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Manojlovich M, Bettencourt AP, Mangus CW, Parker SJ, Skurla SE, Walters HM, Mahajan P. Refining a Framework to Enhance Communication in the Emergency Department During the Diagnostic Process: An eDelphi Approach. Jt Comm J Qual Patient Saf 2024; 50:348-356. [PMID: 38423950 DOI: 10.1016/j.jcjq.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Emergency departments (EDs) are susceptible to diagnostic error. Suboptimal communication between the patient and the interdisciplinary care team increases risk to diagnostic safety. The role of communication remains underrepresented in existing diagnostic decision-making conceptual models. METHODS The authors used eDelphi methodology, whereby data are collected electronically, to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. This study examined the entire diagnostic process in the ED, from prehospital to discharge or transfer to inpatient care, and identified where communication breakdowns could occur. After four iterative rounds of the eDelphi process, including a final validation round by all participants, the project's a priori consensus threshold of 80% agreement was reached. RESULTS The authors developed a final framework that positions communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. Specific points in the ED journey were identified where more attention to communication might be helpful. Two specific types of communication-information exchange and shared understanding-were identified as high priority for optimal outcomes. Ideas for communication-focused interventions to prevent diagnostic error in the ED fell into three categories: patient-facing, clinician-facing, and system-facing interventions. CONCLUSION This project's refinement of the NASEM framework adapted to the ED can be used to develop communications-focused interventions to reduce diagnostic error in this highly complex and error-prone setting.
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Guetterman TC, Manojlovich M. Grand rounds in methodology: designing for integration in mixed methods research. BMJ Qual Saf 2024:bmjqs-2023-016112. [PMID: 38575310 DOI: 10.1136/bmjqs-2023-016112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
Mixed methods research is a popular approach used to understand persistent and complex problems related to quality and safety, such as reasons why interventions are not implemented as intended or explaining differential outcomes. However, the quality and rigour of mixed methods research proposals and publications often miss opportunities for integration, which is the core of mixed methods. Achieving integration remains challenging, and failing to integrate reduces the benefits of a mixed methods approach. Therefore, the purpose of this article is to guide quality and safety researchers in planning and designing a mixed methods study that facilitates integration. We highlight how meaningful integration in mixed methods research can be achieved by centring integration at the following levels: research question, design, methods, results and reporting and interpretation levels. A holistic view of integration through all these levels will enable researchers to provide better answers to complex problems and thereby contribute to improvement of safety and quality of care.
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Costa DK, Boltey EM, Mosley EA, Manojlovich M, Wright NC. Knowing your team in the intensive care unit: an ethnographic study on familiarity. J Interprof Care 2024:1-9. [PMID: 38517041 DOI: 10.1080/13561820.2024.2329968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/08/2024] [Indexed: 03/23/2024]
Abstract
Effective interprofessional team function is integral to high-quality care in the intensive care unit (ICU). However, little is known about how familiarity develops among teams, which may be an important antecedent to effective team function and quality care. To examine team familiarity and how it impacts ICU team function and care, we conducted an ethnographic study in four ICUs (two medical ICUs, one mixed medical-surgical ICU, and one surgical ICU) in two community hospitals and one academic medical center. We conducted 57.5 h of observation, 26 shadowing experiences, and 26 interviews across the four ICUs sequentially. We used thematic analysis to examine familiarity among the team. We found that ICU team members become familiar with their team through interpersonal, relational interactions, which involved communication, time working together, social interactions, trust, and respect. Our findings underscore the relational aspect of effective teams and demonstrate that time working together, social interactions, communication, developing trust, and respect are pathways to familiarity and optimal team function. Leveraging unique and creative ways to enhance the relational aspects of ICU teams could be an area for future research and lead to improved ICU outcomes.
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Affiliation(s)
- Deena Kelly Costa
- Yale School of Nursing, Yale University, Orange, CT, USA
- Yale School of Medicine, Section on Pulmonary, Critical Care & Sleep Medicine, CT, USA
| | - Emily M Boltey
- Department of Education and Innovative Learning, VA Pittsburgh Health System, Pittsburgh, PA, USA
| | - Elizabeth A Mosley
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Milisa Manojlovich
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA
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Mangus CW, James TG, Parker SJ, Duffy E, Chandanabhumma PP, Cassady CM, Bellolio F, Pasupathy KS, Manojlovich M, Singh H, Mahajan P. Frontline Providers' and Patients' Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00072-2. [PMID: 38643047 DOI: 10.1016/j.jcjq.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety. METHODS Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED-Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews. RESULTS The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED-Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused. CONCLUSION Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.
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Jiang Y, Hwang M, Cho Y, Friese CR, Hawley ST, Manojlovich M, Krauss JC, Gong Y. The Acceptance and Use of Digital Technologies for Self-Reporting Medication Safety Events After Care Transitions to Home in Patients With Cancer: Survey Study. J Med Internet Res 2024; 26:e47685. [PMID: 38457204 PMCID: PMC10960221 DOI: 10.2196/47685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/18/2023] [Accepted: 02/09/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Actively engaging patients with cancer and their families in monitoring and reporting medication safety events during care transitions is indispensable for achieving optimal patient safety outcomes. However, existing patient self-reporting systems often cannot address patients' various experiences and concerns regarding medication safety over time. In addition, these systems are usually not designed for patients' just-in-time reporting. There is a significant knowledge gap in understanding the nature, scope, and causes of medication safety events after patients' transition back home because of a lack of patient engagement in self-monitoring and reporting of safety events. The challenges for patients with cancer in adopting digital technologies and engaging in self-reporting medication safety events during transitions of care have not been fully understood. OBJECTIVE We aim to assess oncology patients' perceptions of medication and communication safety during care transitions and their willingness to use digital technologies for self-reporting medication safety events and to identify factors associated with their technology acceptance. METHODS A cross-sectional survey study was conducted with adult patients with breast, prostate, lung, or colorectal cancer (N=204) who had experienced care transitions from hospitals or clinics to home in the past 1 year. Surveys were conducted via phone, the internet, or email between December 2021 and August 2022. Participants' perceptions of medication and communication safety and perceived usefulness, ease of use, attitude toward use, and intention to use a technology system to report their medication safety events from home were assessed as outcomes. Potential personal, clinical, and psychosocial factors were analyzed for their associations with participants' technology acceptance through bivariate correlation analyses and multiple logistic regressions. RESULTS Participants reported strong perceptions of medication and communication safety, positively correlated with medication self-management ability and patient activation. Although most participants perceived a medication safety self-reporting system as useful (158/204, 77.5%) and easy to use (157/204, 77%), had a positive attitude toward use (162/204, 79.4%), and were willing to use such a system (129/204, 63.2%), their technology acceptance was associated with their activation levels (odds ratio [OR] 1.83, 95% CI 1.12-2.98), their perceptions of communication safety (OR 1.64, 95% CI 1.08-2.47), and whether they could receive feedback after self-reporting (OR 3.27, 95% CI 1.37-7.78). CONCLUSIONS In general, oncology patients were willing to use digital technologies to report their medication events after care transitions back home because of their high concerns regarding medication safety. As informed and activated patients are more likely to have the knowledge and capability to initiate and engage in self-reporting, developing a patient-centered reporting system to empower patients and their families and facilitate safety health communications will help oncology patients in addressing their medication safety concerns, meeting their care needs, and holding promise to improve the quality of cancer care.
