Quality improvement implementation and hospital performance on patient safety indicators

Hospital Cultural Competency and Attributes of Patient Safety Culture: A Study of U.S. Hospitals

OBJECTIVE

Given the increasing racial and ethnic diversity in the United States, hospitals face challenges in providing safe and high-quality care to minority patients. Cultural competency fostered through engagement in diversity programs can be used as a resourceful strategy to provide safe care and improve the patient safety culture. This article examined the association of cultural competency and employee's perceived attributes of safety culture.

METHODS

A longitudinal study design was used with 283 unique hospital observations from 2014 to 2016. The dependent variables were percent composite scores for 4 attributes of perceived safety culture: (1) management support for patient safety, (2) teamwork across units, (3) communication openness, and (4) nonpunitive response to an error. The independent variable was an engagement in diversity programs, considered in 3 categories: (1) high, (2) medium, and (3) low. Controls included hospital characteristics, market characteristics, and percent. Ordinal logistic regression was used for imputation, whereas multiple linear regression was used for analyses.

RESULTS

Results indicate that hospitals with high engagement have 4.64% higher perceptions of management support for safety, 3.17% higher perceptions of teamwork across units, and 3.97% higher perceptions of nonpunitive response, as compared with hospitals that have a low engagement in diversity programs (P < 0.05).

CONCLUSIONS

Culturally competent hospitals have better safety culture than their counterparts. Cultural competency is an important resource to build a safety culture so that safe care for patients from minority and diverse backgrounds can be delivered.

Better hospital context increases success of care pathway implementation on achieving greater teamwork: a multicenter study on STEMI care

OBJECTIVE

To evaluate whether hospital context influences the effect of care pathway implementation on teamwork processes and output in STEMI care.

DESIGN

A multicenter pre-post intervention study.

SETTING

Eleven acute hospitals.

PARTICIPANTS

Cardiologists-in-chief, nurse managers, quality staff, quality managers and program managers reported on hospital context. Teamwork was rated by professional groups (medical doctors, nurses, allied health professionals, other) in the following departments: emergency room, catheterization lab, coronary care unit, cardiology ward and rehabilitation.

INTERVENTION

Care pathway covering in-hospital care from emergency services to rehabilitation.

MAIN OUTCOME MEASURES

Hospital context was measured by the five dimensions of the Model for Understanding Success in Quality: microsystem, quality improvement team, quality improvement support, high-level organization, external environment. Teamwork process measures reflected teamwork between professional groups within departments and teamwork between departments. Teamwork output was measured through the level of organized care. Two-level regression analysis accounted for clustering of respondents within hospitals and assessed the influence of hospital context on the impact of care pathway implementation on teamwork.

RESULTS

Care pathway implementation significantly improved teamwork processes both between professional groups (P < 0.001) and between departments (P < 0.001). Teamwork output also improved (P < 0.001). The effect of care pathway implementation on teamwork was more pronounced when the quality improvement team and quality improvement support and capacity were more positively reported on.

CONCLUSIONS

Hospitals can leverage the effect of quality improvement interventions such as care pathways by evaluating and improving aspects of hospital context.

Lean management and operational performance in health care

Purpose

The purpose of this paper is to examine the impact of lean management (LM) on operational performance (OP) in the context of health care in Jordanian private hospitals. LM is measured using four bundles: total quality management (TQM), human resource management (HRM), just-in-time system (JIT) and total productive maintenance (TPM). The study also investigates the effects of OP dimensions on hospitals’ business performance (BP).

Design/methodology/approach

The study is based on survey data collected from 260 respondents from 25 private hospitals in Jordan. Validity and reliability analyses were performed using SPSS and Amos, and the study hypotheses were tested using structural equation modeling.

Findings

The study found that the TQM bundle affects quality performance positively, but does not affect efficiency and accessibility performances, while the HRM bundle positively affects all OP dimensions. Furthermore, the JIT bundle positively contributes to both efficiency and accessibility performances, while the TPM bundle positively influences quality and accessibility performances. Moreover, the results have demonstrated that OP dimensions of quality and accessibility significantly and positively affect hospitals’ BP.

Originality/value

This study is one of the first to adapt the four lean bundles popularized in the manufacturing sector and apply them in a health-care context. It examines the effects of the four lean bundles on hospitals’ OP in terms of efficiency, quality and accessibility. In addition, the study demonstrates the role of OP dimensions in improving private hospitals’ BP.

Impact of Patient Safety Indicators on readmission after abdominal aortic surgery

Patient safety is a critical component of health-care quality and measures created by the Agency for Healthcare Research and Quality (AHRQ) to identify hospitalizations with potentially preventable adverse events. This analysis evaluated whether Patient Safety Indicator (PSI) events after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) were associated with increased risk of readmission. Patients undergoing elective repair of nonruptured AAA from 2009 to 2012 were selected in the Medicare Provider Analysis and Review files using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. To identify PSI events, we used the AHRQ PSI International Classification of Diseases, Ninth Revision, Clinical Modification numerator codes. Chi-square test, multivariable logistic regression analysis, nonparametric Wilcoxon rank sum test, and Kaplan-Meier survival analysis were used for statistics. A total of 66,923 patients undergoing elective AAA repair were evaluated: (1) 9,315 with OSR and (2) 57,608 with EVAR. The most frequent PSI events after OSR versus EVAR were postoperative respiratory failure (PSI, 11; 17.7% vs 1.8%; P < .0001); perioperative hemorrhage/hematoma (PSI, 9; 3.6% vs 2.6%; P < .0001); postoperative sepsis (PSI, 13; 3.5% vs 0.4%; P < .0001); accidental puncture or laceration (PSI, 15; 2.1% vs 0.6%; P < .0001); and postoperative acute kidney injury requiring dialysis (PSI, 10; 1.4% vs 0.2%; P < .0001). The overall 30-day readmission rate was 10.5%. The occurrence of any PSI event overall significantly increased 30-day readmission compared with no event cases (odds ratio [OR] = 1.71; 95% confidence interval [CI], 1.57-1.86). Likelihood of 30-day readmission was greater for postoperative acute kidney injury requiring dialysis (OR = 1.66; 95% CI, 1.28-2.15), postoperative respiratory failure (OR = 1.36; 95% CI, 1.22-1.52), perioperative hemorrhage (OR = 1.34; 95% CI, 1.18-1.52), and postoperative pressure ulcer (OR = 2.88; 95% CI, 1.99-4.17). Occurrence of any PSI event was associated with an increased total hospital and intensive care unit length of stay and total hospital charges (all P < .001). In conclusion, AHRQ PSI events may be used to identify patients at the greatest risk for readmission after AAA repair. The risk for 30-day readmission was 71% higher when a PSI event occurred and was not associated with the type of repair. Minimizing preventable PSI events may be beneficial to reducing hospital readmissions after open and endovascular AAA repair and to improving hospital resource utilization.

