Cottage industry to postindustrial care--the revolution in health care delivery

Common practices among consistently high-performing in vitro fertilization programs in the United States: 10-year update

OBJECTIVE

To evaluate similarities and differences in clinical and laboratory practices among high-performing fertility clinics.

DESIGN

Cross-sectional questionnaire study of selected programs.

SETTING

Academic and private fertility practices performing in vitro fertilization (IVF).

PATIENT(S)

Not applicable.

INTERVENTION(S)

A comprehensive survey was conducted of 13 IVF programs performing at least 100 cycles a year and having high cumulative singleton delivery rates for 2 years.

MAIN OUTCOME MEASURE(S)

Clinical and laboratory IVF practices.

RESULT(S)

Although many areas of clinical practice varied among top programs, some commonalities were observed. All programs used a combination of follicle-stimulating hormone and luteinizing hormone for IVF stimulation, intramuscular progesterone in frozen embryo transfer cycles, ultrasound-guided embryo transfers, and a required semen analysis before starting the IVF cycle. Common laboratory practices included vitrification of embryos at the blastocyst stage, air quality control with positive air pressure and high-efficiency particulate air filtration, use of incubator gas filters, working on heated microscope stages, and incubating embryos in a low-oxygen environment, most often in benchtop incubators.

CONCLUSION(S)

Some areas of consistency in clinical and laboratory practices were noted among high-performing IVF programs that are likely contributing to their success. High-performing programs focused on singleton deliveries. As the field of IVF is rapidly evolving, it is imperative that we share best practices in an effort to improve outcomes from all clinics for the good of our patients.

The Seamless Communication on a Rural Island in Japan: A Qualitative Study from the Perspective of Healthcare Professionals

On remote islands, interprofessional collaboration is essential to support older adults who live at home, despite the limited number of healthcare professionals (HCPs). Therefore, it is important for HCPs to collect and share information about older adults with health problems. This study aimed to clarify how rural HCPs collaborate using limited resources to support older adults in remote islands. We conducted semi-structured interviews with 10 healthcare providers for older adults on Zamami Island of Okinawa, Japan. We performed a qualitative analysis using the steps for coding and theorization method. Four themes were extracted: “Collection and communication of information between residents”, “Communication of information from non-HCPs to HCPs”, “Sharing of information between HCPs”, and “HCPs taking action to initiate their approach”. Islanders take care of each other and know each other’s health status, while HCPs gather their health information. When necessary, HCPs on the island gain essential information regarding older adult patients from islanders not only through work, but also through personal interactions. Afterward, HCPs approach older adults who need health care. The human connections on this remote island serve as social capital and enable flexibility in both gathering information and seamless communication among islanders who also serve as informal resources that contribute support for older adults.

Defending Against Medical Error: Personal Reflections on the Legacy of John Senders

OBJECTIVE

To honor the legacy of John Senders, a distinguished member of the Human Factors and Ergonomics Society, by a short, personal history of him, but then to honor his legacy by extending it through our own professional opinions, with an emphasis on the study of human error and its implications for healthcare systems-two topics in which he excelled.

BACKGROUND

The authors are familiar with the topic and subject matter. One was a friend of Senders for over 50 years. Another was a collaborator and joint author with Senders (as well as his stepdaughter). All three authors have extensive publications in the topic areas.

METHOD, RESULTS, AND CONCLUSION

The authors used personal accounts of interactions with Senders at conferences, experiences living and working with him, and a brief review of his most personal, notable publications in healthcare. The reflections indicate a strong resonance on Senders' contributions to system design that are relevant today in healthcare's most challenging period in its history.

Early Findings on the Use of Clinical Pathways for Management of Unwarranted Variation in Cancer Care

Clinical pathways have the potential to improve complex clinical decision-making in cancer care. The authors implemented pathways with customized content to assist oncologists to select treatments, aiming for an on-pathway rate of 70%-85%. Treatment decisions were captured as on or off pathway, and metrics were shared monthly with users. Oncologists were categorized into quintiles based on on-pathway performance during the first 90 days of use. On-pathway rates were then calculated for days 91-360 (N = 121). Median on-pathway quintile rates varied from 50% to 100% in the initial 90-day period. During follow-up, median on-pathway rates shifted into the prespecified goal range for all groups. Clinical pathways resulted in greater uniformity in medical oncology practice. Monthly feedback about usage, familiarity with the electronic platform, and regular content updates are some factors that may influence on-pathway rates. Clinical pathways hold promise to manage unwarranted variation in cancer care.

Identifying the active ingredients of cardiac rehabilitation: A behaviour change technique and qualitative analysis

OBJECTIVES

Despite evidence that cardiac rehabilitation (CR) can be effective, the active ingredients or behaviour change techniques (BCTs) constituting effective CR remain unclear. There is also a lack of research surrounding patient and facilitator perceptions of active ingredients. This study sought to identify the active ingredients of a community-based CR programme and explore patient and facilitator perceptions of the active ingredients.

DESIGN

A multimethod design conducted in two stages, a BCT coding stage and a qualitative stage.

