Factors that impact the transfer and retention of best practices for reducing error in hospitals

Context counts: a qualitative study exploring the interplay between context and implementation success

PURPOSE

Implementing change in healthcare is difficult to accomplish due to the unpredictability associated with challenging the status quo. Adapting the intervention/practice/program being implemented to better fit the complex context is an important aspect of implementation success. Despite the acknowledged influence of context, the concept continues to receive insufficient attention at the team-level within implementation research. Using two heterogeneous multidisciplinary healthcare teams as implementation case studies, this study evaluates the interplay between context and implementation and highlights the ways in which context influences the introduction of a collective leadership intervention in routine practice.

DESIGN/METHODOLOGY/APPROACH

The multiple case study design adopted, employed a triangulation of qualitative research methods which involved observation (Case A = 16 h, Case B = 15 h) and interview data (Case A = 13 participants, Case B = 12 participants). Using an inductive approach, an in-depth thematic analysis of the data outlined the relationship between team-level contextual factors and implementation success.

FINDINGS

Themes are presented under the headings: (1) adapting to the everyday realities, a key determinant for implementation success and (2) implementation stimulating change in context. The findings demonstrate a dynamic relationship between context and implementation. The challenges of engaging busy healthcare professionals emphasised that mapping the contextual complexity of a site and adapting implementation accordingly is essential to enhance the likelihood of successful implementation. However, implementation also altered the surrounding context, stimulating changes within both teams.

ORIGINALITY/VALUE

By exposing the reciprocal relationship between team-level contextual factors and implementation, this research supports the improved design of implementation strategies through better understanding the interplay and mutual evolution of evidence-based healthcare interventions within different contexts.

Context, complexity and process in the implementation of evidence-based innovation: a realist informed review

Background

This review of scholarly work in health care knowledge translation advances understanding of implementation components that support the complete and timely integration of new knowledge. We adopt a realist approach to investigate what is known from the current literature about the impact of, and the potential relationships between, context, complexity and implementation process.

Methods

Informed by two distinct pathways, knowledge utilization and knowledge translation, we utilize Rogers’ Diffusion of Innovations theory (DOI) and Harvey and Kitson’s integrated- Promoting Action on Research Implementation in Health Service framework (PARIHS) to ground this review. Articles from 5 databases; Medline, Scopus, PsycInfo, Web of Science, and Google Scholar and a search of authors were retrieved. Themes and patterns related to these implementation components were extracted. Literature was selected for inclusion by consensus. Data extraction was iterative and was moderated by the authors.

Results

A total of 67 articles were included in the review. Context was a central component to implementation. It was not clear how and to what extent context impacted implementation. Complexity was found to be a characteristic of context, implementation process, innovations and a product of the relationship between these three elements. Social processes in particular were reported as influential however; descriptions of how these social process impact were limited. Multiple theoretical and operational models were found to ground implementation processes. We offer an emerging conceptual model to illustrate the key discoveries.

Conclusions

The review findings indicate there are dynamic relationship between context, complexity and implementation process for enhancing uptake of evidence-based knowledge in hospital settings. These are represented in a conceptual model. Limited empiric evidence was found to explain the nature of the relationships.

Learning from experience in a National Healthcare System: organizational dynamics that enable or inhibit change processes

OBJECTIVE

To study the organizational dynamics that either enable or inhibit the changes needed by the system for the ongoing organizational development of the major acute general public hospital in Malta.

SETTING

The main public acute general hospital in Malta. Malta is the main island of a small archipelago in the Mediterranean with a total population reaching around 460 000.

DESIGN AND PARTICIPANTS

This qualitative study utilized two major research methods: action research and in-depth interviews. Data collection and analysis were guided by the grounded theory paradigm and operated within a constructivist and informed grounded theory approach. The action research was conducted through the documentation and interpretation of a practitioner-researcher experience working within a multi-disciplinary hospital team consisting of up to 15 members from different healthcare professional groups. The in-depth interviews involved 25 interviewees using theoretical sampling techniques.

RESULTS

The findings affirmed the high potential and capabilities of the hospital workforce. This potential is nonetheless susceptible to be affected and gradually transformed by identified organizational and external forces into a workforce that is highly territorial, cynical and showing lack of 'ownership' of the organizational vision and objectives. The organizational culture, structures, systems and leadership as well as external factors that were frequently rooted at the national level were identified as strong impacting and underlying factors.

CONCLUSIONS

A theoretical framework was generated depicting a vicious circle that needs to be broken to enable the desired organizational development and learning. This additional knowledge can be used by and inspire other organizations operating within comparable conditions.

Digital health technology enhances resilient behaviour: evidence from the ward

Purpose

In the healthcare management domain, there is a lack of knowledge concerning the role of resilience practices in improving patient safety. The purpose of this paper is to understand the capabilities that enable healthcare resilience and how digital technologies can support these capabilities.

