Knowledge sharing and organizational learning in the context of hospital infection prevention

Integrating Inter-Professional Insights for Enhanced Disaster Response: A Cross-Sectional Analysis in Jubail's Royal Commission Hospital, Saudi Arabia

Introduction

This study aimed to evaluate disaster preparedness and management among an inter-professional team at the Royal Commission Hospital (RCH) in Jubail, Saudi Arabia.

Methods

Conducted between May and July 2023, this cross-sectional study involved healthcare providers in both patient-facing and non-patient-facing roles. Participants responded to a comprehensive online questionnaire comprising 22 questions across seven sections covering aspects of emergency response, disaster management, and infection control. The study targeted a minimum sample size of 500 participants, successfully garnering responses from 512 individuals.

Results

Of the 512 participants, 59.9% (n=312) were healthcare providers in patient-facing roles, and 40.1% (n=209) were in non-patient-facing roles. The results revealed notable disparities in awareness and preparedness between these two groups. Healthcare providers demonstrated higher awareness levels compared to their non-patient-facing counterparts. For instance, 76.9% of healthcare providers were aware of the hospital's emergency response plan compared to 56.2% of non-healthcare providers (χ² = 52.165, p < 0.001). Similar disparities were observed in understanding the term "disaster" (86.5% vs 54.1%, χ² = 27.931, p < 0.001), and awareness of a command center (73.4% vs 45.2%, χ² = 42.934, p < 0.001).

Discussion

These findings underscore the critical need for enhancing awareness, education, and preparedness within healthcare facilities, emphasizing an integrated approach that includes both healthcare and non-healthcare staff. By addressing these gaps, healthcare facilities can significantly improve their emergency response efficiency, disaster management capabilities, and infection control measures, thereby enhancing the overall safety and quality of patient care.

Perspectives on research needs in healthcare epidemiology, infection prevention, and antimicrobial stewardship: what's on the horizon-Part II

In this overview, we articulate research needs and opportunities in the field of infection prevention that have been identified from insights gained during operative infection prevention work, our own research in healthcare epidemiology, and from reviewing the literature. The 10 areas of research need are: 1) Transmissions and interruptions, 2) personal protective equipment and other safety issues in occupational health, 3) climate change and other crises, 4) device, diagnostic, and antimicrobial stewardship, 5) implementation and deimplementation, 6) healthcare outside the acute care hospital, 7) low- and middle-income countries, 8) networking with the "neighbors," 9) novel research methodologies, and 10) the future state of surveillance. An introduction and chapters 1-5 are presented in part I of the article and chapters 6-10 and the discussion in part II. There are many barriers to advancing the field, such as finding and motivating the future IP workforce including professionals interested in conducting research, a constant confrontation with challenges and crises, the difficulty of performing studies in a complex environment, the relative lack of adequate incentives and funding streams, and how to disseminate and validate the often very local quality improvement projects. Addressing research gaps now (i.e., in the post-pandemic phase) will make healthcare systems more resilient when facing future crises.

Understanding Evidence-Based Practice (EBP) Implementation in HCOs Through the Lens of Organizational Theory

Despite the increasing use of theory in the field of implementation science over the past decade, the literature has largely focused on using deterministic frameworks to retrospectively understand "what" factors are essential for the effective implementation of evidence-based practices (EBPs). On the other hand, gaps remain in using organizational theory to prospectively understand "how" successful EBP implementation occurs in health-care organizations (HCOs). This article discusses the theoretical and empirical contributions of two selected recent exploratory research works, which provide a starting point for addressing the identified gaps in the literature, with the purpose of deriving implications for theory, practice, and future research in implementation science. The selected works used the theory of "effective knowledge sharing network structures in professional complex systems (PCS)," developed through an integration of organizational theories, to design prospective interventions for enabling EBP implementation in HCOs. In doing so, these studies have helped explain "how" inter-professional knowledge exchange and collective learning occurred, to enable successful EBP implementation in HCOs. Correspondingly, the selected works have served a dual purpose in: 1) identifying evidence-based management (EBM) practice strategies for successful EBP implementation; while 2) further developing the theoretical literature on "effective knowledge sharing networks in PCS." Importantly, by addressing the identified gaps in the literature, the selected works serve to either complement or supplement existing theoretical approaches in implementation science. To this effect, they provide unique insights for theory, practice, and research in implementation science, including insights into a potential "dual-role" for the future implementation researcher-one of advancing implementation science, while working to strengthen implementation practice. Based on these contributions, it could be argued that the selected works provide a starting point for a new research stream that has the potential to occupy a distinct position in the taxonomy of theoretical approaches used in implementation science.

Preserving Organizational Resilience, Patient Safety, and Staff Retention during COVID-19 Requires a Holistic Consideration of the Psychological Safety of Healthcare Workers

During the COVID-19 pandemic, healthcare workers are fighting a lethal virus with acute shortages of Personal Protective Equipment (PPE). These unprecedented circumstances have amplified the sources of emotional distress and worker burnout. However, many healthcare organizations (HCOs) in the United States, have opted for a “stoic approach” to healthcare worker support, i.e., no additional support beyond federal and state policy protections for the licensing and liability of healthcare workers. In this scenario, a key public health concern is sustaining an adequate healthcare workforce, both by way of quantity (adequate numbers) and quality (maximizing clinician resilience to provide safe care to large volumes of patients under challenging conditions). Therefore, it is imperative for HCO leaders to recognize that a limited view of worker psychological safety, without due consideration for the broader emotional distress created by the pandemic, could have the effect of restricting organizational resilience and adversely impacting patient safety and staff retention during and beyond the pandemic. This paper uses the organizational resilience framework to discuss the potential impact of a stoic approach to healthcare worker support on patient safety and staff retention in a hospital intensive care unit (ICU) during COVID-19. The discussion in turn, helps to develop recommendations for HCOs to overcome these challenges.