The role of the built environment and private rooms for reducing central line-associated bloodstream infections

Private hospital rooms are believed to offer some protective effect against hospital-acquired infections, including central line-associated bloodstream infections. Yet a recent meta-analysis found the evidence-base to be lacking from a policy perspective. We sought to determine whether private rooms were associated with a lower risk of central-line infections. We examined the discharge records of more than one million inpatients from 335 Texas hospitals to determine patients that stayed in private rooms. Patients who stayed in bay rooms had 64 percent more central line infections than patients who stayed in private rooms. Even after adjusting for relevant covariates, patients assigned to bay rooms had a 21 percent greater relative risk of a central line infection (p = 0.005), compared with patients assigned to private rooms. At the hospital level, a 10% increase in private rooms was associated with an 8.6% decrease in central line infections (p<0.001), regardless of individual patients' room assignment. This study demonstrates and validates the use of private rooms as a structural measure and independent predictor of hospital quality.

Adoption of high technology medical imaging and hospital quality and efficiency: Towards a conceptual framework

Measuring the value of medical imaging is challenging, in part, due to the lack of conceptual frameworks underlying potential mechanisms where value may be assessed. To address this gap, this article proposes a framework that builds on the large body of literature on quality of hospital care and the classic structure-process-outcome paradigm. The framework was also informed by the literature on adoption of technological innovations and introduces 2 distinct though related aspects of imaging technology not previously addressed specifically in the literature on quality of hospital care: adoption (a structural hospital characteristic) and use (an attribute of the process of care). The framework hypothesizes a 2-part causality where adoption is proposed to be a central, linking factor between hospital structural characteristics, market factors, and hospital outcomes (ie, quality and efficiency). The first part indicates that hospital structural characteristics and market factors influence or facilitate the adoption of high technology medical imaging within an institution. The presence of this technology, in turn, is hypothesized to improve the ability of the hospital to deliver high quality and efficient care. The second part describes this ability throughout 3 main mechanisms pointing to the importance of imaging use on patients, to the presence of staff and qualified care providers, and to some elements of organizational capacity capturing an enhanced clinical environment. The framework has the potential to assist empirical investigations of the value of adoption and use of medical imaging, and to advance understanding of the mechanisms that produce quality and efficiency in hospitals.

Management Control Systems and Clinical Experience of Managers in Public Hospitals

Healthcare authorities are encouraging managers in hospitals to acquire clinical experience and knowledge in order to better carry out and coordinate healthcare service delivery. The main objective of this paper is to analyse how the clinical experience of hospital managers is related to public health institutions’ performance. It is proposed that the effect of the clinical experience on operative and financial organizational performance is indirect through the mediating variables of perceived utility of management information and horizontal management control system. This paper analyses how these variables impact hospital performance through the data from a survey sent to 364 hospital managers in Brazil. The results show that managers’ clinical experience is related to higher perceived utility of historical, financial, short-term, and internal information, but not with horizontal control adoption in hospitals. Furthermore, our results show that, in hospitals, perceived utility of forecasted, non-financial, long-term, and external managerial information positively affects hospitals’ financial performance, while adoption of horizontal control management positively affects operational performance. Through showing evidence that clinical background could explain the differences not only in hospital service management but also in information capabilities and management control processes, this study offer meaningful implications for healthcare authorities and hospital managers involved in the development and implementation of strategies in the health sector.

Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California

OBJECTIVE

To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices.

METHODS

Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests.

RESULTS

Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04).

CONCLUSION

Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.

Does lean cure variability in health care?

Purpose

The purpose of this paper is to investigate the roles that employee-initiated Lean improvement projects play in health care. Lean ideas are introduced to improve flow in health care. Although variability is detrimental to flow performance, it is unclear whether Lean initiatives set out to reduce this variability and the associated buffers.

Design/methodology/approach

Longitudinal field research is combined with an exploratory field-quasi-experiment. First, a large set of Lean interventions were explored and their focus classified. Semi-structured interviews with practitioners supported the initial findings regarding the focus. Second, this study investigated whether a knowledge deficiency could explain the identified focus through a quasi-experiment in which the authors’ stimulated knowledge on the roles of variability and buffers and then classified subsequent interventions.

Findings

The results reflected a narrow application of Lean, with most interventions directed at reducing direct waste. A quasi-experiment demonstrated that a small investment in knowledge enables the focus to shift toward buffers and variability issues – i.e. toward a more complete Lean approach.

Research limitations/implications

This research supports the commonly held view that there is a tendency to focus on waste. Furthermore, a lengthy experience of Lean does not guarantee interventions will focus on buffers and variability, issues with arguably a higher complexity compared to obvious waste. However, small investments in knowledge can broaden the focus of practitioners’ interventions.

