National inventory of hospital trauma centers

CONTEXT

Trauma centers benefit thousands of injured individuals every day and play a critical role in responding to disasters. The last full accounting of the number and distribution of trauma centers identified 471 trauma centers in the United States in 1991.

OBJECTIVE

To determine the number and configuration of trauma centers and identify gaps in coverage.

DESIGN, SETTING, AND SUBJECTS

Interviews with trauma center directors (September 2001 to April 2002), data from the American Hospital Association's Annual Survey of Hospitals (2000), and the US Health Resources Administration's Area Resource File (2001) were used to determine characteristics of trauma center hospitals and the geographic areas they serve in all 50 states and in the District of Columbia. Characteristics of trauma centers were examined by level of care and compared with nontrauma centers. Hospitals are designated or certified as trauma centers by a state or regional authority or verified as trauma centers by the American College of Surgeons Committee on Trauma. Trauma centers that treat only children (n = 31) were excluded.

MAIN OUTCOME MEASURE

Total number of trauma centers and number of trauma centers per million population.

RESULTS

In 2002, there were 1154 trauma centers in the United States, including 190 level I centers and 263 level II centers. Several states have categorized every hospital with an emergency department at some level of trauma care while others have designated a limited number of level I and level II centers only. The number of level I and II centers per million population ranges from 0.19 to 7.8 by state. When compared with nontrauma center hospitals, trauma centers are larger, more likely to be teaching hospitals, and more likely to offer specialized services.

CONCLUSIONS

Although the availability of trauma centers has improved, challenges remain to ensure the optimal number, distribution, and configuration of trauma centers. These challenges must be addressed, especially in light of the recent emphasis on hospital preparedness and homeland security.

Corporatization and the social transformation of doctoring

Corporatization of health care is dramatically transforming the medical workplace and profoundly altering the everyday work of the doctor. In this article, the authors discuss recent changes in U.S. health care and their impact on doctoring, and outline the major theoretical explanations of the social transformation of medical work under advanced capitalism. The adequacy of the prevailing view of professionalism (Freidson's notion of professional dominance) is considered, and an alternative view, informed by recent changes, is offered. While the social transformation of doctoring is discussed with reference to recent U.S. experience, no country or health system can be considered immune. Indeed, U.S. experience may be instructive for doctors and health care researchers in other national settings as to what they may expect.

Emergency departments and crowding in United States teaching hospitals

STUDY OBJECTIVES

To assess the extent and distribution of hospital and emergency department crowding nationally.

DESIGN

The research design consisted of a mailed questionnaire disseminated in the fall of 1988 to the member institutions of the National Association of Public Hospitals (NAPH) and the Council of Teaching Hospitals (COTH).

TYPE OF PARTICIPANTS

Study participants included hospital administrators and ED directors from 239 of the non-Veterans Administration, general acute care, US members of COTH and NAPH.

MEASUREMENTS

Key measures of hospital and ED crowding including mean ED holding times for floor and ICU beds.

MAIN RESULTS

Three fourths of responding hospitals reported increases in ED visits over the preceding three years. Mean ED holding times for admitted patients were 3.5 hours (median, 2.0 hours) for a floor bed and 2.9 hours (median, 1.5 hours) for an ICU bed. Half of all hospitals noted maximum waits for floor and ICU beds of ten hours or more and seven hours or more, respectively. Measures taken by hospitals to manage crowding during August 1988 included restricting access to some types of patients (mean, 3.6 days), actively transferring patients to other hospitals (mean, 2.2 days), transfer refusal (mean, 2.8 days), and total ambulance diversion (mean, 1.6 days).

CONCLUSIONS

Our study strongly suggests that ED crowding is not an isolated phenomenon; ED crowding and its attendant problems appear to affect hospitals with similar adverse effects regardless of ownership. Although our results suggest that ED crowding is concentrated in metropolitan areas and in a smaller subset of hospitals, we found instances of crowding among hospitals nationwide.