A Health System's Pilot Experience with Using Social Knowledge Networking (SKN) Technology to Enable Meaningful Use of EHR Medication Reconciliation Technology

Similar to issues faced in health systems across USA, AU Health, based in Augusta, Georgia, faced a scenario of low physician engagement in, and limited-use of its Electronic Health Record (EHR) Medication Reconciliation (MedRec) technology, which translated to high rates of medication discrepancies and low accuracy of the patient's active medication list, during transitions of care. In fall 2016, a two-year grant was secured from the U.S. Agency for Healthcare Research and Quality (AHRQ), to pilot a Social Knowledge Networking (SKN) system pertaining to "EHR-MedRec," to enable AU Health to progress from "limited use" of EHR MedRec technology, to "meaningful use." The rationale behind an SKN system, is that it could provide a platform for inter-professional knowledge exchange on practice issues related to EHR MedRec, across diverse provider subgroups and care settings, to highlight adverse consequences of gaps in practice for patient safety, and emphasize the value of adhering to best-practices in EHR MedRec. This, in turn, is expected to increase provider engagement in addressing issues related to EHR MedRec, and promote inter-professional learning of best-practices, to create a foundation for practice change or improvement (e.g., Meaningful Use of EHR MedRec technology). This Case Report describes AU Health's experiences with this novel initiative to pilot an SKN system for enabling Meaningful Use of EHR MedRec technology. It also discusses lessons learned in regard to the potential of an SKN system to enable inter-professional learning and practice improvement in the context of EHR MedRec, which, in turn, helps identify strategies and practice implications for healthcare managers.

Network analysis of the structure of inter-professional knowledge exchange related to Electronic Health Record Medication Reconciliation within a Social Knowledge Networking system

Background

In fall 2016, a 2-year grant was secured to pilot a Social Knowledge Networking (SKN) system pertaining to Electronic Health Record (EHR) Medication Reconciliation (MedRec), to enable Augusta University Health System to progress from “limited use” of EHR MedRec technology, to “meaningful use” (MU). A total of 50 “SKN users” (practitioners), participated in discussing practice issues related to EHR MedRec, over a 1-year period. These discussions were moderated by five “SKN moderators” (senior administrators). The pilot study, completed in fall 2018, found that inter-professional knowledge exchanges on the SKN, enabled several collective learning (“aha”) moments to emerge. These learning dynamics in turn, were associated with distinct improvement trends in two measures of MU of EHR MedRec technology, identified for the study. A key takeaway was that an SKN could be a valuable tool in enabling MU of EHR MedRec technology.

Purpose

The study’s key findings related to the content and dynamics of inter-professional knowledge exchange on the SKN system, and their association with trends in measures of MU of EHR MedRec technology, have been described in a separate publication. This paper seeks to describe the structure of inter-professional knowledge exchange (or the pattern of connections) related to EHR MedRec, over the 1-year SKN period.

Methods

Social network analysis (SNA) techniques were used to describe the structure of inter-professional knowledge exchange on the SKN system.

Results

Results revealed that three of the five SKN moderators played a strong “collective brokerage” role in facilitating inter-professional knowledge exchange related to EHR MedRec, to enable learning and practice change. Together, they played complementary roles in reinforcing best-practice assertions, providing IT system education, and synthesizing collective learning moments, to enable “champions for change” to emerge from among SKN users.

Conclusion

Results provide insight into the structure of effective knowledge-sharing networks for enabling inter-professional learning and practice change in health care organizations.

A qualitative study of interprofessional learning related to electronic health record (EHR) medication reconciliation within a social knowledge networking (SKN) system

Background: Similar to issues faced in health systems across the USA, AU Health faced a scenario of low physician engagement in and limited use of its Electronic Health Record (EHR) Medication Reconciliation (MedRec) technology, which translated to high rates of medication discrepancies and low accuracy of the patient’s active medication list, during transitions of care. In fall 2016, a 2-year research grant was secured to pilot a Social Knowledge Networking (SKN) system on “EHR MedRec” to enable AU Health to progress from “limited use” of EHR MedRec technology to “meaningful use.”

Purpose: The aims of this study were to 1) examine dynamics of interprofessional knowledge exchange and learning related to EHR MedRec on the SKN system and 2) explore associations between “SKN Use” and “Meaningful Use (MU) of EHR MedRec,” with the latter being assessed in terms of adherence to best practices in EHR MedRec.

Methods: Over a 1-year period, 50 SKN Users (practitioners from inpatient and outpatient medicine settings), participated in discussing issues related to EHR MedRec, moderated by five SKN Moderators (senior administrators). Qualitative analysis was used to understand dynamics of interprofessional knowledge exchange and descriptive analysis was used to examine trends in two measures of MU of EHR MedRec, identified for the study.

Results: Interprofessional knowledge exchanges related to EHR MedRec on the SKN system, progressed from “problem statements” to “problem-solving statements” to “IT system education” to “best-practice assertions” to “culture change assertions” to “collective learning (aha) moments” to lay a foundation for practice change. These interprofessional learning dynamics were associated with distinct improvement trends in both measures of MU of EHR MedRec technology.