Design/methodology/approach

Within- and cross-case research methodology was used to study resilience mechanisms and capabilities in healthcare and to understand how digital health technologies impact healthcare resilience. The authors analyze data from two Italian hospitals through the lens of the operational failure literature and anchor the findings to the theory of dynamic capabilities.

Findings

Five different dynamic capabilities emerged as crucial for managing operational failure. Furthermore, in relation to these capabilities, medical, organizational and patient-related knowledge surfaced as major enablers. Finally, the findings allowed the authors to better explain the role of knowledge in healthcare resilience and how digital technologies boost this role.

Practical implications

When trying to promote a culture of patient safety, the research suggests healthcare managers should focus on promoting and enhancing resilience capabilities. Furthermore, when evaluating the role of digital technologies, healthcare managers should consider their importance in enabling these dynamic capabilities.

Originality/value

Although operations management (OM) research points to resilience as a crucial behavior in the supply chain, this is the first research that investigates the concept of resilience in healthcare systems from an OM perspective, with only a few authors having studied similar concepts, such as “workaround” practices.

Understanding middle managers' influence in implementing patient safety culture

BACKGROUND

The past fifteen years have been marked by large-scale change efforts undertaken by healthcare organizations to improve patient safety and patient-centered care. Despite substantial investment of effort and resources, many of these large-scale or "radical change" initiatives, like those in other industries, have enjoyed limited success - with practice and behavioural changes neither fully adopted nor ultimately sustained - which has in large part been ascribed to inadequate implementation efforts. Culture change to "patient safety culture" (PSC) is among these radical change initiatives, where results to date have been mixed at best.

DISCUSSION

This paper responds to calls for research that focus on explicating factors that affect efforts to implement radical change in healthcare contexts, and focuses on PSC as the radical change implementation. Specifically, this paper offers a novel conceptual model based on Organizational Learning Theory to explain the ability of middle managers in healthcare organizations to influence patient safety culture change. We propose that middle managers can capitalize on their unique position between upper and lower levels in the organization and engage in 'ambidextrous' learning that is critical to implementing and sustaining radical change. This organizational learning perspective offers an innovative way of framing the mid-level managers' role, through both explorative and exploitative activities, which further considers the necessary organizational context in which they operate.

Volume-Mortality Relationships during Hospitalization with Severe Sepsis Exist Only at Low Case Volumes

RATIONALE

Volume-outcome associations have been demonstrated in conditions with high morbidity and mortality; however, the existing literature regarding such associations in sepsis is not definitive.

OBJECTIVES

To test the hypothesis that annual hospital severe sepsis case volume is associated with mortality during admissions with severe sepsis in teaching and nonteaching hospitals.

METHODS

This work was a retrospective cohort study of administrative data from the South Carolina State Inpatient Database using multivariate logistic regression and case mix adjustment.

MEASUREMENTS AND MAIN RESULTS

In the calendar year 2010, 9,815 patients were admitted with severe sepsis or septic shock. Hospitals were stratified into low- (0-75 cases/yr, n = 26), intermediate- (76-300 cases/yr, n = 19), and high (>300 cases/yr, n = 12) -volume tertiles. Patients admitted to hospitals with a low annual case volume for sepsis had higher adjusted odds of dying before discharge (odds ratio, 1.56; 95% confidence interval, 1.25-1.94) compared with patients admitted to high-volume hospitals. Hospitalization at intermediate-volume hospitals was not associated with a difference in mortality (odds ratio, 0.99; 95% confidence interval, 0.90-1.09) compared with high-volume hospitals. There was no difference between the mortality rates of intermediate- and high-volume hospitals at different severity of illness quartiles. Hospital length of stay differed significantly by hospital case volume (low = 8.0, intermediate = 12.7, high = 14.9 [d]; P < 0.0001).

CONCLUSIONS

Hospitals with low annual sepsis case volume are associated with higher mortality rates, whereas hospitals with intermediate sepsis case volumes are associated with similar mortality rates compared with hospitals with high case volumes.

Management practices in Australian healthcare: can NSW public hospitals do better?

Purpose

– The purpose of this paper is to investigate the determinants of best management practices in an Australian state-run healthcare system, namely New South Wales (NSW), and studies the impact of a range of hospital factors in driving best management practices as a means of enhancing healthcare delivery.

Design/methodology/approach

– This study adapts a unique survey instrument globally tested to quantify the multi-dimensional nature of hospital management practices in 42 acute care public hospitals of NSW. The authors then analysed the role of hospital-specific characteristics in driving best management practices, namely hospital size (measured by the number of hospital beds, employees and doctors), level of skill and education, degree of hospital manager autonomy and organisational hierarchy.

Findings

– The findings of this study show the areas of strength and potential areas of improvement in NSW hospitals. The authors find a positive association between the adoption of better management practices and hospital size (measured by the number of hospital beds and employees), level of skills and education, degree of hospital manager autonomy and organisational hierarchy. However, hospital size as measured by the number of doctors did not have a statistically significant relationship.

Practical implications

– This paper is of interest to both hospital administrators, clinical doctors and healthcare policy-makers who want to improve and develop strategies for better management in the healthcare sector.

