Exploring the hospital patient journey: What does the patient experience?

PURPOSE

To understand how different methodologies of qualitative research are able to capture patient experience of the hospital journey.

METHODS

A qualitative study of orthopaedic patients admitted for hip and knee replacement surgery in a 250-bed university hospital was performed. Eight patients were shadowed from the time they entered the hospital to the time of transfer to rehabilitation. Four patients and sixteen professionals, including orthopaedists, head nurses, nurses and administrative staff, were interviewed.

RESULTS

Through analysis of the data collected four main themes emerged: the information gap; the covering patient-professionals relationship; the effectiveness of family closeness; and the micro-integration of hospital services. The three different standpoints (patient shadowing, health professionals' interviews and patients' interviews) allowed different issues to be captured in the various phases of the journey.

CONCLUSIONS

Hospitals can significantly improve the quality of the service provided by exploring and understanding the individual patient journey. When dealing with a key cross-functional business process, the time-space dynamics of the activities performed have to be considered. Further research in the academic field can explore practical, methodological and ethical challenges more deeply in capturing the whole patient journey experience by using multiple methods and integrated tools.

Expectations and experiences of hospital postnatal care in the UK: a systematic review of quantitative and qualitative studies

OBJECTIVES

To report on women's and families' expectations and experiences of hospital postnatal care, and also to reflect on women's satisfaction with hospital postnatal care and to relate their expectations to their actual care experiences.

DESIGN

Systematic review.

SETTING

UK.

PARTICIPANTS

Postnatal women.

PRIMARY AND SECONDARY OUTCOMES

Women's and families' expectations, experiences and satisfaction with hospital postnatal care.

METHODS

Embase, MEDLINE, PsycINFO, Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health (CINAHL Plus), Science Citation Index, and Social Sciences Citation Index were searched to identify relevant studies published since 1970. We incorporated findings from qualitative, quantitative and mixed-methods studies. Eligible studies were independently screened and quality-assessed using a modified version of the National Institutes of Health Quality Assessment Tool for quantitative studies and the Critical Appraisal Skills Programme for qualitative studies. Data were extracted on participants' characteristics, study period, setting, study objective and study specified outcomes, in addition to the summary of results.

RESULTS

Data were included from 53 studies, of which 28 were quantitative, 19 were qualitative and 6 were mixed-methods studies. The methodological quality of the included studies was mixed, and only three were completely free from bias. Women were generally satisfied with their hospital postnatal care but were critical of staff interaction, the ward environment and infant feeding support. Ethnic minority women were more critical of hospital postnatal care than white women. Although duration of postnatal stay has declined over time, women were generally happy with this aspect of their care. There was limited evidence regarding women's expectations of postnatal care, families' experience and social disadvantage.

CONCLUSION

Women were generally positive about their experiences of hospital postnatal care, but improvements could still be made. Individualised, flexible models of postnatal care should be evaluated and implemented.

PROSPERO REGISTRATION NUMBER

CRD42017057913.

PARENTS 2 Study: a qualitative study of the views of healthcare professionals and stakeholders on parental engagement in the perinatal mortality review-from 'bottom of the pile' to joint learning

OBJECTIVE

Engaging bereaved parents in the review process that examines their care before and after a perinatal death might help parents deal with their grief more effectively and drive improvements in patient safety. The objective of this study is to explore whether healthcare professionals would accept or support parent engagement in the perinatal mortality review process.

DESIGN

Qualitative focus group interviews. Transcripts were analysed with an inductive thematic approach.

SETTING

Two geographically distinct tertiary maternity hospitals in the UK.

PARTICIPANTS

Five focus groups were conducted with clinical staff including midwives, obstetricians, neonatologists, nursing staff and chaplaincy services.