Conclusion: Results suggest that an SKN system could be a valuable tool in enabling MU of EHR MedRec technology. The study helps identify strategies for the creation of “learning health systems,” to enable successful change implementation in healthcare organizations.

The effects of collaborative cultures and knowledge sharing on organizational learning

Purpose

The purpose of this paper is to investigate the effects of collaborative cultures and knowledge sharing on organization learning.

Design/methodology/approach

This research used a sample of 288 non-profit state-owned organization employees, which was taken using the simple random sampling technique. The hypotheses were tested using the partial least square approach.

Findings

This research provides insights that organizational learning is influenced significantly by knowledge sharing and collaborative cultures existing within the organization. The successfully built theoretical implication provides evidence that knowledge sharing and collaborative cultures within an organization can provide support for the real organizational learning to take place. Knowledge sharing and collaborative cultures prove to be among the determinants for the occurrence of organizational learning. The right culture can promote good organizational learning.

Research limitations/implications

The right culture can promote organizational learning. This research investigates the effects of collaborative cultures and knowledge sharing on organizational learning in a non-profit state-owned organization. Future research can further expand the scope of various types of organizations, both for-profit and non-profit ones.

Practical implications

This research reveals the effects of collaborative cultures and knowledge sharing on organizational learning.

Originality/value

This research provides insights into the factors supporting organizational learning.

Creating a foundation for implementing an electronic health records (EHR)-integrated Social Knowledge Networking (SKN) system on medication reconciliation

Background

In fall 2016, Augusta University received a two-year grant from AHRQ, to implement a Social Knowledge Networking (SKN) system for enabling its health system, AU-Health, to progress from "limited use" of EHR Medication Reconciliation (MedRec) Technology, to "meaningful use." Phase 1 sought to identify a comprehensive set of issues related to EHR MedRec encountered by practitioners at AU-Health. These efforts helped develop a Reporting Tool, which, along with a Discussion Tool, was incorporated into the AU-Health EHR, at the end of Phase 1. Phase 2 (currently underway), comprises a 52-week pilot of the EHR-integrated SKN system in outpatient and inpatient medicine units. The purpose of this paper is to describe the methods and results of Phase 1.

Methods

Phase 1 utilized an exploratory mixed-method approach, involving two rounds of data collection. This included 15 individual interviews followed by a survey of 200 practitioners, i.e., physicians, nurses, and pharmacists, based in the outpatient and inpatient medicine service at AU Health.

Results

Thematic analysis of interviews identified 55 issue-items related to EHR MedRec under 9 issue-categories. The survey sought practitioners' importance-rating of all issue-items identified from interviews. A total of 127 (63%) survey responses were received. Factor analysis served to validate the following 6 of the 9 issue-categories, all of which, were rated "Important" or higher (on average), by over 70% of all respondents: 1) Care-Coordination (CCI); 2) Patient-Education (PEI); 3) Ownership-and-Accountability (OAI); 4) Processes-of-Care (PCI); 5) IT-Related (ITRI); and 6) Workforce-Training (WTI). Significance-testing of importance-rating by professional affiliation revealed no statistically significant differences for CCI and PEI; and some statistically significant differences for OAI, PCI, ITRI, and WTI.

Conclusion

There were two key gleanings from the issues related to EHR MedRec unearthed by this study: 1) there was an absence of shared understanding among practitioners, of the value of EHR MedRec in promoting patient safety, which contributed to workarounds, and suboptimal use of the EHR MedRec system; and 2) there was a socio-technical dimension to many of the issues, creating an added layer of complexity. These gleanings in turn, provide insights into best practices for managing both clinical transitions-of-care in the EHR MedRec process; and socio-technical challenges encountered in EHR MedRec implementation.

Innovation Implementation in the Context of Hospital QI: Lessons Learned and Strategies for Success

In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care. Circa 2009, nearly a decade after the release of the IOM report, the health care organizational literature began referring to this challenge as "innovation implementation failure" in health care organizations (HCOs), ie, failure to implement an evidence-based practice that is new to a HCO. This stream of literature drew upon management research to explain why innovation implementation failure occurs in HCOs and what could be done to prevent it. This paper conducts an integrative review of the literature on "innovation implementation" in hospitals and health systems over the last decade, since the spotlight was cast on "innovation implementation failure" in HCOs. The review reveals that while some studies have retrospectively sought to identify the key drivers of innovation implementation, through surveys and interviews of practitioners (the "what"), other studies have prospectively sought to understand how innovation implementation occurs in hospitals and health systems (the "how"). Both make distinctive contributions to identifying strategies for success in innovation implementation. While retrospective studies have helped identify the key drivers of innovation implementation, prospective studies have shed light on how these drivers could be attained, thereby helping to develop context-sensitive management strategies for success. The literature has called for more prospective research on the implementation and sustainability of health care innovations. This paper summarizes the lessons learned from the literature, discusses the relevance of management research on innovation implementation in HCOs, and identifies future research avenues.