Originality/value

This study is one of the first to research the focus of Lean interventions through a data set spanning several years. The results are based on a unique data set covering a large number of documented Lean interventions.

Quality improvement in hospitals: barriers and facilitators

Purpose

The purpose of this paper is to examine quality improvement (QI) initiatives in acute care hospitals, the factors associated with success, and the impacts on patient care and safety.

Design/methodology/approach

An extensive online survey was completed by senior managers responsible for QI. The survey assessed QI project types, QI methods, staff engagement, and barriers and factors in the success of QI initiatives.

Findings

The response rate was 37 percent, 46 surveys were completed from 125 acute care hospitals. QI initiatives had positive impacts on patient safety and care. Staff in all hospitals reported conducting past or present hand-hygiene QI projects and C. difficile and surgical site infection were the next most frequent foci. Hospital staff not having time and problems with staff prioritizing QI with other duties were identified as important QI barriers. All respondents reported hospital leadership support, data utilization and internal champions as important QI facilitators. Multiple regression models identified nurses’ active involvement and medical staff engagement in QI with improved patient care and physicians’ active involvement and medical staff engagement with greater patient safety.

Practical implications

There is the need to study how best to support and encourage physicians and nurses to become more engaged in QI.

Originality/value

QI initiatives were shown to have positive impacts on patient safety and patient care and barriers and facilitating factors were identified. The results indicated patient care and safety would benefit from increased physician and nurse engagement in QI initiatives.

Lean Thinking in Global Health Care

This chapter explains the overview of Lean production; the overview of value stream mapping (VSM); the applications of Lean production in global health care; the implementation of Lean production in global health care; and the challenges and implications of Lean production in global health care. Lean production can be used to identify and eliminate the wastes in any health care activity performed within a health care facility. Lean production can be applied to hospitals and health care organizations to redesign health care processes toward improving the quality of care and reducing costs and wastes. Successful Lean health care efforts result in the measurable improvements in patient outcomes, such as improved quality, less harm due to preventable errors, better access, shorter waiting times, and better service. Implementing Lean production has the potential to enhance health care performance and gain sustainable competitive advantage in global health care.

Do daily ward interviews improve measurement of hospital quality and safety indicators? A prospective observational study

RATIONALE, AIMS AND OBJECTIVES

The aim of this study was to determine if the addition of daily ward interview data improves the capture of hospital quality and safety indicators compared with incident reporting systems alone. An additional aim was to determine the potential characteristics influencing under-reporting of hospital quality and safety indicators in incident reporting systems.

METHODS

A prospective, observational study was performed at two tertiary metropolitan public hospitals. Research assistants from allied health backgrounds met daily with the nurse in charge of the ward and discussed the occurrence of any falls, pressure injuries and rapid response medical team calls. Data were collected from four general medical wards, four surgical wards, an orthopaedic, neurosciences, plastics, respiratory, renal, sub-acute and acute medical assessment unit.

RESULTS

An estimated total of 303 falls, 221 pressure injuries and 884 rapid response medical team calls occurred between 15 wards across two hospitals, over a period of 6 months. Hospital incident reporting systems underestimated falls by 30.0%, pressure injuries by 59.3% and rapid response medical team calls by 17.0%. The use of ward interview data collection in addition to hospital incident reporting systems improved data capture of falls by 23.8% (n = 72), pressure injuries by 21.7% (n = 48) and rapid response medical team calls by 12.7% (n = 112). Falls events were significantly less likely to be reported if they occurred on a Monday (P = 0.04) and pressure injuries significantly more likely to be reported if they occurred on a Wednesday (P = 0.01).

CONCLUSIONS

Hospital quality and safety indicators (falls, pressure injuries and rapid response medical team calls) were under-reported in incident reporting systems, with variability in under-reporting between wards and the day of event occurrence. The use of ward interview data collection in addition to hospital incident reporting systems improved reporting of hospital quality and safety indicators.

Organizational coherence in health care organizations: conceptual guidance to facilitate quality improvement and organizational change

OBJECTIVE

We sought to improve our understanding of how health care quality improvement (QI) methods and innovations could be efficiently and effectively translated between settings to reduce persistent gaps in health care quality both within and across countries. We aimed to examine whether we could identify a core set of organizational cultural attributes, independent of context and setting, which might be associated with success in implementing and sustaining QI systems in health care organizations.

METHODS

We convened an international group of investigators to explore the issues of organizational culture and QI in different health care contexts and settings. This group met in person 3 times and held a series of conference calls to discuss emerging ideas over 2 years. Investigators also conducted pilot studies in their home countries to examine the applicability of our conceptual model.

RESULTS AND CONCLUSIONS

We suggest that organizational coherence may be a critical element of QI efforts in health care organizations and propose that there are 3 key components of organizational coherence: (1) people, (2) processes, and (3) perspectives. Our work suggests that the concept of organizational coherence embraces both culture and context and can thus help guide both researchers and practitioners in efforts to enhance health care QI efforts, regardless of organizational type, location, or context.

Deliberation Makes a Difference: Preparation Strategies for TeamSTEPPS Implementation in Small and Rural Hospitals

Small and rural hospitals face special challenges to implement and sustain organization-wide quality improvement (QI) initiatives due to limited resources and infrastructures. We studied the implementation of TeamSTEPPS, a national QI initiative, in 14 critical access hospitals. Drawing on QI and organization development theories, we propose five strategic preparation steps for TeamSTEPPS: assess needs, reflect on the context, set goals, develop a shared understanding, and select change agents. We explore how hospitals' practices correspond to suggested best practices by analyzing qualitative data collected through quarterly interviews with key informants. We find that the level of deliberation was a key factor that differentiated hospitals' practices. Hospitals that were more deliberate in preparing for the five strategic steps were more likely to experience engagement, perceive efficacy, foresee and manage barriers, and achieve progress during implementation. We discuss potential steps that hospitals may take to better prepare for TeamSTEPPS implementation.

