The implementation of quality and safety measures: from rhetoric to reality

The evolution of American healthcare is the history of recurrent attempts to enhance quality of care. The latest wave of debate in this area was sparked by the 1999 Institute of Medicine Report, To Err is Human. In the current debate over how best to improve safety and quality, however, there has been a disconnect between the theoretical optimum and the practical possibilities. The author examines the history of our nation's efforts at healthcare improvement over the years, and concludes that the present debate will likely lead to improvements--but only after a messy (and necessary) political struggle over what price Americans are willing to pay for improvement, and where that money will come from. When reform occurs, the author believes that it will be on multiple levels, with accreditation organizations and various levels of government acting in the manner (and for the constituencies) appropriate to each. Ultimately, the political processes will yield a variety of approaches to be watched, studied, and amended as the healthcare system evolves to provide safer, more effective care.     

Framing New Directions for Theory from the Experience of Practitioners

Parallel, powerful tensions exist both in mediation and in the general worlds of the scholar and the practitioner. One response to balancing these tensions, which could be called "practice romanticism," has evolved from the reflective practitioner model. But more could be done to improve our analysis and build practice-oriented theory. A key ingredient in this investigation is a healthy critical approach.     

Psychosocial antecedents of unwed motherhood among indigent adolescents

Theoretically based hypotheses regarding psychosocial antecedents of unwed motherhood among indigent adolescents are tested. Data regarding psychosocial antecedents were obtained from a survey of a 50% sample of seventhgraders in a large urban school system. Hypotheses were tested by comparing three groups of subjects from among these respondents: (1) 82 female adolescents who received perinatal care at an adult development clinic for indigent adolescents (all gave birth out of wedlock at least one year following the baseline survey and prior to their eighteenth birthday); (2) 164 matched (by race, mother's education, and school) controls — two matches for each pre-unwed mother; and (3) 164 randomly selected controls — two controls for each preunwed mother. The results were consistent with the assertion that deviant behaviors related to and including unwed motherhood are alternative deviant responses to the subjectively recognized inability to defend against self-rejection in the course of membership group experiences in anticipation of self-enhancing consequences of the deviant behaviors. The positions in the social structure occupied by the pre-unwed mothers predispose the subjects to deviant responses by (1) increasing the probability of self-devaluing experiences and the subjective association of these experiences with the normative structure and (2) offering highly visible deviant alternatives that offer greater self-enhancing potential than the perceived low self-enhancing potential of the normative environment. The deviant patterns to which the subjects are predisposed are in fact adopted when prior social controls effictively exercised by parental and school authorities erode (as a result of the subject's identification of family and school as persistent sources of self-devaluing experiences). The specific modes of deviance adopted, including patterns associated with unwed motherhood outcomes, are apparently consistent with subculturally influenced values and adaptive/coping/defensive patterns. The total pattern of findings suggests that the same general theory of deviant behavior that has been applied to other modes of deviance is appropriate in understanding precursors of unwed motherhood among indigent adolescents.Received his Ph.D. in sociology from New York University in 1958. Current research interests are social psychiatry and, more specifically, the reciprocal relationship between self-attitudes and the adoption of deviant response patterns.Received her Ph.D. in educational psychology from University of Texas at Austin. Main interest is adult development.Received his M. D. from University of Texas Medical Branch in Galveston. Research interests are self-destructive behavior and alcoholism.     

Increase in self-rejection as an antecedent of deviant responses

The hypothesis that increase in negative self-attitudes is an antecedent condition of deviant responses was tested. Subjects were seventhgrade students who responded to a questionnaire three times at annual intervals (N=3148). Self-attitudes were measured by a sevenitem self-derogation scale. Change in self-derogation was determined by expressing the posttest score as a deviation from the posttest-on-pretest regression line. For each of 22 deviant acts it was hypothesized and observed that, among students denying performance of the act prior to T₂ T₃, students affirming performance during T₂ T₃, relative to students continuing denial of performance, will have manifested significantly greater antecedent increases in self-derogation during T₁ T₂. The comparisons were significant in 19 of the 22 instances. The findings provide strong support for the position that the genesis of negative self-attitudes is a common influence mediating between adverse membership group experiences and the adoption of any of a wide variety of deviant responses.Received his Ph.D. in sociology from New York University in 1958. Current research interests are social psychiatry and, more specifically, the reciprocal relationship between self-attitudes and the adoption of deviant response patterns.