A framework for measuring self-management effectiveness and health care use among pediatric asthma patients and families

Asthma is associated with substantial health care expenditures, including an estimated US$56 billion per year in direct costs. A recurring theme in the asthma management literature is that costly asthma symptoms, including hospitalizations and multiple emergency department (ED)/outpatient visits, can often be prevented through patient/family adherence to the national (National Institutes of Health Expert Panel Report-3) guidelines for effective self-management of asthma, specifically 1) medication adherence and 2) environmental trigger avoidance, as outlined in the patient's personalized Asthma-Action Plan. It is important to note however that while effective self-management of asthma is known to reduce ED visits and hospitalizations, the relationship between asthma self-management effectiveness and outpatient visit frequency remains ambiguous, reflecting a gap in the literature. For instance, do patients/families who self-manage effectively visit outpatient clinics more frequently for asthma care (compared to those who do not self-manage effectively), after accounting for differences in asthma severity, demographic characteristics, and risk factors? Do patients/families who visit outpatient clinics more frequently for asthma care, in turn have fewer ED and inpatient encounters for asthma? On the other hand, do patients/families who do not revisit outpatient clinics regularly have higher ED visits and hospitalizations? It is important to address these gaps, in order to reduce the costs and public health burden of asthma. This paper provides a foundation for addressing these gaps, by conducting an integrative review of the asthma management literature, to develop a conceptual framework for measuring self-management effectiveness and health care use among pediatric asthma patients/families. In doing so, the paper lays the groundwork for future research seeking to explicate the relationship between asthma self-management effectiveness and health care use, which in turn has potential to engage asthma providers in promoting ideal self-management and optimal health care use for pediatric asthma, in accordance with national evidence-based guidelines for asthma management.

Cumulative impact of periodic top-down communications on infection prevention practices and outcomes in two units

BACKGROUND

The problem of interest in this study is the challenge of consistent implementation of evidence-based infection prevention practices at the unit level, a challenge broadly characterized as "change implementation failure." The theoretical literature suggests that periodic top-down communications promoting tacit knowledge exchanges across professional subgroups may be effective for enabling change in health care organizations. However, gaps remain in understanding the mechanisms by which top-down communications enable practice change at the unit level. Our study sought to both validate the theoretical literature and address this gap.

PURPOSE

Correspondingly, this study posed two research questions. (1) What is the impact of periodic "top-down" communications on practice change at the unit level? (2) What are the "unit-level" communication dynamics enabling practice changes? Whereas this article focuses on addressing the first question, the second question has been addressed in an earlier Health Care Management Review article (Rangachari et al., 2013).

METHODS

A prospective study was conducted in two intensive care units at an academic health center. Both units had low baseline adherence to central line bundle (CLB) and higher-than-expected catheter-related bloodstream infections (CRBSIs). Periodic top-down communication interventions were conducted over 52 weeks to promote CLB adherence in both units. Simultaneously, the study examined (a) unit-level communication dynamics related to CLB through weekly "communication logs," completed by unit physicians, nurses, and managers, and (b) unit outcomes, that is, CLB adherence and CRBSI rates.

FINDINGS

Both units showed increased adherence to CLB and significant, sustained declines in CRBSIs. Results showed that the interventions cumulatively had a significant negative (desired) impact on "catheter days," that is, central catheter use.

PRACTICE IMPLICATIONS

Results help validate the theoretical literature and identify evidence-based management strategies for practice change at the unit level. They suggest that periodic top-down communications have the potential to modify interprofessional knowledge exchanges and enable practice change at the unit level, leading to significantly improved outcomes and reduced costs.

Role of Social Knowledge Networking technology in facilitating meaningful use of Electronic Health Record medication reconciliation

Despite the federal policy impetus towards EHR Medication Reconciliation, hospital adherence has lagged for one chief reason; low physician engagement, which in turn emanates from lack of consensus in regard to which physician is responsible for managing a patient's medication list, and the importance of medication reconciliation as a tool for improving patient safety and quality of care. The Technology-in-Practice (TIP) framework stresses the role of human action in enacting structures of technology use or "technologies-in-practice." Applying the TIP framework to the EHR Medication Reconciliation context, helps frame the problem as one of low physician engagement in performing EHR Medication Reconciliation, translating to limited-use-EHR-in-practice. Concurrently, the problem suggests a hierarchical network structure, reflecting limited communication among hospital administrators and clinical providers on the importance of EHR Medication Reconciliation in improving patient safety. Integrating the TIP literature with the more recent knowledge-in-Practice (KIP) literature suggests that EHR-in-practice could be transformed from "limited use" to "meaningful use" through the use of Social Knowledge Networking (SKN) Technology to create new social network structures, and enable engagement, learning, and practice change. Correspondingly, the objectives of this paper are to: 1) Conduct a narrative review of the literature on "technology use," to understand how technologies-in-practice may be transformed from limited use to meaningful use; 2) Conduct a narrative review of the literature on "organizational change implementation," to understand how changes in technology use could be successfully implemented and sustained in a healthcare organizational context; and 3) Apply lessons learned from the narrative literature reviews to identify strategies for the meaningful use and successful implementation of EHR Medication Reconciliation technology.

Short or Long End of the Lever? Associations between Provider Communication of the "Asthma-Action Plan" and Outpatient Revisits for Pediatric Asthma

BACKGROUND

At the Children's Hospital of Georgia (CHOG), we found that outpatient revisits for pediatric asthma were significantly above national norms. According to the NIH, costly hospital revisits for asthma can be prevented through guidelines-based self-management of asthma, central to which, is the use of a written Asthma-Action Plan (AAP).

PURPOSE

The asthma services literature has emphasized the role of the healthcare provider in promoting asthma self-management using the AAP, to prevent hospital revisits. On the other hand, the asthma policy literature has emphasized the need for community-based interventions to promote asthma self-management. A gap remains in understanding the extent of leverage that healthcare providers may have in preventing hospital revisits for asthma, through effective communication of AAP in the outpatient setting. Our study sought to address this gap.

