent.About half of the physicians (56%) reported that, in the wake of the quality monitoring effort, they had made changes in their practices. General changes included more testing and more thorough patient monitoring. Specific changes included those in referral, testing, counseling, and consultations of patients with diabetes; in outreach to women and explanations about the importance of mammograms; and in explanations and outreach to patients about vaccinations.Almost two thirds of the respondents (65%) indicated that their workload had increased to a great or very great extent as a result of the quality monitoring program. Almost as many (60%) indicated that there existed excess managerial pressure regarding the quality indicators. About half (48%) indicated feeling that there is over-competition regarding the indicators, to a great or very great extent Chart .Respondents who indicated that they felt over-competition to a great or very great extent were asked what changes, if any, should be made to reduce the over-competition; 27% of them provided specific suggestions, with the most common being not to make/publicize comparisons and to present the results in a different manner.Respondents who indicated that they felt excess managerial pressure to a great or very great extent were similarly asked what changes, if any, should be made to reduce the pressure; 28% of them provided specific suggestions, with the most common being reducing the workload, providing more time for patient encounters, and changing managerial attitudes.When asked to identify the main change they would make in how the health plans use the indicators, 29% of the full sample responded; the most common responses were allocating more time for each patient encounter, reducing the number of indicators, adjusting indicators to reflect patient socioeconomic status, reducing the workload , and not using the indicators as a tool for pressuring the physicians or for promoting competition among them.Generally speaking, the physicians who participated in this survey were quite satisfied with their work; 80% indicated that they were generally satisfied or very satisfied with their practice, 15% were moderately satisfied, and 5% were unsatisfied or very unsatisfied. About half (46%) of the respondents reported an improvement in job satisfaction since the implementation of the monitoring program, about a third (32%) stated that the program had not affected their satisfaction, and about a fifth (22%) responded that the program had made them less satisfied with their work.Bivariate analyses were used to examine how five of the study's main outcome variables varied across key subgroups of physicians. Three of these variables focused on perceived problems associated with the program , while the other two focused on positive dimensions . As indicated in Table Table Table We performed the first survey of physicians’ perspectives on Israel’s quality monitoring system. Two main findings emerge from the present survey. First, the vast majority of the physicians perceived the quality monitoring program as contributing positively and substantially to patient care, and most physicians supported the continuation of the program. They also indicated, by a 2 to 1 margin, that the program had increased their work satisfaction. Physicians' widespread support is remarkable in light of the enormity of the changes that accompanied the introduction of Israel's national quality assurance program. The survey finding of widespread support contrasts with the impression that had been created by a limited number of highly visible objections.over-competition and excessive managerial pressure are definitely worthy of attention and may also be ameliorable.Second, physicians reported six main problems that they associated with the program: increased workload, over-competition, excessive managerial pressure, distraction from other clinical issues, concerns about the validity of some of the quality standards, and encouragement of unnecessary tests or treatments. To be sure, it is hard to imagine that a quality monitoring system could be implemented without some increase in workload and managerial pressure. Still the large percentages of physicians reporting These findings are consistent with those of qualitative studies in the UK and North America. Specifically, they support the association between doctors' perceptions of quality monitoring and the validity of the quality standards ,12. Our On the other hand, when compared to their counterparts abroad, Israeli physicians appear to be more likely to consider computerized reminders effective, and less likely to perceive performance indicators as detrimental to physician-patient relations. For example, the qualitative studies carried out among UK physicians found that various quality monitoring efforts (some of which were accompanied by pay for performance incentives) may have eroded doctor–patient relations and reduced doctors' focus on patients' complaints. In contrast, only 10% of Israeli physicians reported that quality monitoring (in the absence of P4P incentives) had eroded their relationships with patients and 50% even reported improved relationships. Furthermore, the preponderance of our respondents reported that they