RESULTS

Twenty-seven healthcare professionals unanimously agreed that parents' involvement in the perinatal mortality review process is useful and necessary. Six key themes emerged including: parental engagement; need for formal follow-up; critical structure of perinatal mortality review meeting; coordination and streamlining of care; advocacy for parents including role of the bereavement care lead; and requirement for training and support for staff to enable parental engagement.

CONCLUSIONS

Healthcare professionals strongly advocated engaging bereaved parents in the perinatal mortality review: empowering parents to ask questions, providing feedback on care, helping generate lessons and providing them with the opportunity to discuss a summary of the review conclusions with their primary healthcare professional contact. The participants agreed it is time to move on from 'a group of doctors reviewing notes' to active learning and improvement together with parents, to enable better care and prevention of perinatal death.

Digital Patient Communication: Improving the Hospital-Patient Relationship

Digitally engaging patients in their care processes was for many years limited to sharing care related documents (e.g. laboratory or radiology findings, discharge letters) with them through personal electronic health records. Newer concepts have led to the establishment of patient portals as patient frontends to a hospitalś electronic health record. Rarely however have complete patient pathways with pre-hospitalization, inpatient stay and post-hospitalization been evaluated to identify chains of communication processes involving clinical care scenarios, as well as subsequent home monitoring scenarios. Neither have such approaches been integrated with digital communication processes related to a patientś engagement in medical research projects. In order to enhance hospital-patient relationships in a holistic manner, we hypothesize that an integrated environment (e.g. patient portal) supporting shared decision making and communication in a patient´s care situation and in the same time providing communication processes for patient research engagement will optimize the patient-hospital relationship and be supportive in binding a patient to this care providing institution.

Treatment of tobacco dependence in UK hospitals: an observational study

Over a million smokers are admitted to hospitals in the UK each year. The extent to which tobacco dependence is identified and addressed in this population is unclear. Data on 14,750 patients from 146 hospitals collected for the British Thoracic Society smoking cessation audit were analysed to determine smoking prevalence, attempts to ask smokers about quitting, and referrals to smoking cessation services. Associations with hospital organisational factors were assessed by logistic regression. Overall hospital smoking prevalence was 25%. Only 28% of smokers were asked whether they would like to quit, and only one in 13 smokers was referred for treatment of tobacco dependence. There was a higher chance of smokers being asked about quitting in organisations with smoke-free sites, dedicated smoking cessation practitioners, regular staff training, and availability of advanced pharmacotherapy. Treatment of tobacco dependence in smokers attending UK hospitals is poor and could be associated with organisational factors.

PARENTS 2 study protocol: pilot of Parents' Active Role and ENgagement in the review of Their Stillbirth/perinatal death

BACKGROUND

The perinatal mortality review meeting that takes place within the hospital following a stillbirth or neonatal death enables clinicians to learn vital lessons to improve care for women and their families for the future. Recent evidence suggests that parents are unaware that a formal review following the death of their baby takes place. Many would welcome the opportunity to feedback into the meeting itself. Parental involvement in the perinatal mortality review meeting has the potential to improve patient satisfaction, drive improvements in patient safety and promote an open culture within healthcare. Yet evidence on the feasibility of involving bereaved parents in the review process is lacking. This paper describes the protocol for the Parents' Active Role and Engangement iN the review of their Stillbirth/perinatal death study (PARENTS 2) , whereby healthcare professionals' and stakeholders' perceptions of parental involvement will be investigated, and parental involvement in the perinatal mortality review will be piloted and evaluated at two hospitals.

METHODS AND ANALYSIS

We will investigate perceptions of parental involvement in the perinatal mortality review process by conducting four focus groups. A three-round modified Delphi technique will be employed to gain a consensus on principles of parental involvement in the perinatal mortality review process. We will use three sequential rounds, including a national consensus meeting workshop with experts in stillbirth, neonatal death and bereavement care, and a two-stage anonymous online questionnaire. We will pilot a new perinatal mortality review process with parental involvement over a 6-month study period. The impact of the new process will be evaluated by assessing parents' experiences of their care and parents' and staff perceptions of their involvement in the process by conducting further focus groups and using a Parent Generated Index questionnaire.

