Advancing Global Health Equity: The Role of the Liberal Arts in Health Professional Education

Much innovation has taken place in the development of medical schools and licensure exam processes across the African continent. Still, little attention has been paid to education that enables the multidisciplinary, critical thinking needed to understand and help shape the larger social systems in which health care is delivered. Although more than half of medical schools in Canada, the United Kingdom, and the United States offer at least one medical humanities course, this is less common in Africa. We report on the "liberal arts approach" to medical curricula undertaken by the University of Global Health Equity beginning in 2019. The first six-month semester of the curriculum, called Foundations in Social Medicine, includes courses in critical thinking and communication, African history and global political economy, medical anthropology and social medicine, psychology and health, gender and social justice, information technology and health, and community-based training. Additionally, an inquiry-based pedagogy with relatively small classes is featured within an overall institutional culture that emphasizes health equity. We identify key competencies for physicians interested in pursuing global health equity and how such competencies relate to liberal arts integration into the African medical school curriculum and pedagogical approach. We conclude with a call for a research agenda that can better evaluate the impact of such innovations on physicians' education and subsequent practices.

Dealing with Unexpected Crises: Organizational Resilience and Its Discontents

The chapter summarizes key literature, including emerging ideas, that is pertinent to the question of how organizations and their leadership deal with and are resilient through crises - highlighting what works in surviving unexpected crises. The chapter presents an illustration of organizational response; it concludes with an analysis of what is missing from the literature and recommends a path forward to expanding actionable knowledge in this area. Multiple, interdependent factors that foster resilience are identified including (1) being sensitive to possible threats - even seemingly small failures, (2) not relying on simple interpretations of events but rather seeking diversity to create a complete view of the environment, (3) leadership that embraces communication, transparency, and continuous learning, (4) valuing expertise and allowing expert staff to make decisions during a crisis, and (5) a cultural commitment to a resiliency mindset that accepts failures as opportunities to learn and improve. Emerging concepts that may foster resilience but require more research include managing paradox, emotional ambivalence and diversity. Additional areas for fruitful research include: the impact of short-term versus long-term, or successive, crises; external versus internal shocks and the framing of the source of shocks; how crisis affect the pace of innovation and change; the role of diversity in organizational responses to crises; and a set of methodological opportunities to leverage natural experiments or simulations in ways that allow for longitudinal data illuminating the full cycle of crises across organizations from anticipation, to response, to longer-term adaptation to the new normal.

Structural quality of labor and delivery care in government hospitals of Ethiopia: a descriptive analysis

Background

Ethiopia has low skilled birth attendance rates coupled with low quality of care within health facilities contributing to one of the highest maternal mortality rates in Sub-Saharan Africa, at 412 deaths per 100,000 live births. There is lack of evidence on the readiness of health facilities to deliver quality labor and delivery (L&D) care. This paper describes the structural quality of routine L&D care in government hospitals of Ethiopia.

Methods

A facility-based cross-sectional study design, involving census of all government hospitals in Southern Nations Nationalities and People’s Region (SNNPR) (N = 20) was conducted in November 2016 through facility audit using a structured checklist. Data collectors verified the availability and functioning of the required items through observation and interview with the heads of labor and delivery case team. An overall mean score of structural quality was calculated considering domain scores such as general infrastructure, human resource and essential drugs, supplies, equipment and laboratory services. Summary statistics such as proportion, mean and standard deviation were computed to describe the degree of adherence of the hospitals to the standards related to structural quality of routine labor and delivery care.

Results

One third of hospitals had low readiness to provide quality routine L&D care, with only two approaching near fulfilment of all the standards. Hospitals had fulfilled 68.2% of the standards for the structural aspects of quality of L&D care. Of the facility audit criteria, the availability of essential equipment and supplies for infection prevention scored the highest (88.8%), followed by safety, comfort and woman friendliness of the environment (76.4%). Availability skilled health professionals and quality management practices scored 72.5% each, while availability of the required items of general infrastructure was 64.6%. The two critical domains with the lowest score were availability of essential drugs, supplies and equipment (52.2%); and laboratory services and safe blood supply (50%).

Conclusion

Substantial capacity gaps were observed in the hospitals challenging the provision of quality routine L&D care services, with only two thirds of required resources available. The largest gaps were in laboratory services and safe blood, and essential drugs, supplies and equipment. The results suggest the need to ensure that all public hospitals in SNNPR meet the required structure to enable the provision of quality routine L&D care with emphases on the identified gaps.

Diversity, Inclusive Leadership, and Health Outcomes

In this time of polarization and divisiveness across increasingly diverse communities, health policy and management research offers an important insight: engaging diversity meaningfully through inclusive leadership—that embraces staff across hierarchies and engages difference perspectives so that all healthcare workers of all kinds feel they can speak up and participate—can save lives. In multiple studies of quality in cardiovascular care, top performing hospitals have been shown to exhibit the capacity to embrace staff across hierarchies and engage differences so that healthcare workers of all kinds feel they can speak up and participate meaningfully in improvement efforts. Most recently, in the two-year, longitudinal Leadership Saves Lives study of 10 hospitals, the ability to adopt a culture of improvement rather than blaming was linked to significant reductions in risk-standardized mortality rates. Moreover, the guiding coalitions (ie, quality improvement teams) in six of the 10 hospitals that were most successful were distinguished in three ways that give insight about effective modes of engaging differences: (1) including staff from difference disciplines and levels in the organizational hierarchy, (2) encouraging authentic participation by the members, and (3) using constructive patterns of managing conflict (ie, having clear role definitions, working to surface minority viewpoints, and collectively revisiting the shared goal of saving lives). Based on this literature, adequately engaging a wide range of diverse viewpoints and staff roles can have a marked impact on health outcomes. Although the studies reviewed do not examine racial/ethnic diversity per se, they do lend insight into effectively navigating environments with extensive diversity of perspectives, professional identities, and experiences. Future research may assess whether these insights have application to other forms of diversity as well. In this time of extreme polarization and division globally and locally, health policy and management research has an opportunity to share evidence that could help navigate an increasingly diverse environment, at least within the field of healthcare, towards a more inclusive, humane, and life-giving approach to our collective future.