Originality/value

– This study provides an internationally comparable robust measure of management capability in public hospitals, and contributes to the evidence-base of management practices and performance in hospitals.

How best practices are copied, transferred, or translated between health care facilities: A conceptual framework

INTRODUCTION

In spite of significant investment in quality programs and activities, there is a persistent struggle to achieve quality outcomes and performance improvements within the constraints and support of sociopolitical parsimonies. Equally, such constraints have intensified the need to better understand the best practice methods for achieving quality improvements in health care organizations over time.This study proposes a conceptual framework to assist with strategies for the copying, transferring, and/or translation of best practice between different health care facilities.

PURPOSE

Applying a deductive logic, the conceptual framework was developed by blending selected theoretical lenses drawn from the knowledge management and organizational learning literatures.

FINDINGS

The proposed framework highlighted that (a) major constraints need to be addressed to turn best practices into everyday practices and (b) double-loop learning is an adequate learning mode to copy and to transfer best practices and deuteron learning mode is a more suitable learning mode for translating best practice. We also found that, in complex organizations, copying, transferring, and translating new knowledge is more difficult than in smaller, less complex organizations. We also posit that knowledge translation cannot happen without transfer and copy, and transfer cannot happen without copy of best practices. Hence, an integration of all three learning processes is required for knowledge translation (copy best practice-transfer knowledge about best practice-translation of best practice into new context). In addition, the higher the level of complexity of the organization, the more best practice is tacit oriented and, in this case, the higher the level of K&L capabilities are required to successfully copy, transfer, and/or translate best practices between organizations.

PRACTICE IMPLICATIONS

The approach provides a framework for assessing organizational context and capabilities to guide copy/transfer/translation of best practices. A roadmap is provided to assist managers and practitioners to select appropriate learning modes for building success and positive systemic change.

Benchmarking management practices in Australian public healthcare

Purpose

– The purpose of this paper is to investigate the quality of management practices of public hospitals in the Australian healthcare system, specifically those in the state-managed health systems of Queensland and New South Wales (NSW). Further, the authors assess the management practices of Queensland and NSW public hospitals jointly and globally benchmark against those in the health systems of seven other countries, namely, USA, UK, Sweden, France, Germany, Italy and Canada.

Design/methodology/approach

– In this study, the authors adapt the unique and globally deployed Bloom et al. (2009) survey instrument that uses a “double blind, double scored” methodology and an interview-based scoring grid to measure and internationally benchmark the management practices in Queensland and NSW public hospitals based on 21 management dimensions across four broad areas of management – operations, performance monitoring, targets and people management.

Findings

– The findings reveal the areas of strength and potential areas of improvement in the Queensland and NSW Health hospital management practices when compared with public hospitals in seven countries, namely, USA, UK, Sweden, France, Germany, Italy and Canada. Together, Queensland and NSW Health hospitals perform best in operations management followed by performance monitoring. While target management presents scope for improvement, people management is the sphere where these Australian hospitals lag the most.

Practical implications

– This paper is of interest to both hospital administrators and health care policy-makers aiming to lift management quality at the hospital level as well as at the institutional level, as a vehicle to consistently deliver sustainable high-quality health services.

Originality/value

– This study provides the first internationally comparable robust measure of management capability in Australian public hospitals, where hospitals are run independently by the state-run healthcare systems. Additionally, this research study contributes to the empirical evidence base on the quality of management practices in the Australian public healthcare systems of Queensland and NSW.

Why (we think) facilitation works: insights from organizational learning theory

Background

Facilitation is a guided interactional process that has been popularized in health care. Its popularity arises from its potential to support uptake and application of scientific knowledge that stands to improve clinical and managerial decision-making, practice, and ultimately patient outcomes and organizational performance. While this popular concept has garnered attention in health services research, we know that both the content of facilitation and its impact on knowledge implementation vary. The basis of this variation is poorly understood, and understanding is hampered by a lack of conceptual clarity.

Discussion

In this paper, we argue that our understanding of facilitation and its effects is limited in part by a lack of clear theoretical grounding. We propose a theoretical home for facilitation in organizational learning theory. Referring to extant literature on facilitation and drawing on theoretical literature, we discuss the features of facilitation that suggest its role in contributing to learning capacity. We describe how facilitation may contribute to generating knowledge about the application of new scientific knowledge in health-care organizations.

Summary

Facilitation’s promise, we suggest, lies in its potential to stimulate higher-order learning in organizations through experimenting with, generating learning about, and sustaining small-scale adaptations to organizational processes and work routines. The varied effectiveness of facilitation observed in the literature is associated with the presence or absence of factors known to influence organizational learning, since facilitation itself appears to act as a learning mechanism. We offer propositions regarding the relationships between facilitation processes and key organizational learning concepts that have the potential to guide future work to further our understanding of the role that facilitation plays in learning and knowledge generation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0323-0) contains supplementary material, which is available to authorized users.