usually begin a patient encounter by focusing on the patient's presenting complaints.The study identified the following characteristics as being independently associated with above average levels of support for the monitoring program: being over age 45, female, non-Israeli born, non-Jewish, and/or without board certification as well as working as an independent contractor and/or primarily as a specialist. The present study does not provide any empirical data on the reasons behind these associations. Possible explanations could relate to such factors as the extent to which each group is exposed to managerial oversight on a day-to-day basis, has confidence in its professional capabilities and status in the system, has achieved improvements on the quality indicators, engages in ongoing CME activities, and has been culturally or socially influenced to be open to standards, monitoring, and supervision. It would be informative to test the existence and power of these factors in future research.Some readers of the article may be surprised or even puzzled by the findings that many physicians report that the quality monitoring/improvement effort has improved their work satisfaction and their relationships with their patients. With regard to work satisfaction, it may be that, for many physicians, the disadvantages in terms of increased workload and managerial pressures are outweighed by the advantages of having clearer guidance from their employers about what is expected of them, receiving from their employers additional resources and tools for improving quality, seeing improvements in their performance on the quality measures along with recognition for those improvements, etc. This, too, could be the subject of future research and, in this case, our own database can probably be mined further to generate at least partial answers to these questions.With regard to relationships with patients, it may be that many physicians have figured out how to successfully integrate the need to respond to patients' presenting complaints with the pro-active encouragement of various screening tests and behavioral changes emphasized by the indicators. Moreover, it may be that many patients appreciate a proactive approach on the part of their personal physicians and interpret it as concern and professionalism. Of course, there are probably additional possible explanations, as well as a great deal of variation on this issue among both patients and physicians. Clearly, this is an also a fertile area for further research.The finding that about one-third of the physicians perceive the monitoring program as promoting unnecessary tests or treatments should concern health plan executives. If possible, this perception should be tested empirically, and efforts should be made to quantify the cost impact of any program-generated unnecessary tests and identify their causes. It may be that imprecision in the definition of the target populations for some of the indicators are contributing to unnecessary testing. If so, any data on the cost impact would give further impetus to efforts to refine these definitions.It is somewhat disheartening that only about one-third of the respondents report that physicians provide suggestions to one another on how to improve performance on the indicators to a great or very great extent. This may be related, in part, to the high prevalence of reports of "over-competition". Other factors may include insufficient time to provide suggestions due to the work burden, the paucity of opportunities to observe the work of peers in clinic settings, and a culture of non-interference. It might be useful for the health plans to explore further the reasons for the limited peer input and to seek ways to expand it.The study is limited by the lack of full comparative data regarding the characteristics of the sample and the population. In the largest health plan, we found that the sample contained a higher concentration of board-certified and younger physicians than did the population – two groups that tend to be less supportive of the program than the average. If a similar situation obtains in the other health plans, the results presented in this paper may constitute an underestimate of the extent of primary care physician support of the monitoring program.mIt is also possible that the physicians' perceptions of certain program effects  may have been influenced somewhat by exogenous and unrelated health system changes. For example, between 2000 and 2010 the number of Israeli physicians up to age 65 per 1,000 population dropped from 3.7 to 3.4 and this may well have affected the workloads of community-based physicians. In addition, over the past decade the health plans have also increased the responsibilities of the physicians in many areas unrelated to the quality monitoring program.On the other hand, it is important to note that the study took place during a period when responsibility for the monitoring project at the national level was being shifted from one university to another. During this period, efforts to improve performance within the health plans reportedly continued unabated. Still, the absence of changes in the number of indicators and their definitions emanating from the national level may have temporarily reduced the amount of work generated by the program for primary care physicians.A final study limitation is that the analyses do not distinguish among health plans, as the health plans' agreement to participate in the study was conditioned on a commitment from the study team not to publish plan-specific findings. Thus, the study does not include an analysis of the relationships between plan-specific factors  and key outcome variables .Addressing the perceived problems of the Israeli quality-monitoring program may further increase the physicians' motivation in promoting quality, strengthen their support of the program, and contribute to its continuation and further development. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves, while others, such as the need to refine the quality indicators, are probably best addressed at the national level.As indicated in the findings section, the physicians were given several opportunities in the questionnaire to suggest ways to improve the quality monitoring program and address the problems that had arisen. The recommendations cited relatively frequently included:n· Re-defining or deleting some of the quality standards, such as body mass index.· Considering differences in the patient mix when evaluating performance and providing feedback to individual physicians.· Reducing perceived over-competition and managerial pressure, for example, by reconsidering the frequency and prominence of the performance comparisons among physicians.· Exploring ways to reduce workload, such as expanding the staff that assists the physicians.· Increasing the time allotted for patients' visits, especially in the case of patients with chronic diseases.While implementing either of the latter two proposals on a nationwide basis would no doubt be quite costly, health plan executives are encouraged to give them due consideration, particularly in light of the findings of this survey.In addition, it would appear to us that, in light of the study findings, health plans and the national project team might consider the following:· Strengthening awareness of the positive aspects of the program, such as the contribution of the program to teamwork and quality of care.· Proceeding cautiously when adding new indicators, and assessing the trade-off between the benefits of adding indicators  and its costs .Improvements in quality of care are often the product of the combined efforts of health plan managers and health care professionals engaged in direct service delivery. Accordingly, the study reported here, which examined how primary care physicians perceive the program and how it has affected their practices, was part of a larger, two-part study. The first part of the study used in-depth interviews to examine how managers in the health plans perceived the quality-monitoring program and what they did in order to translate its results into improved quality . One of It will be important for physicians and health plan managers to continue to work together, along with the leadership of the national quality monitoring program, in planning for the forthcoming release of plan-specific performance data. Currently, health care performance data are publicly available at the national level only, and the present study did not address the question of whether it is desirable to publish performance by health plan. In May 2011, the Jerusalem District Court ruled in favor of publishing performance data by individual health plans. Our findings suggest that implementation of this decision be handled cautiously by all involved – the national program, the plans, and the physicians. This is because, while publication of plan-specific data may provide consumers with important information, it may also reduce the spirit of cooperation among the parties, which has contributed so much to the program's success to date ,17. It cIn this context it is worth noting that, in a recent IJHPR article, Jaffe and colleagues reported continued overall improvements in the quality indicators in the 2007–2009 period . In a coAs one of the world's first large scale surveys of health care professionals' perceptions of quality monitoring, this study makes a contribution that goes beyond the specific Israeli context by identifying issues that should be explored in other countries as well. Moreover, the correlates of Israeli physicians' support for the quality monitoring may be relevant for other countries. For example, our finding that excess managerial pressure and lack of confidence in the quality measures may erode physician support for monitoring systems may be generalizable. Similarly, some of the features of the Israeli health care system that appear to contribute to physician support of the quality monitoring program may be relevant to other countries as well. As reported recently , when coIn future studies, it would be worthwhile to investigate why physicians in Israel, unlike their colleagues in the U.S., find computerized follow-up more useful and why fewer Israeli physicians report that performance measures are detrimental to their relationships with patients. Future studies may also attempt to find out whether Israeli physicians are concerned that clinical guidelines and performance management limit their clinical autonomy and