Attitudes about Care at the End of Life among Clinicians: A Quick, Reliable, and Valid Assessment Instrument

Several initiatives to improve care at the end of life involve educational programs to influence clinicians’ attitudes about care for patients with terminal illnesses. The objective of this research was to develop and test a short and easily administered instrument for measuring physicians’ and nurses’ attitudes towards care at the end of life. The instrument was tested using a cross-sectional study of 50 clinicians (25 physicians and 25 nurses) from general medicine, cardiology, oncology, and geriatric medicine. Both reliability and validity were assessed, and the instrument was found to have acceptable test-retest reliability and construct validity. Such an assessment instrument may be useful in evaluating the impact of initiatives to modify attitudes towards terminal care and in improving the quality of care at the end of life.

Referral of Terminally Ill Patients for Hospice: Frequency and Correlates

Background

Despite the central role of hospice in end-of-life care, little is known about the proportion of terminally ill patients referred for hospice and the physician factors associated with hospice referral.

Methods

Cross-sectional data from a self-administered survey of 231 physicians were used to estimate the proportion of terminally ill patients who were referred for hospice and to assess the independent effects of physician factors on hospice referral.

Results

On average, physicians reported referring about 55% of their terminally ill patients for hospice; 26.7% of the physicians referred less than one quarter of their terminally ill patients. Physician specialty, board certification, and physicians’ knowledge level about hospice were independently associated with the proportions of terminally ill patients referred for hospice.

Conclusion

Many terminally ill patients are not referred for hospice care and physician factors influence the use of hospice significantly. The study suggests effective factors and groups to target with interventions to enhance the appropriate use of hospice.

District-level health management and health system performance

Strengthening district-level management may be an important lever for improving key public health outcomes in low-income settings; however, previous studies have not established the statistical associations between better management and primary healthcare system performance in such settings. To explore this gap, we conducted a cross-sectional study of 36 rural districts and 226 health centers in Ethiopia, a country which has made ambitious investment in expanding access to primary care over the last decade. We employed quantitative measure of management capacity at both the district health office and health center levels and used multiple regression models, accounting for clustering of health centers within districts, to estimate the statistical association between management capacity and a key performance indicator (KPI) summary score based on antenatal care coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. In districts with above median district management capacity, health center management capacity was strongly associated (p < 0.05) with KPI performance. In districts with below median management capacity, health center management capacity was not associated with KPI performance. Having more staff at the district health office was also associated with better KPI performance (p < 0.05) but only in districts with above median management capacity. The results suggest that district-level management may provide an opportunity for improving health system performance in low-income country settings.

Association Between Community Social Capital and Hospital Readmission Rates

Hospital readmissions remain frequent, and are partly attributable to patients' social needs. The authors sought to examine whether local community levels of social capital are associated with hospital readmission rates. Social capital refers to the connections among members of a society that foster norms of reciprocity and trust, which may influence the availability of support for postdischarge recovery after hospitalization. Associations between hospital-wide, risk-stratified readmission rates for hospitals in the United States (n = 4298) and levels of social capital in the hospitals' service areas were examined. Social capital was measured by an index of participation in associational activities and civic affairs. A multivariate linear regression model was used to adjust for hospital and community factors such as hospital financial performance, race, income, and availability of heath care services. Results showed that higher social capital was significantly associated with lower readmission rates (P < .01), a finding that held across income-stratified analyses as well as sensitivity analyses that included hospital performance on process quality measures and hospital community engagement activities. A hospital is unlikely to be able to influence prevailing levels of social capital in its region, but in areas of low social capital, it may be possible for public or philanthropic sectors to buttress the types of institutions that address nonmedical causes of readmission.

Unit Costing of Health Extension Worker Activities in Ethiopia: A Model for Managers at the District and Health Facility Level

Background: Over the last decade, Ethiopia has made impressive national improvements in health outcomes, including reductions in maternal, neonatal, infant, and child mortality attributed in large part to their Health Extension Program (HEP). As this program continues to evolve and improve, understanding the unit cost of health extension worker (HEW) services is fundamental to planning for future growth and ensuring adequate financial support to deliver effective primary care throughout the country.

Methods: We sought to examine and report the data needed to generate a HEW fee schedule that would allow for full cost recovery for HEW services. Using HEW activity data and estimates from national studies and local systems we were able to estimate salary costs and the average time spent by an HEW per patient/community encounter for each type of services associated with specific users. Using this information, we created separate fee schedules for activities in urban and rural settings with two estimates of non-salary multipliers to calculate the total cost for HEW services.

Results: In the urban areas, the HEW fees for full cost recovery of the provision of services (including salary, supplies, and overhead costs) ranged from 55.1 birr to 209.1 birr per encounter. The rural HEW fees ranged from 19.6 birr to 219.4 birr.

Conclusion: Efforts to support health system strengthening in low-income settings have often neglected to generate adequate, actionable data on the costs of primary care services. In this study, we have combined time-motion and available financial data to generate a fee schedule that allows for full cost recovery of the provision of services through billable health education and service encounters provided by Ethiopian HEWs. This may be useful in other country settings where managers seek to make evidence-informed planning and resource allocation decisions to address high burden of disease within the context of weak administrative data systems and severe financial constraints.

Variation In Health Outcomes: The Role Of Spending On Social Services, Public Health, And Health Care, 2000-09

Although spending rates on health care and social services vary substantially across the states, little is known about the possible association between variation in state-level health outcomes and the allocation of state spending between health care and social services. To estimate that association, we used state-level repeated measures multivariable modeling for the period 2000-09, with region and time fixed effects adjusted for total spending and state demographic and economic characteristics and with one- and two-year lags. We found that states with a higher ratio of social to health spending (calculated as the sum of social service spending and public health spending divided by the sum of Medicare spending and Medicaid spending) had significantly better subsequent health outcomes for the following seven measures: adult obesity; asthma; mentally unhealthy days; days with activity limitations; and mortality rates for lung cancer, acute myocardial infarction, and type 2 diabetes. Our study suggests that broadening the debate beyond what should be spent on health care to include what should be invested in health-not only in health care but also in social services and public health-is warranted.

Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study

BACKGROUND

Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced.

METHODS

This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services.

RESULTS

We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011-2014 and 2012-2015.

CONCLUSIONS

Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.

Links between social environment and health care utilization and costs

The social environment influences health outcomes for older adults and could be an important target for interventions to reduce costly medical care. We sought to understand which elements of the social environment distinguish communities that achieve lower health care utilization and costs from communities that experience higher health care utilization and costs for older adults with complex needs. We used a sequential explanatory mixed methods approach. We classified community performance based on three outcomes: rate of hospitalizations for ambulatory care sensitive conditions, all-cause risk-standardized hospital readmission rates, and Medicare spending per beneficiary. We conducted in-depth interviews with key informants (N = 245) from organizations providing health or social services. Higher performing communities were distinguished by several aspects of social environment, and these features were lacking in lower performing communities: 1) strong informal support networks; 2) partnerships between faith-based organizations and health care and social service organizations; and 3) grassroots organizing and advocacy efforts. Higher performing communities share similar social environmental features that complement the work of health care and social service organizations. Many of the supportive features and programs identified in the higher performing communities were developed locally and with limited governmental funding, providing opportunities for improvement.

How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study

Background

Quality collaboratives are widely endorsed as a potentially effective method for translating and spreading best practices for acute myocardial infarction (AMI) care. Nevertheless, hospital success in improving performance through participation in collaboratives varies markedly. We sought to understand what distinguished hospitals that succeeded in shifting culture and reducing 30-day risk-standardised mortality rate (RSMR) after AMI through their participation in the Leadership Saves Lives (LSL) collaborative.

Procedures

We conducted a longitudinal, mixed methods intervention study of 10 hospitals over a 2-year period; data included surveys of 223 individuals (response rates 83%–94% depending on wave) and 393 in-depth interviews with clinical and management staff most engaged with the LSL intervention in the 10 hospitals. We measured change in culture and RSMR, and key aspects of working related to team membership, turnover, level of participation and approaches to conflict management.

Main findings

The six hospitals that experienced substantial culture change and greater reductions in RSMR demonstrated distinctions in: (1) effective inclusion of staff from different disciplines and levels in the organisational hierarchy in the team guiding improvement efforts (referred to as the ‘guiding coalition’ in each hospital); (2) authentic participation in the work of the guiding coalition; and (3) distinct patterns of managing conflict. Guiding coalition size and turnover were not associated with success (p values>0.05). In the six hospitals that experienced substantial positive culture change, staff indicated that the LSL learnings were already being applied to other improvement efforts.

Principal conclusions

Hospitals that were most successful in a national quality collaborative to shift hospital culture and reduce RSMR showed distinct patterns in membership diversity, authentic participation and capacity for conflict management.

Ethiopia's health extension workers use of work time on duty: time and motion study

Ethiopia implemented an innovative community-based health program, called the health extension program, to enhance access to basic health promotion, disease prevention and selected curative services by establishing health posts in every village, also called kebeles, with average of 5000 people, staffed with two health extension workers (HEWs). This time and motion study was done to estimate the amount of time that HEWs spend on various work duties and to explore differences in urban compared with rural settings and among regions. A total of 44 HEWs were observed for 21 consecutive days, and time and motion data were collected using tablet computers. On average, HEWs were on duty for 15.5 days out of the 21 days of observation period, and on average, they stayed on duty for about 6 hours per day. Out of the total observed work time, the percentages of total time spent on various activities were as follows: providing health education or services (12.8%); participating in meetings and giving trainings (9.3%); conducting community mapping and mobilization (0.8%); recordkeeping, reporting, managing family folders (13.2%); managing commodities and supplies (1.3%); receiving supervision (3.2%); receiving training (1.6%); travel between work activities (15.5%); waiting for clients in the health post (or health centre in urban settings) (24.9%); building relationships in the community (13.3%); and other activities that could not be meaningfully categorized (4%). The proportion of time spent on different activities and the total time worked varied significantly between rural and urban areas and among the regions (at P < 0.05). Findings of this study indicate that only a minority of HEW time is spent on providing health education and services, and substantial time is spent waiting for clients. The efficiency of the HEW model may be improved by creating more demand for services or by redesigning service delivery modalities.

Development and Psychometric Properties of a Scale to Measure Hospital Organizational Culture for Cardiovascular Care

BACKGROUND

Because organizational culture is increasingly understood as fundamental to achieving high performance in hospital and other healthcare settings, the ability to measure this nuanced concept empirically has gained importance. Aside from measures of patient safety culture, no measure of organizational culture has been widely endorsed in the medical literature, limiting replication of previous findings and broader use in interventional studies.

METHODS AND RESULTS

We sought to develop and assess the validity and reliability of a scale for assessing organizational culture in the context of hospitals' efforts to reducing 30-day risk-standardized mortality after acute myocardial infarction. The 31-item scale was completed by 147 individuals representing 10 hospitals during August and September 2014. The resulting organizational culture scale demonstrated high level of construct validity and internal consistency. Factor analyses indicated that the 31 items loaded well (loading values 0.48-0.90), supporting distinguishable domains of (1) learning environment, (2) psychological safety, (3) commitment to the organization, (4) senior management support, and (5) time for improvement efforts. Cronbach α coefficients were 0.94 for the scale and ranged from 0.77 to 0.88 for the subscales. The scale displayed reasonable convergent validity and statistically significant variability across hospitals, with hospital identity accounting for 11.3% of variance in culture scores across respondents.