ETHICS AND DISSEMINATION

This study has ethical approval from the UK Health Research Authority. We will disseminate the findings through national and international conferences and international peer-reviewed journals.

RFID of next generation network for enhancing customer relationship management in healthcare industries

This paper aims to analyze possible next generation of networked radio frequency identification (NGN-RFID) system for customer relationship management (CRM) in healthcare industries. Customer relationship and its management techniques in a specific healthcare industry are considered in this development. The key objective of using NGN-RFID scheme is to enhance the handling of patients' data to improve the CRM efficiency in healthcare industries. The proposed NGN-RFID system is one of the valid points to improve the ability of CRM by analyzing different prior and current traditional approaches. The legacy of customer relationship management will be improved by using this modern NGN-RFID technology without affecting the novelty.

Changes to physician processing times in response to clinic congestion and patient punctuality: a retrospective study

OBJECTIVES

We examine interactions among 3 factors that affect patient waits and use of overtime in outpatient clinics: clinic congestion, patient punctuality and physician processing rates. We hypothesise that the first 2 factors affect physician processing rates, and this adaptive physician behaviour serves to reduce waiting times and the use of overtime.

SETTING

2 urban academic clinics and an affiliated suburban clinic in metropolitan Baltimore, Maryland, USA.

PARTICIPANTS

Appointment times, patient arrival times, start of service and physician processing times were collected for 105 visits at a low-volume suburban clinic 1, 264 visits at a medium-volume academic clinic 2 and 22 266 visits at a high-volume academic clinic 3 over 3 distinct spans of time.

INTERVENTION

Data from the first clinic were previously used to document an intervention to influence patient punctuality. This included a policy that tardy patients were rescheduled.

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinicians' processing times were gathered, conditioned on whether the patient or clinician was tardy to test the first hypothesis. Probability distributions of patient unpunctuality were developed preintervention and postintervention for the clinic in which the intervention took place and these data were used to seed a discrete-event simulation.

RESULTS

Average physician processing times differ conditioned on tardiness at clinic 1 with p=0.03, at clinic 2 with p=10^-5 and at clinic 3 with p=10^-7. Within the simulation, the adaptive physician behaviour degrades system performance by increasing waiting times, probability of overtime and the average amount of overtime used. Each of these changes is significant at the p<0.01 level.

CONCLUSIONS

Processing times differed for patients in different states in all 3 settings studied. When present, this can be verified using data commonly collected. Ignoring these behaviours leads to faulty conclusions about the efficacy of efforts to improve clinic flow.

Commentary: A Patient-Centered Theory of Satisfaction

The Primary Provider Theory holds that patient satisfaction occurs at the nexus of provider power and patient expectations. More specifically, patient satisfaction is principally the function of an underlying network of interrelated satisfaction constructs--satisfaction with the primary provider, waiting for the provider, and satisfaction with the provider's assistant(s). Hierarchically linked to patient-centered expectations of provider value, the Theory specifies that primary providers offer the greatest clinical utility to patients. The Theory is operationalized by patient-centered measures exclusively, where only patients judge the quality of service and all other judgments are immaterial. Bearing in mind the Institute of Medicine's recent recommendations to clinicians regarding the implementation of a new level of patient-centered care, the Primary Provider Theory offers an alternative paradigm for the measurement and realization of patient satisfaction. It can inform patient-centered physician practice, medical education, quality improvement, outcome measurement, and satisfaction survey construction.

Dissatisfaction of hospital patients, their relatives, and friends: Analysis of accounts collected in a complaints center

OBJECTIVE

This study aimed to analyze complaints of patients, their relatives, and friends who consulted a complaints center based (Espace Patients & Proches (EPP)) in a hospital so as to better understand the reasons that motivated them and their underlying expectations.