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Affiliation(s)
- Yun Jiang
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
| | - Misun Hwang
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Youmin Cho
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
- McWilliams School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Christopher R Friese
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
- School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Sarah T Hawley
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
- School of Public Health, University of Michigan, Ann Arbor, MI, United States
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, United States
| | | | - John C Krauss
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Yang Gong
- McWilliams School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States
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Terwilliger IA, Johnson JK, Manojlovich M, Astik GJ, Kim JS, Williams MV, O'Leary KJ. Contextual Factors Influencing the Implementation of a Multifaceted Intervention to Improve Teamwork and Quality for Hospitalized Patients: A Multisite Qualitative Comparative Case Study. Jt Comm J Qual Patient Saf 2024; 50:193-201. [PMID: 37838603 DOI: 10.1016/j.jcjq.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Many hospitals have begun to implement models that combine interventions to redesign care for medical patients. These models include localization of physicians to specific units, nurse-physician co-leadership, and interprofessional rounds. Understanding contextual factors, the circumstances surrounding an implementation effort that influence its success, is essential to provide guidance to leaders implementing similar models of care. METHODS A multisite qualitative comparative case study was conducted with four hospitals in the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Researchers conducted observations and semistructured interviews with 40 health care professionals and four implementation mentors. Researchers used inductive qualitative content analysis, reviewed fidelity of implementation trends, and performed cross-case analysis to identify contextual factors and their influence on implementation. RESULTS Four contextual factors were associated with implementation success: (1) senior hospital leader involvement and organizational support; (2) alignment of RESET with organizational, hospital, and professional group priorities; (3) site leaders' engagement in RESET and relationship with one another; and (4) perceptions of need and intervention benefits among professionals. Implementation was optimal when senior leadership was stable and tangibly involved; organizational, hospital, and group goals were aligned; site leaders were committed and collaborated well; and nurses and physicians perceived a need for and benefits from the interventions. CONCLUSION Four interrelated contextual factors are associated with the implementation of combined interventions to redesign care for hospitalized medical patients. Hospital leaders should consider these findings prior to implementing similar interventions and be prepared to address challenges related to these factors during implementation.
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Rizvi-Toner A, Coe AB, Friese CR, Manojlovich M, Wallner L, Farris KB. Patient symptoms, self-management, and unscheduled healthcare use during the first 6 months of targeted oral anticancer agent therapy: protocol for a mixed-methods US study. BMJ Open 2024; 14:e081375. [PMID: 38355181 PMCID: PMC10868296 DOI: 10.1136/bmjopen-2023-081375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Targeted oral anticancer agents (OAAs) are increasingly used to treat cancer, including haematological malignancies and ovarian cancer, but they can cause serious symptomatic side effects such as arrhythmias, hypertension, and hyperglycaemia. Unaddressed OAA symptoms or inadequately managed symptoms may also lead to unnecessary and unscheduled healthcare use that decreases patient quality of life and financially burdens both patients and the healthcare system. Limited information is available about patient symptoms, self-management behaviours, and use of healthcare services over time while taking targeted OAAs, but is needed to ensure successful OAA therapy. The primary objective is to understand patient experiences and behaviours on initiating targeted OAA, and elicit cancer care clinicians' (ie, physicians, advanced practice practitioners, nurses, and pharmacists) perspectives on supporting patients during therapy. Study results will inform comprehensive and realistic interventions that minimise disruptions to therapy while maximising quality of life. METHODS AND ANALYSIS We will conduct a remote single-arm, convergent-parallel mixed-methods cohort study within a large academic medical centre. A minimum of 60 patients will be enrolled. Patients will complete several validated patient-reported outcome measures at six timepoints over 6 months. Mixed-effects logistic regression will be used to predict the primary binary outcome of unscheduled healthcare use by patient self-efficacy for symptom self-management. Semistructured interviews will be conducted with patients and clinicians and thematically analysed. Triangulated quantitative and qualitative results will be reported using cross-case comparison joint display. ETHICS AND DISSEMINATION This study protocol is approved by the Institutional Review Board of University of Michigan Medical School (IRBMED). Study results will be published in peer-reviewed journals, presented at conferences, and disseminated to study participants.
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Affiliation(s)
- Amna Rizvi-Toner
- Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Antoinette B Coe
- Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Lauren Wallner
- Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Karen B Farris
- Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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Manojlovich M, Barwig K, Bekele J, Bradshaw K, Ali Charania NAM, Lundy F, Streelman M, Leech C. Using Video to Describe the Patient-Controlled Analgesia Pump Programming Process: A Qualitative Study. J Nurs Care Qual 2024; 39:31-36. [PMID: 37094576 DOI: 10.1097/ncq.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
BACKGROUND Patient-controlled analgesia (PCA) pumps are complex medical devices frequently used for postoperative pain control. Differences in how nurses program PCA pumps can lead to preventable medication errors. PURPOSE To describe similarities and differences in how surgical nurses program PCA pumps. METHODS We conducted a qualitative study using video reflexive ethnography (VRE) to film nurses as they programmed a PCA pump. We spliced and collated videos into separate clips and showed to nursing leaders for their deliberation and action. RESULTS We found nurses ignored or immediately silenced alarms, were uncertain about the correct programming sequence, and interpreted how to load a syringe in the pump in multiple ways; in addition, the PCA pump design did not align with nurses' workflow. CONCLUSIONS VRE was effective in visualizing common challenges nurses experienced during PCA pump programming. Nursing leaders are planning several nursing process changes due to these findings.
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Affiliation(s)
- Milisa Manojlovich
- School of Nursing, University of Michigan, Ann Arbor (Drs Manojlovich and Ali Charania); Von Voigtlander Women's Hospital (Dr Bradshaw), and Surgical Services and PM&R, Pain Service (Ms Lundy), University of Michigan Health, Ann Arbor (Mss Barwig, Bekele, and Streelman)
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Mathis MR, Janda AM, Yule SJ, Dias RD, Likosky DS, Pagani FD, Stakich-Alpirez K, Kerray FM, Schultz ML, Fitzgerald D, Sturmer D, Manojlovich M, Krein SL, Caldwell MD. Nontechnical Skills for Intraoperative Team Members. Anesthesiol Clin 2023; 41:803-818. [PMID: 37838385 PMCID: PMC10703542 DOI: 10.1016/j.anclin.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Nontechnical skills, defined as the set of cognitive and social skills used by individuals and teams to reduce error and improve performance in complex systems, have become increasingly recognized as a key contributor to patient safety. Efforts to characterize, quantify, and teach nontechnical skills in the context of perioperative care continue to evolve. This review article summarizes the essential behaviors for safety, described in taxonomies for nontechnical skills assessments developed for intraoperative clinical team members (eg, surgeons, anesthesiologists, scrub practitioners, perfusionists). Furthermore, the authors describe emerging methods to advance understanding of the impact of nontechnical skills on perioperative outcomes.