Examining the Relationship Among Ambulatory Surgical Settings Work Environment, Nurses' Characteristics, and Medication Errors Reporting

PURPOSE

To describe work environment characteristics (leadership style and safety climate) of ambulatory surgical settings and to examine the relationship between work environment and nurses' willingness to report medication errors in ambulatory surgical settings.

DESIGN

Descriptive correlational design using survey methodology.

METHODS

The sample of this study consisted of 40 unit-based registered nurses, working as full time, part time, or as needed in four ambulatory surgical settings affiliated with one health care system located in Northeast Ohio.

FINDINGS

The results of two separate regression analyses, one with three nurse manager's leadership styles and another with five safety climate dimensions as independent variables, explained 44% and 50%, respectively, on variance of nurses' willingness to report medication errors.

CONCLUSION

To increase nurses' willingness to report medication errors, ambulatory surgical settings administrators should invest in nurse manager leadership training programs and focus on enhancing safety climate aspects, particularly errors feedback and organizational learning.

Interpersonal mentoring and its influence on retention of valued health care workers: the moderating role of affective commitment

BACKGROUND

Health care organizations (HCOs) invest in knowledge transfer to promote improved patient outcomes; however, these investments prove costly when health care workers with enhanced knowledge and skills leave to seek better employment opportunities.

PURPOSE

The aim of this study was to examine the impact of interpersonal mentoring on affective organizational commitment and the potential moderating effect of affective commitment in the knowledge transfer-retention relationship.

METHODOLOGY/APPROACH

One hundred fifty-three clinicians working at a Midwestern acute care hospital and associated clinics were surveyed at their worksite.

FINDINGS

Clinicians who received more interpersonal mentoring were also more likely to have stronger affective commitment. In addition, affective commitment moderated the relationship between knowledge transfer and turnover intentions, that is, when affective commitment was low, clinicians with higher levels of knowledge transfer indicated higher turnover intentions. However, clinicians with high levels of affective commitment and knowledge transfer reported lower turnover intentions.

PRACTICE IMPLICATIONS

HCOs must simultaneously invest in knowledge transfer while implementing strategies that assist in retaining knowledgeable workers. Interpersonal mentoring appears to play an important role in the retention of valued clinicians through its influence on affective commitment. HCOs must facilitate cultures that show top management support for mentoring through practices such as educational programs, flexible scheduling, and reward systems.

Professional networks and EBM use: a study of inter-physician interaction across levels of care

Physicians around the globe are increasingly encouraged to adopt guidelines, protocols and other scientific material when making clinical decisions. Extant research suggests that the clinicians' propensity to use evidence-based medicine (EBM) is strongly associated with the professional collaborative networks they establish and maintain with peers. In this paper we explore whether and how the connectedness of primary care physicians with colleagues working in hospital settings is related to their frequency of EBM use in clinical practice. We used survey data from 104 pediatricians working in five local health authorities in the Italian NHS. Social network and attributional data concerning single physicians, as well as their self-reported frequency of EBM use, were collected for three major pathologies in pediatric care: asthmatic, gastro-enteric and urinary pathologies. Ordered regression analysis was employed. Our findings documented a positive association between the number of physicians' relationships with hospital colleagues and the frequency of use EBM. Results also indicated that physicians' organizational affiliations influence the frequency of EBM use. Finally, contrary to our expectations, it was found that clinicians' affiliation to formal collaborative arrangements is at odds with the likelihood of reporting higher frequency of EBM use.

Deliberate learning in health care: the effect of importing best practices and creative problem solving on hospital performance improvement

This article examines the effect on quality improvement of two common but distinct approaches to organizational learning: importing best practices (an externally oriented approach rooted in learning by imitating others' best practices) and internal creative problem solving (an internally oriented approach rooted in learning by experimenting with self-generated solutions). We propose that independent and interaction effects of these approaches depend on where organizations are in their improvement journey - initial push or later phase. We examine this contingency in hospitals focused on improving treatment time for patients with heart attacks. Our results show that importing best practices helps hospitals achieve initial phase but not later phase improvement. Once hospitals enter the later phase of their efforts, however, significant improvement requires creative problem solving as well. Together, our results suggest that importing best practices delivers greater short-term improvement, but continued improvement depends on creative problem solving.

Health care administrators' perspectives on the role of absorptive capacity for strategic change initiatives: a qualitative study

BACKGROUND

The dimensions of absorptive capacity (ACAP) are defined, and the importance of ACAP is established in the management literature, but the concept has not been applied to health care organizations attempting to implement multiple strategic initiatives.

PURPOSE

The aim of this study was to test the utility of ACAP by analyzing health care administrators' experiences with multiple strategic initiatives within two health systems.

METHODOLOGY

Results are drawn from administrators' assessments of multiple initiatives within two health systems using in-depth personal interviews with a total of 61 health care administrators. Data analysis was performed following deductive qualitative analysis guidelines. Interview transcripts were coded based on the four dimensions of ACAP: acquiring, assimilating, internalizing/transforming, and exploiting knowledge. Furthermore, we link results related to utilization of management resources, including number of key personnel involved and time consumption, to dimensions of ACAP.