CONCLUSIONS

We developed and validated a relatively easy-to-administer survey that was able to detect substantial variability in organizational culture across different hospitals and may be useful in measuring hospital culture and evaluating changes in culture over time as part performance improvement efforts.

Spending on social and public health services and its association with homicide in the USA: an ecological study

OBJECTIVE

To examine whether state-level spending on social and public health services is associated with lower rates of homicide in the USA.

DESIGN

Ecological study.

SETTING

USA.

PARTICIPANTS

All states in the USA and the District of Columbia for which data were available (n=42).

PRIMARY OUTCOME MEASURE

Homicide rates for each state were abstracted from the US Department of Justice Federal Bureau of Investigation's Uniform Crime Reporting.

RESULTS

After adjusting for potential confounding variables, we found that every $10 000 increase in spending per person living in poverty was associated with 0.87 fewer homicides per 100 000 population or approximately a 16% decrease in the average homicide rate (estimate=-0.87, SE=0.15, p<0.001). Furthermore, there was no significant effect in the quartile of states with the highest percentages of individuals living in poverty but significant effects in the quartiles of states with lower percentages of individuals living in poverty.

CONCLUSIONS

Based on our findings, spending on social and public health services is associated with significantly lower homicide rates at the state level. Although we cannot infer causality from this research, such spending may provide promising avenues for homicide reduction in the USA, particularly among states with lower levels of poverty.

Professionalizing Healthcare Management: A Descriptive Case Study

Despite international recognition of the importance of healthcare management in the development of high-performing systems, the path by which countries may develop and sustain a professional healthcare management workforce has not been articulated. Accordingly, we sought to identify a set of common themes in the establishment of a professional workforce of healthcare managers in low- and middle-income country (LMIC) settings using a descriptive case study approach. We draw on a historical analysis of the development of this profession in the United States and Ethiopia to identify five common themes in the professionalization of healthcare management: (1) a country context in which healthcare management is demanded; (2) a national framework that elevates a professional management role; (3) standards for healthcare management, and a monitoring function to promote adherence to standards; (4) a graduatelevel educational path to ensure a pipeline of well-prepared healthcare managers; and (5) professional associations to sustain and advance the field. These five components can to inform the creation of a long-term national strategy for the development of a professional cadre of heathcare managers in LMIC settings.

Patterns of Collaboration among Health Care and Social Services Providers in Communities with Lower Health Care Utilization and Costs

OBJECTIVE

To understand how health care providers and social services providers coordinate their work in communities that achieve relatively low health care utilization and costs for older adults.

STUDY SETTING

Sixteen Hospital Service Areas (HSAs) in the United States.

STUDY DESIGN

We conducted a qualitative study of HSAs with performance in the top or bottom quartiles nationally across three key outcomes: ambulatory care sensitive hospitalizations, all-cause risk-standardized readmission rates, and average reimbursements per Medicare beneficiary. We selected 10 higher performing HSAs and six lower performing HSAs for inclusion in the study.

DATA COLLECTION

To understand patterns of collaboration in each community, we conducted site visits and in-depth interviews with a total of 245 representatives of health care organizations, social service agencies, and local government bodies.

PRINCIPAL FINDINGS

Organizations in higher performing communities regularly worked together to identify challenges faced by older adults in their areas and responded through collective action-in some cases, through relatively unstructured coalitions, and in other cases, through more hierarchical configurations. Further, hospitals in higher performing communities routinely matched patients with needed social services.

CONCLUSIONS

The collaborative approaches used by higher performing communities, if spread, may be able to improve outcomes elsewhere.

Association between Hospice Spending on Patient Care and Rates of Hospitalization and Medicare Expenditures of Hospice Enrollees

BACKGROUND

Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice.

OBJECTIVE

To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees.

DESIGN

Longitudinal, observational cohort study (2008-2010).

SETTING/SUBJECTS

Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355).

MEASUREMENTS

We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures.

RESULTS

Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices.

CONCLUSIONS

Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

Maternal and neonatal services in Ethiopia: measuring and improving quality

Problem

Maternal and neonatal mortality remains high in low- and middle-income countries, with poor quality of intrapartum care as a barrier to further progress.

Approach

We developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intrapartum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services.

Local setting

Ethiopia has invested in hospital quality improvement for more than a decade and this tool was integrated into existing quality improvement mechanisms within lead hospitals, with the potential for scale-up to all government hospitals.

Relevant changes

Significant improvements in quality of intrapartum care were detected from baseline (June–July 2015) to follow-up (February–March 2016) in targeted hospitals. The overall mean quality score rose from 65.6 (standard deviation, SD: 10.5) to 91.2 (SD: 12.4) out of 110 items (P < 0.001).

Lessons learnt

The method was feasible, requiring a total of 3 days and two to three trained data collectors per hospital visit. It produced data that detected substantial changes made during 8 months of national hospital quality improvement efforts. With additional replication studies, this tool may be useful in other low- and middle-income countries.

American health care paradox-high spending on health care and poor health

BACKGROUND

For decades, US taxpayers have been lamenting the high cost of health care. Since the mid-1980s, Americans have had double-digit spending on health care. Despite this investment, Americans are less healthy than their European and Scandinavian counterparts across an array of health measures.

AIM

We sought to explore how inadequate attention to the social, behavioral and environmental determinants of health may contribute to the American health care paradox of high health care spending and poor health outcomes.

DESIGN

Mixed methods.

METHODS

We report previous findings related from a 10-year analysis of national-level health and social service spending and health outcome data from the Organization of Economic and Cooperation and Development (OECD). We also put forth case studies representing different socioeconomic strata to illustrate the relationship between health care and social service spending and health.

RESULTS

Although the US spending more of its GDP on health care than any other country, it is not a high spender when one sums spending on both health care and social services. The U.S. however has the lowest ratio of our social service spending to health care spending in the OECD, and countries with lower ratios on average have worse health outcomes. Cases from diverse socioeconomic strata demonstrate how limited attention to the social determinants of health can result in extremely high health care costs and poor health outcomes.