METHODS

The BCT coding stage involved the observation and audio recording of ten sessions from a community-based CR programme and the collection of programme materials. Data were coded using the BCT Taxonomy version 1 (Ann Behav Med, 46, 2013, 81). During the qualitative stage, six focus groups were carried out separately with patients (n = 16) and facilitators (n = 4). Qualitative data were analysed using an inductive thematic analysis.

RESULTS

The BCT coding phase identified 34 BCTs, many of which were highlighted by patients and facilitators. Patients and facilitators felt the group effort, motivation provided by facilitators, individualized care, knowledge gained, acceptance, and fear reduction enabled change. The majority of BCTs identified in the qualitative stage were also identified in the BCT coding stage, excluding a component related to self-acceptance. Facilitators felt the programme was limited by duration and inadequate psychological support.

CONCLUSIONS

The study provides a comprehensive overview of objectively coded BCTs and perceived active ingredients of CR. The findings can be used to inform future refinement and improvement of CR.

Improving Quality as a Solution to the Health Care Cost Problem? Health Policy Experts and the Promotion of a Controversial Idea

CONTEXT

In the late 2000s, the contention that quality improvements achieved by reforms in the delivery of care would slow the growth of costs throughout the US health care system became the predominant strategy for cost containment in the discourses and programs of all the 2008 presidential candidates. The question that this paper addresses is why, despite all of the critiques of this idea (especially those of the Congressional Budget Office), what the author terms the quality solution has remained credible enough to be a possible argument in policy makers' discourses and programs. To answer this question, the article explores the role of health policy experts-who are expected to provide credibility and legitimacy to proposals defended by policy makers-in supporting and diffusing this quality solution.

METHODS

The empirical research combines written sources with evidence from 78 interviews.

FINDINGS

This article highlights the political factors that explain the rise and growing prominence of the quality solution in the community of policy analysts: the political support for delivery reform-oriented research since the 1980s and also the importance of political calculations for prominent health policy experts.

CONCLUSIONS

This policy history contributes to works that underscore the political dimension of policy analysis.

Improved Procedural Efficiency of Atrial Fibrillation Ablation Using a Dedicated Ablation Protocol and Lean Management

OBJECTIVES

In this study the authors hypothesized that "Lean management" within a dedicated ablation protocol could standardize the pulmonary vein isolation (PVI) procedure and improve quality.

BACKGROUND

There is a large variability in safety, effectiveness, and efficiency of PVI.

METHODS

This was a single-center prospective study with inclusion of all consecutive PVI procedures from 2017 to 2019. A 3-step intervention was introduced based on Lean management: step 1) simplification (CLOSE protocol); step 2) waste elimination (higher power shorter duration); and step 3) improved standardization (Lab Optimization Tool [LOT]). PVI was divided into steps that were tracked (in minutes) using LOT. Parameters were compared in 6-month intervals.

RESULTS

Overall, 295 patients (146 patients with LOT) were analyzed. Step 1 reduced skin-to-skin procedure duration (2017: 119 ± 21 min vs. 2018: 77 ± 15 min; p < 0.001) and variance (from 2018 to 2019 p = 0.024). Step 2 reduced the radiofrequency time (2017: 38 ± 6 min vs. 2018: 20 ± 3 min; p < 0.001) and variance (from 2018 to 2019 p < 0.001). Analysis of step 3 demonstrated that only 53% of the entire procedure length (143 ± 22 min) was used for treatment (skin-to-skin time 77 ± 16 min), the remaining time being devoted for setup (42 ± 12 min, 29%); left atrial access (16 ± 7 min, 12%); respiratory gating, left atrial map, and pseudo-circle annotation (10 ± 6 min, 7%); ablation (39 ± 10 min, 27%); and bilateral block validation (10 ± 8 min, 7%).

CONCLUSIONS

Standardization of PVI using a dedicated ablation protocol and Lean management can help to reduce procedure and radiofrequency ablation duration and variance, and increase procedural efficiency without compromising safety. To improve health care utilization, increased efficiency should become an accepted goal in addition to procedural safety and effectiveness.

Insights From Organized Crime for Disorganized Health Care

During college and medical school, the author's summer employment acquainted him with members of organized crime families. After a full career as a primary care clinician and geriatrician with research on improving health care delivery, the author opines that several insights from organized crime should be of interest to health care professionals: (1) don't damage the host; (2) protect the brand; and (3) lead necessary adaption. From these insights, the author presents symptoms of failure evidenced by the US health care system, followed by several adaptations that would reduce the system's costs, improve its image, and address future challenges.

Image-guided ablation of scar-related ventricular tachycardia: towards a shorter and more predictable procedure

PURPOSE

The aim of this study was to analyze the feasibility and reproducibility of using image integration software at a remote setting over the MUSIC network to perform image-guided VT ablation. Furthermore, we analyzed the efficacy of a focused workflow with electroanatomical mapping (EAM) limited to imaging-defined scar.

METHODS

In a prospective two-centre study, consecutive patients undergoing image integration-guided VT ablation (magnetic resonance [DE-MRI] and/or multidetector computed tomography [MDCT]) were included. Patients were divided into two groups (Group 1, complete EAM; Group 2, EAM limited to imaging-defined substrate).