Implementation of Departmental Quality Strategies Is Positively Associated with Clinical Practice: Results of a Multicenter Study in 73 Hospitals in 7 European Countries

BACKGROUND

Given the amount of time and resources invested in implementing quality programs in hospitals, few studies have investigated their clinical impact and what strategies could be recommended to enhance its effectiveness.

OBJECTIVE

To assess variations in clinical practice and explore associations with hospital- and department-level quality management systems.

DESIGN

Multicenter, multilevel cross-sectional study.

SETTING AND PARTICIPANTS

Seventy-three acute care hospitals with 276 departments managing acute myocardial infarction, deliveries, hip fracture, and stroke in seven countries.

INTERVENTION

None.

MEASURES

Predictor variables included 3 hospital- and 4 department-level quality measures. Six measures were collected through direct observation by an external surveyor and one was assessed through a questionnaire completed by hospital quality managers. Dependent variables included 24 clinical practice indicators based on case note reviews covering the 4 conditions (acute myocardial infarction, deliveries, hip fracture and stroke). A directed acyclic graph was used to encode relationships between predictors, outcomes, and covariates and to guide the choice of covariates to control for confounding.

RESULTS AND LIMITATIONS

Data were provided on 9021 clinical records by 276 departments in 73 hospitals. There were substantial variations in compliance with the 24 clinical practice indicators. Weak associations were observed between hospital quality systems and 4 of the 24 indicators, but on analyzing department-level quality systems, strong associations were observed for 8 of the 11 indicators for acute myocardial infarction and stroke. Clinical indicators supported by higher levels of evidence were more frequently associated with quality systems and activities.

CONCLUSIONS

There are significant gaps between recommended standards of care and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, which appear to be more effective than generic hospital-wide quality systems.

Do relationships exist between the scope and intensity of quality improvement activities and hospital operation performance? A 10-year observation in Taiwan

BACKGROUND

The relationship between the scope and intensity of quality improvement (QI) activities and hospital performance remains unclear. This study investigated the relationship between performance, external environment, and the scope and intensity of QI activities in hospitals.

METHODS

The study used a longitudinal observation. Data regarding the scope and intensity of QI activities were collected using a questionnaire survey among the administrative deputy superintendents / directors of quality management center in 139 hospitals. Hospital performance indicators were abstracted from the 2000-2009 national hospitals profiles. We adopted year 2000 as the baseline, and divided the study period into three 3-year periods. The Generalized Estimating Equations (GEE) model was used for the statistical analysis.

RESULTS

Seventy-two hospitals responded to the survey, giving a response rate of 52%. The results showed a significant increase in the scope and intensity of QI activities between 2000 and 2009. The results also showed that the scope and intensity of a hospital's QI activities were associated with the scope and intensity of its competitors' QI activities in the previous period and its own prior performance. The scope of QI activities in the previous period was not significantly related to the selected hospital performance measures. However, the intensity of QI activities in the previous period showed a significant and positive relationship with the number of inpatients and the turnover of beds.

CONCLUSION

The study demonstrates that the intensity of QI activities is associated with the external environment and the hospital's own performance in the previous period. Furthermore, some performance measures are associated with the intensity of the QI activities in the previous period.

Patient Experience Shows Little Relationship with Hospital Quality Management Strategies

OBJECTIVES

Patient-reported experience measures are increasingly being used to routinely monitor the quality of care. With the increasing attention on such measures, hospital managers seek ways to systematically improve patient experience across hospital departments, in particular where outcomes are used for public reporting or reimbursement. However, it is currently unclear whether hospitals with more mature quality management systems or stronger focus on patient involvement and patient-centered care strategies perform better on patient-reported experience. We assessed the effect of such strategies on a range of patient-reported experience measures.

MATERIALS AND METHODS

We employed a cross-sectional, multi-level study design randomly recruiting hospitals from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. Each hospital contributed patient level data for four conditions/pathways: acute myocardial infarction, stroke, hip fracture and deliveries. The outcome variables in this study were a set of patient-reported experience measures including a generic 6-item measure of patient experience (NORPEQ), a 3-item measure of patient-perceived discharge preparation (Health Care Transition Measure) and two single item measures of perceived involvement in care and hospital recommendation. Predictor variables included three hospital management strategies: maturity of the hospital quality management system, patient involvement in quality management functions and patient-centered care strategies. We used directed acyclic graphs to detail and guide the modeling of the complex relationships between predictor variables and outcome variables, and fitted multivariable linear mixed models with random intercept by hospital, and adjusted for fixed effects at the country level, hospital level and patient level.

RESULTS

Overall, 74 hospitals and 276 hospital departments contributed data on 6,536 patients to this study (acute myocardial infarction n = 1,379, hip fracture n = 1,503, deliveries n = 2,088, stroke n = 1,566). Patients admitted for hip fracture and stroke had the lowest scores across the four patient-reported experience measures throughout. Patients admitted after acute myocardial infarction reported highest scores on patient experience and hospital recommendation; women after delivery reported highest scores for patient involvement and health care transition. We found no substantial associations between hospital-wide quality management strategies, patient involvement in quality management, or patient-centered care strategies with any of the patient-reported experience measures.

CONCLUSION

This is the largest study so far to assess the complex relationship between quality management strategies and patient experience with care. Our findings suggest absence of and wide variations in the institutionalization of strategies to engage patients in quality management, or implement strategies to improve patient-centeredness of care. Seemingly counterintuitive inverse associations could be capturing a scenario where hospitals with poorer quality management were beginning to improve their patient experience. The former suggests that patient-centered care is not yet sufficiently integrated in quality management, while the latter warrants a nuanced assessment of the motivation and impact of involving patients in the design and assessment of services.