The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units[ISRCTN85147255] [corrected]

Background

Executive walk rounds (EWRs) are a widely used but unstudied activity designed to improve safety culture in hospitals. Therefore, we measured the impact of EWRs on one important part of safety culture – provider attitudes about the safety climate in the institution.

Methods

Randomized study of EWRs for 23 clinical units in a tertiary care teaching hospital. All providers except physicians participated. EWRs were conducted at each unit by one of six hospital executives once every four weeks for three visits. Providers were asked about their concerns regarding patient safety and what could be done to improve patient safety. Suggestions were tabulated and when possible, changes were made. Provider attitudes about safety climate measured by the Safety Climate Survey before and after EWRs. We report mean scores, percent positive scores (percentage of providers who responded four or higher on a five point scale (agree slightly or agree strongly), and the odds of EWR participants agreeing with individual survey items when compared to non-participants.

Results

Before EWRs the mean safety climate scores for nurses were similar in the control units and EWR units (78.97 and 76.78, P = 0.458) as were percent positive scores (64.6% positive and 61.1% positive). After EWRs the mean safety climate scores were not significantly different for all providers nor for nurses in the control units and EWR units (77.93 and 78.33, P = 0.854) and (56.5% positive and 62.7% positive). However, when analyzed by exposure to EWRs, nurses in the control group who did not participate in EWRs (n = 198) had lower safety climate scores than nurses in the intervention group who did participate in an EWR session (n = 85) (74.88 versus 81.01, P = 0.02; 52.5% positive versus 72.9% positive). Compared to nurses who did not participate, nurses in the experimental group who reported participating in EWRs also responded more favorably to a majority of items on the survey.

Conclusion

EWRs have a positive effect on the safety climate attitudes of nurses who participate in the walk rounds sessions. EWRs are a promising tool to improve safety climate and the broader construct of safety culture.

The role of hospital managers in quality and patient safety: a systematic review

OBJECTIVES

To review the empirical literature to identify the activities, time spent and engagement of hospital managers in quality of care.

DESIGN

A systematic review of the literature.

METHODS

A search was carried out on the databases MEDLINE, PSYCHINFO, EMBASE, HMIC. The search strategy covered three facets: management, quality of care and the hospital setting comprising medical subject headings and key terms. Reviewers screened 15,447 titles/abstracts and 423 full texts were checked against inclusion criteria. Data extraction and quality assessment were performed on 19 included articles.

RESULTS

The majority of studies were set in the USA and investigated Board/senior level management. The most common research designs were interviews and surveys on the perceptions of managerial quality and safety practices. Managerial activities comprised strategy, culture and data-centred activities, such as driving improvement culture and promotion of quality, strategy/goal setting and providing feedback. Significant positive associations with quality included compensation attached to quality, using quality improvement measures and having a Board quality committee. However, there is an inconsistency and inadequate employment of these conditions and actions across the sample hospitals.

CONCLUSIONS

There is some evidence that managers' time spent and work can influence quality and safety clinical outcomes, processes and performance. However, there is a dearth of empirical studies, further weakened by a lack of objective outcome measures and little examination of actual actions undertaken. We present a model to summarise the conditions and activities that affect quality performance.

Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine

BACKGROUND

Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians.

METHODS

We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores.

RESULTS

There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). od Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .).

CONCLUSIONS

There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blo

Effect of education and performance feedback on handwashing: the benefit of administrative support in Argentinean hospitals

BACKGROUND

Patients admitted to hospitals are at risk of acquiring nosocomial infections. Many peer-reviewed studies show that handwashing (HW) significantly reduces hospital infections and mortality. Our objective was to evaluate the effects of HW by health care workers (HCW) before contact with patients in 3 Argentinean hospitals. We performed an observational study of HCW to measure the effect of 2 interventions: education alone and education plus performance feedback.

METHODS

A total of 3 hospitals were studied for adherence to a HW protocol. The observed HCW included physicians, nursing personnel, and ancillary staff. After initial observations to establish baseline rates of HW (phase 1), we evaluated the effect of education alone (phase 2), followed by education plus performance feedback (phase 3). We also evaluated the relationship between the administrative support and HW adherence.