RESULTS

Forty-nine patients (62 ± 15 years; 90% male; LVEF 41 ± 14%; ischemic 69%) who underwent image integration-guided VT ablation were included (MDCT 98%; DE-MRI in 35%). Total procedure time was 172 ± 48 min (ablation 31 ± 17 min; fluoroscopy 23 ± 13 min). Procedure time was shorter in Group 2 as compared to Group 1 (Group 2 [n = 26] vs. Group 1 [n = 23]; procedure time: 151 ± 33 vs. 180 ± 53 min, P = 0.01). Non-inducibility of all VT was achieved in 37 (76%), with no difference between Group 1 and 2 (Group 2 vs. Group 1; VT non-inducibility 71 vs. 74%, P = 0.8). During a follow-up period of 19 ± 8 months, 13 patients (27%) had a VT recurrence. Two patients (4%) died during follow-up. There were no differences in VT-free survival between Group 1 and Group 2 (p = 0.77).

CONCLUSION

Image-integrated VT ablation is feasible through a network between highly experienced centers and remotely located centers. Focused image integration-guided VT ablation is associated with short and predictable procedure duration, achieving high-long term success rates.

A Model for Improving Health Care Quality for Transgender and Gender Nonconforming Patients

PROBLEM DEFINITION

Transgender and gender nonconforming (TGNC) populations are disproportionately affected by limited health care access and poor health outcomes and commonly report discrimination and mistreatment in health care settings. Despite these disparities, comprehensive approaches to improve the quality of health care of TGNC patient populations are currently lacking.

INITIAL APPROACH

The Vanderbilt Program for LGBTQ Health has developed a multifaceted, community-engaged approach to improve the quality of health care of TGNC patients, which includes the creation of a transgender patient advocacy program, a community advisory board, and a transgender health clinic. To support the continuous quality improvement of transgender health care, the program is currently piloting a novel multilevel monitoring and evaluation (M&E) system to collect information at the individual patient visit and health systems levels.

NEXT STEPS

The next steps for Vanderbilt's community-engaged M&E system are to identify the clinics and health services most used by TGNC patients and assess the level of patient satisfaction in each area. This process will support the identification of high- and low-performing clinics and health services and allow for targeted delivery of trainings to improve the quality of culturally competent health care TGNC patients receive systemwide.

CONCLUSION

In collaboration with TGNC patient populations and community stakeholders, Vanderbilt has created a model to improve the quality of both transition- and non-transition-related health care at the systems level that can be adopted by other health care systems nationally.

Preoccupation with failure and adherence to shared baselines: Measuring high-reliability organizational culture

OBJECTIVE

To create, administer, and psychometrically examine a survey to measure two new organizational culture factors - preoccupation with failure and adherence to shared baselines - in healthcare settings.

METHOD

Direct care providers (n = 4484) from a large healthcare system in the Southern United States completed a survey as part of their annual safety culture assessment.

RESULTS

We provide evidence about the internal consistency (Cronbach's alpha ranged from .80 to .89) factor structure, concurrent validity (correlation with overall patient safety grade ranged from .60 to .67, p <.05), and discriminant validity (correlations less than .85 with safety and teamwork culture) of these two factors.

CONCLUSIONS

We established evidence for internal consistency and validity of two new factors that measure aspects of organizational culture - preoccupation with failure and adherence to shared baselines - that are distinct from safety culture and teamwork culture.

Trends in High-Impact Neurosurgical Randomized Controlled Trials Published in General Medical Journals: A Systematic Review

BACKGROUND

The neurosurgery literature lacks a comprehensive report of neurosurgical randomized controlled trials (RCTs) published in general medical journals. RCTs published in these journals have high visibility and impact on decision-making by general medical practitioners and health care policymakers.

METHODS

A systematic review of neurosurgical RCTs in the New England Journal of Medicine, The Lancet, Journal of the American Medical Association, The BMJ, and Annals of Internal Medicine was completed.

RESULTS

There were 78 neurosurgical RCTs published in the selected high-impact journals from 2000 to 2017. The most common study topics were neurovascular (n = 39, 50%) and spine (n = 24, 30.8%). Of these RCTs, 44 (56.4%) compared operative with nonoperative management. For studies published before 2017, the mean number of citations was 899. Approximately half of the studies showed superiority of operative management over nonoperative management in the intent to treat primary outcome of interest (n = 24, 54.5%). However, stratified by subsubspecialty, 7 (87.5%) of the functional RCTs, 9 (50%) of the neurovascular RCTs, 1 (50%) of the trauma RCTs, and 7 (43.8%) of the spinal RCTs demonstrated superiority of operative management over nonoperative management. Additionally, there were large subspecialty differences in study characteristics, such as rate of double blinding, proportion of patient enrollment from patients screened, and proportion of crossover from nonsurgical to surgical arm.

CONCLUSIONS

Neurosurgical RCTs in general medical journals have large subspecialty differences in characteristics such as crossovers from nonsurgical to surgical treatment arms and the proportion of studies demonstrating benefit of operative intervention over nonoperative management.