METHODS

We conducted a 6-month intervention to implement "patient-and-family-centered communication of the AAP" in CHOG outpatient clinics, based on the "change-management" theoretical framework. Provider communication of AAP was assessed through a survey of "Parent Understanding of the Child's AAP." A quasi-experimental approach was used to measure outpatient revisits for pediatric asthma, pre- and post-intervention.

RESULTS

Survey results showed that provider communication of the AAP was unanimously perceived highly positively by parents of pediatric asthma patients, across various metrics of patient-centered care. However, there were no statistically significant differences in outpatient "revisit behavior" for pediatric asthma between pre- and post-intervention periods after controlling for several demographic variables. Additionally, revisits remained significantly above national norms.

CONCLUSIONS

Results suggest limited potential of "effective provider communication of AAP," in reducing outpatient revisits for pediatric asthma; and indicate need for broader community-based interventions to address patient life variables impacting self-management and hospital revisits for pediatric asthma. Findings suggest need for a revised "socio-ecological" theoretical framework, and also provide insight into various policy, research, and practice implications for asthma management and control.

The evolution of knowledge exchanges enabling successful practice change in two intensive care units

BACKGROUND

Many hospitals are unable to consistently implement evidence-based practices. For example, implementation of the central line bundle (CLB), known to prevent catheter-related bloodstream infections (CRBSIs), is often challenging. This problem is broadly characterized as "change implementation failure."

PURPOSE

The theoretical literature on organizational change has suggested that periodic top-down communications promoting tacit knowledge exchanges across professional subgroups may be effective for enabling learning and change in health care organizations. However, gaps remain in understanding the mechanisms by which top-down communications enable practice change at the unit level. Addressing these gaps could help identify evidence-based management strategies for successful practice change at the unit level. Our study sought to address this gap.

METHODS

A prospective study was conducted in two intensive care units within an academic health center. Both units had low baseline adherence to CLB and higher-than-expected CRBSIs. Periodic top-down quality improvement communications were conducted over a 52-week period to promote CLB implementation in both units. Simultaneously, the study examined (a) the content and frequency of communication related to CLB through weekly "communication logs" completed by unit physicians, nurses, and managers and (b) unit outcomes, that is, CLB adherence rates through weekly chart reviews.

FINDINGS

Both units experienced substantially improved outcomes, including increased adherence to CLB and statistically significant (sustained) declines in both CRBSIs and catheter days (i.e., central line use). Concurrently, both units indicated a statistically significant increase in "proactive" communications-that is, communications intended to reduce infection risk-between physicians and nurses over time. Further analysis revealed that, during the early phase of the study, "champions" emerged within each unit to initiate process improvements.

PRACTICE IMPLICATIONS

The study helps identify evidence-based management strategies for successful practice change at the unit level. For example, it underscores the importance of (a) screening each unit for change champions and (b) enabling champions to emerge from within the unit to foster change implementation.

Role of communication content and frequency in enabling evidence-based practices

Many hospitals are unable to successfully implement evidence-based practices. For example, implementation of the central line bundle (CLB), proven to prevent catheter-related bloodstream infections (CRBSIs), is often challenging. This problem is broadly characterized as a "change implementation failure." A prospective study was conducted in 2 intensive care units (ICUs), a medical ICU (MICU) and a pediatric ICU (PICU), within an academic health center. Both units had low baseline adherence to CLB and higher-than-expected CRBSIs. The study sought to promote CLB implementation in both units through periodic quality improvement (QI) interventions over a 52-week period. Simultaneously, it examined (1) the content and frequency of communication related to CLB through weekly "communication logs" completed by physicians, nurses, and managers, and (2) outcomes, that is, CLB adherence rates through weekly medical record reviews. The aim of the study was 2-fold: (1) to examine associations between QI interventions and communication content and frequency at the unit level, and (2) to examine associations between communication content and frequency and outcomes at the unit level. The periodic QI interventions were expected to increase CLB adherence and reduce CRBSIs through their influence on communication content and frequency. A total of 2638 instances of communication were analyzed. Both units demonstrated a statistically significant increase in "proactive" communications-that is, communication intended to reduce infection risk between physicians and nurses over time. Proactive communications increased by 68% in the MICU (P < .05) and 61% in the PICU (P < .05). During the same timeframe, both units increased CLB adherence to 100%. Both units also demonstrated statistically significant declines in (1) catheter days: 34% decline in the MICU (P < .05) and 30% in the PICU (P < .05); and (2) CRBSI rates: 63% decline in the MICU (P < .05) and 100% in the PICU (P < .10). Direct costs savings from reduced CRBSIs in 1 year were estimated to be at least $840 000. Periodic QI interventions were effective in reframing interprofessional communication dynamics and enabling practice change. The prospective design provides insights into communication content and frequency associated with collective learning and culture change. The study identifies evidence-based management strategies for positive practice change at the unit level.