RESULTS

We observed 15,531 patient contacts in 3 hospitals. The baseline rate of HW before contact with patients was 17%. With education, HW before contact with the patients increased to 44% (relative risk 2.65; 95% confidence interval 2.33-3.02; P <.001). Using education and performance feedback HW further increased to 58% (relative risk 1.86; 95% confidence interval 1.38-2.51; P <.001). In the private hospitals where administrative support for the HW program was significantly greater, HW compliance was significantly higher (logistic regression analysis: odds ratio 5.57; 95% confidence interval 5.25-6.31; P <.001).

CONCLUSIONS

In this study, HW policies and education of HCW significantly improved HCW adherence to the HW protocol, however, when performance feedback was incorporated, the HW compliance increased to a greater degree. We identified that administrative support provides a positive influence in efforts to improve HW adherence.

Error reporting and disclosure systems: views from hospital leaders

CONTEXT

The Institute of Medicine has recommended establishing mandatory error reporting systems for hospitals and other health settings.

OBJECTIVE

To examine the opinions and experiences of hospital leaders with state reporting systems.

DESIGN AND SETTING

Survey of chief executive and chief operating officers (CEOs/COOs) from randomly selected hospitals in 2 states with mandatory reporting and public disclosure, 2 states with mandatory reporting without public disclosure, and 2 states without mandatory systems in 2002-2003.

MAIN OUTCOME MEASURES

Perceptions of the effects of mandatory systems on error reporting, likelihood of lawsuits, and overall patient safety; attitudes regarding release of incident reports to the public; and likelihood of reporting incidents to the state or to the affected patient based on hypothetical clinical vignettes that varied the type and severity of patient injury.

RESULTS

Responses were received from 203 of 320 hospitals (response rate = 63%). Most CEOs/COOs thought that a mandatory, nonconfidential system would discourage reporting of patient safety incidents to their hospital's own internal reporting system (69%) and encourage lawsuits (79%) while having no effect or a negative effect on patient safety (73%). More than 80% felt that the names of both the hospital and the involved professionals should be kept confidential, although respondents from states with mandatory public disclosure systems were more willing than respondents from the other states to release the hospital name (22% vs 4%-6%, P = .005). Based on the vignettes, more than 90% of hospital leaders said their hospital would report incidents involving serious injury to the state, but far fewer would report moderate or minor injuries, even when the incident was of sufficient consequence that they would tell the affected patient or family.

CONCLUSIONS

Most hospital leaders expressed substantial concerns about the impact of mandatory, nonconfidential reporting systems on hospital internal reporting, lawsuits, and overall patient safety. While hospital leaders generally favor disclosure of patient safety incidents to involved patients, fewer would disclose incidents involving moderate or minor injury to state reporting systems.

E-mail versus conventional postal mail survey of geriatric chiefs

PURPOSE

This study compared the response time, response rate, and cost of two types of survey administration techniques: e-mail/web-based versus conventional postal mail. The main aim of the survey was to collect descriptive information on the existence of Acute Care for Elders units and their characteristics by surveying geriatric division chiefs.

DESIGN AND METHODS

Two randomized cohorts of geriatric division chiefs were formed to receive a survey either by electronic mail (n = 57) or by conventional postal mail (n = 57). If there was no response to the initial mailing, two follow-up mailings were sent to both groups using the original modality; a third follow-up was performed using the alternative modality. For each group, response rate and response time were calculated. The average total cost was computed and compared across two groups.

RESULTS

The aggregate response rate was 58% (n = 31) for the e-mail group versus 77% (n = 44) for the postal mail group. The overall average response time was shorter in the e-mail group, 18 days compared with 33 days for the conventional postal mailing group. The cost comparison showed that average cost was $7.70 for the e-mail group, compared to $10.50 per response for the conventional mail group.