The physician mentored implementation model: a promising quality improvement framework for health care change

Quality improvement (QI) efforts hold great promise for improving care delivery. However, hospitals often struggle with QI implementation and fail to sustain improvement in either process changes or patient outcomes. Physician mentored implementation (PMI) is a novel approach that promotes the success and sustainability of QI initiatives at hospitals. It leverages the expertise of external physician mentors who coach QI teams to implement interventions at their local hospitals. The PMI model includes five core components: (1) a hospital self-assessment tool, (2) a face-to-face training session including direct interaction with a physician mentor, (3) a guided continuous quality improvement and systems approach, (4) yearlong individual physician mentoring, and (5) a learning community supported by a resource center, listserv, and webinars. Mentors provide content and process expertise, rather than offering "one-size-fits-all" technical assistance that might not be sustained after the mentoring year ends. Mentors support and motivate QI teams throughout the planning and implementation phases of their interventions, help to engage hospital leadership, garner local physician buy-in, and address institutional barriers. Mentors also guide hospitals to identify opportunities for the adaptation and customization of original evidence-based models of care while ensuring the fidelity of those models. More than 350 hospitals have used the PMI model to implement successful national and statewide QI initiatives. Academic medical centers are charged with improving the health of patients and reengineering care delivery; thus, they serve as the ideal source for physician mentors and can act as leaders in implementing QI projects using the PMI model.

Illusion or delusion--Lean management in the health sector

PURPOSE

There has been considerable interest in the implementation of practices imported from manufacturing into healthcare as a solution to rising healthcare spending and disappointing patient safety indicators. One approach that has attracted particular interest is Lean management and the purpose of this paper is to engage with this topic.

DESIGN/METHODOLOGY/APPROACH

Secondary research.

FINDINGS

Despite widespread enthusiasm about the potential of Lean management processes, evidence about its contribution to higher organisational performance remains inconsistent.

RESEARCH LIMITATIONS/IMPLICATIONS

This paper engages with the major Lean concepts of operations management and human resource management, including just-in-time, total quality management, total productive maintenance and does not engage in-depth with concepts related to employee empowerment, and training

PRACTICAL IMPLICATIONS

This paper contributes to the organisational management literature in healthcare by showing that although Lean management seems to have the potential to improve organisational performance it is far from a panacea against under performing hospitals.

SOCIAL IMPLICATIONS

It informs policy making by suggesting that a progressive managerial philosophy has a stronger impact on healthcare performance than the adoption of practices from any particular managerial approach.

ORIGINALITY/VALUE

This paper provides a critical evaluation of the impact of Lean practices in informing healthcare policy. The paper contributes to the organisational management literature in healthcare by showing that even though Lean management in healthcare appears to have the potential to improve organisational performance; there remain problems with its application.

Organizational coherence in health care organizations: conceptual guidance to facilitate quality improvement and organizational change

OBJECTIVE

We sought to improve our understanding of how health care quality improvement (QI) methods and innovations could be efficiently and effectively translated between settings to reduce persistent gaps in health care quality both within and across countries. We aimed to examine whether we could identify a core set of organizational cultural attributes, independent of context and setting, which might be associated with success in implementing and sustaining QI systems in health care organizations.

METHODS

We convened an international group of investigators to explore the issues of organizational culture and QI in different health care contexts and settings. This group met in person 3 times and held a series of conference calls to discuss emerging ideas over 2 years. Investigators also conducted pilot studies in their home countries to examine the applicability of our conceptual model.

RESULTS AND CONCLUSIONS

We suggest that organizational coherence may be a critical element of QI efforts in health care organizations and propose that there are 3 key components of organizational coherence: (1) people, (2) processes, and (3) perspectives. Our work suggests that the concept of organizational coherence embraces both culture and context and can thus help guide both researchers and practitioners in efforts to enhance health care QI efforts, regardless of organizational type, location, or context.

Detecting adverse events in surgery: comparing events detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators

BACKGROUND

The Patient Safety Indicators (PSIs) use administrative data to screen for select adverse events (AEs). In this study, VA Surgical Quality Improvement Program (VASQIP) chart review data were used as the gold standard to measure the criterion validity of 5 surgical PSIs. Independent chart review was also used to determine reasons for PSI errors.

METHODS

The sensitivity, specificity, and positive predictive value of PSI software version 4.1a were calculated among Veterans Health Administration hospitalizations (2003-2007) reviewed by VASQIP (n = 268,771). Nurses re-reviewed a sample of hospitalizations for which PSI and VASQIP AE detection disagreed.

RESULTS

Sensitivities ranged from 31% to 68%, specificities from 99.1% to 99.8%, and positive predictive values from 31% to 72%. Reviewers found that coding errors accounted for some PSI-VASQIP disagreement; some disagreement was also the result of differences in AE definitions.

CONCLUSIONS

These results suggest that the PSIs have moderate criterion validity; however, some surgical PSIs detect different AEs than VASQIP. Future research should explore using both methods to evaluate surgical quality.

Examining the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case of readmissions

BACKGROUND

By focusing primarily on outcomes in the inpatient setting one may overlook serious adverse events that may occur after discharge (eg, readmissions, mortality) as well as opportunities for improving outpatient care.

OBJECTIVE

Our overall objective was to examine whether experiencing an Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) event in an index medical or surgical hospitalization increased the likelihood of readmission.

METHODS

We applied the Agency for Healthcare Research and Quality PSI software (version 4.1.a) to 2003-2007 Veterans Health Administration inpatient discharge data to generate risk-adjusted PSI rates for 9 individual PSIs and 4 aggregate PSI measures: any PSI event and composite PSIs reflecting "Technical Care," "Continuity of Care," and both surgical and medical care (Mixed). We estimated separate logistic regression models to predict the likelihood of 30-day readmission for individual PSIs, any PSI event, and the 3 composites, adjusting for age, sex, comorbidities, and the occurrence of other PSI(s).