Using social knowledge networking technology to enable meaningful use of electronic health record technology in hospitals and health systems

Despite the federal policy momentum towards "meaningful use" of Electronic Health Records, the healthcare organizational literature remains replete with reports of unintended adverse consequences of implementing Electronic Health Records, including: increased work for clinicians, unfavorable workflow changes, and unexpected changes in communication patterns & practices. In addition to being costly and unsafe, these unintended adverse consequences may pose a formidable barrier to "meaningful use" of Electronic Health Records. Correspondingly, it is essential for hospital administrators to understand and detect the causes of unintended adverse consequences, to ensure successful implementation of Electronic Health Records. The longstanding Technology-in-Practice framework emphasizes the role of human agency in enacting structures of technology use or "technologies-in-practice." Given a set of unintended adverse consequences from health information technology implementation, this framework could help trace them back to specific actions (types of technology-in-practice) and institutional conditions (social structures). On the other hand, the more recent Knowledge-in-Practice framework helps understand how information and communication technologies (e.g., social knowledge networking systems) could be implemented alongside existing technology systems, to create new social structures, generate new knowledge-in-practice, and transform technology-in-practice. Therefore, integrating the two literature streams could serve the dual purpose of understanding and overcoming unintended adverse consequences of Electronic Health Record implementation. This paper seeks to: (1) review the theoretical literatures on technology use & implementation, and identify a framework for understanding & overcoming unintended adverse consequences of implementing Electronic Health Records; (2) outline a broad project proposal to test the applicability of the framework in enabling "meaningful use" of Electronic Health Records in a healthcare context; and (3) identify strategies for successful implementation of Electronic Health Records in hospitals & health systems, based on the literature review and application.

Flux, questions, exclusion and compassion: collective learning in secondary care

CONTEXT

Health care organisations are increasingly conceptualised as complex, indivisible entities made up of web-like networks of staff that connect to each other in changeable ways. This study draws on the theoretical framework of activity theory and the concept of knotworking to illustrate how health professionals improvise collaboratively to negotiate everyday challenges and contribute positively to patients' health priorities.

OBJECTIVES

The aim of this paper is to contribute to evolving ideas about collective learning, change and improvement in secondary care by exploring how health professionals work and learn together and how this compares with earlier findings from primary care.

METHODS

This study applied a constructionist methodology within the research paradigm of interpretivism. Qualitative data were gathered through 26 hours of observations and 17 field interviews within the natural environment of a working hospital over a 3-month period. The research site encompassed a medical receiving ward, a chronic ward, an out-patient clinic and the connecting corridors. Staff participants included a range of clinical, nursing, ancillary and clerical staff.

RESULTS

The study found a recurring pattern of spontaneous team forming and interprofessional shared learning to respond to care needs within the hospital as they arise. These are presented in four analytical themes: motion, flux and the unpredictability of 'team spirit'; adaptive, responsive learning through seeing, doing and asking questions; the collective learning gap between doctors and other staff; and frustration, compassion and the desire for improvement.

CONCLUSIONS

Health care professionals in the hospital setting both create and experience complex inclusion and exclusion behaviours that define who is empowered to act with professional authority in any given moment of care. This paper discusses issues of power, the particular exclusion of doctors from interprofessional knotworking, and the greater emphasis on questions as the pivotal aspect of shared collective learning when compared with primary care.

Effective communication network structures for hospital infection prevention: a study protocol

Many hospitals are unable to successfully implement "evidence-based practices" at the unit level. For example, consistent implementation of the central line bundle (CLB), proven to prevent catheter-related bloodstream infections (CRBSIs) is often difficult. This problem has been broadly characterized as "change implementation failure" in health care organizations. Several studies have used retrospective designs to examine the problem; however, there are few prospective studies examining communication dynamics underlying successful implementation of change (eg, evidence-based practices). This prospective study will be set in 2 intensive care units at an academic medical center. At baseline, both units have low compliance with CLB and higher-than-expected CRBSIs. Periodic quality improvement (QI) interventions will be conducted over a 52-week period to promote implementation of CLB in both units. Simultaneously, the following parameters will be examined: (1) Structure and content of communication related to CLB in both units through "communication logs" completed weekly by nurses, physicians, and managers; and (2) outcomes, that is, CLB adherence in both units through weekly chart review. Catheter utilization and CRBSI (infection) rates will serve as additional unit-level outcome measures. The aim is 2-fold: (1) to examine associations between QI interventions and structure and content of communication at the unit level; and (2) to examine associations between structure and content of communication and outcomes at the unit level. The periodic QI interventions are expected to increase CLB adherence and reduce CRBSIs through their influence on structure and content of communication. The prospective design would help examine dynamics in unit-level communication structure and content related to CLB, as well as unit-level outcomes. The study has potential to make significant contributions to theory and practice, particularly if interventions are found to be effective in enabling successful practice change at the unit level. To this effect, the study has potential to provide insights into communication structure and content associated with collective learning and culture change at the unit level. Results and insights are expected to lay a foundation for generating context-sensitive "evidence-based management" strategies for successful practice change at the unit level. An ultimate expected deliverable is the development of an "action-learning framework" for successful implementation of evidence-based practices in health care organizations.

Positive Deviance: A New Tool for Infection Prevention and Patient Safety

Positive deviance (PD) may have an important role in infection prevention and patient safety in the hospital. There are many descriptions of successful stories of PD in different sectors from public health to education to business. PD has been applied in the healthcare setting to improve hand hygiene compliance, reduce methicillin-resistant Staphylococcus aureus, and reduce bloodstream infections in an outpatient hemodialysis center. PD promotes dialogue among leaders, managers and healthcare workers, which is a key factor in establishing a safety culture. It also enables cultural changes aimed at empowering frontline workers (the positive deviants) to innovate and improve compliance with infection prevention measures. The structure and the process of PD, and its ability to offer a space for experience discussions, changing ideas and making plans that emerge from team participation will also be discussed.

Addressing the need for an infection prevention and control framework that incorporates the role of surveillance: a discussion paper

AIM

To present a discussion on theoretical frameworks in infection prevention and control.

BACKGROUND

Infection prevention and control programmes have been in place for several years in response to the incidence of healthcare-associated infections and their associated morbidity and mortality. Theoretical frameworks play an important role in formalizing the understanding of infection prevention activities.