FINDINGS

Participants' description of multiple strategic change initiatives confirmed the importance of the four ACAP dimensions. ACAP can be a useful framework to assess organizational capacity with respect to the organization's ability to concurrently implement multiple strategic initiatives. This capacity specifically revolves around human capital requirements from upper management based on the initiatives' location or stage within the ACAP framework.

PRACTICE IMPLICATIONS

Strategic change initiatives in health care can be usefully viewed from an ACAP perspective. There is a tendency for those strategic initiatives ranking higher in priority and time consumption to reflect more advanced dimensions of ACAP (assimilate and transform), whereas few initiatives were identified in the ACAP "exploit" dimension. This may suggest that health care leaders tend to no longer identify as strategic initiatives those innovations that have moved to the exploitation stage or that less attention is given to the exploitation elements of a strategic initiative than to the earlier stages.

Effect of a system-oriented intervention on compliance problems in schizophrenia: a pragmatic controlled trial

Background. Numerous studies have been conducted with a view to developing strategies for improvement of medical compliance in patients with schizophrenia. All of the studies conducted so far have had an individual approach to compliance based on the assumption that noncompliance is determined individually due to inappropriate behavior in the patient. We conducted a pragmatic controlled trial with a system-oriented approach, to provide a new perspective on compliance and test the efficacy of a multifactorial intervention at the system level in a routine clinical setting, an approach that has not previously been used for the improvement of compliance. Methods. 30 patients were allocated to the system-oriented therapy and 40 patients were allocated to the reference intervention, which consisted of individually based compliance therapy. The follow-up period was six months. Primary endpoint was improvement in compliance, measured by improvement in a compliance scale specifically developed for the project. Results. When accounting for missing values with a multiple imputation approach, we found a tendency toward a difference in both the compliance scale and PANSS favoring the system-oriented therapy, although it did not reach statistical significance. A significant difference in incidence of adverse events and time to first readmission was found. Attrition rates were significantly higher in the reference group and nonsignificant among individuals with lower compliance, which may have diluted effect estimates. This was reflected by significant differences found in an analysis based on a last observation carried forward approach. Conclusion. This study suggests that compliance problems are better solved by a multifactorial intervention at the system level than at the individual level.

Improving health service delivery organisational performance in health systems: a taxonomy of strategy areas and conceptual framework for strategy selection

Health systems strengthening (HSS) is a priority for global health funders, policy-makers and practitioners. Although many HSS efforts have focused on policy levers such as financing approaches, payment schemes or regulatory reforms, less attention has been directed to targeting the organisations that deliver health services such as hospitals, health centres and clinics. Evidence suggests that the impact of organisation-level interventions varies by context; however, we lack a general framework for integrating organisational context into performance improvement strategies for health service delivery organisations. Drawing on open systems theories from organisational behaviour and management as well as a review of 181 empirical studies of health service delivery organisations in low- and middle-income countries, we propose a taxonomy of seven strategy areas for improving organisational performance as well as a multistage conceptual framework for selecting among them. We propose that the choice of strategy for improving health service delivery organisational performance should be informed by: (i) the root cause of the organisation's performance gap; (ii) the environmental conditions facing the organisation; and (iii) the implementation capability of the organisation. We also highlight conditions under which different strategy areas may be expected to be optimally effective. The approaches presented in this paper offer a way for health system decision-makers and researchers to systematically assess and incorporate organisational context in the process of developing strategies to improve the performance of health service delivery organisations and, ultimately, of health systems.

Teamwork, organizational learning, patient safety and job outcomes

PURPOSE

This article aims to encourage healthcare administrators to consider the learning organization concept and foster collaborative learning among teams in their attempt to improve patient safety.

DESIGN/METHODOLOGY/APPROACH

Relevant healthcare, organizational behavior and human resource management literature was reviewed.

FINDINGS

A patient safety culture, fostered by healthcare leaders, should include an organizational culture that encourages collaborative learning, replaces the blame culture, prioritizes patient safety and rewards individuals who identify serious mistakes.

PRACTICAL IMPLICATIONS

As healthcare institution staffs are being asked to deliver more complex medical services with fewer resources, there is a need to understand how hospital staff can learn from other organizational settings, especially the non-healthcare sectors.

ORIGINALITY/VALUE

The paper provides suggestions for improving patient safety which are drawn from the health and business management literature.

All teach, all learn, all improve?: the role of interorganizational learning in quality improvement collaboratives

BACKGROUND

Quality improvement collaboratives are an increasingly common strategy for implementing evidence-based practices in health care. However, research shows that many participating organizations do not achieve the level of performance improvement desired.

PURPOSE

This study examined the use of interorganizational learning activities (inter-OLAs) as an explanation for mixed performance improvement among collaborative participants. We tested the hypotheses that inter-OLA use is positively associated with participants' performance improvement and that this relationship is moderated by the use of intraorganizational learning activities (intra-OLAs) and quality-focused human resource (Q-HR) practices.