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Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Allison M Janda
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Steven J Yule
- Department of Clinical Surgery, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, Scotland
| | - Roger D Dias
- Department of Emergency Medicine, Brigham & Women's Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Korana Stakich-Alpirez
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Fiona M Kerray
- Department of Clinical Surgery, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, Scotland
| | - Megan L Schultz
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - David Fitzgerald
- Department of Clinical Sciences, Medical University of South Carolina College of Health Professions, A 151 Rutledge Avenue, Charleston, SC 29403, USA
| | - David Sturmer
- Department of Perfusion, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Milisa Manojlovich
- School of Nursing, University of Michigan, 426 N Ingalls Street, Ann Arbor, MI 48104, USA
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA
| | - Matthew D Caldwell
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Manojlovich M, Rizvi-Toner A, DasGupta R, Farris K, Friese C, Kostoff D, Mackler E, Millisor V, Titler MG. Video reflexive ethnography as an intervention to improve oral anti-cancer agent patient education: A pilot study. PEC Innov 2023; 2:100148. [PMID: 37214518 PMCID: PMC10194178 DOI: 10.1016/j.pecinn.2023.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 02/27/2023] [Accepted: 03/20/2023] [Indexed: 05/24/2023]
Abstract
Objective Oral anticancer agents (OAAs) are associated with side effects that interfere with medication adherence, despite patient education regarding side effect management. Video reflexive ethnography (VRE) captures care processes on video that allow participants to learn from videos. The purpose of this pilot study was to assess the usefulness and impact of VRE on improving OAA education. Methods This qualitative study was conducted in a pharmacist-managed OAA clinic: two pharmacists and four patients participated. We filmed each pharmacist providing education to two patients. We conducted patient interviews and one reflexivity session with both pharmacists to learn participants' perspectives. We used thematic content analysis to analyze data. Results Two themes emerged: what patients liked/helped, and things that were unclear. Patients liked instructions on temperature taking, directions to safely handle and store OAAs. Unclear areas included knowing the timing of the worst side effects.During the reflexivity session, pharmacists found patients' comments useful to improve their practice. Conclusion VRE was acceptable to pharmacists and patients. Pharmacists recognized VRE as a helpful technique to improve patient education on OAAs. Innovation The use of video enables participants to scrutinize and reshape their practices, making VRE a powerful innovation and adjunct to quality improvement initiatives.
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Affiliation(s)
| | - Amna Rizvi-Toner
- University of Michigan College of Pharmacy, United States of America
| | | | - Karen Farris
- University of Michigan College of Pharmacy, United States of America
| | - Chris Friese
- University of Michigan School of Nursing, United States of America
| | | | - Emily Mackler
- University of Michigan College of Pharmacy, United States of America
| | | | - Marita G. Titler
- University of Michigan School of Nursing, United States of America
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O'Leary KJ, Johnson JK, Williams MV, Estrella R, Hanrahan K, Leykum LK, Smith GR, Goldstein JD, Kim JS, Thompson S, Terwilliger I, Song J, Lee J, Manojlovich M. Effect of Complementary Interventions to Redesign Care on Teamwork and Quality for Hospitalized Medical Patients : A Pragmatic Controlled Trial. Ann Intern Med 2023; 176:1456-1464. [PMID: 37903367 DOI: 10.7326/m23-0953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Multiple challenges impede interprofessional teamwork and the provision of high-quality care to hospitalized patients. OBJECTIVE To evaluate the effect of interventions to redesign hospital care delivery on teamwork and patient outcomes. DESIGN Pragmatic controlled trial. Hospitals selected 1 unit for implementation of interventions and a second to serve as a control. (ClinicalTrials.gov: NCT03745677). SETTING Medical units at 4 U.S. hospitals. PARTICIPANTS Health care professionals and hospitalized medical patients. INTERVENTION Mentored implementation of unit-based physician teams, unit nurse-physician coleadership, enhanced interprofessional rounds, unit-level performance reports, and patient engagement activities. MEASUREMENTS Primary outcomes were teamwork climate among health care professionals and adverse events experienced by patients. Secondary outcomes were length of stay (LOS), 30-day readmissions, and patient experience. Difference-in-differences (DID) analyses of patient outcomes compared intervention versus control units before and after implementation of interventions. RESULTS Among 155 professionals who completed pre- and postintervention surveys, the median teamwork climate score was higher after than before the intervention only for nurses (n = 77) (median score, 88.0 [IQR, 77.0 to 91.0] vs. 80.0 [IQR, 70.0 to 89.0]; P = 0.022). Among 3773 patients, a greater percentage had at least 1 adverse event after compared with before the intervention on control units (change, 1.61 percentage points [95% CI, 0.01 to 3.22 percentage points]). A similar percentage of patients had at least 1 adverse event after compared with before the intervention on intervention units (change, 0.43 percentage point [CI, -1.25 to 2.12 percentage points]). A DID analysis of adverse events did not show a significant difference in change (adjusted DID, -0.92 percentage point [CI, -2.49 to 0.64 percentage point]; P = 0.25). Similarly, there were no differences in LOS, readmissions, or patient experience. LIMITATION Adverse events occurred less frequently than anticipated, limiting statistical power. CONCLUSION Despite improved teamwork climate among nurses, interventions to redesign care for hospitalized patients were not associated with improved patient outcomes. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (K.J.O., G.R.S., J.S.K.)
| | - Julie K Johnson
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.K.J.)
| | - Mark V Williams
- Division of Hospital Medicine, Washington University School of Medicine, St. Louis, Missouri (M.V.W.)
| | | | | | - Luci K Leykum
- Department of Medicine, University of Texas at Austin Dell Medical School, Austin, and South Texas Veterans Health Care System, San Antonio, Texas (L.K.L.)
| | - G Randy Smith
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (K.J.O., G.R.S., J.S.K.)
| | - Jenna D Goldstein
- Society of Hospital Medicine, Philadelphia, Pennsylvania (J.D.G., S.T.)
| | - Jane S Kim
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (K.J.O., G.R.S., J.S.K.)
| | - Sara Thompson
- Society of Hospital Medicine, Philadelphia, Pennsylvania (J.D.G., S.T.)
| | - Iva Terwilliger
- Center for Education in Health Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois (I.T.)
| | - Jing Song
- Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.S., J.L.)
| | - Jungwha Lee
- Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.S., J.L.)
| | - Milisa Manojlovich
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan (M.M.)
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Manojlovich M, Blok A, Wright N, Azhari E, Farris KB, Friese CR, Mackler E, Titler M, Byrnes M. Photo elicitation, an approach to better understanding the patient experience with OAAs: pilot study and future implications. Support Care Cancer 2023; 31:652. [PMID: 37878093 DOI: 10.1007/s00520-023-08128-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/19/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE Oral anti-cancer agents (OAAs) represent a new frontier in cancer treatment, but we do not know how well patients incorporate the strategies that they are taught for managing the side effects of OAAs into their daily lives. The purpose of this study was to understand how OAA side effects influenced patients' lives and what strategies patients used to manage them. METHODS The study used an interpretive descriptive design utilizing photo elicitation interviews (PEI). Two pharmacists employed at the study ambulatory oncology clinic assisted with recruitment. Participants took photos and subsequent interviews focused on talking to participants about each photo, eliciting participant perspectives describing side effects of OAAs and management strategies. A directed content analysis approach was used to analyze the transcribed interviews. RESULTS A total of nine participants were included in the study. Three themes and associated sub-themes emerged: making changes to nutritional habits due to OAA side effects (hydration and food), strategies to alleviate OAA side effects (medication and non-medication related), and methods of coping with OAA effects (intra- and interpersonal). Changing nutritional habits was an important strategy to manage OAA side effects. Medication-related strategies to alleviate OAA side effects could be nuanced and, additionally, there was wide variability in coping methods used. CONCLUSION Patient education on OAAs and side effects is not always tailored to each unique patient and their circumstances. This study uncovered how participants devised their own distinct strategies to prevent or manage OAA side effects in an effort to help improve patients' experiences when taking OAAs.