RESULTS

The odds of readmission were 23% higher for index hospitalizations with any PSI event compared with those with no event [confidence interval (CI), 1.19-1.26], and ranged from 22% higher for Iatrogenic Pneumothorax (CI, 1.03-1.45) to 61% higher for Postoperative Wound Dehiscence (CI, 1.27-2.05). For the composites, the odds of readmission ranged from 15% higher for the Technical Care composite (CI, 1.08-1.22) to 37% higher for the Continuity of Care composite (CI, 1.26-1.50).

CONCLUSIONS

Our results suggest that interventions that focus on minimizing preventable inpatient safety events as well as improving coordination of care between and across settings may decrease the likelihood of readmission.

Improving medical personnel selection and appointment processes

PURPOSE

This paper seeks to argue that processes for selecting and appointing medically qualified personnel in some healthcare organizations may be limited, especially those that emphasize qualifications rather than expanding the criteria to include practice scope, person-organization fit and capability to function within a healthcare team.

DESIGN/METHODOLOGY/APPROACH

The paper is based on the authors' experiences and a literature review.

FINDINGS

Selection based purely on academic merit, advanced clinical training, skills and professional achievements may not address other essential selection criteria. Medical personnel need to possess competencies such as ability to give high quality care and work constructively in a clinical team; communication skills; willingness to actively participate in quality and safety programs; teaching ability; management and leadership skills; and support institutional values and corporate aims. These attributes are often over-looked and cannot be assumed from academic merit and achievements.

RESEARCH LIMITATIONS/IMPLICATIONS

The study's conclusions are based on the authors' experiences and literature review. Future studies may wish to examine selection technique efficacy and outcomes empirically.

PRACTICAL IMPLICATIONS

Better medical personnel selection and appointment processes are likely to reduce unnecessary costs associated with poorly-made appointments, improve patient outcomes and may have a formative role encouraging medical personnel to take a broader view of their healthcare organization roles.

ORIGINALITY/VALUE

The authors challenge selection panel members to consider non-traditional with normal selection criteria for medical appointments. Nine recommendations for enhancing selection processes are provided.

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective

BACKGROUND

For almost a decade, public and private organizations have pressured hospitals to improve their patient safety records. Since 2008, the Centers for Medicare & Medicaid Services has no longer been reimbursing hospitals for secondary diagnoses not reported during the point of admission. This ruling has motivated some hospitals to engage in safety-oriented programs to decrease adverse events.

PURPOSE

This study examined which hospitals may engage in patient safety solutions and whether they create these patient safety solutions within their structures or use suppliers in the market.

METHODOLOGY

We used a theoretical model that incorporates the key constructs of resource dependence theory and transaction cost economics theory to predict a hospital's reaction to Centers for Medicare & Medicaid Services "never event" regulations. We present propositions that speculate on how forces conceptualized from the resource dependence theory may affect adoption of patient safety innovations and, when they do, whether the adopting hospitals will do so internally or externally according to the transaction cost economics theory.

FINDINGS

On the basis of forces identified by the resource dependence theory, we predict that larger, teaching, safety net, horizontally integrated, highly interdependent, and public hospitals in concentrated, high public payer presence, competitive, and resource-rich environments will be more likely to engage in patient safety innovations. Following the logic of the transaction cost economics theory, we predict that of the hospitals that react positively to the never event regulation, most will internalize their innovations in patient safety solutions rather than approach the market, a choice that helps hospitals economize on transaction costs.

PRACTICE IMPLICATIONS

This study helps hospital managers in their strategic thinking and planning in relation to current and future regulations related to patient safety. For researchers and policy analysts, our propositions provide the basis for empirical testing.

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign

BACKGROUND

Little is known about how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign differ among levels of healthcare staff.

DESIGN

Evaluation of a mixed qualitative and quantitative methodology ("trilogic evaluation model").

SETTING

Six hospitals that joined the campaign before June 2006.

PARTICIPANTS

Three strata of staff (executive leadership, midlevel, and frontline) at each hospital. RESULTS. Surveys were completed in 2008 by 135 hospital personnel (midlevel, 43.7%; frontline, 38.5%; executive, 17.8%) who also participated in 20 focus groups. Overall, 93% of participants were aware of the IHI campaign in their hospital and perceived that 58% (standard deviation, 22.7%) of improvements in quality at their hospital were a direct result of the campaign. There were significant differences between staff levels on the organizational culture (OC) items, with executive-level staff having higher scores than midlevel and frontline staff. All 20 focus groups perceived that the campaign interventions were sustainable and that data feedback, buy-in, hardwiring (into daily activities), and leadership support were essential to sustainability.

CONCLUSIONS

The trilogic model demonstrated that the 3 levels of staff had markedly different perceptions regarding the IHI campaign and OC. A framework in which frontline, midlevel, and leadership staff are simultaneously assessed may be a useful tool for future evaluations of OC and quality initiatives such as the IHI campaign.

The influence of context on quality improvement success in health care: a systematic review of the literature

CONTEXT

The mixed results of success among QI initiatives may be due to differences in the context of these initiatives.

METHODS

The business and health care literature was systematically reviewed to identify contextual factors that might influence QI success; to categorize, summarize, and synthesize these factors; and to understand the current stage of development of this research field.

FINDINGS

Forty-seven articles were included in the final review. Consistent with current theories of implementation and organization change, leadership from top management, organizational culture, data infrastructure and information systems, and years involved in QI were suggested as important to QI success. Other potentially important factors identified in this review included: physician involvement in QI, microsystem motivation to change, resources for QI, and QI team leadership. Key limitations in the existing literature were the lack of a practical conceptual model, the lack of clear definitions of contextual factors, and the lack of well-specified measures.