Obligation for transparency regarding treating physician credentials at academic health centres

Academic health centres have historically treated patients with the most complex of diseases, served as training grounds to teach the next generations of physicians and fostered an innovative environment for research and discovery. The physicians who hold faculty positions at these institutions have long understood how these key academic goals are critical to serve their patient community effectively. Recent healthcare reforms, however, have led many academic health centres to recruit physicians without these same academic expectations and to partner with non-faculty physicians at other health systems. There has been limited transparency in regard to the expertise among the physicians and the academic faculty within these larger entities. Such lack of transparency may lead to confusion among patients regarding the qualifications of who is actually treating them. This could threaten the ethical principles of patient autonomy, benevolence and non-maleficence as patients risk making uninformed decisions that might lead to poorer outcomes. Furthermore, this lack of transparency unjustly devalues the achievements of physician faculty members as well as potentially the university they represent. In this paper, it is suggested that academic health centres have an obligation to foster total transparency regarding what if any role a physician has at a university or medical school when university or other academic monikers are used at a hospital.

It Takes Two to Tango: Customization and Standardization as Colluding Logics in Healthcare Comment on "(Re) Making the Procrustean Bed Standardization and Customization as Competing Logics in Healthcare"

The healthcare context is characterized with new developments, technologies, ideas and expectations that are continually reshaping the frontline of care delivery. Mannion and Exworthy identify two key factors driving this complexity, 'standardization' and 'customization,' and their apparent resulting paradox to be negotiated by healthcare professionals, managers and policy makers. However, while they present a compelling argument an alternative viewpoint exists. An analysis is presented that shows instead of being 'competing' logics in healthcare, standardization and customization are long standing 'colluding' logics. Mannion and Exworthy's call for further sustained work to understand this complex, contested space is endorsed, noting that it is critical to inform future debates and service decisions.

Effects of an Interprofessional Project on Students' Perspectives on Interprofessional Education and Knowledge of Health Disciplines

Context: Interprofessional education (IPE) is encouraged in health care education in the hope that it will improve communication among future health care professionals. In response, health professional education programs are developing IPE curricula.

Objective: To determine if a multicourse interprofessional (IP) project impacted students' knowledge and views on other health care professions, as well as their attitudes toward IPE.

Design: Cross-sectional survey.

Setting: Four university classrooms.

Patients or Other Participants: Eighty-one undergraduate students (32 men, 49 women) from 4 introductory courses (2 athletic training sections, 41 students; 1 health administration section, 19 students; and 1 nursing section, 21 students) participated in 2 surveys and an IP project.

Main Outcome Measure(s): Participants completed a modified Readiness for Interprofessional Learning Scale (RIPLS) questionnaire. The faculty assigned students to an IP group with representation from each discipline. Groups were instructed to produce a presentation on an assigned health care profession. After completing the project, students completed the same modified RIPLS questionnaire. Means and frequency were calculated. Quantitative data were analyzed with analysis of variance followed by Tukey post hoc testing when appropriate.

Results: After the IP project, students from all disciplines reported an increased knowledge regarding nursing, health administration, athletic training, and other health care professions in general and how their discipline differed from other health care disciplines. All students agreed that they should practice communication with other health care disciplines. Other perceptions related to IPE did not change.

Conclusions: Undergraduate athletic training, health administration, and nursing students who completed an IP project reportedly increased their knowledge of health care disciplines and increased their appreciation for practicing communication among health care disciplines. Future studies should assess how increasing basic knowledge of health care professions may impact the integration of advanced IPE concepts later in one's professional education.

Clinical Assessment of Risk Management: an INtegrated Approach (CARMINA)

Purpose - The European Union recommendations for patient safety calls for shared clinical risk management (CRM) safety standards able to guide organizations in CRM implementation. The purpose of this paper is to develop a self-evaluation tool to measure healthcare organization performance on CRM and guide improvements over time. Design/methodology/approach - A multi-step approach was implemented including: a systematic literature review; consensus meetings with an expert panel from eight Italian leader organizations to get to an agreement on the first version; field testing to test instrument feasibility and flexibility; Delphi strategy with a second expert panel for content validation and balanced scoring system development. Findings - The self-assessment tool - Clinical Assessment of Risk Management: an INtegrated Approach includes seven areas (governance, communication, knowledge and skills, safe environment, care processes, adverse event management, learning from experience) and 52 standards. Each standard is evaluated according to four performance levels: minimum; monitoring; outcomes; and improvement actions, which resulted in a feasible, flexible and valid instrument to be used throughout different organizations. Practical implications - This tool allows practitioners to assess their CRM activities compared to minimum levels, monitor performance, benchmarking with other institutions and spreading results to different stakeholders. Originality/value - The multi-step approach allowed us to identify core minimum CRM levels in a field where no consensus has been reached. Most standards may be easily adopted in other countries.