DESIGN

Discussion paper.

DATA SOURCES

A literature search using electronic databases was conducted for published articles in English addressing theoretical frameworks in infection prevention and control between 1980-2012.

RESULTS

Nineteen papers that included a reference to frameworks were identified in the review. A narrative analysis of these papers was completed. Two models were identified and neither included the role of surveillance.

DISCUSSION

To reduce the risk of acquiring a healthcare-associated infection, a multifaceted approach to infection prevention is required. One key component in this approach is surveillance. The review identified two infection prevention and control frameworks, yet these are rarely applied in infection prevention and control programmes. Only one framework considered the multifaceted approach required for infection prevention. It did not, however, incorporate the role of surveillance. We present a framework that incorporates the role of surveillance into a biopsychosocial approach to infection prevention and control.

CONCLUSION

Infection prevention and control programmes and associated research are led primarily by nurses. There is a need for an explicit infection prevention and control framework incorporating the important role that surveillance has in infection prevention activities. This study presents one framework for further critique and discussion.

Bridges, brokers and boundary spanners in collaborative networks: a systematic review

BACKGROUND

Bridges, brokers and boundary spanners facilitate transactions and the flow of information between people or groups who either have no physical or cognitive access to one another, or alternatively, who have no basis on which to trust each other. The health care sector is a context that is rich in isolated clusters, such as silos and professional "tribes," in need of connectivity. It is a key challenge in health service management to understand, analyse and exploit the role of key agents who have the capacity to connect disparate groupings in larger systems.

METHODS

The empirical, peer reviewed, network theory literature on brokerage roles was reviewed for the years 1994 to 2011 following PRISMA guidelines.

RESULTS

The 24 articles that made up the final literature set were from a wide range of settings and contexts not just healthcare. Methods of data collection, analysis, and the ways in which brokers were identified varied greatly. We found four main themes addressed in the literature: identifying brokers and brokerage opportunities, generation and integration of innovation, knowledge brokerage, and trust. The benefits as well as the costs of brokerage roles were examined.

CONCLUSIONS

Collaborative networks by definition, seek to bring disparate groups together so that they can work effectively and synergistically together. Brokers can support the controlled transfer of specialised knowledge between groups, increase cooperation by liaising with people from both sides of the gap, and improve efficiency by introducing "good ideas" from one isolated setting into another.There are significant costs to brokerage. Densely linked networks are more efficient at diffusing information to all their members when compared to sparsely linked groups. This means that while a bridge across a structural hole allows information to reach actors that were previously isolated, it is not the most efficient way to transfer information. Brokers who become the holders of, or the gatekeepers to, specialised knowledge or resources can become overwhelmed by the role and so need support in order to function optimally.

Communication strategies in acute health care: evaluation within the context of infection prevention and control

BACKGROUND

Communication in healthcare settings has recently received significant attention in the literature. However, there continues to be a large gap in current understanding of the effectiveness of different communication channels used in acute healthcare settings, particularly in the context of infection prevention and control (IPC).

AIM

To explore and evaluate the main communication channels used within hospitals to communicate with healthcare workers (HCWs) and to propose practical recommendations.

METHODS

Critical review of the main communication channels used within acute health care to communicate information to HCWs, and analysis of their impact on practice.

FINDINGS

The analysis covers verbal communications, standardization via guidelines, education and training, electronic communications and marketing strategies. Traditional communication channels have not been successful in changing and sustaining best practice in IPC, but newer approaches (electronic messages and marketing) also have pitfalls.

CONCLUSION

A few simple recommendations are made in relation to the development, implementation and evaluation of communications to HCWs; top-down vs bottom-up communications; and the involvement of HCWs, particularly ward personnel.

Evaluation of the knowledge-sharing social network of hospital-based infection preventionists in Kentucky

BACKGROUND

The role of the infection preventionist (IP) has become increasingly complex, underscoring the need for rapid mechanisms of knowledge acquisition. One mechanism for knowledge acquisition is knowledge-sharing through social networks. In a state such as Kentucky with predominantly rural health care facilities, an optimal knowledge-sharing network is critical; however, descriptions of these networks are absent from the literature. The objective of this study was to evaluate the knowledge-sharing networks of hospital-based IPs in Kentucky.

METHODS

A survey was sent to all hospital-based IPs in Kentucky in November 2010. Density and component analyses were used to evaluate network cohesion, and centrality statistics and key player algorithms were used to identify IPs important to the network.

RESULTS

A total of 75 (58%) IPs completed the survey. The network density was 1.8%. Three components were identified. The median (range) centrality measures were as follows: in-degree, 2 (0-11); out-degree, 0.5 (0-5); betweenness, 0 (0-567); and eigenvector 0.02 (0-0.45). Three key players were identified.

CONCLUSIONS

Low network statistics indicate that the knowledge-sharing network of hospital-based IPs might not be adequate for efficient knowledge-sharing. Interventions to increase the density of the network and reduce the number of components are needed.

Use of Lean response to improve pandemic influenza surge in public health laboratories

These tools enabled laboratory response to the 10-fold increase in testing demands.

A novel influenza A (H1N1) virus detected in April 2009 rapidly spread around the world. North American provincial and state laboratories have well-defined roles and responsibilities, including providing accurate, timely test results for patients and information for regional public health and other decision makers. We used the multidisciplinary response and rapid implementation of process changes based on Lean methods at the provincial public health laboratory in British Columbia, Canada, to improve laboratory surge capacity in the 2009 influenza pandemic. Observed and computer simulating evaluation results from rapid processes changes showed that use of Lean tools successfully expanded surge capacity, which enabled response to the 10-fold increase in testing demands.