CONCLUSIONS

Greater investment in addressing the social, behavioral and environmental determinants of health may foster better health without accelerating health care costs in America.

Community factors related to healthy eating & active living in counties with lower than expected adult obesity rates

Background

Adult obesity rates in the United States have reached epidemic proportions, yet vary considerably across states and counties. We sought to explore community-level factors that may be associated with reduced adult obesity rates at the county level.

Methods

We identified six U.S. counties that were positive deviants for adult obesity and conducted semi-structured interviews with community leaders and government officials involved in efforts to promote healthier lifestyles. Using site visits and in-depth qualitative interviews, we identified several recurrent themes and strategies.

Results

Participants: 1) developed a nuanced understanding of their communities; 2) recognized the complex nature of obesity, and 3) implemented a county-wide strategic approach for promoting healthy living. This county-wide approachwas used to a) break down silos and build partnerships, b) access community resources and connections, and c) transfer ownership to community members.

Conclusions

We found that county leaders focused on establishing a county-wide structure to connect and support community-led initiatives to promote healthy living, reduce obesity, and foster sustainability. Findings from this study can help inform county-level efforts to improve healthy living and combat the multi-faceted challenges of adult obesity across the U.S.

Prayer Camps and Biomedical Care in Ghana: Is Collaboration in Mental Health Care Possible?

Background

Experts have suggested that intersectoral partnerships between prayer camps and biomedical care providers may be an effective strategy to address the overwhelming shortage of mental health care workers in Africa and other low-income settings. Nevertheless, previous studies have not explored whether the prayer camp and biomedical staff beliefs and practices provide sufficient common ground to enable cooperative relationships. Therefore, we sought to examine the beliefs and practices of prayer camp staff and the perspective of biomedical care providers, with the goal of characterizing interest in—and potential for—intersectoral partnership between prayer camp staff and biomedical care providers.

Methods

We conducted 50 open-ended, semi-structured interviews with prophets and staff at nine Christian prayer camps in Ghana, and with staff within Ghana’s three public psychiatric hospitals. We used the purposive sampling method to recruit participants and the constant comparative method for qualitative data analysis.

Results

Prayer camp staff expressed interest in collaboration with biomedical mental health care providers, particularly if partnerships could provide technical support introducing medications in the prayer camp and address key shortcomings in their infrastructure and hygienic conditions. Nevertheless, challenges for collaboration were apparent as prayer camp staff expressed strong beliefs in a spiritual rather than biomedical explanatory model for mental illness, frequently used fasting and chained restraints in the course of treatment, and endorsed only short-term use of medication to treat mental illness—expressing concerns that long-term medication regimens masked underlying spiritual causes of illness. Biomedical providers were skeptical about the spiritual interpretations of mental illness held by faith healers, and were concerned by the use of chains, fasting, and the lack of adequate living facilities for patients in prayer camps; many, however, expressed interest in engaging with prayer camps to expand access to clinical care for patients residing in the camps.

Conclusions

The findings demonstrate that biomedical care providers are interested in engaging with prayer camps. Key areas where partnerships may best improve conditions for patients at prayer camps include collaborating on creating safe and secure physical spaces and delivering medication for mental illness to patients living in prayer camps. However, while prayer camp staff are willing to engage biomedical knowledge, deeply held beliefs and routine practices of faith and biomedical healers are difficult to reconcile Additional discussion is needed to find the common ground on which the scarce resources for mental health care in Ghana can collaborate most effectively.

Leveraging the Social Determinants of Health: What Works?

We summarized the recently published, peer-reviewed literature that examined the impact of investments in social services or investments in integrated models of health care and social services on health outcomes and health care spending. Of 39 articles that met criteria for inclusion in the review, 32 (82%) reported some significant positive effects on either health outcomes (N = 20), health care costs (N = 5), or both (N = 7). Of the remaining 7 (18%) studies, 3 had non-significant results, 2 had mixed results, and 2 had negative results in which the interventions were associated with poorer health outcomes. Our analysis of the literature indicates that several interventions in the areas of housing, income support, nutrition support, and care coordination and community outreach have had positive impact in terms of health improvements or health care spending reductions. These interventions may be of interest to health care policymakers and practitioners seeking to leverage social services to improve health or reduce costs. Further testing of models that achieve better outcomes at less cost is needed.

Interventions for Reducing Hospital Readmission Rates: The Role of Hospice and Palliative Care

Background:

Despite evidence that enrollment with hospice services has the potential to reduce hospital readmission rates, previous research has not examined exactly how hospitals may promote the appropriate use of hospice and palliative care for their discharged patients. Therefore, we sought to explore the strategies used by hospitals to increase the use of hospice and palliative care for patients at risk of readmission.

Methods:

We conducted a secondary analysis of qualitative data from a study of hospitals that were participating in the State Action on Avoidable Readmissions (STAAR) initiative, a quality improvement collaborative. We used data attained from 46 in-depth interviews conducted during 10 hospital site visits using a standard discussion guide and protocol. We used a grounded theory approach using the constant comparative method to generate recurrent and unifying themes.

Results:

We found that a positive effect for hospitals participating in the STAAR initiative was enhanced engagement in efforts to promote greater use of hospice and palliative care as a possible method of reducing unplanned readmissions, the central goal of the STAAR initiative. Hospital staff described strategies to increase the use of hospice and palliative care that included (1) designing and implementing tracking systems to identify patients most at risk of being readmitted, (2) providing education about hospice and palliative care to family, internal and external clinical groups, and (3) establishing closer links to posthospital settings.

Conclusion:

National efforts to reduce rehospitalizations may result in improved integration of hospice and palliative care for patients who are at risk of readmission.

Use of a national collaborative to improve hospital quality in a low-income setting

Background

Quality improvement collaboratives are a widely used mechanism to improve hospital performance in high-income settings, but we lack evidence about their effectiveness in low-income settings.