METHODS

This study was based on the analysis of written accounts of the 253 situations that occurred during the first year of operation of the EPP. The accounts were analyzed qualitatively using an inductive, thematic analytic approach.

RESULTS

We identified 372 different types of complaints and 28 main analytic themes. Five clustered themes emerged from the analysis of the interconnections among the core themes: (1) interpersonal relationship (N=160-the number of accounts including a complaint related to this general theme); (2) technical aspects of care (N=106); (3) health-care institution (N=69); (4) billing and insurance; (5) access to information (N=13).

CONCLUSION

The main reason for patients, their relatives, and friends going to EPP was related to the quality of the interpersonal relationship with health-care professionals. Such complaints were markedly more frequent than those concerning technical aspects of care.

PRACTICE IMPLICATIONS

These results raise important questions concerning changing patient expectations as well as how hospitals integrate complaints into the process of quality health care.

Difficult conversations: the kind thing to do

The author discusses what she believes are the right and wrong ways to handle a customer complaint about the behavior of one of your officers.

[Breastfeeding-Friendly Primary Care Unit Initiative and the relationship with exclusive breastfeeding]

OBJECTIVE

To analyze the prevalence of exclusive breastfeeding and the association with the Breastfeeding-Friendly Primary Care Unit Initiative.

METHODS

Cross-sectional study, whose data source were research on feeding behaviors in the first year of life conducted in the vaccination campaigns of 2003 and 2006, at the municipality of Barra Mansa, RJ, Southeastern Brazil. For the purposes of this study, infants under six months old, accounting for a total of 589 children in 2003 and 707 children in 2006, were selected. To verify the relationship between being followed-up by Breastfeeding-Friendly Primary Care Unit Initiative units and exclusive breastfeeding practice, only data from the 2006 inquiry was used. Variables that in the bivariate analysis were associated (p-value ≤ 0.20) with the outcome (exclusive breastfeeding practice) were selected for multivariate analysis. Prevalence ratios (PR) of exclusive breastfeeding were obtained by Poisson Regression with robust variance through a hierarchical model. The final model included the variables that reached p-value ≤ 0.05.

RESULTS

The prevalence of exclusive breastfeeding increased from 30.2% in 2003 to 46.7% in 2006. Multivariate analysis showed that mother's low education level reduced exclusive breastfeeding practice by 20.0% (PR = 0.798; 95%CI 0.684;0.931), cesarean delivery by 16.0% (PR = 0.838; 95%CI 0.719;0.976), and pacifier use by 41.0% (PR = 0.589; 95%CI 0.495;0.701). In the multiple analysis, each day of the infant's life reduced exclusive breastfeeding prevalence by 1.0% (PR = 0.992; 95%CI 0.991;0.994). Being followed-up by Breastfeeding-Friendly Primary Care Initiative units increased exclusive breastfeeding by 19.0% (PR = 1.193; 95%CI 1.020;1.395).

CONCLUSIONS

Breastfeeding-Friendly Primary Care Unit Initiative contributed to the practice of exclusive breastfeeding and to the advice for pregnant women and nursing mothers when implemented in the primary health care network.

Hospital trains CMs on IMs, HINNs

Scottsdale (AZ) Healthcare System provides training for case managers on delivery of the Important Message from Medicare (IM) and has developed a system to ensure that delivery of the IMs doesn't fall through the cracks. Case managers spend an average of 15 minutes discussing the IM with patients using a prepared script and give patients who may be confused a Medicare publication that explains the IM. To ensure that no one falls through the cracks on weekends when there is a smaller case management staff, the Friday case managers concentrate on delivering the IMs to patients who are expected to go home over the weekend. Appeals are rare and most of the time are made because the family expected the patient stay to be longer so they'd have more time to get ready at home.