The contribution of work environment to nurses' assessments of the quality of patient care

The quality of patient care was found to be significantly correlated with work environment measures in a quasi-experimental study in the Saskatoon Health Region. Since first line supervisors face multiple pressures in organizing the work of their units, they need to be supported by senior leadership for continuity in instilling a common purpose and shared values to the patient care staff. The role of supervision and leadership is crucial in strategically managing the human, financial and technical resources in our healthcare system, especially when such resources are likely to remain limited.

The challenge of methicillin-resistant Staphylococcus aureus prevention in hemodialysis therapy

Methicillin-resistant Staphylococcus aureus (MRSA) infections have challenged care process and resource utilization in the acute hospital care setting for nearly 30 years. These infections have become important causes of morbidity, mortality, and a source of concern in the primary and emergency care context over the past decade. As individuals receiving recurrent therapy with features of both ambulatory care and acute care, hemodialysis patients are exposed to numerous opportunities for MRSA acquisition. Surprisingly, high prevalence rates for MRSA colonization have been demonstrated for both hemodialysis patients and their care providers. The necessity of vascular access and the persistent high prevalence of endovascular catheter use among patients repeatedly exposed to healthcare settings provide the perfect milieu for the troubling rates of MRSA infection, particularly bloodstream infections, in outpatient dialysis care. Dialysis industry shifts, including increased requirements for compliance and reporting in other areas of dialysis care, tax resources for infection prevention processes. Multifaceted strategies that include reassessment of vascular access care, attention to the interruption of MRSA transmission dynamics, and emphasis on organizational learning processes are needed to accomplish a meaningful reduction in the morbidity, mortality, and cost associated with MRSA infections in dialysis care.

Lean manufacturing and Toyota Production System terminology applied to the procurement of vascular stents in interventional radiology

Objectives

To apply the economic terminology of lean manufacturing and the Toyota Production System to the procurement of vascular stents in interventional radiology.

Methods

The economic- and process-driven terminology of lean manufacturing and the Toyota Production System is first presented, including information and product flow as well as value stream mapping (VSM), and then applied to an interdisciplinary setting of physicians, nurses and technicians from different medical departments to identify wastes in the process of endovascular stent procurement in interventional radiology.

Results

Using the so-called seven wastes approach of the Toyota Production System (waste of overproducing, waiting, transport, processing, inventory, motion and waste of defects and spoilage) as well as further waste characteristics (gross waste, process and method waste, and micro waste), wastes in the process of endovascular stent procurement in interventional radiology were identified and eliminated to create an overall smoother process from the procurement as well as from the medical perspective.

Conclusion

Economic terminology of lean manufacturing and the Toyota Production System, especially VSM, can be used to visualise and better understand processes in the procurement of vascular stents in interventional radiology from an economic point of view.

If we only knew what we know: principles for knowledge sharing across people, practices, and platforms

The improvement of health outcomes for both individual patients and entire populations requires improvement in the array of structures that support decisions and activities by healthcare practitioners. Yet, many gaps remain in how even sophisticated healthcare organizations manage knowledge. Here we describe the value of a trans-institutional network for identifying and capturing how-to knowledge that contributes to improved outcomes. Organizing and sharing on-the-job experience would concentrate and organize the activities of individual practitioners and subject their rapid cycle improvement testing and refinement to a form of collective intelligence for subsequent diffusion back through the network. We use the existing Cancer Research Network as an example of how a loosely structured consortium of healthcare delivery organizations could create and grow an implementation registry to foster innovation and implementation success by communicating what works, how, and which practitioners are using each innovation. We focus on the principles and parameters that could be used as a basis for infrastructure design. As experiential knowledge from across institutions builds within such a system, the system could ultimately motivate rapid learning and adoption of best practices. Implications for research about healthcare IT, invention, and organizational learning are discussed.

A baseline study of communication networks related to evidence-based infection prevention practices in an intensive care unit

This study seeks to gain a baseline understanding of the communication network structure, content of communication, and outcomes in a medical intensive care unit experiencing higher-than-expected central line blood stream infection (CLBSI) rates. The communication network structure refers to the direction and frequency of communication on evidence-based CLBSI prevention practices across various professional subgroups and hierarchical levels in the unit, including medical faculty, nurses, residents, students, unit managers, and hospital administrators. The content of communication refers to the type of knowledge (ie, tacit vs explicit knowledge) exchanged on CLBSI prevention practices. Outcomes include (1) compliance with CLBSI prevention practices and (2) hospital-acquired CLBSI rates in the unit. Data on communication network structure and content of communication are collected using communication logs completed weekly for 4 weeks, by individual participants in each professional subgroup and hierarchical level. Outcomes are collected weekly through chart (medical record) review. Study results indicate a sparse communication network structure with minimal interaction across professional subgroups and hierarchical levels. They also indicate that primarily explicit knowledge on general infection topics is being exchanged as against tacit knowledge on specific infection prevention practices. Unit outcomes are poor, with the central line bundle score at zero during all 4 weeks. The study represents an original attempt at developing methods for measuring the communication network structure related to evidence-based infection prevention practices at the unit level. It lays a foundation for testing hypotheses related to effective communication network structures for hospital infection prevention in a larger study. More significantly, the study lays a foundation for generating concrete and context-sensitive strategies for organizational learning and improvement in the context of evidence-based practices. Such insight is critical from the perspective of evidence-based health care management.