Methods

We conducted cross-sectional and longitudinal analysis of data from the Ethiopian Hospital Alliance for Quality, a national collaborative sponsored by Ethiopia's Federal Ministry of Health. We identified hospital strategies associated with more positive patient satisfaction using linear regression and assessed changes in patient experience over a 3-year period (2012–2014) using matched t-tests.

Results

A total of 68 hospitals (response rate 68/120, 56.7%) were included in cross-sectional analysis. Four practices were significantly associated with more positive patient satisfaction (p<0.05): posting a record of cleaning activity in toilets and in patient wards, distributing leaflets in the local language with each prescription, and sharing ideas about patient experience across the hospital. Among hospitals that had complete data for longitudinal analysis (44/68, 65%), we found a 10% improvement in a 10-point measure of patient satisfaction (7.7 vs 8.4, p<0.01) from the start to the end of the study period.

Conclusions

Quality improvement collaboratives can be useful at scale in low-income settings in sub-Saharan Africa, particularly for hospitals that adopt strategies associated with patient satisfaction.

Trends in end-of-life cancer care in the Medicare program

OBJECTIVES

To examine contemporary trends in end-of-life cancer care and geographic variation of end-of-life care aggressiveness among Medicare beneficiaries.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare data, we identified 132,051 beneficiaries who died as a result of cancer in 2006-2011. Aggressiveness of end-of-life care was measured by chemotherapy received within 14 days of death, >1 emergency department (ED) visit within 30 days of death, >1 hospitalization within 30 days of death, ≥1 intensive care unit (ICU) admission within 30 days of death, in-hospital death, or hospice enrollment ≤3 days before death. Using hierarchical generalized linear models, we assessed potentially aggressive end-of-life care adjusting for patient demographics, tumor characteristics, and hospital referral region (HRR)-level market factors.

RESULTS

The proportion of beneficiaries receiving at least one potentially aggressive end-of-life intervention increased from 48.6% in 2006 to 50.5% in 2011 (P<.001). From 2006 to 2011, increases were apparent in repeated hospitalization (14.1% vs. 14.8%; P=.01), repeated ED visits (34.3% vs. 36.6%; P<.001), ICU admissions (16.2% vs. 21.3%; P<.001), and late hospice enrollment (11.2% vs. 12.9%; P<.001), whereas in-hospital death declined (23.5% vs. 20.9%; P<.001). End-of-life chemotherapy use (4.4% vs. 4.5%) did not change significantly over time (P=.12). The use of potentially aggressive end-of-life care varied substantially across HRRs, ranging from 40.3% to 58.3%. Few HRRs had a decrease in aggressive end-of-life care during the study period.

CONCLUSIONS

Despite growing focus on providing appropriate end-of-life care, there has not been an improvement in aggressive end-of-life cancer care in the Medicare program.

Integrating new practices: a qualitative study of how hospital innovations become routine

Background

Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs.

Methods

We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n = 7) or deteriorated (n = 3) over the course of the first 2 years of the STAAR initiative (2010–2011 to 2011–2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes.

Results

When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks.

Conclusions

Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations.

A national system for monitoring the performance of hospitals in Ethiopia

Many countries struggle to develop and implement strategies to monitor hospitals nationally. The challenge is particularly acute in low-income countries where resources for measurement and reporting are scarce. We examined the experience of developing and implementing a national system for monitoring the performance of 130 government hospitals in Ethiopia. Using participatory observation, we found that the monitoring system resulted in more consistent hospital reporting of performance data to regional health bureaus and the federal government, increased transparency about hospital performance and the development of multiple quality-improvement projects. The development and implementation of the system, which required technical and political investment and support, would not have been possible without strong hospital-level management capacity. Thorough assessment of the health sector’s readiness to change and desire to prioritize hospital quality can be helpful in the early stages of design and implementation. This assessment may include interviews with key informants, collection of data about health facilities and human resources and discussion with academic partners. Aligning partners and donors with the government’s vision for quality improvement can enhance acceptability and political support. Such alignment can enable resources to be focused strategically towards one national effort – rather than be diluted across dozens of potentially competing projects. Initial stages benefit from having modest goals and the flexibility for continuous modification and improvement, through active engagement with all stakeholders.

Implementing Role-Changing Versus Time-Changing Innovations in Health Care

Health care organizations often fail in their effort to implement care-improving innovations. This article differentiates role-changing innovations, altering what workers do, from time-changing innovations, altering when tasks are performed or for how long. We examine our hypothesis that the degree to which access to groups that can alter organizational learning—staff, management, and external network—facilitates implementation depends on innovation type. Our longitudinal study using ordinal logistic regression and survey data on 517 hospitals’ implementation of evidence-based practices for treating heart attack confirmed our thesis for factors granting access to each group: improvement team’s representativeness (of affected staff), senior management engagement, and network membership. Although team representativeness and network membership were positively associated with implementing role-changing practices, senior management engagement was not. In contrast, senior management engagement was positively associated with implementing time-changing practices, whereas team representativeness was not, and network membership was not unless there was limited management engagement. These findings advance implementation science by explaining mixed results across past studies: Nature of change for workers alters potential facilitators’ effects on implementation.

Massage, Music, and Art Therapy in Hospice: Results of a National Survey

CONTEXT

Complementary and alternative medicine (CAM) provides clinical benefits to hospice patients, including decreased pain and improved quality of life. Yet little is known about the extent to which U.S. hospices employ CAM therapists.

OBJECTIVES

To report the most recent national data regarding the inclusion of art, massage, and music therapists on hospice interdisciplinary teams and how CAM therapist staffing varies by hospice characteristics.

METHODS

A national cross-sectional survey of a random sample of hospices (n = 591; 84% response rate) from September 2008 to November 2009.