Bereavement photography for children: program development and health care professionals' response

Reports of in-hospital bereavement photography focus largely on stillborns and neonates. Empiric data regarding the implementation of bereavement photography in pediatrics beyond the neonatal period and the impact of such programs on healthcare professionals (HCPs) is lacking. The authors describe the implementation of a pediatric intensive care unit (PICU) bereavement photography program and use questionnaire data from HCPs to describe HCPs' reflections on the program and to identify program barriers. From July 2007 through April 2070, families of 59 (36%) of the 164 patients who died in the PICU participated in our bereavement photography program. Forty questionnaires from 29 HCPs caring for 39 participating patients/families indicated that families seemed grateful for the service (n = 34; 85%) and that the program helped HCPs feel better about their role (n = 30; 70%). Many HCPs disagreed that the program consumed too much of his/her time (n = 34; 85%) and that the photographer made his/her job difficult (n = 37; 92.5%). Qualitative analysis of responses to open-ended questions revealed 4 categories: the program's general value; positive aspects of the program; negative aspects of the program; and suggestions for improvements. Implementing bereavement photography in the PICU is feasible though some barriers exist. HCPs may benefit from such programs.

Value-based leadership. Is your hospital management team prepared for the future?

This foldout section looks at the seven steps to a value-structured hospital, 10 must-do strategies for thriving in the new health care era, and what new skills management, physicians and trustees should have.

Don't let go of the rope: reducing readmissions by recognizing hospitals' fiduciary duties to their discharged patients

In the early years of the twenty-first century, it was widely speculated that massive, multi-purpose hospitals were becoming the "dinosaurs" of health care, to be largely replaced by community-based clinics providing specialty services on an outpatient basis. Hospitals, however, have roared back to life, in part by reworking their business model. There has been a wave of consolidations and acquisitions (including acquisitions of community-based clinics), with deals valued at $7.9 billion in 2011, the most in a decade, and the number of deals increasing another 18% in 2012. The costs of hospital care are enormous, with 31.5% ($851 billion) of the total health expenditures in the United States in 2011 devoted to these services. Hospitals are (1) placing growing emphasis on increasing revenue and decreasing costs; (2) engaging in pervasive marketing campaigns encouraging patients to view hospitals as an all-purpose care provider; (3) geographically targeting the expansion of their services to "capture" well-insured patients, while placing greater pressure on patients to pay for the services delivered; (4) increasing their size, wealth, and clout, with two-thirds of hospitals undertaking renovations or additional construction and smaller hospitals being squeezed out, and (5) expanding their use of hospital-employed physicians, rather than relying on community-based physicians with hospital privileges, and exercising greater control over medical staff. Hospitals have become so pivotal in the U.S. healthcare system that the Patient Protection and Affordable Care Act of 2010 (PPACA) frequently targeted them as a vehicle to enhance patient safety and control escalating health care costs. One such provision--the Hospital Readmissions Reduction Program, which goes into effect in fiscal year 2013--will reduce payments ordinarily made to hospitals if they have an "excess readmission" rate. It is estimated that adverse events following a hospital discharge impact as many as 19% of all discharged patients. When hospitals and similar health care facilities fail to adequately manage the discharge of their patients, devastating medical emergencies and sizeable healthcare costs can result. The urgency to better manage these discharges is compounded by the fact that the average length of hospital stays continues to shorten, potentially increasing the number of discharged patients who are at considerable risk of relapse. Also exacerbating the problem is a lack of clarity regarding who, if anyone, is responsible for these patients following discharge. Confusion over who bears responsibility for discharge-related preparation and community outreach, concerns about compensation, a lack of clear institutional policies, and the absence of legal mandates that patients be properly prepared for and monitored after discharge all contribute to the potential abandonment of patients at a crucial juncture. Although the PPACA establishes financial incentives for hospitals and similar facilities to combat the long-standing problem of high readmission rates, it does not provide a remedy for patients who have suffered avoidable harm after being discharged without adequate preparation or post-discharge assistance. This omission is particularly problematic as existing legal remedies, including medical malpractice suits, have provided little recourse for patients who have suffered injury that could have been prevented through the implementation of reasonable discharge-related policies. To protect the many patients who are highly vulnerable to complications following discharge and to provide them redress when needed services are not provided, hospitals' obligations to these patients should be recognized for what they are: a fiduciary duty to provide adequate discharge preparation and post-discharge services. The recognition of this duty is driven by changes in the nature of hospital care that enhance the perception that hospitals have become a "big business" that should "carry their own freight." Properly interpreted, this duty requires facilities to implement an appropriate discharge plan and provide post-discharge services for a period of time commensurate with a patient's continuing health risks. Notably, this is not the same as a generalized duty to provide all patients with continuing post-discharge treatment. It is a more limited obligation to offer necessary clarification and direction to patients upon discharge, and to institute a reasonable post-discharge monitoring program for patients with continuing health risks.