METHODOLOGY

We conducted a survey of organizational teams participating in 4 Institute for Healthcare Improvement Breakthrough Series collaboratives. Survey responses from 52 teams, regarding the use of inter-OLAs, intra-OLAs and Q-HR practices, were linked to performance improvement data obtained from the Institute for Healthcare Improvement and demographic data obtained from secondary sources.

FINDINGS

The more collaborative teams used inter-OLAs, the more their organizations' performance improved. Contrary to our hypothesis, the use of intra-OLAs did not moderate this relationship; teams' use of intra-OLAs added to, but did not multiply, the effect of inter-OLA use. In contrast, an organization's use of Q-HR practices multiplied the performance benefit of inter-OLA use.

PRACTICE IMPLICATIONS

Our findings suggest that organizations that participate in collaboratives are more likely to improve their performance if they use the inter-OLAs offered by the collaborative. Our results also suggest that complementing high use of inter-OLAs with intra-OLA use and Q-HR practices enhances performance improvement. For collaborative sponsors, our findings imply that including activities that facilitate interorganizational and intraorganizational learning are worthwhile.

Enhancing team learning in nursing teams through beliefs about interpersonal context

AIM

This article is a report of a study that examines the relationship between team-level learning and performance in nursing teams, and the role of beliefs about the interpersonal context in this relationship.

BACKGROUND

Over recent years, there has been an increasing interest in the learning processes of work teams. Researchers have investigated the impact of team learning on team performance, and the enabling conditions for this learning. However, team learning in nursing teams has been largely ignored.

DESIGN

A cross-sectional field survey design was used.

METHODS

The sample comprises a total of 468 healthcare professionals working in 89 nursing teams at different public hospitals throughout Spain. Members of nursing teams participated voluntarily by completing a confidential individual questionnaire. Team supervisors evaluated nursing teams' performance. Data were collected over 2007-2008.

RESULTS

The results show a mediating effect of team learning on the relationship between beliefs about interpersonal context (psychological safety, perceived task interdependence, and group potency) and team performance.

CONCLUSION

Our findings suggest that beliefs about interpersonal context and team learning are important to effective nursing team performance.

Crew resource management and teamwork training in health care: a review of the literature and recommendations for how to leverage such interventions to enhance patient safety

PURPOSE

In an attempt to enhance patient safety, health care facilities are increasingly turning to crew resource management (CRM) and other teamwork training interventions. However, there is still quite a bit about such training interventions that remain unclear. Accordingly, our primary intent herein is to provide some clarity by providing a review of the literature, in hopes of highlighting the current state of the literature as well as identifying the areas that should be addressed by researchers in this field going forward.

DESIGN/METHODOLOGY/APPROACH

We searched various electronic databases and utilized numerous relevant search terms to maximize the likelihood of identifying all empirical research related to the use of CRM training within health care. Additionally, we conducted a manual search of the most relevant journals and also conducted a legacy search to identify even more articles. Furthermore, given that as a research team we have experience with CRM initiatives, we also integrate the lessons learned through this experience.

FINDINGS

Based on our review of the literature, CRM and teamwork training programs generally appear beneficial to individual employees, the groups and teams within such settings, and overall health care organizations.

ORIGINALITY/VALUE

In addition to reviewing the literature that addressed CRM and teamwork training, we also highlight some of the more critical aspects of CRM training programs in order for such initiatives to be as successful as possible. Additionally, we detail various factors that appear essential to sustaining any benefits of CRM over the long haul.

Improving Outpatient Diabetes Care

More than 20% of patients in the Veterans Health Administration (VHA) have diabetes; therefore, disseminating “best practices” in outpatient diabetes care is paramount. The authors’ goal was to identify such practices and the factors associated with their development. First, a national VHA diabetes registry with 2008 data identified clinical performance based on the percentage of patients with an A1c >9%. Facilities (n = 140) and community-based outpatient clinics (n = 582) were included and stratified into high, mid, and low performers. Semistructured telephone interviews (31) and site visits (5) were conducted. Low performers cited lack of teamwork between physicians and nurses and inadequate time to prepare. Better performing sites reported supportive clinical teams sharing work, time for non-face-to-face care, and innovative practices to address local needs. A knowledge management model informed our process. Notable differences between performance levels exist. “Best practices” will be disseminated across the VHA as the VHA Patient-Centered Medical Home model is implemented.

Trust as a Moderator of the Relationship Between Mentoring and Knowledge Transfer

To be effective, organizations must facilitate knowledge transfer between employees. Mentoring has long been viewed as a vehicle for effective knowledge transfer. The authors break new ground in examining the role of trust as a moderator of the relationship between mentoring and knowledge transfer. Results of a study conducted among employees of a hospital who indicated they had mentors show main effects for both mentoring and trust as well as a significant interaction effect. Implications of these findings for knowledge transfer are discussed.

Effects of learning climate and registered nurse staffing on medication errors

BACKGROUND

Despite increasing recognition of the significance of learning from errors, little is known about how learning climate contributes to error reduction.