RESULTS

Twenty-nine percent of hospices (169 of 591) reported employing an art, massage, or music therapist. Of those hospices, 74% employed a massage therapist, 53% a music therapist, and 22% an art therapist, and 42% expected the therapist to attend interdisciplinary staff meetings, indicating a significant role for these therapists on the patient's care team. In adjusted analyses, larger hospices compared with smaller hospices had significantly higher odds of employing a CAM therapist (adjusted odds ratio 6.38; 95% CI 3.40, 11.99) and for-profit hospices had lower odds of employing a CAM therapist compared with nonprofit hospices (adjusted odds ratio 0.52; 95% CI 0.32, 0.85). Forty-four percent of hospices in the Mountain/Pacific region reported employing a CAM therapist vs. 17% in the South Central region.

CONCLUSION

Less than one-third of U.S. hospices employ art, massage, or music therapists despite the benefits these services may provide to patients and families. A higher proportion of large hospices, nonprofit hospices, and hospices in the Mountain/Pacific region employ CAM therapists, indicating differential access to these important services.

Management Matters: A Leverage Point for Health Systems Strengthening in Global Health

Despite a renewed focus in the field of global health on strengthening health systems, inadequate attention has been directed to a key ingredient of high-performing health systems: management. We aimed to develop the argument that management - defined here as the process of achieving predetermined objectives through human, financial, and technical resources - is a cross-cutting function necessary for success in all World Health Organization (WHO) building blocks of health systems strengthening. Management within health systems is particularly critical in low-income settings where the efficient use of scarce resources is paramount to attaining health goals. More generally, investments in management capacity may be viewed as a key leverage point in grand strategy, as strong management enables the achievement of large ends with limited means. We also sought to delineate a set of core competencies and identify key roles to be targeted for management capacity building efforts. Several effective examples of management interventions have been described in the research literature. Together, the existing evidence underscores the importance of country ownership of management capacity building efforts, which often challenge the status quo and thus need country leadership to sustain despite inevitable friction. The literature also recognizes that management capacity efforts, as a key ingredient of effective systems change, take time to embed, as new protocols and ways of working become habitual and integrated as standard operating procedures. Despite these challenges, the field of health management as part of global health system strengthening efforts holds promise as a fundamental leverage point for achieving health system performance goals with existing human, technical, and financial resources. The evidence base consistently supports the role of management in performance improvement but would benefit from additional research with improved methodological rigor and longer-time horizon investigations. Meanwhile, greater emphasis on management as a critical element of global health efforts may open new and sustainable avenues for advancing health systems performance.

State-level spending on health care and social services for people living with HIV/AIDS in the USA: a systematic review

Every year for the past decade, approximately 50,000 people have been diagnosed with HIV or AIDS in the USA, and the incidence of HIV/AIDS varies considerably from state to state. Studies have shown that health care services, most notably treatment with combination antiretroviral therapy, can help people living with HIV/AIDS (PLWHA) live healthier, longer lives, and prevent the spread of HIV from person to person. In addition, social services, such as housing support and provision of meals, have also shown to be important for helping PLWHA adhere to antiretroviral treatment and maintain contact with health care providers for improved health outcomes. Although spending on health care and social services for PLWHA varies across the USA, the relationship between state-level spending on these services and HIV/AIDS-related outcomes is not clear. We therefore conducted a systematic review of peer-reviewed literature to identify studies that explore state-level spending on health care services and/or social services for PLWHA and HIV/AIDS-related health outcomes in the USA.

Leadership development programs for physicians: a systematic review

BACKGROUND

Physician leadership development programs typically aim to strengthen physicians' leadership competencies and improve organizational performance. We conducted a systematic review of medical literature on physician leadership development programs in order to characterize the setting, educational content, teaching methods, and learning outcomes achieved.

METHODS

Articles were identified through a search in Ovid MEDLINE from 1950 through November 2013. We included articles that described programs designed to expose physicians to leadership concepts, outlined teaching methods, and reported evaluation outcomes. A thematic analysis was conducted using a structured data entry form with categories for setting/target group, educational content, format, type of evaluation and outcomes.

RESULTS

We identified 45 studies that met eligibility criteria, of which 35 reported on programs exclusively targeting physicians. The majority of programs focused on skills training and technical and conceptual knowledge, while fewer programs focused on personal growth and awareness. Half of the studies used pre/post intervention designs, and four studies used a comparison group. Positive outcomes were reported in all studies, although the majority of studies relied on learner satisfaction scores and self-assessed knowledge or behavioral change. Only six studies documented favorable organizational outcomes, such as improvement in quality indicators for disease management. The leadership programs examined in these studies were characterized by the use of multiple learning methods, including lectures, seminars, group work, and action learning projects in multidisciplinary teams.

DISCUSSION

Physician leadership development programs are associated with increased self-assessed knowledge and expertise; however, few studies have examined outcomes at a system level. Our synthesis of the literature suggests important gaps, including a lack of programs that integrate non-physician and physician professionals, limited use of more interactive learning and feedback to develop greater self-awareness, and an overly narrow focus on individual-level rather than system-level outcomes.

Abstract 120: Organizational Culture Change to Reduce 30-day Mortality in Patients With Acute Myocardial Infarction: A Mixed Methods Study

Background: Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospitals, clinicians, and policymakers. Evidence suggests hospital organizational culture is linked to patient outcomes; however, few studies have attempted to change organizational culture in order to improve patient outcomes, and none have addressed mortality for patients with AMI. We seek to address these gaps through a novel longitudinal intervention study, Leadership Saves Lives (LSL). We hypothesize that we will observe: 1) positive shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) increased use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) reduced in-hospital AMI mortality.

Methodology and Results: We describe the methodology of LSL, a 3-year intervention study using a concurrent mixed methods design, guided by open systems theory and the AIDED model of diffusion, implemented in a national sample of 10 diverse U.S. hospitals and hospitals in their peer networks. Intervention hospital teams participate in: 1) annual convenings of the 10 hospitals; 2) semiannual workshops at each intervention hospital; and 3) a web-based learning community that includes a discussion board and a repository for resources and tools. We describe features of program design that allow us to promote and measure intervention fidelity, while also allowing for tailoring of the intervention to the unique local context in each hospital. We quantify changes in hospital practices, culture, and mortality through annual surveys of both intervention hospitals in their peer networks. In-person, in-depth interviews and selective observations of key interactions in care for patients with AMI allow us to describe the change process. The intervention began with an annual meting of the 10 intervention hospitals in June 2014. The first wave of survey data collection, hospital-specific workshops and qualitative data collection were completed between September and November 2014.