[Knowledge of the cost of the treatments delivered from the Hospital Pharmacy Department and perception of the health status]

OBJECTIVE

To assess the influence of the knowledge of the financial cost of the treatment and perception of the patient of his/her health status and the health care received from the Hospital Pharmacy Department (HPD).

METHOD

During a four-month period, from July to October of 2009, a questionnaire was provided to all the patients coming to the Hospital Pharmacy Department to gather their medications, except for those starting their therapies. The patients returning the completed questionnaire at a next visit were provided with the second part, in which they were informed on the monthly cost of their treatments and some questions from the main questionnaire were asked again.

RESULTS

682 questionnaires were provided, of which 240 (35.3%) were returned completed. 223 patients were given the second part, of which 151 (22.1%) were returned. In general, the patients were satisfied with their treatments (90.4%) and with the care provided at the HPD (95.4%), 69.2% had good knowledge of their treatment, and 59.2% considered themselves as good compliers, and 17.5% did not usually consult with the pharmacist at the HPD. The patient's satisfaction analysis before (7.75; SD: 1.90) and after knowing the treatment cost (7.80; SD: 1.91) did not show statistically significant differences, with the exception of those patients derived from the Infectious Disease Department (p = 0.015) that were less satisfied after knowing the cost.

CONCLUSIONS

The knowledge on the treatment cost could not be related in general with changes in the attitude of the patients towards their treatments, being necessary the design of more profound studies. Besides, it should be recommended to undertake the improvement actions detected by the patients in order to increase the quality of the pharmacy care delivered.

How do hospitals handle patients complaints? An overview from the Paris area

BACKGROUND

The incidence of complaints about health care has been rising. Reviewing the reasons why patients complain and how hospital staff respond to them can participate in an evaluation of quality in health care. There is a dearth of published information on complaints handling.

METHODS

In order to analyse complaints handling, we surveyed complaints referred to hospital managers in two French hospitals over one year: characteristics of complaints and characteristics of responses made to complainants. We used a scale for 10 criteria evaluating the responses to complaints.

RESULTS

A total of 115 complaints were analysed. Complaints mainly concerned the communication, the quality of medical care, waiting delays, and inadequate bills. Consequences of dissatisfaction included loss of confidence and refusal to pay the bill. Complainants wanted an explanation, their bill to be reduced, or something to change after the complaint. Most complainants wrote to the hospital manager. Hospital managers answered, using medical information as a basis for their responses. Median response time was 23 days. Interobserver agreement on evaluation criteria was almost perfect, substantial or moderate for 8 of 10 criteria. Major weaknesses of the responses were their lack of comprehensiveness (52%), the absence of intention to investigate (50%) and to act (77%), and of practical support (51%). The response of hospital managers misinterpreted the medical information given by the physician concerned in 5 (11%) of 45 cases.

CONCLUSION

We suggest that quality of complaints handling should be improved, possibly through the systematic reception of complainants by a physician not involved in the patient's care.