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Affiliation(s)
| | - Amanda Blok
- US Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Nathan Wright
- US Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Emily Azhari
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Karen B Farris
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Emily Mackler
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Marita Titler
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Mary Byrnes
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA
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Choi KR, Brush BL, Chapman SA, Costa DK, Feder SL, Gutierrez JI, Heilemann MV, Manojlovich M, Noonan D, Park LG, Potempa K, Sochalski J. Preparing nurse scientists for health services and policy research: Five-year outcomes of interprofessional postdoctoral training in the National Clinician Scholars Program. Nurs Outlook 2023; 71:102024. [PMID: 37487421 DOI: 10.1016/j.outlook.2023.102024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND The National Clinician Scholars Program (NCSP) is an interprofessional postdoctoral fellowship for physicians and nurses with a PhD. or DNP focused on health services research, policy, and leadership. PURPOSE To evaluate 5-year outcomes of nurse postdoctoral scholars in the NCSP. METHODS We describe the 5-year outcomes of nurse fellows and graduates from six NCSP sites (positions, number of peer-reviewed publications, citations, and h-index). CONCLUSION There were 53 nurses in the sample (34 alumni, 19 fellows). Approximately half (47%, n = 16) of alumni had tenure-track faculty positions and had bibliometric performance indicators (such as h-indices) 2 to 4 times greater than those previously reported for assistant professors in nursing schools nationally. NCSP nurse scholars and alumni also had an impact on community partnerships, health equity, and health policy DISCUSSION: This study highlights the potential of interprofessional postdoctoral fellowships such as the NCSP to prepare nurse scientists for health care leadership roles.
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Affiliation(s)
- Kristen R Choi
- School of Nursing, University of California, Los Angeles, CA; Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA; National Clinician Scholars Program, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Barbara L Brush
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI; Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Susan A Chapman
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, CA; National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
| | - Deena Kelly Costa
- School of Nursing, Yale University, Orange, CT; Section of Pulmonary, Critical Care & Sleep Medicine, Yale School of Medicine, New Haven, CT; National Clinician Scholars Program, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
| | - Shelli L Feder
- School of Nursing, Yale University, Orange, CT; National Clinician Scholars Program, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT; Pain Research, Informatics, Multi-Morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
| | - José I Gutierrez
- National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA; Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, CA
| | - MarySue V Heilemann
- School of Nursing, University of California, Los Angeles, CA; National Clinician Scholars Program, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Milisa Manojlovich
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, Ann Arbor, MI
| | - Devon Noonan
- School of Nursing, Duke University, Durham, NC; National Clinician Scholars Program, Clinical and Translational Science Institute, Duke University, Durham, NC
| | - Linda G Park
- National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA; Department of Community Health Systems, School of Nursing, University of California, San Francisco, CA; San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Kathleen Potempa
- Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, Ann Arbor, MI
| | - Julie Sochalski
- School of Nursing, Department of Biobehavioral Health Sciences, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute for Health Economics, Philadelphia, PA; National Clinician Scholars Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Blok AC, Costa DK, Wright NC, Manojlovich M, Friese CR. Development and Evaluation of a Data-Driven, Interactive Workshop to Facilitate Communication and Teamwork in Ambulatory Medical Oncology Settings. Cancer Care Res Online 2023; 3:e043. [PMID: 37719163 PMCID: PMC10501213 DOI: 10.1097/cr9.0000000000000043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Background While adverse events and toxicities related to cancer drug therapy in the ambulatory oncology setting are common and often rooted in communication challenges, few studies have examined the problems of communication or tested tools to improve communication in this unique, high-risk setting. Objective To determine the feasibility and acceptability of a virtual interdisciplinary communication Workshop designed to strengthen communication across ambulatory oncology teams members. Methods Surveys of patients and clinicians in one ambulatory oncology clinic were analyzed and informed the communication intervention: an interdisciplinary virtual Workshop. Workshop evaluation included an implementation survey measure and a structured debrief with Workshop attendees. Results 87 patients and 56 clinicians participated in pre-workshop surveys that revealed patient satisfaction with timely care and information, yet a range of rating communication experiences with the clinical team, and clinicians perceiving a high amount of organizational safety, yet rated discussion of alternatives to normal work processes low. Survey results guided reflection and discussion within the Workshop. Six clinicians participated in the interactive Workshop. Feasibility and acceptability of the virtual Workshop were supported by formative and summative data, along with suggestions for improvement. Conclusions The patient and clinician surveys coupled with an interactive virtual Workshop were feasible and acceptable. Implications for Practice The Workshop identified opportunities for individual- and system-level improvements in clinical team communication. This promising strategy requires replication in larger, diverse practice samples. Foundational Clinicians accepted an interactive workshop that incorporated clinic-specific data and communication strategies. The program is feasible and acceptable in ambulatory oncology settings.
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Affiliation(s)
- Amanda C Blok
- Center for Improving Patient and Population Health, Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan; Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System
| | - Deena Kelly Costa
- Yale School of Nursing and Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine
| | - Nathan C Wright
- Center for Improving Patient and Population Health, Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan
| | - Milisa Manojlovich
- Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan
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Chang HE, Manojlovich M. Clinical nurses' patient safety competency, systems thinking and missed nursing care: A cross-sectional survey. Int J Nurs Pract 2023; 29:e13130. [PMID: 36597211 DOI: 10.1111/ijn.13130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/12/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023]
Abstract
AIM The aim of this study was to examine the relationships among patient safety competency, systems thinking and missed nursing care. BACKGROUND Patient safety competency and systems thinking are important nurse attributes that promote patient safety. Missed nursing care is known to negatively impact patient safety. However, how nurses' patient safety competency and systems thinking relate to missed nursing care is unknown. METHODS A cross-sectional survey design was used to collect data from nurses practicing in two general hospitals in South Korea. Data were collected between 3 March and 17 April 2020. Questionnaires were distributed to nurses providing direct care in general and specialty units. Patient safety competency, systems thinking and missed nursing care were measured using reliable and valid instruments. A total of 432 complete sets of data were used in final analysis. RESULTS Higher patient safety competency of nurses was associated with lower missed nursing care. Systems thinking partially mediated the relationship between knowledge of patient safety competency and missed nursing care, and attitudes of patient safety competency and missed nursing care. CONCLUSIONS The knowledge, skills and attitudes sub-scales of patient safety competency showed somewhat different effects in the relationship between missed nursing care and systems thinking, suggesting that each attribute may tap into a separate aspect of patient safety.
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Affiliation(s)
- Hyoung Eun Chang
- Research Institute of Nursing Science, College of Nursing, Jeonbuk National University, Jeonju-si, Republic of Korea
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16
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Louis N, Zhou L, Yule SJ, Dias RD, Manojlovich M, Pagani FD, Likosky DS, Corso JJ. Temporally guided articulated hand pose tracking in surgical videos. Int J Comput Assist Radiol Surg 2023; 18:117-125. [PMID: 36190616 PMCID: PMC9883342 DOI: 10.1007/s11548-022-02761-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 09/13/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Articulated hand pose tracking is an under-explored problem that carries the potential for use in an extensive number of applications, especially in the medical domain. With a robust and accurate tracking system on surgical videos, the motion dynamics and movement patterns of the hands can be captured and analyzed for many rich tasks. METHODS In this work, we propose a novel hand pose estimation model, CondPose, which improves detection and tracking accuracy by incorporating a pose prior into its prediction. We show improvements over state-of-the-art methods which provide frame-wise independent predictions, by following a temporally guided approach that effectively leverages past predictions. RESULTS We collect Surgical Hands, the first dataset that provides multi-instance articulated hand pose annotations for videos. Our dataset provides over 8.1k annotated hand poses from publicly available surgical videos and bounding boxes, pose annotations, and tracking IDs to enable multi-instance tracking. When evaluated on Surgical Hands, we show our method outperforms the state-of-the-art approach using mean Average Precision, to measure pose estimation accuracy, and Multiple Object Tracking Accuracy, to assess pose tracking performance. CONCLUSION In comparison to a frame-wise independent strategy, we show greater performance in detecting and tracking hand poses and more substantial impact on localization accuracy. This has positive implications in generating more accurate representations of hands in the scene to be used for targeted downstream tasks.