Health sector employment growth calls for improvements in labor productivity

While rising costs of healthcare have put increased fiscal pressure on public finance, job growth in the health sector has had a stabilizing force on overall employment levels - not least in times of economic crises. In 2014 EU-15 countries employed 21 million people in the health and social care sector. Between 2000 and 2014 the share of employed persons in this sector rose from 9.5% to 12.5% of the total labor force in EU-15 countries. Over time labor input growth has shifted towards residential care activities and social work while labor in human health activities including hospitals and ambulatory care still comprises the major share. About half of the human health labor force works in hospital. Variation of health and social care employment is large even in countries with generally comparable institutional structures. While standard measures of productivity in health and social care are not yet comparable across countries, we argue that labor productivity of a growing health work force needs more attention. The long-term stability of the health system will require care delivery models that better utilize a growing health work force in concert with smart investments in digital infrastructure to support this transition. In light of this, more research is needed to explain variations in health and social care labor endowments, to identify effective policy measures of labor productivity enhancement including enhanced efforts to develop comparable productivity indicators in these areas.

Outcomes and Quality: Key Characteristics of a Successful SLP Value Journey

We are living in a challenging era of healthcare reform marked by dramatic change and unprecedented political and legal turmoil surrounding this reform. Healthcare reform in the name of the Patient Protection and Affordable Care Act (PPACA, 2010) is becoming “hardwired” over the five years since its inception, yet as recently as March of 2015, the Supreme Court of the United States heard arguments to roll back subsidies for the Federal Health Exchanges which if approved could increase insurance rates by nearly 75% on over 8 million subscribers. The national healthcare landscape including reforms, changes, wins, and losses to date will be described. The “secret sauce” for meeting these challenges is to embrace value in healthcare which can be defined as outcomes over cost. In the context of our current levels of care, an inexorable movement away from volume to value will be described focusing on outcomes. The challenges we face especially in reporting outcomes and shifting from volume to value are described. Finally, arguments and illustrations are provided for how speech-language pathologists (SLPs) can continue to espouse value in becoming critical players in the value-based healthcare economy.

A register-based study of variations in services received among dental care attenders

OBJECTIVES

To investigate whether receipt of dental services, among attenders, reflects variations in dental health or whether and to what degree it is associated with socioeconomic status, with irregular or regular dental attendance and with the availability of dentists in residential areas.

MATERIALS AND METHODS

This retrospective register-based study followed two Danish cohorts, aged 25 and 40, with a dental examination in 2009 (n = 32,351). The dental service data were registered during 2005-2009. The number of dental examinations, individual preventive services (IPS), tooth extractions, root fillings and composite fillings were analyzed in relation to socioeconomic status, irregular/regular dental attendance, inhabitant/dentist ratio and to DMFT at age 15 (DMFT15) and change in DMFT (ΔDMFT) from age 15 to age 25 and age 40, respectively. Poisson regression and negative binomial regression analyses were used.

RESULTS

The variations in number of services received in the study population were small (SD = 0.2-2.7). However, with a few exceptions, high levels of DMFT15 and ΔDMFT were associated with receipt of more dental services. Socioeconomically-privileged individuals received more dental examinations but fewer tooth extractions, root fillings and composite fillings compared to disadvantaged persons, when controlled for dental health levels. Irregular attenders received fewer IPS and composite fillings but had more extractions compared to regular attenders.

CONCLUSIONS

Variations in dental care services were found to reflect variations in dental health, but the variations were also related to individual socioeconomic status, residential area and dental attendance patterns.

Understanding variations in pediatric asthma care processes in the emergency department using visual analytics

Health care delivery processes consist of complex activity sequences spanning organizational, spatial, and temporal boundaries. Care is human-directed so these processes can have wide variations in cost, quality, and outcome making systemic care process analysis, conformance testing, and improvement challenging. We designed and developed an interactive visual analytic process exploration and discovery tool and used it to explore clinical data from 5784 pediatric asthma emergency department patients.

Testing feasibility and reliability of a set of quality indicators to evaluate the organization of palliative care across Europe: a pilot study in 25 countries

BACKGROUND

A well-organized palliative care service is a prerequisite for offering good palliative care. Reliable and feasible quality indicators are needed to monitor the quality of their organization.

AIM

To test feasibility and reliability of a previously developed set of quality indicators in settings and services that provide palliative care across Europe.

METHODS

A total of 38 quality indicators, applicable in all types of settings, rated in a RAND Delphi process, and operationalized into 38 yes/no questions, were used. Descriptives statistics, factor and reliability analyses, analysis of variance, and chi-square analyses were used.

DESIGN

Cross-sectional online survey.

SETTING/PARTICIPANTS

Questionnaires were sent to representatives of 217 palliative care settings in 25 countries. Included settings were hospices, inpatient dedicated palliative care beds, palliative care outpatient clinics, palliative care units, day care centers for palliative care, palliative care home support teams, inpatient palliative care support teams, care homes, and nursing homes.

RESULTS

All invited 25 European Association of Palliative Care countries took part. In total, 107 out of 217 participants responded (57%). The quality indicators were reduced to four coherent sub-scales, being "equipment and continuity of care," "structured documentation of essential palliative care elements in the medical record," "training and appraisal of personnel," and "availability of controlled drugs." No significant differences in quality criteria between the different types of settings and services were identified.