Improving outpatient access and patient experiences in academic ambulatory care

Effective scheduling of and ready access to doctor appointments affect ambulatory patient care quality, but these are often sacrificed by patients seeking care from physicians at academic medical centers. At one center, Beth Israel Deaconess Medical Center, the authors developed interventions to improve the scheduling of appointments and to reduce the access time between telephone call and first offered appointment. Improvements to scheduling included no redirection to voicemail, prompt telephone pickup, courteous service, complete registration, and effective scheduling. Reduced access time meant being offered an appointment with a physician in the appropriate specialty within three working days of the telephone call. Scheduling and access were assessed using monthly "mystery shopper" calls. Mystery shoppers collected data using standardized forms, rated the quality of service, and transcribed their interactions with schedulers. Monthly results were tabulated and discussed with clinical leaders; leaders and frontline staff then developed solutions to detected problems. Eighteen months after the beginning of the intervention (in June 2007), which is ongoing, schedulers had gone from using 60% of their registration skills to over 90%, customer service scores had risen from 2.6 to 4.9 (on a 5-point scale), and average access time had fallen from 12 days to 6 days. The program costs $50,000 per year and has been associated with a 35% increase in ambulatory volume across three years. The authors conclude that academic medical centers can markedly improve the scheduling process and access to care and that these improvements may result in increased ambulatory care volume.

Hospitals, providers collaborate on transitions

Baystate Health, a three-hospital system with headquarters in Springfield, MA, is partnering with post-acute providers to improve transitions as patients move through the continuum of care. A multidisciplinary post-acute performance team partnered with post-acute providers to determine why patients are readmitted to the hospital and to work on ways to avoid readmissions. Facilities share information with the hospitals how they operate and what they need to ensure patients receive the care they need. The health system's director of post-acute services holds regular meetings with providers to brainstorm on improving patient care.

Notifying patients of their right to complain

A proposed rule issued by the Centers for Medicare and Medicaid Services would require hospitals and other providers to formally notify Medicare beneficiaries about their right to complain to the state Medicare Quality Improvement Organization (QIO). Rule applies to outpatients as well as inpatients. Process is likely to tie into value-based purchasing. Case managers should take proactive steps to deal with complaints.

Why board diversity matters

Ideally, membership on your board of trustees should mirror the community your hospital serves. Here is some practical advice to help.

Responses of Massachusetts hospitals to a state mandate to collect race, ethnicity and language data from patients: a qualitative study

BACKGROUND

A Massachusetts regulation implemented in 2007 has required all acute care hospitals to report patients' race, ethnicity and preferred language using standardized methodology based on self-reported information from patients. This study assessed implementation of the regulation and its impact on the use of race and ethnicity data in performance monitoring and quality improvement within hospitals.

METHODS

Thematic analysis of semi-structured interviews with executives from a representative sample of 28 Massachusetts hospitals in 2009.

RESULTS

The number of hospitals using race, ethnicity and language data internally beyond refining interpreter services increased substantially from 11 to 21 after the regulation. Thirteen of these hospitals were utilizing patient race and ethnicity data to identify disparities in quality performance measures for a variety of clinical processes and outcomes, while 16 had developed patient services and community outreach programs based on findings from these data. Commonly reported barriers to data utilization include small numbers within categories, insufficient resources, information system requirements, and lack of direction from the state.

CONCLUSIONS

The responses of Massachusetts hospitals to this new state regulation indicate that requiring the collection of race, ethnicity and language data can be an effective method to promote performance monitoring and quality improvement, thereby setting the stage for federal standards and incentive programs to eliminate racial and ethnic disparities in the quality of health care.

A qualitative study of the experiences and expectations of women receiving in-patient postnatal care in one English maternity unit

BACKGROUND

Studies consistently highlight in-patient postnatal care as the area of maternity care women are least satisfied with. As part of a quality improvement study to promote a continuum of care from the birthing room to discharge home from hospital, we explored women's expectations and experiences of current in-patient care.