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Affiliation(s)
| | | | - Steven J. Yule
- Clinical Surgery, University of Edinburgh, Edinburgh, Scotland, UK
| | - Roger D. Dias
- Emergency Medicine, Harvard Medical School, Boston, MA USA
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Cohen-Mekelburg S, Van T, Yu X, Costa DK, Manojlovich M, Saini S, Gilmartin H, Admon AJ, Resnicow K, Higgins PDR, Siwo G, Zhu J, Waljee AK. Understanding clinician connections to inform efforts to promote high-quality inflammatory bowel disease care. PLoS One 2022; 17:e0279441. [PMID: 36574370 PMCID: PMC9794045 DOI: 10.1371/journal.pone.0279441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/07/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Highly connected individuals disseminate information effectively within their social network. To apply this concept to inflammatory bowel disease (IBD) care and lay the foundation for network interventions to disseminate high-quality treatment, we assessed the need for improving the IBD practices of highly connected clinicians. We aimed to examine whether highly connected clinicians who treat IBD patients were more likely to provide high-quality treatment than less connected clinicians. METHODS We used network analysis to examine connections among clinicians who shared patients with IBD in the Veterans Health Administration between 2015-2018. We created a network comprised of clinicians connected by shared patients. We quantified clinician connections using degree centrality (number of clinicians with whom a clinician shares patients), closeness centrality (reach via shared contacts to other clinicians), and betweenness centrality (degree to which a clinician connects clinicians not otherwise connected). Using weighted linear regression, we examined associations between each measure of connection and two IBD quality indicators: low prolonged steroids use, and high steroid-sparing therapy use. RESULTS We identified 62,971 patients with IBD and linked them to 1,655 gastroenterologists and 7,852 primary care providers. Clinicians with more connections (degree) were more likely to exhibit high-quality treatment (less prolonged steroids beta -0.0268, 95%CI -0.0427, -0.0110, more steroid-sparing therapy beta 0.0967, 95%CI 0.0128, 0.1805). Clinicians who connect otherwise unconnected clinicians (betweenness) displayed more prolonged steroids use (beta 0.0003, 95%CI 0.0001, 0.0006). The presence of variation is more relevant than its magnitude. CONCLUSIONS Clinicians with a high number of connections provided more high-quality IBD treatments than less connected clinicians, and may be well-positioned for interventions to disseminate high-quality IBD care. However, clinicians who connect clinicians who are otherwise unconnected are more likely to display low-quality IBD treatment. Efforts to improve their quality are needed prior to leveraging their position to disseminate high-quality care.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Tony Van
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
| | - Xianshi Yu
- Department of Statistics, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Deena Kelly Costa
- School of Nursing, Yale University, New Haven, Connecticut, United States of America
- Section on Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Milisa Manojlovich
- School of Nursing, Yale University, New Haven, Connecticut, United States of America
- Section on Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Sameer Saini
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Heather Gilmartin
- Denver/Seattle Center of Innovation, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
- Pulmonary Service, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
| | - Ken Resnicow
- Department of Health Education and Health Behavior, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Peter D. R. Higgins
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Geoffrey Siwo
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Ji Zhu
- Department of Statistics, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
| | - Akbar K. Waljee
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
- Division of Gastroenterology & Hepatology, University of Michigan Medicine, Ann Arbor, Michigan, United States of America
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Terwilliger IA, Manojlovich M, Johnson JK, Williams MV, O’Leary KJ. Effect of COVID-19 on the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a qualitative interview study. BMC Health Serv Res 2022; 22:1379. [DOI: 10.1186/s12913-022-08795-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/06/2022] [Indexed: 11/21/2022] Open
Abstract
Abstract
Background
Healthcare organizations made major adjustments to deliver care during the COVID pandemic, yet little is known about how these adjustments shaped ongoing quality and safety improvement efforts. We aimed to understand how COVID affected four U.S. hospitals’ prospective implementation efforts in an ongoing quality improvement initiative, the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) project, which implemented complementary interventions to redesign systems of care for medical patients.
Methods
We conducted individual semi-structured interviews with 40 healthcare professionals to determine how COVID influenced RESET implementation. We used conventional qualitative content analysis to inductively code transcripts and identify themes in MAXQDA 2020.
Results
We identified three overarching themes and nine sub-themes. The three themes were (1) COVID exacerbated existing problems and created new ones. (2) RESET and other quality improvement efforts were not the priority during the pandemic. (3) Fidelity of RESET implementation regressed.
Conclusion
COVID had a profound impact on the implementation of a multifaceted intervention to improve quality and teamwork in four hospitals. Notably, COVID led to a diversion of attention and effort away from quality improvement efforts, like RESET, and sites varied in their ability to renew efforts over time. Our findings help explain how COVID adversely affected hospitals’ quality improvement efforts throughout the pandemic and support the need for research to identify elements important for fostering hospital resilience.
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Manojlovich M, Krein SL. We don't talk about communication: why technology alone cannot save clinically deteriorating patients. BMJ Qual Saf 2022; 31:bmjqs-2022-014798. [PMID: 35868850 DOI: 10.1136/bmjqs-2022-014798] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/03/2022]
Affiliation(s)
| | - Sarah L Krein
- School of Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Boltey EM, Wright N, Mosley EA, White MR, Iwashyna TJ, Manojlovich M, Costa DK. Exploring the process of information sharing in an adult intensive care unit: an ethnographic study. J Interprof Care 2022; 36:168-176. [PMID: 33906566 PMCID: PMC8548388 DOI: 10.1080/13561820.2021.1899147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Information sharing, a component of patient and family engagement (PFE), is an important process that may contribute to intensive care unit (ICU) quality of care. Yet, virtually no studies explore how the process of information sharing unfolds in the ICU from the interprofessional team and family member perspectives. To better understand the process of information sharing, we conducted ethnographic fieldwork in a 20-bed medical ICU, focusing on behaviors and interactions of the interprofessional team and family members (May 2016 - October 2016). We completed 17.5 observation hours, 6 shadowing sessions, and 12 semi-structured interviews with 17 total participants. We used thematic content analysis and iterative inductive coding to identify three themes about the information sharing process: 1) family factors (health literacy and past experience with the ICU environment) influence information sharing; 2) clinicians strategies can support engagement in the process of information sharing (assessing families' need for information, understanding a families' hope, using rounds as an opportunity for information sharing); 3) the process of information sharing allows for trust building between families and the ICU team. Our findings suggest that information sharing is a crucial process that may serve as a catalyst for effective patient and family engagement in the ICU.