CONCLUSION

The set of quality indicators appeared to measure four reliable domains that assess the organization of different palliative care settings. It can be used as a starting point for quality improvement activities.

Orthopaedic Surgery Under National Health Reform: An Analysis of Power, Process, Adaptation, and Leadership: AOA Critical Issues

Morrison argued that demography, economy, and technology drive the evolution of industries from a formative first-generation state ("First Curve") to a radically different way of doing things ("Second Curve") that is marked by new skills, strategies, and partners. The current health-reform movement in the United States reflects these three key evolutionary trends: surging medical needs of an aging population, dramatic expansion of Medicare spending, and care delivery systems optimized through powerful information technology. Successful transition from a formative first-generation state (First Curve) to a radically different way of doing things (Second Curve) will require new skills, strategies, and partners. In a new world that is value-driven, community-centric (versus hospital-centric), and prevention-focused, orthopaedic surgeons and health-care administrators must form new alliances to reduce the cost of care and improve durable outcomes for musculoskeletal problems. The greatest barrier to success in the Second Curve stems not from lack of empirical support for integrated models of care, but rather from resistance by those who would execute them. Porter's five forces of competitive strategy and the behavioral analysis of change provide insights into the predictable forms of resistance that undermine clinical and economic success in the new environment of care. This paper analyzes the components that will differentiate orthopaedic care provision for the Second Curve. It also provides recommendations for future-focused orthopaedic surgery and health-care administrative leaders to consider as they design newly adaptive, mutually reinforcing, and economically viable musculoskeletal care processes that drive the level of orthopaedic care that our nation deserves-at a cost that it can afford.

An exploration of management practices in hospitals

BACKGROUND

Management practices, including, for example, "Lean" methodologies originally developed at Toyota, may represent one mechanism for improving healthcare performance.

METHODS

We surveyed 597 nurse managers at cardiac units to score management on the basis of poor, average, or high performance on 18 practices across 4 dimensions (Lean operations, performance measurement, targets, and employee incentives). We assessed the relationship of management scores to hospital characteristics (size, non-profit status) and market level variables.

RESULTS

Our findings provide concrete examples of the high degree of management proficiency of some hospitals, as well as wide variation in management practices. Although the exact ways in which these tools have been implemented vary across hospitals, we identified multiple examples of units that use standardization in their care, track performance on a frequent basis and display data in a visual manner, and set aggressive goals and communicate them clearly to their staff. Regression models indicate that higher management scores are associated with hospitals in more competitive markets, teaching hospitals, and hospitals with a higher net income from patient services (p<0.05).

CONCLUSIONS

High quality management practices have been successfully adopted by some hospitals in the US, but the ways in which these practices have been implemented may vary, reflecting the specific context or environment of the hospital. The adoption of modern management practices may be driven in part by market pressure.

IMPLICATIONS

An improved understanding of key management practices may assist researchers and policy-makers in identifying mutable hospital characteristics that can drive efficiency, safety, and quality.

Retrospective cost-effectiveness analysis of treatments for aphasia: an approach using experimental data

PURPOSE

Evidence supports the effectiveness of speech-language treatment for individuals with aphasia, yet less is known about the cost-effectiveness of such treatments. The purpose of this study was to examine the incremental cost and cost-effectiveness of aphasia treatment using previously published data.

METHOD

The authors completed a retrospective cost-effectiveness analysis using experimental data that they extracted from 19 previously published aphasia treatment studies. Average and incremental cost-effectiveness ratios were calculated based on participants' pre- and posttreatment proficiency scores.

RESULTS

The average cost-effectiveness ratio for all sessions was $9.54 for each 1% increase in the outcome of interest. Measures of incremental cost-effectiveness indicated that aphasia treatments resulted in statistically significant improvements up to and including 17 treatment sessions. Increases in proficiency occurred at a cost of approximately $7.00 per 1% increase for the first 3 sessions to more than $20.00 in the 14th session; the ratio was either not statistically significant or dominated (more costly and less effective) in later sessions.

CONCLUSIONS

This cost-effectiveness analysis demonstrated that initial aphasia treatment sessions resulted in relatively larger and more cost-effective benefits than did later aphasia treatment sessions. The findings reported here are preliminary and have limitations. Prospective studies are needed to examine the cost-effectiveness of speech-language treatment for individuals with aphasia.

Health information technology in urologic care: current status and implications for quality of care

Health information technology (HIT) is expected to transform the delivery of health care in the United States, but implementation and adoption vary widely across settings, specialties, and geographies. Significant barriers to high-level adoption persist despite federal incentives to hospitals and health-care providers. This article will review the current status and future impact of HIT in the specialty of urology, with emphasis on the intersection of HIT and quality measurement.