CONCLUSIONS

Several contextual factors were shown to be important to QI success, although the current body of literature lacks adequate definitions and is characterized by considerable variability in how contextual factors are measured across studies. Future research should focus on identifying and developing measures of context tied to a conceptual model that examines context across all levels of the health care system and explores the relationships among various aspects of context.

The influence of context on quality improvement success in health care: a systematic review of the literature

CONTEXT

The mixed results of success among QI initiatives may be due to differences in the context of these initiatives.

METHODS

The business and health care literature was systematically reviewed to identify contextual factors that might influence QI success; to categorize, summarize, and synthesize these factors; and to understand the current stage of development of this research field.

FINDINGS

Forty-seven articles were included in the final review. Consistent with current theories of implementation and organization change, leadership from top management, organizational culture, data infrastructure and information systems, and years involved in QI were suggested as important to QI success. Other potentially important factors identified in this review included: physician involvement in QI, microsystem motivation to change, resources for QI, and QI team leadership. Key limitations in the existing literature were the lack of a practical conceptual model, the lack of clear definitions of contextual factors, and the lack of well-specified measures.

CONCLUSIONS

Several contextual factors were shown to be important to QI success, although the current body of literature lacks adequate definitions and is characterized by considerable variability in how contextual factors are measured across studies. Future research should focus on identifying and developing measures of context tied to a conceptual model that examines context across all levels of the health care system and explores the relationships among various aspects of context.

Investigating organizational quality improvement systems, patient empowerment, organizational culture, professional involvement and the quality of care in European hospitals: the 'Deepening our Understanding of Quality Improvement in Europe (DUQuE)' project

Background

Hospitals in European countries apply a wide range of quality improvement strategies. Knowledge of the effectiveness of these strategies, implemented as part of an overall hospital quality improvement system, is limited.

Methods/Design

We propose to study the relationships among organisational quality improvement systems, patient empowerment, organisational culture, professionals' involvement with the quality of hospital care, including clinical effectiveness, patient safety and patient involvement. We will employ a cross-sectional, multi-level study design in which patient-level measurements are nested in hospital departments, which are in turn nested in hospitals in different EU countries. Mixed methods will be used for data collection, measurement and analysis. Hospital/care pathway level constructs that will be assessed include external pressure, hospital governance, quality improvement system, patient empowerment in quality improvement, organisational culture and professional involvement. These constructs will be assessed using questionnaires. Patient-level constructs include clinical effectiveness, patient safety and patient involvement, and will be assessed using audit of patient records, routine data and patient surveys. For the assessment of hospital and pathway level constructs we will collect data from randomly selected hospitals in eight countries. For a sample of hospitals in each country we will carry out additional data collection at patient-level related to four conditions (stroke, acute myocardial infarction, hip fracture and delivery). In addition, structural components of quality improvement systems will be assessed using visits by experienced external assessors. Data analysis will include descriptive statistics and graphical representations and methods for data reduction, classification techniques and psychometric analysis, before moving to bi-variate and multivariate analysis. The latter will be conducted at hospital and multilevel. In addition, we will apply sophisticated methodological elements such as the use of causal diagrams, outcome modelling, double robust estimation and detailed sensitivity analysis or multiple bias analyses to assess the impact of the various sources of bias.

Discussion

Products of the project will include a catalogue of instruments and tools that can be used to build departmental or hospital quality and safety programme and an appraisal scheme to assess the maturity of the quality improvement system for use by hospitals and by purchasers to contract hospitals.

Hospital Safety Climate and Safety Outcomes: Is There a Relationship in the VA?

Strengthening safety climate is recognized as a necessary strategy for improving patient safety. Yet there is little empirical evidence linking hospitals’ safety climate with safety outcomes.The authors explored the potential relationship between safety climate and Veterans Health Administration hospital safety performance using the Patient Safety Indicator (PSI) rates. Safety climate survey data were merged with hospital discharge data to calculate PSIs. Linear regressions examined the relationship between hospitals’ safety climate and dimensions of safety climate with individual PSIs and a PSI composite measure, controlling for organizational-level variables. Safety climate overall was not related to the PSIs or to the PSI composite, although a few individual dimensions of safety climate were associated with specific PSIs. Perceptions of frontline staff were more closely aligned with PSIs than those of senior managers.

Keeping an eye on patient safety using human factors engineering (HFE): a family affair for the hospitalized child

Barbara L. Wilson Column Editor: Bonnie Gance-Cleveland Family-Centered Care provides a forum for sharing information about basic components of caring for children and families, including respect, information sharing, collaboration, family-to-family support, and confidence building.

Testing the association between patient safety indicators and hospital structural characteristics in VA and nonfederal hospitals

This study tested the association between hospital structural characteristics-teaching status, bedsize, and nurse staffing-and potentially preventable adverse events. The authors calculated 14 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) and a PSI composite, using discharge databases from VA and nonfederal hospitals. This study compared the likelihood of PSI events in hospitals, controlling for structural and other characteristics, including patients' case-mix. Additional controls were employed to account for differences in VA versus nonfederal patients and data. The study found some associations, most notably a positive (unfavorable) association between status as a major teaching hospital and six PSIs. However, for most PSIs, the authors found no association between the structural characteristics tested and likelihood of PSI events. The study's findings extend previous research showing a lack of consistent relationship between structural characteristics and patient safety. However, the results also suggest continued need for examination of the relationship between teaching status and potentially preventable adverse events.

Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients

OBJECTIVE

Improving patient safety was a strong motivation behind duty hour regulations implemented by Accreditation Council for Graduate Medical Education on July 1, 2003. We investigated whether rates of patient safety indicators (PSIs) changed after these reforms.

RESEARCH DESIGN

Observational study of patients admitted to Veterans Health Administration (VA) (N = 826,047) and Medicare (N = 13,367,273) acute-care hospitals from July 1, 2000 to June 30, 2005. We examined changes in patient safety events in more versus less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform, using conditional logistic regression, adjusting for patient age, gender, comorbidities, secular trends, baseline severity, and hospital site.