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Affiliation(s)
| | - Nathan Wright
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor Michigan
| | | | | | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor MI,VA Ann Arbor, Center for Clinical Management Research, Ann Arbor MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor MI
| | - Milisa Manojlovich
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor Michigan,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor MI
| | - Deena Kelly Costa
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor Michigan,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor MI
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Abstract
OBJECTIVES The study of communication has evolved from diverse academic disciplines, yet those diverse fields are not well represented in theoretical frameworks that describe communication in health care, narrowing our ability to explain how communication affects patient safety. The purpose of this review article is to describe a conceptual framework of communication drawn from multiple academic disciplines and apply it to health care, specifically for examining communication between providers about the clinical care of their patients. METHODS A seminal article in the field of communication that attempted to map the entire field of communication theory inspired our conceptual framework. We adapted these concepts, largely from the social science literature, to find alternative ways of conceptualizing communication and ways to enhance communication in health care. RESULTS There are 8 theoretical traditions that informed our conceptual framework: rhetorical, phenomenological, semiotic, cybernetic, sociopsychological, sociocultural, critical, and pragmatic. We provide practical, clinical applications of our conceptual framework, encompassing the interpersonal nature of communication, relationship building and trust, hierarchical differences, and the role of technology in communication. In adopting our conceptual framework, we suggest that researchers and clinicians can choose from any combination of these 8 theoretical traditions to more fully describe and ultimately enhance communication-related phenomena. CONCLUSIONS Poor communication remains a stubborn problem in health care in part because of a narrow theoretical and definitional approach to resolving it. Our conceptual framework suggests ways to build relationships and trust, addresses hierarchical differences between communicators, and illuminates the role of technology in communication. It also importantly expands the definition of the value of communication beyond simple information exchange to include creation of new knowledge during communication through the development of shared understanding.
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Lafferty M, Harrod M, Krein S, Manojlovich M. It's like sending a message in a bottle: A qualitative study of the consequences of one-way communication technologies in hospitals. J Am Med Inform Assoc 2021; 28:2601-2607. [PMID: 34569593 PMCID: PMC8763228 DOI: 10.1093/jamia/ocab191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We examine how physicians and nurses use available communication technologies and identify the implications for communication and patient care based on the theory of workarounds. MATERIALS AND METHODS We conducted a qualitative study at 4 U.S. hospitals during 2017. Researchers spent 2 weeks at each hospital conducting unit-based observation, shadowing, interviews, and focus groups with nurses and physicians. Using an iterative process, we inductively coded and thematically analyzed data to derive preliminary themes. The theory of workarounds provides an organizational lens on workarounds, consisting of 5 components: antecedents, types, effects, managerial stance, and organizational challenges of workarounds. The first 3 components of the theory helped us to organize and explain our findings. RESULTS Communication technologies consisted of pagers and telephones. Antecedents to workarounds included one-way information flow, differential access related to differences in technology types, and technology mismatch. Types of workarounds included bypassing a variety of obstacles and substituting for unavailable resources. Direct effects of workarounds included pager fatigue, interruptions in patient care, and potential errors. DISCUSSION One-way communication technologies created an environment where workarounds could flourish. By placing results within the context of the theory of workarounds, we extend what we know about why and how workarounds develop, and offer strategies to minimize workarounds' adverse effects. CONCLUSIONS Through the theory of workarounds, we see that there is a trajectory to workarounds with potential consequences for clinicians and patients. Two-way communication technologies could minimize workarounds and gaps in information exchange, and reduce unnecessary interruptions and the potential for adverse events.
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Affiliation(s)
- Megan Lafferty
- United States Department of Veterans Affairs, Center to Improve Veteran Involvement in Care, VA Medical Center, Portland, Oregon, USA
| | - Molly Harrod
- United States Department of Veterans Affairs, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Sarah Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System and Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Milisa Manojlovich
- School of Nursing, Department of Systems, Populations, and Leadership, University of Michigan, Ann Arbor, Michigan, USA
- Corresponding Author: Milisa Manojlovich, PhD, RN, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, 400 N. Ingalls, Ann Arbor, MI 48103, USA;
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Sirihorachai R, Saylor KM, Manojlovich M. Interventions for the Prevention of Retained Surgical Items: A Systematic Review. World J Surg 2021; 46:370-381. [PMID: 34773133 PMCID: PMC10186264 DOI: 10.1007/s00268-021-06370-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Retained surgical items (RSI) are preventable error events. Interest in reducing RSI is increasing globally because of increasing demand for safe surgery. While research of interventions to prevent RSI have been reported, no rigorous analysis of the type and effectiveness of interventions exists. This systematic review examines (1) what types of intervention have been implemented to prevent RSI; and (2) what is the effectiveness of those interventions. METHODS We performed a systematic review of PubMed, Embase, CINAHL, Cochrane Library, Scopus, ClinicalTrials.gov, Mednar, and OpenGrey databases. Two reviewers independently screened a total of 1,792 titles and abstracts, and reviewed 87 full-text articles, resulting in 17 articles in the final analysis. Study characteristics included qualitative and quantitative studies that examined the effectiveness of RSI prevention interventions for adult patients who undergo open surgery. The primary outcome was RSI and related error events. RESULTS Four studies and 13 quality improvement projects described RSI interventions categorized into four groups: (1) technology-based, (2) communication-based, (3) practice- or guideline-based, (4) interventions that fell into more than one category. Following guidance in the Quality Improvement minimum quality criteria set, the quality of all studies ranged from poor to fair. Heterogeneity in the interventions used and variable study quality limit our confidence in the interventions' ability to reduce RSI. CONCLUSION Since technology-based interventions may not be financially feasible in low and middle-income countries (LMIC), in those settings interventions that target the social system may be more appropriate. Rigorous methods to investigate local contexts and build knowledge are needed so that interventions to prevent RSI have a greater likelihood of success.
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Affiliation(s)
- Rattima Sirihorachai
- Faculty of Nursing, Mahidol University, 2 Wang Lang Road, Siriraj, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Kate M Saylor
- MSI, Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
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Abstract
BACKGROUND Ambulatory oncology practices treat thousands of Americans on a daily basis with high-risk and high-cost antineoplastic agents. However, we know relatively little about these diverse practices and the organizational structures influencing care delivery. OBJECTIVE The aim of this study was to examine clinician-reported factors within ambulatory oncology practices that affect care delivery processes and outcomes for patients and clinicians. METHODS Survey data were collected in 2017 from 298 clinicians (nurses, physicians, nurse practitioners, and physician assistants) across 29 ambulatory practices in Michigan. Clinicians provided written comments about favorable and unfavorable aspects of their work environments that affected their ability to deliver high-quality care. We conducted inductive content analysis and used the Systems Engineering Initiative for Patient Safety work system model to organize and explain our findings. RESULTS Clinicians reported factors within all 5 work-system components of the Systems Engineering Initiative for Patient Safety model that affected care delivery and outcomes. Common themes surfaced, such as unfavorable aspects including staffing inadequacy and high patient volume, limited physical space, electronic health record usability issues, and order entry. Frequent favorable aspects focused on the skills of colleagues, collaboration, and teamwork. Some clinicians explicitly reported how work system factors were relational and influenced patient, clinician, and organizational outcomes. CONCLUSIONS These findings show how work-system components are interactive and relational reflecting the complex nature of care delivery. IMPLICATIONS FOR NURSING PRACTICE Data obtained from frontline clinicians can support leaders in making organizational changes that are congruent with clinician observations of practices' strengths and opportunities for improvement.