IMPLICATIONS

It appears that although the web-based technology is gaining popularity and leads to lower cost per response, the conventional postal method of surveying continues to deliver a better response rate among the geriatric medicine division chiefs. The web-based approach holds promise given its lower costs and acceptable response rate combined with the shorter response time.

Guidelines for medical audit: seven principles

The government, general managers, and professional bodies all agree that medical audit should be implemented throughout the United Kingdom. Nevertheless, it is not yet decided either nationally or locally how audit should be defined and what its implications will be. In an analysis to find ways of measuring the design and effectiveness of hospital audit, therefore, seven main measures emerged that might serve as practical criteria. These were the definition of medical and managerial responsibilities; medical organisation; scope of audit; essential characteristics; resources needed; record keeping; and evaluation. Though generally consistent with the proposals of the government and the Department of Health, these seven principles offer some alternative approaches.

How do Perceptions of Autonomy Differ in General Surgery Training Between Faculty, Senior Residents, Hospital Administrators, and the General Public? A Multi-Institutional Study

OBJECTIVE

Identify barriers to resident autonomy in today's educational environment as perceived through 4 selected groups: senior surgical residents, teaching faculty, hospital administration, and the general public.

DESIGN

Anonymous surveys were created and distributed to senior residents, faculty, and hospital administrators working within 3 residency programs. The opinions of a convenience sample of the general public were also assessed using a similar survey.

SETTING

Keesler Medical Center, Keesler AFB, MS; the University of Texas Health Science of San Antonio, TX; and the University of Nebraska Medical Center, Omaha, NE.

PARTICIPANTS

A total of 169 responses were collected: 32 residents, 50 faculty, 20 administrators, and 67 general public.

RESULTS

Faculty and residents agree that when attending staff grant more autonomy, residents' self-confidence and sense of ownership improve. Faculty felt that residents should have less autonomy than residents did (p < 0.001). When asked to reflect on the current level of autonomy at their institution, 47% of residents felt that they had too little autonomy and 38% of faculty agreed. No resident or faculty felt that residents had too much autonomy at their institution. The general public were more welcoming of resident participation than faculty (p = 0.002) and administrators (p = 0.02) predicted they would be. When the general public were asked regarding their opinions about resident participation with complex procedures, they were less welcoming than faculty, administrators, and residents thought (p < 0.001). The general public were less likely to think that resident involvement would improve their quality of care (p < 0.001).

CONCLUSION

Faculty and senior residents both endorse resident autonomy as important for resident development. The general public are more receptive to resident participation than anticipated. However, with increasing procedural complexity and resident independence, they were less inclined to have residents involved. The general public also had more concerns regarding quality of care provided by residents than the other groups had.

Hospitals' strategies for orchestrating selection of physician preference items

This article analyzes hospitals' strategies to shape physicians' behavior and counter suppliers' power in purchasing physician preference items. Two models of standardization are limitations on the range of manufacturers or products (the "formulary" model) and price ceilings for particular item categories (the "payment-cap" model), both requiring processes to define product equivalencies often with inadequate product comparison data. The formulary model is more difficult to implement because of physicians' resistance to top-down dictates. The payment-cap model is more feasible because it preserves physicians' choice while also restraining manufacturers' power. Hospitals may influence physicians' involvement through a process of orchestration that includes committing to improve clinical facilities, scheduling, and training and fostering a culture of mutual trust and respect.

The health information literacy research project

OBJECTIVES

This research studied hospital administrators' and hospital-based health care providers' (collectively, the target group) perceived value of consumer health information resources and of librarians' roles in promoting health information literacy in their institutions.

METHODS

A web-based needs survey was developed and administered to hospital administrators and health care providers. Multiple health information literacy curricula were developed. One was pilot-tested by nine hospital libraries in the United States and Canada. Quantitative and qualitative methods were used to evaluate the curriculum and its impact on the target group.

RESULTS

A majority of survey respondents believed that providing consumer health information resources was critically important to fulfilling their institutions' missions and that their hospitals could improve health information literacy by increasing awareness of its impact on patient care and by training staff to become more knowledgeable about health literacy barriers. The study showed that a librarian-taught health information literacy curriculum did raise awareness about the issue among the target group and increased both the use of National Library of Medicine consumer health resources and referrals to librarians for health information literacy support.