OBJECTIVES

The purpose of this study was to investigate whether learning climate moderates the relationship between error-producing conditions and medication errors.

METHODS

A cross-sectional descriptive study was done using data from 279 nursing units in 146 randomly selected hospitals in the United States. Error-producing conditions included work environment factors (work dynamics and nurse mix), team factors (communication with physicians and nurses' expertise), personal factors (nurses' education and experience), patient factors (age, health status, and previous hospitalization), and medication-related support services. Poisson models with random effects were used with the nursing unit as the unit of analysis.

RESULTS

A significant negative relationship was found between learning climate and medication errors. It also moderated the relationship between nurse mix and medication errors: When learning climate was negative, having more registered nurses was associated with fewer medication errors. However, no relationship was found between nurse mix and medication errors at either positive or average levels of learning climate. Learning climate did not moderate the relationship between work dynamics and medication errors.

DISCUSSION

The way nurse mix affects medication errors depends on the level of learning climate. Nursing units with fewer registered nurses and frequent medication errors should examine their learning climate. Future research should be focused on the role of learning climate as related to the relationships between nurse mix and medication errors.

Can systematic analysis of morbidity and mortality reduce complication rates in neurosurgery?

OBJECTIVE

Morbidity and mortality conferences (M&MC) are a traditional part of residency programs in a large number of countries to increase the training quality. The purpose of the present publication is to report our experience with a monthly M&MC over a 5-year period and, in particular, to describe the methods to identify critical cases, the system of analysis, classification of morbidity and mortality, and the resulted impact.

METHOD

Monthly identification of M&M was done through a system of electronically coding hospital course at the time of discharge. Morbidity was classified as moderate if sequels resolved within 3 months or otherwise as severe. Morbidity included management complications not directly related the neurosurgical procedure, such as pneumonia or thromboembolism. Mortality was classified as related to surgery or unrelated, e.g., after severe trauma. Mortality in relation to surgery was subclassified in terms of causal relation or not. Statistical comparison of incidence rates was calculated statistically.

RESULTS

Overall management morbidity rate was 7.1%, and mortality with causal relation to surgery was 0.38%. The leading cause of morbidity was additional neurological deficit (25%) followed by postoperative hemorrhage (23%) and second unplanned surgery due to incomplete result of the primary procedure (14%). Overall, the monthly incidence varied without a discernable annual pattern. Over the years, there were only a handful of guideline updates triggered by incidents.

CONCLUSION

Our system to identify complication proved to be reliable. During the study period, the M&MC developed into a well-accepted instrument of quality control and problem-oriented teaching, but the impact on quality improvement remained questionable.

Research in action: using positive deviance to improve quality of health care

Background

Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality.

Methods

We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction.

Results

The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices.

Conclusion

The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality.

Learning and improving in quality improvement collaboratives: which collaborative features do participants value most?

OBJECTIVE

To understand participants' views on the relative helpfulness of various features of collaboratives, why each feature was helpful and which features the most successful participants viewed as most central to their success.

DATA SOURCES

Primary data collected from 53 teams in four 2004-2005 Institute for Healthcare Improvement (IHI) Breakthrough Series collaboratives; secondary data from IHI and demographic sources.

STUDY DESIGN

Cross-sectional analyses were conducted to assess participants' views of 12 features, and the relationship between their views and performance improvement.

DATA COLLECTION METHODS

Participants' views on features were obtained via self-administered surveys and semi-structured telephone interviews. Performance improvement data were obtained from IHI and demographic data from secondary sources.

PRINCIPAL FINDINGS

Participants viewed six features as most helpful for advancing their improvement efforts overall and knowledge acquisition in particular: collaborative faculty, solicitation of their staff's ideas, change package, Plan-Do-Study-Act cycles, Learning Session interactions, and collaborative extranet. These features also provided participants with motivation, social support, and project management skills. Features enabling interorganizational learning were rated higher by teams whose organizations improved significantly than by other teams.

CONCLUSIONS

Findings identify features of collaborative design and implementation that participants view as most helpful and highlight the importance of interorganizational features, at least for those organizations that most improve.

Patient Safety, Knowledge Creation and the Absorptive Capacity of Rural Hospitals

Patient safety is a priority issue in health care and rural hospitals face unique circumstances in this arena. This article applies the concepts of organisational learning in general and absorptive capacity in particular to the efforts by rural hospitals to continuously improve patient safety performance. Strategies are discussed through which rural hospitals might better identify patient safety related information, techniques and technologies and convert them to organisational use.