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Affiliation(s)
- Megan Lafferty
- Author Affiliations: University of Michigan School of Nursing (Drs. Lafferty, Manojlovich, and Friese and Mr. Wright); Michigan Oncology Quality Consortium (Dr Griggs); Ann Arbor Veterans Administration Health System, Center for Clinical Management Research (Dr Harrod); and Division of Hematology/Oncology, Internal Medicine, University of Michigan (Dr Griggs), Ann Arbor
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Fauer A, Wright N, Lafferty M, Harrod M, Manojlovich M, Friese CR. Influences of Physical Layout and Space on Patient Safety and Communication in Ambulatory Oncology Practices: A Multisite, Mixed Method Investigation. HERD 2021; 14:270-286. [PMID: 34169761 DOI: 10.1177/19375867211027498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication. BACKGROUND Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes. METHODS This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians (n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews (n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis. RESULTS Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients. CONCLUSIONS Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.
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Affiliation(s)
- Alex Fauer
- National Clinician Scholars Program, Division of General Internal Medicine and Health Services Research, School of Medicine, University of California, Los Angeles, CA, USA
| | - Nathan Wright
- Center for Improving Patient and Population Health, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Christopher R Friese
- Center for Improving Patient and Population Health, School of Nursing, University of Michigan, Ann Arbor, MI, USA.,Rogel Cancer Center, Ann Arbor, MI, USA.,School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Mathis MR, Yule S, Wu X, Dias RD, Janda AM, Krein SL, Manojlovich M, Caldwell MD, Stakich-Alpirez K, Zhang M, Corso J, Louis N, Xu T, Wolverton J, Pagani FD, Likosky DS. The impact of team familiarity on intra and postoperative cardiac surgical outcomes. Surgery 2021; 170:1031-1038. [PMID: 34148709 PMCID: PMC8733606 DOI: 10.1016/j.surg.2021.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/19/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Familiarity among cardiac surgery team members may be an important contributor to better outcomes and thus serve as a target for enhancing outcomes. METHODS Adult cardiac surgical procedures (n = 4,445) involving intraoperative providers were evaluated at a tertiary hospital between 2016 and 2020. Team familiarity (mean of prior cardiac surgeries performed by participating surgeon/nonsurgeon pairs within 2 years before the operation) were regressed on cardiopulmonary bypass duration (primary-an intraoperative measure of care efficiency) and postoperative complication outcomes (major morbidity, mortality), adjusting for provider experience, surgeon 2-year case volume before the surgery, case start time, weekday, and perioperative risk factors. The relationship between team familiarity and outcomes was assessed across predicted risk strata. RESULTS Median (interquartile range) cardiopulmonary bypass duration was 132 minutes (91-192), and 698 (15.7%) patients developed major postoperative morbidity. The relationship between team familiarity and cardiopulmonary bypass duration significantly differed across predicted risk strata (P = .0001). High (relative to low) team familiarity was associated with reduced cardiopulmonary bypass duration for medium-risk (-24 minutes) and high-risk (-27 minutes) patients. Increasing team familiarity was not significantly associated with the odds of major morbidity and mortality. CONCLUSION Team familiarity, which was predictive of improved intraoperative efficiency without compromising major postoperative outcomes, may serve as a novel quality improvement target in the setting of cardiac surgery.
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Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI. https://twitter.com/Michael_Mathis
| | - Steven Yule
- Department of Clinical Surgery, University of Edinburgh, Scotland; Department of Surgery, Brigham & Women's Hospital/Harvard Medical School, Boston, MA. https://twitter.com/NOTSS_lab
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Roger D Dias
- Department of Emergency Medicine, Brigham & Women's Hospital/ Harvard Medical School, Boston, MA. https://twitter.com/RogerDDias
| | - Allison M Janda
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, MI. https://twitter.com/Sarahlkrein
| | - Milisa Manojlovich
- School of Nursing, University of Michigan, Ann Arbor, MI. https://twitter.com/mmanojlo
| | - Matthew D Caldwell
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jason Corso
- Department of Electrical Engineering and Computer Science, College of Engineering, University of Michigan, Ann Arbor, MI. https://twitter.com/ProfJasonCorso
| | - Nathan Louis
- Department of Electrical Engineering and Computer Science, College of Engineering, University of Michigan, Ann Arbor, MI
| | - Tongbo Xu
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jeremy Wolverton
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI. https://twitter.com/JeremyWolverton
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI. https://twitter.com/FPaganiMD
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI.
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Friese CR, Mendelsohn-Victor K, Medvec BR, Ghosh B, Bedard L, Griggs JJ, Manojlovich M. Factors Associated With Job Satisfaction in Medical Oncology Practices: Results From a Multisite Survey. J Nurs Adm 2021; 51:200-205. [PMID: 33734179 PMCID: PMC7988747 DOI: 10.1097/nna.0000000000000998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to examine the factors influencing job satisfaction of nurses, physicians, and advanced practice providers in ambulatory oncology settings. BACKGROUND Job satisfaction is essential to clinician well-being and quality of care. METHODS In 2017, clinicians from 29 ambulatory medical oncology practices completed anonymous paper questionnaires that examined job satisfaction, clinician-to-clinician communication, and perceptions of patient safety. Linear regression, adjusted for clustered observations, examined the relationship between job satisfaction, clinician communication, and patient safety perceptions. RESULTS Of 280 respondents (response rate of 68%), 85% reported that they were satisfied or very satisfied with their current position. Patient safety and accuracy of clinician communication were positively and significantly associated with job satisfaction. CONCLUSIONS Although most surveyed clinicians were satisfied, 15% were dissatisfied and reported communication and safety concerns. Leadership efforts to strengthen clinician communication actions and develop positive safety cultures are promising strategies to promote clinician well-being and high-quality cancer care.
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Affiliation(s)
- Christopher R Friese
- Author Affiliations: Elizabeth Tone Hosmer Professor of Nursing, Health Management and Policy (Dr Friese), Project Manager (Ms Mendelsohn-Victor), Clinical Assistant Professor (Dr Medvec), Biostatistician (Ms Ghosh), and Professor (Dr Manojlovich), University of Michigan School of Nursing; Program Manager (Ms Bedard) and Program Director (Dr Griggs), Michigan Oncology Quality Consortium; and Professor of Medicine, Health Management and Policy (Dr Griggs), University of Michigan Medical School and School of Public Health, Ann Arbor
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O'Leary KJ, Manojlovich M, Johnson JK, Estrella R, Hanrahan K, Leykum LK, Smith GR, Goldstein JD, Williams MV. A Multisite Study of Interprofessional Teamwork and Collaboration on General Medical Services. Jt Comm J Qual Patient Saf 2020; 46:667-672. [PMID: 33228852 DOI: 10.1016/j.jcjq.2020.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/08/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Teamwork and collaboration are essential to providing high-quality care. Prior research has found discrepancies between nurses' and physicians' perceptions in operating rooms, ICUs, and labor and delivery units. Less is known about health care professionals' perceptions of teamwork and collaboration on general medical services. METHODS This cross-sectional study included nurses, nurse assistants, and physicians working on general medical services in four mid-sized hospitals. Researchers assessed teamwork climate using the Safety Attitudes Questionnaire and asked respondents to rate the quality of collaboration experienced with their own and other professional categories. RESULTS Data for 380 participants (80 hospitalists, 13 resident physicians, 193 nurses, and 94 nurse assistants) were analyzed. Hospitalists had the highest median teamwork climate score (83.3, interquartile range [IQR] = 72.3-91.1), and nurses had the lowest (78.6, IQR = 69.6-87.5), but the difference was not statistically significant (p = 0.42). Median teamwork climate scores were significantly different across the four sites (highest = 83.3, IQR = 75.0-91.1; lowest = 76.8, IQR = 66.7-88.4; p = 0.003). Ratings of the quality of collaboration differed significantly based on professional category. Specifically, 63.3% (50/79) of hospitalists rated the quality of collaboration with nurses as high or very high, while 48.7% (94/193) of nurses rated the quality of collaboration with hospitalists as high or very high. CONCLUSION This study found significant differences in perceptions of teamwork climate across sites and in collaboration across professional categories on general medical services. Given the importance in providing high-quality care, leaders should consider conducting similar assessments to characterize teamwork and collaboration on general medical services within their own hospitals.