METHODS

For this part of the study, qualitative data from semi-structured interviews were transcribed and analysed using content analyses to identify issues and concepts. Women were recruited from two postnatal wards in one large maternity unit in the South of England, with around 6,000 births a year.

RESULTS

Twenty women, who had a vaginal or caesarean birth, were interviewed on the postnatal ward. Identified themes included; the impact of the ward environment; the impact of the attitude of staff; quality and level of support for breastfeeding; unmet information needs; and women's low expectations of hospital based postnatal care. Findings informed revision to the content and planning of in-patient postnatal care, results of which will be reported elsewhere.

CONCLUSIONS

Women's responses highlighted several areas where changes could be implemented. Staff should be aware that how they inter-act with women could make a difference to care as a positive or negative experience. The lack of support and inconsistent advice on breastfeeding highlights that units need to consider how individual staff communicate information to women. Units need to address how and when information on practical aspects of infant care is provided if women and their partners are to feel confident on the woman's transfer home from hospital.

The geography of hospital admission in a national health service with patient choice

Each year about 20% of the 10 million hospital inpatients in Italy get admitted to hospitals outside the Local Health Authority of residence. In this paper we carefully explore this phenomenon and estimate gravity equations for 'trade' in hospital care using a Poisson pseudo-maximum likelihood method. Consistency of the PPML estimator is guaranteed under the null of independence provided that the conditional mean is correctly specified. In our case we find that patients' flows are affected by network autocorrelation. We correct for it by relying upon spatial filtering. Our results suggest that the gravity model is a good framework for explaining patient mobility in most of the examined diagnostic groups. We find that the ability to restrain patients' outflows increases with the size of the pool of enrollees. Moreover, the ability to attract patients' inflows is reduced by the size of pool of enrollees for all LHAs except for the very big LHAs. For LHAs in the top quintile of size of enrollees, the ability to attract inflows increases with the size of the pool.

Counselling in neonatal intensive care unit

Counselling is a professional intervention based on skills to communicate and to build relationships. The project "Not alone", related to counselling at our Neonatal Intensive Care Unit, is aimed to let counselling become a "shared culture" for all the care givers. The first essential aspect is to form the ability of counselling through periodic courses for all professionals of the department (physicians, nurses, physiotherapists). In our department a professional counsellor is present assisting the medical staff in direct counselling. The counsellor's intervention allows a better parent orientation in the situation. A more effective sharing of these rules also facilitates the communication among parents and medical staff. Periodic meetings are established among the medical staff, in which the professional counsellor discusses difficult situations in order to share possible communicative strategies. We wanted to have not only a common communicative style, but also common subjects, independent from the characteristics of each of us. Individuals are often faced with diverse situations. For every setting that we more frequently face in communication (for example the first interview with a parent of a very preterm infant) we have built an "algorithm" that follows a pattern: (1) information always given; (2) frequent questions from parents, (3) frequent difficulties in the communication. We also need to record important moments, for instance the "case history of the communication": in fact it would be desirable to have the case history, a sheet dedicated to important communications that are absolutely to be shared with other professionals.

Principal agent relationships and the efficiency of hospitals

The efficiency of hospitals is an important political issue and has been the subject of a number of studies. Most studies find evidence for inefficiency but provide no theoretical explanations for differences in efficiency. This study used principal agent theory to explain differences in efficiency between hospitals. Two agency issues are examined: (1) quality of care in the relationship between hospital and patient, and (2) internal organisation, i.e. the relationship between the hospital and its main departments. It was found that efficiency and quality go together. This implies that the potential harmful information asymmetry between hospitals and patients does not appear to be a major problem, because increasing efficiency does not seem to reduce quality. Further, we find no relationship between the efficiency of departments and the efficiency of the entire hospital. The interest of hospital departments is currently not in line with the interests of the entire hospital.