CONCLUSIONS

It is hoped that many hospital administrators and health care providers will take the health information literacy curricula and recognize that librarians can educate about the topic and that providers will use related consumer health services and resources.

VA QUERI informatics paper: information technology for clinical guideline implementation: perceptions of multidisciplinary stakeholders

OBJECTIVE

This multisite study compared the perceptions of three stakeholder groups regarding information technologies as barriers to and facilitators of clinical practice guidelines (CPGs).

DESIGN

The study settings were 18 U.S. Veterans Affairs Medical Centers. A purposive sample of 322 individuals participated in 50 focus groups segmented by profession and included administrators, physicians, and nurses. Focus group participants were selected based on their knowledge of practice guidelines and involvement in facility-wide guideline implementation.

MEASUREMENTS

Descriptive content analysis of 1,500 pages of focus group transcripts.

RESULTS

Eighteen themes clustered into four domains. Stakeholders were similar in discussing themes in the computer function domain most frequently but divergent in other domains, with workplace factors more often discussed by administrators, system design issues discussed most by nurses, and personal concerns discussed by physicians and nurses. Physicians and nurses most often discussed barriers, whereas administrators focused most often on facilitation. Facilitators included guideline maintenance and charting formats. Barriers included resources, attitudes, time and workload, computer glitches, computer complaints, data retrieval, and order entry. Themes with dual designations included documentation, patient records, decision support, performance evaluation, CPG implementation, computer literacy, essential data, and computer accessibility.

CONCLUSION

Stakeholders share many concerns regarding the relationships between information technologies and clinical guideline use. However, administrators, physicians, and nurses hold different opinions about specific facilitators and barriers. Health professionals' disparate perceptions could undermine guideline initiatives. Implementation plans should specifically incorporate actions to address these barriers and enhance the facilitative aspects of information technologies in clinical practice guideline use.

Participation as a complicating mechanism: the effect of clinical professional and middle manager participation on hospital performance

One way hospitals complicate themselves is by increasing the participation of clinical professionals and middle managers in making strategic decisions. Using a survey methodology this article investigates the relationships between the participation of clinical professionals (MDs and RNs) and middle managers with hospital costs, as well as the possible moderating effect of strategic complexity.

Analysis of the effect of conflict-management and resolution training on employee stress at a healthcare organization

Conflict is inevitable and can be both positive and negative. Although it is impossible, and probably not wise, to eliminate conflict, it is prudent for healthcare organizations to provide direct instruction in conflict-management training. In this study, 23 supervisors and managers in a local healthcare organization participated in two 3-hour sessions designed to teach practical conflict-management strategies immediately applicable to their workplace duties and responsibilities. A comparison of pretest and posttest measures indicates statistically significant differences in four areas and suggests a positive influence of the brief intervention.

Changing the use of electronic fetal monitoring and labor support: a case study of barriers and facilitators

BACKGROUND

Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline.

METHODS

This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals.

RESULTS

Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use.

CONCLUSIONS

When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

Survey of US academic hospitalist leaders about mentorship and academic activities in hospitalist groups

BACKGROUND

Few data describe the structure, activities, and goals of academic hospital medicine groups.

METHODS

We carried out a cross sectional email survey of academic hospitalist leaders. Our survey asked about group resources, services, recruitment and growth, as well as mentoring of faculty, future priorities, and general impressions of group stability.

RESULTS

A total of 57 of 142 (40%) potential hospitalist leaders responded to our email survey. Hospitalist groups were generally young (<5 years old). Hospitalist group leaders worried about adequate mentorship and burnout while placing a high priority on avoiding physician turnover. However, most groups also placed a high priority on expanding nonclinical activities (teaching, research, etc.). Leaders felt financially and philosophically unsupported, a sentiment which seemed to stem from being viewed primarily as a clinical rather than an academic service.