MEASURES

Ten PSIs were aggregated into 3 composite measures based on factor analyses: "Continuity of Care," "Technical Care," and "Other" composites.

RESULTS

Continuity of Care composite rates showed no significant changes postreform in hospitals of different teaching intensity in either VA or Medicare. In the VA, there were no significant changes postreform for the technical care composite. In Medicare, the odds of a Technical Care PSI event in more versus less teaching-intensive hospitals in postreform year 1 were 1.12 (95% CI; 1.01-1.25); there were no significant relative changes in postreform year 2. Other composite rates increased in VA in postreform year 2 in more versus less teaching-intensive hospitals (odds ratio, 1.63; 95% CI; 1.10-2.41), but not in Medicare in either postreform year.

CONCLUSIONS

Duty hour reform had no systematic impact on PSI rates. In the few cases where there were statistically significant increases in the relative odds of developing a PSI, the magnitude of the absolute increases were too small to be clinically meaningful.

The growth of partnerships to support patient safety practice adoption

OBJECTIVES

To document the numbers and types of interorganizational partnerships within the national patient safety domain, changes over time in these networks, and their potential for disseminating patient safety knowledge and practices.

DATA SOURCES

Self-reported information gathered from representatives of national-level organizations active in promoting patient safety.

STUDY DESIGN

Social network analysis was used to examine the structure and composition of partnership networks and changes between 2004 and 2006.

DATA COLLECTION

Two rounds of structured telephone interviews (n=35 organizations in 2004 and 55 in 2006).

PRINCIPAL FINDINGS

Patient safety partnerships expanded between 2004 and 2006. The average number of partnerships per interviewed organization increased 40 percent and activities per reported partnership increased over 50 percent. Partnerships increased in all activity domains, particularly dissemination and tools development. Fragmentation of the overall partnership network decreased and potential for information flow increased. Yet network centralization increased, suggesting vulnerability to partnership failure if key participants disengage.

CONCLUSIONS

Growth in partnerships signifies growing strength in the capacity to disseminate and implement patient safety advancements in the U.S. health care system. The centrality of AHRQ in these networks of partnerships bodes well for its leadership role in disseminating information, tools, and practices generated by patient safety research projects.

CKD as an underrecognized threat to patient safety

Chronic kidney disease (CKD) is common, but underrecognized, in patients in the health care system, where improving patient safety is a high priority. Poor disease recognition and several other features of CKD make it a high-risk condition for adverse safety events. In this review, we discuss the unique attributes of CKD that make it a high-risk condition for patient safety mishaps. We point out that adverse safety events in this disease have the potential to contribute to disease progression; namely, accelerated loss of kidney function and increased incidence of end-stage renal disease. We also propose a framework in which to consider patient safety in CKD, highlighting the need for disease-specific safety indicators that reflect unsafe practices in the treatment of this disease. Finally, we discuss the hypothesis that increased recognition of CKD will reduce disease-specific safety events and in this way decrease the likelihood of adverse outcomes, including an accelerated rate of kidney function loss and increased incidence of end-stage renal disease.

Relationship of safety climate and safety performance in hospitals

OBJECTIVE

To examine the relationship between measures of hospital safety climate and hospital performance on selected Patient Safety Indicators (PSIs).

DATA SOURCES

Primary data from a 2004 survey of hospital personnel. Secondary data from the 2005 Medicare Provider Analysis and Review File and 2004 American Hospital Association's Annual Survey of Hospitals.

STUDY DESIGN

A cross-sectional study of 91 hospitals.

DATA COLLECTION

Negative binomial regressions used an unweighted, risk-adjusted PSI composite as dependent variable and safety climate scores and controls as independent variables. Some specifications included interpersonal, work unit, and organizational safety climate dimensions. Others included separate measures for senior managers and frontline personnel's safety climate perceptions.

PRINCIPAL FINDINGS

Hospitals with better safety climate overall had lower relative incidence of PSIs, as did hospitals with better scores on safety climate dimensions measuring interpersonal beliefs regarding shame and blame. Frontline personnel's perceptions of better safety climate predicted lower risk of experiencing PSIs, but senior manager perceptions did not.

CONCLUSIONS

The results link hospital safety climate to indicators of potential safety events. Some aspects of safety climate are more closely related to safety events than others. Perceptions about safety climate among some groups, such as frontline staff, are more closely related than perceptions in other groups.

Chronic kidney disease adversely influences patient safety

Reducing medical errors and improving patient safety have become a national priority. Patients with chronic kidney disease (CKD) may be at higher risk for adverse consequences of medical care, but few studies have evaluated this question. Here, data for patients hospitalized in the Veteran's Health Administration during 2004 to 2005 was analyzed to conduct a cross-sectional study of CKD and adverse safety events. Outcomes included 13 patient safety indicators (PSI) defined by the Agency for Healthcare Research and Quality and six experimental PSI relevant to CKD. The 71,666 (29%) hospitalized veterans with CKD had a higher risk for several PSI, even after case-mix adjustment. Among surgical hospitalizations, CKD was associated with increased risk for hip fracture, physiologic/metabolic derangements, and complications of anesthesia. Among all acute hospitalizations, the PSI with the highest risk in patients with CKD were infection as a result of medical care and death among those in diagnosis-related groups normally associated with low mortality. Furthermore, as preadmission estimated GFR decreased, a significant trend of increasing risk for all PSI was observed (P = 0.001). In conclusion, hospitalized patients with CKD are at increased risk for adverse safety events, measured by established PSI. Further investigation is needed to develop and test interventions to reduce this risk.

Review: how do hospital organizational structure and processes affect quality of care?: a critical review of research methods

Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure-process-outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure-quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.

Cardiovascular health disparities: a systematic review of health care interventions

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.