Conclusions: LSL is novel in its use of a prospective longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, its attention to maintaining fidelity of the intervention across diverse hospital settings, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This study adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change, with direct impact on patients with AMI.

Hospital strategy uptake and reductions in unplanned readmission rates for patients with heart failure: a prospective study

BACKGROUND

Despite recent reductions in national unplanned readmission rates, we have relatively little understanding of which hospital strategies are most associated with changes in risk-standardized readmission rates (RSRR).

OBJECTIVE

We examined associations between the change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies over 12-18 months in a national sample of hospitals.

DESIGN

We conducted a prospective study of hospitals using a Web-based survey at baseline (November 2010-May 2011, n = 599, 91.0% response rate) and 12-18 months later (November 2011-October 2012, n = 501, 83.6% response rate), with RSRR measured at the same time points. The final analytic sample included 478 hospitals.

PARTICIPANTS

The study included hospitals participating in the Hospital-to-Home (H2H) and State Action on Avoidable Rehospitalizations (STAAR) initiatives.

MAIN MEASURES

We examined associations between change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies previously demonstrated to have increased between baseline and follow-up, using unadjusted and adjusted linear regression.

KEY RESULTS

The average number of strategies taken up from baseline to follow-up was 1.6 (SE = 0.06); approximately one-quarter (25.3%) of hospitals took up at least three new strategies. Hospitals that adopted the strategy of routinely discharging patients with a follow-up appointment already scheduled experienced significant reductions in RSRR (reduction of 0.63 percentage point, p value < 0.05). Hospitals that took up three or more strategies had significantly greater reductions in RSRR compared to hospitals that took up only zero to two strategies (reduction of 1.29 versus 0.57 percentage point, p value < 0.05). Among the 117 hospitals that took up three or more strategies, 93 unique combinations of strategies were used.

CONCLUSIONS

Although most individual strategies were not associated with RSRR reduction, hospitals that took up any three or more strategies showed significantly greater reduction in RSRR compared to hospitals that took up fewer than three strategies.

Violence against Congolese refugee women in Rwanda and mental health: a cross-sectional study using latent class analysis

OBJECTIVE

To examine patterns of conflict-related violence and intimate partner violence (IPV) and their associations with emotional distress among Congolese refugee women living in Rwanda.

DESIGN

Cross-sectional study.

SETTING

Two Congolese refugee camps in Rwanda.

PARTICIPANTS

548 ever-married Congolese refugee women of reproductive age (15-49 years) residing in Rwanda.

PRIMARY OUTCOME MEASURE

Our primary outcome was emotional distress as measured using the Self-Report Questionnaire-20 (SRQ-20). For analysis, we considered participants with scores greater than 10 to be experiencing emotional distress and participants with scores of 10 or less not to be experiencing emotional distress.

RESULTS

Almost half of women (49%) reported experiencing physical, emotional or sexual violence during the conflict, and less than 10% of women reported experiencing of any type of violence after fleeing the conflict. Lifetime IPV was reported by approximately 22% of women. Latent class analysis derived four distinct classes of violence experiences, including the Low All Violence class, the High Violence During Conflict class, the High IPV class and the High Violence During and After Conflict class. In multivariate regression models, latent class was strongly associated with emotional distress. Compared with women in the Low All Violence class, women in the High Violence During and After Conflict class and women in the High Violence During Conflict had 2.7 times (95% CI 1.11 to 6.74) and 2.3 times (95% CI 1.30 to 4.07) the odds of experiencing emotional distress in the past 4 weeks, respectively. Furthermore, women in the High IPV class had a 4.7 times (95% CI 2.53 to 8.59) greater odds of experiencing emotional distress compared with women in the Low All Violence class.

CONCLUSIONS

Experiences of IPV do not consistently correlate with experiences of conflict-related violence, and women who experience high levels of IPV may have the greatest likelihood for poor mental health in conflict-affected settings.

A mixed methods study of how clinician 'super users' influence others during the implementation of electronic health records

Background

Despite the potential for electronic health records (EHRs) to improve patient safety and quality of care, the intended benefits of EHRs are not always realized because of implementation-related challenges. Enlisting clinician super users to provide frontline support to employees has been recommended to foster EHR implementation success. In some instances, their enlistment has been associated with implementation success; in other cases, it has not. Little is known about why some super users are more effective than others. The purpose of this study was to identify super users’ mechanisms of influence and examine their effects on EHR implementation outcomes.

Methods

We conducted a longitudinal (October 2012 – June 2013), comparative case study of super users’ behaviors on two medical units of a large, academic hospital implementing a new EHR system. We assessed super users’ behaviors by observing 29 clinicians and conducting 24 in-depth interviews. The implementation outcome, clinicians’ information systems (IS) proficiency, was assessed using longitudinal survey data collected from 43 clinicians before and after the EHR start-date. We used multivariable linear regression to estimate the relationship between clinicians’ IS proficiency and the clinical unit in which they worked.

Results

Super users on both units employed behaviors that supported and hindered implementation. Four super user behaviors differed between the two units: proactivity, depth of explanation, framing, and information-sharing. The unit in which super users were more proactive, provided more comprehensive explanations for their actions, used positive framing, and shared information more freely experienced significantly greater improvement in clinicians’ IS proficiency (p =0.03). Use of the four behaviors varied as a function of super users’ role engagement, which was influenced by how the two units’ managers selected super users and shaped the implementation climate.

Conclusions

Super users’ behaviors in implementing EHRs vary substantively and can have important influence on implementation success.