Gestão Hospitalar: identificação das práticas de aprendizagem existentes em hospitais

A profissionalização da gestão em hospitais, a partir de diferentes práticas da administração, tem sido amplamente discutida, à luz de conceitos como gestão baseada em evidência, gestão do conhecimento e aprendizagem organizacional. Entretanto, são poucos os artigos identificando e discutindo essas práticas nas organizações de saúde. Este é o objetivo do presente artigo. Buscou-se realizar uma análise histórica da gestão em saúde no Brasil, considerando uma mudança a partir do processo de descentralização. Foi realizado o mapeamento das práticas de gestão enfatizando-se as metodologias de aprendizagem existentes no setor, a partir de pesquisas documentais. Pôde-se perceber uma mudança de modelo mental na área, passando de um enfoque linear para um enfoque sistêmico. Da mesma forma, identificou-se o processo de construção do conhecimento nessas organizações, especialmente a partir da prática médica. Constatou-se ainda que o processo de aprendizagem enfatiza a aprendizagem individual e não a aprendizagem organizacional.

Do corporate chains affect quality of care in nursing homes? The role of corporate standardization*

BACKGROUND

Chain-owned nursing homes have become the predominant type of provider in the United States, but little is known about their management structures. Prior research has found that chain ownership has significant effects on health outcomes, but why that is the case is not well understood.

PURPOSE

This study examines the effects of corporate-mandated standardization and corporate-sponsored training in administrative and clinical processes on the total number of deficiencies reported for a facility and on the percentage of residents with pressure ulcers for chain-owned facilities in Michigan and North Carolina.

METHODOLOGY

Data on the corporate practices of standardization and training were collected in a mail survey of facility administrators in Michigan in 2001 and North Carolina in 2002. We received responses from 117 of 239 chain-owned facilities in Michigan and 86 of 270 in North Carolina. Survey responses were merged with facility characteristics taken from the On-line Survey, Certification, and Report System. Seemingly unrelated regression was used to estimate the effects of standardization on the count of health deficiencies and percentage of residents with pressure ulcers simultaneously.

FINDINGS

Health deficiencies, but not pressure ulcers, were lower in facilities of chains with greater overall corporate standardization. More detailed analysis revealed that standardization of facilities' physical plant lowered both deficiencies and pressure ulcers and standardization of clinical activities lowered pressure ulcers (but not deficiencies). In contrast, standardization of administrative practices increased pressure ulcers (but not deficiencies).

PRACTICE IMPLICATIONS

Corporate standardization of resident-centered activities such as clinical guidelines and common facility layouts may contribute to superior resident care, whereas primary reliance on administrative standardization may interfere with residents' needs. Chains need to balance administrative efficiency with the local needs of individual chain-owned facilities and their residents.

Redesigning health systems for quality: Lessons from emerging practices

BACKGROUND

It has been five years since the Institute of Medicine (IOM) report, Crossing the Quality Chasm, proposed systemwide changes to transform our health care system. What progress has been made? What lessons have been learned? How should we move forward?

METHODS

Semistructured telephone interviews were conducted with 16 health care providers and researchers at organizations involved in system redesign. The findings were supplemented with a focused literature review and discussions from a national expert meeting.

RESULTS

Many promising and innovative examples of redesign were identified. However, even delivery systems that are redesigning care in pursuit of the six IOM aims face daunting challenges, reflecting the need to align system changes across multiple levels and to integrate redesign efforts with ongoing system features. Four success factors were reported by providers as crucial in overcoming redesign barriers: (1) directly involving top and middle-level leaders, (2) strategically aligning and integrating improvement efforts with organizational priorities, (3) systematically establishing infrastructure, process, and performance appraisal systems for continuous improvement, and (4) actively developing champions, teams, and staff. A framework that integrates these success factors to facilitate a systems approach to redesigning health care organizations and delivery systems for improved performance is provided.

CONCLUSIONS

Successful system redesign requires coordinating and managing a complex set of changes across multiple levels rather than isolated projects.

Bench-to-bedside review: dealing with increased intensive care unit staff turnover: a leadership challenge

Critical care leaders frequently must face challenging situations requiring specific leadership and management skills for which they are, not uncommonly, poorly prepared. Such a fictitious scenario was discussed at a Canadian interdisciplinary critical care leadership meeting, whereby increasing intensive care unit (ICU) staff turnover had led to problems with staff recruitment. Participants discussed and proposed solutions to the scenario in a structured format. The results of the discussion are presented. In situations such as this, the ICU leader should first define the core problem, its complexity, its duration and its potential for reversibility. These factors often reside within workload and staff support issues. Some examples of core problems discussed that are frequently associated with poor retention and recruitment are a lack of a positive team culture, a lack of a favorable ICU image, a lack of good working relationships between staff and disciplines, and a lack of specific supportive resources. Several tools or individuals (typically outside the ICU environment) are available to help determine the core problem. Once the core problem is identified, specific solutions can be developed. Such solutions often require originality and flexibility, and must be planned, with specific short-term, medium-term and long-term goals. The ICU leader will need to develop an implementation strategy for these solutions, in which partners who can assist are identified from within the ICU and from outside the ICU. It is important that the leader communicates to all stakeholders frequently as the process moves forward.

Introducing the National Patient Safety Goals Department: Sharing Programs of Excellence from Individual Organizations

This new department will provide innovative ideas for meeting the Joint Commission's National Patient Safety Goals as implemented in various health care settings.