From Board to Bedside: How the Application of Financial Structures to Safety and Quality Can Drive Accountability in a Large Health Care System

Hospital staff perspectives towards health technology assessment: data from a multidisciplinary survey

BACKGROUND

Technology adoption in hospitals is usually based on cost-effectiveness analysis, feasibility and potential success. Different countries have embraced a range of principles to accomplish an effective comprehensive process of health technology assessment (HTA). The aim of the study was to analyse the viewpoints and relative weight of technology-oriented hospital staff members toward the clinical, social, technological and economic aspects of HTA.

METHODS

Using a structured questionnaire, a survey was conducted among different professionals in an 850-bed hospital.

RESULTS

We revealed a range of viewpoints among hospital staff members according to their personal characteristics and professional standpoints. The clinical aspects of HTA were considered 'highly important' (HI) by most participants, especially the 'lifesaving' parameter. Similarly, the 'lack of effective alternative technology' was ranked HI by a high percentage of participants, independent of their profession. Economic aspects were ranked HI only by half of the participants, while social and technological aspects were ranked HI only by a relatively low percentage. Nurses added 'improving quality of life', 'increasing teamwork efficiency' and 'improving medical standards'. Allied health professionals focused on 'lack of effective alternative technologies' as a main argument for adoption of HTA, alongside increasing efficiency, budget savings and contribution to hospital reputation. Engineers emphasised the requirement of significant investment in infrastructure and increasing efficiency. Administrators ranked patient experience as HI. Interestingly, the high ranking of social aspects correlated with older responders, while junior staff ranked safety significantly higher.

CONCLUSIONS

A multi-perspective multidisciplinary approach would be beneficial for policy-makers at hospitals and even on a national scale in Israel.

Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians

IMPORTANCE

Current electronic health record (EHR) user interfaces are suboptimally designed and may be associated with excess cognitive workload and poor performance.

OBJECTIVE

To assess the association between the usability of an EHR system for the management of abnormal test results and physicians' cognitive workload and performance levels.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study was conducted in a simulated EHR environment. From April 1, 2016, to December 23, 2016, residents and fellows from a large academic institution were enrolled and allocated to use either a baseline EHR (n = 20) or an enhanced EHR (n = 18). Data analyses were conducted from January 9, 2017, to March 30, 2018.

INTERVENTIONS

The EHR with enhanced usability segregated in a dedicated folder previously identified critical test results for patients who did not appear for a scheduled follow-up evaluation and provided policy-based decision support instructions for next steps. The baseline EHR displayed all patients with abnormal or critical test results in a general folder and provided no decision support instructions for next steps.

MAIN OUTCOMES AND MEASURES

Cognitive workload was quantified subjectively using NASA-Task Load Index and physiologically using blink rates. Performance was quantified according to the percentage of appropriately managed abnormal test results.

RESULTS

Of the 38 participants, 25 (66%) were female. The 20 participants allocated to the baseline EHR compared with the 18 allocated to the enhanced EHR demonstrated statistically significantly higher cognitive workload as quantified by blink rate (mean [SD] blinks per minute, 16 [9] vs 24 [7]; blink rate, -8 [95% CI, -13 to -2]; P = .01). The baseline group showed statistically significantly poorer performance compared with the enhanced group who appropriately managed 16% more abnormal test results (mean [SD] performance, 68% [19%] vs 98% [18%]; performance rate, -30% [95% CI, -40% to -20%]; P < .001).

CONCLUSIONS AND RELEVANCE

Relatively basic usability enhancements to the EHR system appear to be associated with better physician cognitive workload and performance; this finding suggests that next-generation systems should strip away non-value-added EHR interactions, which may help physicians eliminate the need to develop their own suboptimal workflows.

Next level of board accountability in health care quality

Purpose The purpose of this paper is to offer six principles that health system leaders can apply to establish a governance and management system for the quality of care and patient safety. Design/methodology/approach Leaders of a large academic health system set a goal of high reliability and formed a quality board committee in 2011 to oversee quality and patient safety everywhere care was delivered. Leaders of the health system and every entity, including inpatient hospitals, home care companies, and ambulatory services staff the committee. The committee works with the management for each entity to set and achieve quality goals. Through this work, the six principles emerged to address management structures and processes. Findings The principles are: ensure there is oversight for quality everywhere care is delivered under the health system; create a framework to organize and report the work; identify care areas where quality is ambiguous or underdeveloped (i.e. islands of quality) and work to ensure there is reporting and accountability for quality measures; create a consolidated quality statement similar to a financial statement; ensure the integrity of the data used to measure and report quality and safety performance; and transparently report performance and create an explicit accountability model. Originality/value This governance and management system for quality and safety functions similar to a finance system, with quality performance documented and reported, data integrity monitored, and accountability for performance from board to bedside. To the authors' knowledge, this is the first description of how a board has taken this type of systematic approach to oversee the quality of care.