CONCLUSION

Academic hospital medicine groups have an acute need for mentoring and career development programs. These programs should target both individual hospitalists and their leaders while also helping to enhance scholarly work.

Location of in-house organ procurement organization staff in level I trauma centers increases conversion of potential donors to actual donors

BACKGROUND

Of 5810 acute care hospitals in the United States, only 3.9% (231) are Level 1 Trauma Centers (L1TCs). L1TCs have a significant number of potential organ donors (PODs). Placement of Organ Procurement Organization (OPO) staff, In House Coordinators (IHCs), directly within the L1TC to increase the number of families who consent to donate and to provide system management for the trauma center's donation program, was evaluated.

METHODS

Four OPO staff, IHCs, were placed in offices inside two L1TCs in Houston, Texas. The IHCs were responsible for development of a donation system, donor surveillance, management, and most importantly, family support.

RESULTS

Calendar year 2000 data on conversion of PODs to actual donors were compared between the L1TCs with IHCs (IHC-L1TC) (n=2) and trauma centers without IHCs (n=4) within the OPO's service area. IHC-L1TCs converted 44% more of the PODs to actual donors. Furthermore, the IHC-L1TCs were compared with 85 L1TCs (37% of U.S. L1TCs) without IHCs. IHC-L1TCs had a 28% greater donor consent rate and a 48% greater conversion rate of PODs to actual donors than the national L1TCs.

CONCLUSIONS

L1TC status is the America College of Surgeons' highest level of verification for trauma care. To be certified as a L1TC, hospitals must meet strict criteria in both services and patient care. The donation process is often profoundly affected by the burden of demands made on the resources of these institutions and from divergent responsibilities between specialty services within the facility. Dedicated IHCs (OPO staff) are needed to provide early family intervention and to orchestrate the donation process to maximize organ recovery.

Perceptions of postoutbreak management by management and healthcare workers of a Middle East respiratory syndrome outbreak in a tertiary care hospital: a qualitative study

OBJECTIVES

This study examines perceptions of the operational and organisational management of a major outbreak of Middle East Respiratory Syndrome (MERS) caused by a novel coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia (KSA). Perspectives were sought from key decision-makers and clinical staff about the factors perceived to promote and inhibit effective and rapid control of the outbreak.

SETTING

A large teaching tertiary healthcare centre in KSA; the outbreak lasted 6 weeks from June 2015.

PARTICIPANTS

Data were collected via individual and focus group interviews with 28 key informant participants (9 management decision-makers and 19 frontline healthcare workers).

DESIGN

We used qualitative methods of process evaluation to examine perceptions of the outbreak and the factors contributing to, or detracting from successful management. Data were analysed using qualitative thematic content analysis.

RESULTS

Five themes and 15 subthemes were found. The themes were related to: (1) the high stress of the outbreak, (2) factors perceived to contribute to outbreak occurrence, (3) factors perceived to contribute to success of outbreak control, (4) factors inhibiting outbreak control and (5) long-term institutional gains in response to the outbreak management.

CONCLUSION

Management of the MERS-CoV outbreak at King Abdulaziz Medical City-Riyadh was widely recognised by staff as a serious outbreak of local and national significance. While the outbreak was controlled successfully in 6 weeks, progress in management was inhibited by a lack of institutional readiness to implement infection control (IC) measures and reduce patient flow, low staff morale and high anxiety. Effective management was promoted by greater involvement of all staff in sharing learning and knowledge of the outbreak, developing trust and teamwork and harnessing collective leadership. Future major IC crises could be improved via measures to strengthen these areas, better coordination of media management and proactive staff counselling and support.

Understanding stakeholder power and influence gaps in a health care organization: an empirical study

Scholars have vigorously debated the role of stakeholders since Freeman's 1984 landmark work. This article argues that an accurate assessment of relative power levels can enable stakeholders to accept their proper roles and responsibilities in planning and implementing strategy and enabling Top Management Teams to more fully integrate stakeholders' interest into the planning process.