Identifying radiological needs of referring clinicians

To provide prospective information about quality- and satisfaction-related product features in radiology, a customer-centered approach for acquiring clinicians' requirements and their prioritizations is essential. We introduced the Kano model for the first time in radiology to obtain such information. A Kano questionnaire, consisting of pairs of questions regarding 13 clinician requirements related to computed tomography (CT), magnetic resonance imaging (MRI) access and report turnaround time (RTT), was developed and administered. Each requirement was assigned a Kano category, and its satisfaction and dissatisfaction coefficients were calculated and presented in a Kano diagram. The data were stratified based on different clinics and on staff and resident clinicians. The time interval was evaluated between the completion of an examination and the first attempt to access the report by a clinician. Consultation for modality selection and scheduling and access to CT within 24 h and RTT within 8 to 24 h were considered as must-be requirements. Access to CT within 4 h and within 8 h, access to MRI within 8 h and within 24 h, and access to RTT within 4 h were one-dimensional requirements. The extension of operation time for CT or MRI, as well as MRI access within 4 h, was considered attractive. Eight out of nine clinics considered RTT within 8 h as a must-be requirement. There were differences in responses both among different clinics and between staff and resident clinicians. Access attempts to reports by clinicians in the first 4 h after the examination completion accounted for 65 % of CTs and 49 % of MRIs.

Can assessing chronic pain outcomes data improve outcomes?

OBJECTIVE

This manuscript reviews how patient-reported outcomes data can be used to guide efforts to improve patient outcomes.

DESIGN

Review Manuscript.

SETTING

The clinical management of chronic, non-cancer pain.

SUBJECTS

Adult patients receiving treatment for chronic, non-cancer pain.

RESULTS

While there have been great advances in the science of pain and various therapeutic medications and interventions, patient outcomes are variable. This manuscript reviews how outcomes data can be used to guide efforts to improve patient outcomes.

CONCLUSIONS

Patient outcomes can be improved with standardization of the process of patient care, as well as through other quality improvement efforts. The cornerstone to any effort to improve patient outcomes starts with the integration of valid outcomes data collection into ongoing patient care. Outcome measurement tools should provide information on several key domains, yet the process of data collection should not pose a significant burden on either the patient or health care team. Efforts to improve patient outcomes are ongoing, and should be a high priority for every health care team.

Michigan oncology practices showed varying adherence rates to practice guidelines, but quality interventions improved care

Despite improvements in care for patients with cancer, and in their survival rates, it is not clear that best practices are uniformly delivered to patients. We measured the quality of outpatient cancer care, using validated quality measures, in a consortium of thirty-six outpatient oncology practices in Michigan. We discovered that throughout the measurement period, for breast and colorectal cancer care, there was a more than 85 percent rate of adherence to quality care processes. For end-of-life care processes, the adherence rate was 73 percent, and for symptom and toxicity management care processes, adherence was 56 percent. In particular, we found variations in care around the fundamental oncologic task of management of cancer pain. To address quality gaps, we developed interventions to improve adherence to treatment guidelines, improve pain management, and incorporate palliative care into oncology practice. We concluded that statewide consortia that assume much of the cost burden of quality improvement activities can bring together oncology providers and payers to measure quality and design interventions to improve care.

Pre-operative biliary drainage for obstructive jaundice

BACKGROUND

Patients with obstructive jaundice have various pathophysiological changes that affect the liver, kidney, heart, and the immune system. There is considerable controversy as to whether temporary relief of biliary obstruction prior to major definitive surgery (pre-operative biliary drainage) is of any benefit to the patient.

OBJECTIVES

To assess the benefits and harms of pre-operative biliary drainage versus no pre-operative biliary drainage (direct surgery) in patients with obstructive jaundice (irrespective of a benign or malignant cause).

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Clinical Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2012.

SELECTION CRITERIA

We included all randomised clinical trials comparing biliary drainage followed by surgery versus direct surgery, performed for obstructive jaundice, irrespective of the sample size, language, and publication status.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and extracted data. We calculated the risk ratio (RR), rate ratio (RaR), or mean difference (MD) with 95% confidence intervals (CI) based on the available patient analyses. We assessed the risk of bias (systematic overestimation of benefit or systematic underestimation of harm) with components of the Cochrane risk of bias tool. We assessed the risk of play of chance (random errors) with trial sequential analysis.

MAIN RESULTS

We included six trials with 520 patients comparing pre-operative biliary drainage (265 patients) versus no pre-operative biliary drainage (255 patients). Four trials used percutaneous transhepatic biliary drainage and two trials used endoscopic sphincterotomy and stenting as the method of pre-operative biliary drainage. The risk of bias was high in all trials. The proportion of patients with malignant obstruction varied between 60% and 100%. There was no significant difference in mortality (40/265, weighted proportion 14.9%) in the pre-operative biliary drainage group versus the direct surgery group (34/255, 13.3%) (RR 1.12; 95% CI 0.73 to 1.71; P = 0.60). The overall serious morbidity was higher in the pre-operative biliary drainage group (60 per 100 patients in the pre-operative biliary drainage group versus 26 per 100 patients in the direct surgery group) (RaR 1.66; 95% CI 1.28 to 2.16; P = 0.0002). The proportion of patients who developed serious morbidity was significantly higher in the pre-operative biliary drainage group (75/102, 73.5%) in the pre-operative biliary drainage group versus the direct surgery group (37/94, 37.4%) (P < 0.001). Quality of life was not reported in any of the trials. There was no significant difference in the length of hospital stay (2 trials, 271 patients; MD 4.87 days; 95% CI -1.28 to 11.02; P = 0.12) between the two groups. Trial sequential analysis showed that for mortality only a small proportion of the required information size had been obtained. There seemed to be no significant differences in the subgroup of trials assessing percutaneous compared to endoscopic drainage.