judgment similarly to UK  and U.S.Another issue for further exploration in Israel is why some subgroups of physicians (such as young physicians) are less supportive than others of the quality monitoring effort and what could be done to increase their level of support. Similarly, it would be interesting to explore how various dimensions of the physicians' workload (such as the number of patients seen per hour) influence their level of support for the monitoring program. Finally, it will be important to repeat the current study in a few years, to assess whether and how the patterns of physician support for quality monitoring change in the wake of public reporting of plan-specific performance data.a Some of the health plans also use additional indicators that they have developed in-house.b Here, and elsewhere in the article, we use "diabetes" to refer to diabetes mellitus.c As indicated in Table d The numbers of physicians in each health plan estimated to meet the criteria were as follows: 2,166 in Clalit, 1,059 in Maccabi, 835 in Meuhedet, and 857 in Leumit. These figures total 4,971, which is greater than 4,400 cited in the text for the country as a whole. The source of the discrepancy is that approximately 7% of the physicians work in 2 plans and approximately 2% work in 3 plans.e This sample size was chosen to enable identification of differences of 11 percentage points between key subgroups of physicians on the main outcome variables , with an alpha of .05 and a beta of .80.f Factors contributing to the high response rate include: the existence of a stable, professionally trained, fieldwork unit with the Myers-JDC-Brookdale Institute, intensive efforts on the part of the fieldwork staff to obtain correct physician phone numbers in cases where the numbers originally supplied by the health plans proved to be incorrect, the policy of persistent and repeated attempts to reach all potential respondents over a period of several months and at various times of day (as needed), and the referral of potential refusals to the fieldwork supervisor or the investigators for special treatment.g It may be that some of the non-respondents have characteristics that exclude them from the study population; if so, the true response rate would be higher than the 69% reported here.h Health plan-specific response rates ranged from 53% to 77%.i Note that the weighting procedure did change the results, but only to a minimal extent.j Apparently, 4% of respondents work primarily as specialists, but also work secondarily as primary care physicians.k Even in the absence of financial incentives, health plans have a number of ways to communicate their wishes to physicians working with them on either a contractual or salaried basis, and of encouraging the physicians to practice in accord with those wishes. It appears that there are differences both between and within plans in the extent to which managers insist that physicians follow protocols in situations where the physicians have questions about whether the protocols are clinically appropriate.l Interestingly, the percent of respondents indicating that physicians provide suggestions to one another on how to improve performance to a great or very great extent did not differ much between those working primarily as salaried workers vs. those working primarily as independents (27% v. 25%). Similarly, that percentage was only slightly higher among physicians who work in settings with other physicians vs. those working alone (33%. vs. 27%). More substantial differences were related to whether the respondent worked primarily in a health plan-owned setting (29% vs. 16%).m The new responsibilities include improving patients’ electronic medical records, risk management, improving patient satisfaction with services, and inclusion of physicians in the activities related to member recruitment and retention.n Indeed, various efforts are already underway, at both the health plan and national levels, to refine some of the indicators. To date, the foci of these efforts have included refining the definition of the denominator population for the indicators used to monitor whether persons with asthma and certain types of heart disease are being treated appropriately.The authors declare that they have no competing interests.RN and BR were jointly responsible for the study design, data collection, data analysis, and writing of the article; each contributed intensively to all phases of the study. All members of the Quality Monitoring Study Group provided important input into the study design and data analysis, and commented on drafts of the article and/or the study report on which it is based. Eliana Meirowitz Nelson contributed to the literature review. All authors have read and approved the final version of the manuscript.Rachel Nissanholtz-Gannot is a researcher at the Smokler Center for Health Policy Research and a lecturer at the Ariel University Center.Bruce Rosen is the Director of the Smokler Center for Health Policy Research at the Myers-JDC-Brookdale Institute, as well as co-editor of the IJHPR.The members of the Quality Monitoring Study Group, and their positions at the time of the study, were as follows:· Alik Aviram · Arnon Cohen · Tuvia Horev · Boaz Lev · Gordon Littman · Ziva Litvak · Eran Matz · Eliana Meirowitz Nelson · Joseph Rosenblum · Amir Shmueli · Hava Tabenkin, · Rachel Wilf-Miron · Shlomo Vinker (Chairman of the Association of Family Physicians in Israel)ADC, JKR, EM, and RW-M are also members of the steering committee of the National Program for Quality Indicators in Community Healthcare in Israel. AS is also a member of the program directorate.Appendix Table 5A. Logistic regression of "Supports Continuation" on physicians' personal and professional characteristics, including 95% confidence intervals*. Table 5B: Logistic regression of "Contributes Substantially to Quality" on physicians' personal and professional characteristics, including 95% confidence intervals*. Table 5C: Logistic regression of "Excessive Competition" on physicians' personal and professional characteristics, including 95% confidence intervals*. Table 5D: Logistic regression of "Excessive Workload" on physicians' personal and professional characteristics, including 95% confidence intervals*. Table 5E: Logistic regression of "Excessive Managerial Pressure" on physicians' personal and professional characteristics, including 95% confidence intervals*.Click here for file


Anas platyrhynchos) which are the source of the disease in Mazandaran Province, Northern Iran.The aim of the present study was to survey birds’ schistosomes in migratory birds  and intestinal blood vessels were studied for adult worms. The nasal mucosa was separated and observed by a microscope. In order to separate the visceral schistosomes, after separating intestine, vessel mesenteric was studied under the lamp light and then in saline. The parasite sample was collected for subsequent observation.Trichobilharzia sp. egg. Besides that, two birds had adult worms schistosome visceral i.e. Bilharziella sp.Fifteen (13.6%) cases out of 110 studied birds had nasal mucosa contaminated with Trichobilharzia sp. and Bilharziella sp. parasites. Thus, it is necessary for the authorities of health, environmental and agricultural organization of the province to cooperate in order to control this disease.The elements that cause cercarial dermatitis in aforementioned region are  Austrobilharzia, Bilharziella, Ornitobilharzia, Trichobilharzia, Gigantobilharzia, and dendrobilharzia and south (Khuzestan Province) of Iran. On the other hand, this disease is economically and epidemiologically significant and is a new disease in Europe and a recurrent disease (due to migration of birds) in some parts of Iran –6.It is mostly seen in rice farmers. If the farmers get this disease, they will be temporarily out of work. Since the climate of Mazandaran Province is good for the life cycle of this disease and different parts of this province are good places for the migratory birds to spend the winter, every year a considerable number of migratory birds which can contaminate the mollusks’ regional waters-and thus cause skin disease in the rice farmers- migrate to the northern province of Iran from the Central Asia.The aim of the present work was to study birds’ schistosomes in mallards, which are the source of the disease.Anas platyrhynchos) were legally bought from the local hunters of Mazandaran cities, especially Ferydun Kenar. They were dissected in Sari Shahid Babaei Lab and Helminthology lab of the Department of Parasitology. The cold chain was maintained during the transference of these birds to laboratory. Since the present study focused on observing and studying the contamination of nasal vessels to egg and or adult helminthes family schistosomatidae, the birds’ head were dissected in the following way. First, the two parts of the break were opened and two deep cuts were made in the joint point of two jowls thus the two jowls completely opened. Then two linear cuts were made on the sides of the upper jowl and the palate bone and adjacent tissues were removed. In this condition, the nasal mucosa of both sides, which could be completely observed, had to be removed carefully for studying in lab. The birds’ heads were opened by a scalpel and the respiratory tract and the nasal mucosa were dissected and placed between two glass slides, pressed between them, and then was observed by a microscope and loop.In this descriptive study began in December 2010, 110 birds  had Trichobilharzia egg. Totally 15 cases (13.6%) were contaminated. Adult worms Bilharziella sp. were observed in two birds’ intestine mesenteric vessels  had  vessels .Bilharziella sp. are as follows:The noticeable characteristics of Trichobilharzia eggs are spindle-shaped, elongated, curved and sharp on both ends and have a jag on their end parts. These eggs are 253 micron long and 66 micron wide , but no filamentous; gynaecophoric canal absent; posterior end of body tapered and rounded; intestinal ceca unite near middle of body, common cecum without diverticula; suckers present and testes 68. The separated ron wide .Trichobilharzia was 18.1%. Besides, Shovele duck had the most contamination level and cercarial dermatitis was an important health issue in the region  had Considering the prevalence of this disease and contamination of birds, it is necessary for the authorities of health, environmental and agricultural organization of the province to cooperate in order to control this disease.