AUTHORS' CONCLUSIONS

There is currently not sufficient evidence to support or refute routine pre-operative biliary drainage for patients with obstructive jaundice. Pre-operative biliary drainage may increase the rate of serious adverse events. So, the safety of routine pre-operative biliary drainage has not been established. Pre-operative biliary drainage should not be used in patients undergoing surgery for obstructive jaundice outside randomised clinical trials.

Why technology matters as much as science in improving healthcare

Background

More than half a million new items of biomedical research are generated every year and added to Medline. How successful are we at applying this steady accumulation of scientific knowledge and so improving the practice of medicine in the USA?

Discussion

The conventional wisdom is that the US healthcare system is plagued by serious cost, access, safety and quality weaknesses. A comprehensive solution must involve the better translation of an abundance of clinical research into improved clinical practice.

Yet the application of knowledge (i.e. technology) remains far less well funded and less visible than the generation, synthesis and accumulation of knowledge (i.e. science), and the two are only weakly integrated. Worse, technology is often seen merely as an adjunct to practice, e.g. electronic health records.

Several key changes are in order. A helpful first step lies in better understanding the distinction between science and technology, and their complementary strengths and limitations. The absolute level of funding for technology development must be increased as well as being more integrated with traditional science-based clinical research. In such a mission-oriented federal funding strategy, the ties between basic science research and applied research would be better emphasized and strengthened.

Summary

It bears repeating that only by applying the wealth of existing and future scientific knowledge can healthcare delivery and patient care ever show significant improvement.

Multilevel research and the challenges of implementing genomic medicine

Advances in genomics and related fields promise a new era of personalized medicine in the cancer care continuum. Nevertheless, there are fundamental challenges in integrating genomic medicine into cancer practice. We explore how multilevel research can contribute to implementation of genomic medicine. We first review the rapidly developing scientific discoveries in this field and the paucity of current applications that are ready for implementation in clinical and public health programs. We then define a multidisciplinary translational research agenda for successful integration of genomic medicine into policy and practice and consider challenges for successful implementation. We illustrate the agenda using the example of Lynch syndrome testing in newly diagnosed cases of colorectal cancer and cascade testing in relatives. We synthesize existing information in a framework for future multilevel research for integrating genomic medicine into the cancer care continuum.

Patient Safety Considerations in Developing Large Telehealth Networks

Telehealth is an emerging area of healthcare delivery that increases access to care, reduces utilization and offers the potential to improve patient safety, especially in rural and remote areas. The existing telehealthcare environment into which telehealth programmes are being implemented is characterized by its variability. Ensuring telehealth programmes maintain current levels of patient safety, or further improve this, requires standardization of the underlying clinical, technology and business processes. In order to achieve this standardization telehealth must be implemented as part of a ‘systems’ approach to healthcare transformation. Patient safety is an important driver that can help ensure the design, implementation and operational integrity of telehealth programmes conform to this systems approach. It cannot be assumed that existing clinical risk management and patient safety processes within legacy healthcare platforms offer the structure, process and outcomes that are necessary to ensure telehealth programmes are implemented and sustained in a safe, appropriate and effective way.

Perspective: Organizational professionalism: relevant competencies and behaviors

The professionalism behaviors of physicians have been extensively discussed and defined; however, the professionalism behaviors of health care organizations have not been systemically categorized or described. Defining organizational professionalism is important because the behaviors of a health care organization may substantially impact the behaviors of physicians and others within the organization as well as other institutions and the larger community. In this article, the authors discuss the following competencies of organizational professionalism, derived from ethical values: service, respect, fairness, integrity, accountability, mindfulness, and self-motivation. How nonprofit health care organizations can translate these competencies into behaviors is described. For example, incorporating metrics of population health into assessments of corporate success may increase collaboration among regional health care organizations while also benefiting the community. The unique responsibilities of leadership to model these competencies, promote them in the community, and develop relevant organizational strategies are clarified. These obligations elevate the importance of the executive leadership's capacity for self-reflection and the governing boards' responsibility for mapping operational activities to organizational mission. Lastly, the authors consider how medical organizations are currently addressing professionalism challenges. In an environment made turbulent by regulatory change and financial constraints, achieving proficiency in professionalism competencies can assist nonprofit health care organizations to promote population health and the well-being of their workforces.

Quality improvement in interventional radiology: an opportunity to demonstrate value and improve patient-centered care

The changing healthcare environment offers an opportunity for interventional radiology (IR) to showcase its value-specifically, to demonstrate that IR often offers the better, safer, faster, and less expensive treatment option for various clinical scenarios. The best way to demonstrate the value of IR now and to maintain this value in the future is through implementation of patient-centered care built on standardized care delivery, continuous quality improvement, and effective team dynamics.