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Manojlovich M, Harrod M, Hofer T, Lafferty M, McBratnie M, Krein SL. Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study. BMJ Qual Saf 2020; 30:747-754. [PMID: 33168635 PMCID: PMC8140397 DOI: 10.1136/bmjqs-2020-011441] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/15/2020] [Accepted: 10/23/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND How quickly physicians respond to communications from bedside nurses is important for the delivery of safe inpatient care. Delays in physician responsiveness can impede care or contribute to patient harm. Understanding contributory factors to physician responsiveness can provide insights to promote timely physician response, possibly improving communication to ensure safe patient care. The purpose of this study was to describe the factors contributing to physician responsiveness to text or numeric pages, telephone calls and face-to-face messages delivered by nurses on adult general care units. METHODS Using a qualitative design, we collected data through observation, shadowing, interviews and focus groups of bedside registered nurses and physicians who worked in four hospitals in the Midwest USA. We analysed the data using inductive content analysis. RESULTS A total of 155 physicians and nurses participated. Eighty-six nurses and 32 physicians participated in focus groups or individual interviews; we shadowed 37 physicians and nurses across all sites. Two major inter-related themes emerged, message and non-message related factors. Message-related factors included the medium nurses used to convey messages, physician preference for notification via one communication medium over another and the clarity of the message, all of which could cause confusion and thus a delayed response. Non-message related factors included trust and interpersonal relationships, and different perspectives between nurses and physicians on the same clinical issue that affected perceptions of urgency, and contributed to delays in responsiveness. CONCLUSIONS Physician responsiveness to communications from bedside nurses depends on a complex combination of factors related to the message itself and non-message related factors. How quickly physicians respond is a multifactorial phenomenon, and strategies to promote a timely response within the context of a given situation must be directed to both groups.
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Affiliation(s)
| | - Molly Harrod
- Center for Clinical Management Research, Department of Veterans Affair, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Timothy Hofer
- Center for Clinical Management Research, Department of Veterans Affair, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Megan Lafferty
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Sarah L Krein
- Center for Clinical Management Research, Department of Veterans Affair, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Friese CR, Fauer AJ, Kuisell C, Mendelsohn-Victor K, Wright NC, Griggs JJ, Manojlovich M. Patient-reported outcomes collected in ambulatory oncology practices: Feasibility, patterns, and correlates. Health Serv Res 2020; 55:966-972. [PMID: 33125170 DOI: 10.1111/1475-6773.13574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/20/2020] [Accepted: 09/24/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To examine the feasibility of soliciting outcomes from adults who received chemotherapy treatment for cancer and describe the patterns and correlates of patient-reported toxicities. DATA SOURCES Patient survey data from 29 Michigan ambulatory oncology practices collected in 2017. STUDY DESIGN Secondary analysis of patient survey data. Descriptive statistics were generated at the patient and practice levels. Thematic analysis of open-text comments identified clusters of frequently reported toxicities. DATA COLLECTION METHODS Patients completed 11 items from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events. Using a 5-point Likert scale, patients rated the frequency of nausea, vomiting, diarrhea, and pain; the severity of nausea, vomiting, constipation, numbness/tingling, and pain; and how much numbness/tingling and pain interfered with usual or daily activities. Patients could also report two toxicities in open-text comments. Finally, patients reported unplanned health care service for toxicity or side effect management. PRINCIPAL FINDINGS Of 3565 eligible patients, 2245 participated (63%) and 457 (20%) rated at least one toxicity as severe/very severe. Across practices, the proportion of patients who reported at least one severe/very severe toxicity ranged from 8% to 50%. Troubling toxicities included pain frequency (mean 2.3, SD 1.3), pain severity (2.1, 1.1), and diarrhea frequency (1.9, 1.0). From completed assessments, 1653 (74%) reported at least one toxicity in open-text comments; fatigue (n = 182), stomach discomfort (n = 53), and skin/nail changes (n = 41) were most frequently reported. Regarding consequences, 156 patients (7%) reported unplanned health care service use: 41 (26%) visited an emergency department and 32 (21%) were admitted to a hospital. CONCLUSIONS Querying patients on chemotherapy treatment experiences and toxicities was feasible. Toxicity rates varied across practices, which informed quality improvement. Toxicity severity and service use incidence exceed previously published trial data, particularly for pain, fatigue, and gastrointestinal issues. Open-text questions enabled exploration with newer treatment regimens.
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Affiliation(s)
- Christopher R Friese
- Center for Improving Patient and Population Health, School of Nursing, Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Alex J Fauer
- National Clinician Scholars Program, David Geffen School of Medicine, and Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Clare Kuisell
- Hillman Scholar in Nursing Innovation, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Kari Mendelsohn-Victor
- Center for Improving Patient and Population Health, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Nathan C Wright
- Center for Improving Patient and Population Health, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer J Griggs
- Internal Medicine and Health Management and Policy, University of Michigan, Ann Arbor, MI, USA.,Michigan Oncology Quality Collaborative, Ann Arbor, MI, USA
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Friese C, Fauer A, Mendelsohn‐Victor K, Manojlovich M. Patient‐Reported Toxicity Outcomes Collected from a Diverse Sample of Ambulatory Oncology Practices: Feasibility, Patterns, and Correlates. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- C. Friese
- School of Nursing University of Michigan Ann Arbor MI United States
| | - A. Fauer
- University of California, Los Angeles Los Angeles CA United States
| | | | - M. Manojlovich
- School of Nursing University of Michigan Ann Arbor MI United States
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Lafferty M, Fauer A, Wright N, Manojlovich M, Friese CR. Causes and Consequences of Chemotherapy Delays in Ambulatory Oncology Practices: A Multisite Qualitative Study. Oncol Nurs Forum 2020; 47:417-427. [PMID: 32555555 DOI: 10.1188/20.onf.417-427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE In oncology, chemotherapy treatment delays potentially jeopardize patient safety and impede progress toward disease remission. The purpose of this study was to examine the causes and consequences of chemotherapy treatment delays and possible solutions to improve quality of care. PARTICIPANTS & SETTING The current authors selected a purposive sample of eight ambulatory oncology practices for ethnographic site visits, which lasted five days each. METHODOLOGIC APPROACH The authors conducted 290 observation hours, including clinician shadowing, and 46 semistructured interviews with clinicians (oncology nurses, physicians, and advanced practice providers). Deductive and inductive thematic analysis was performed on all data. FINDINGS The authors identified four primary themes from the analysis that affect delays. IMPLICATIONS FOR NURSING Future investigations should examine nurses' communication practices in the context of timely chemotherapy administration because communication and documentation technologies within healthcare settings continuously evolve.
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Affiliation(s)
| | | | | | | | - Christopher R Friese
- University of Michigan School of Nursing and University of Michigan Rogel Cancer Center
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33
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Manojlovich M, Bedard L, Griggs JJ, McBratnie M, Mendelsohn-Victor K, Friese CR. Facilitators and Barriers to Recruiting Ambulatory Oncology Practices Into a Large Multisite Study: Mixed Methods Study. JMIR Cancer 2020; 6:e14476. [PMID: 32310140 PMCID: PMC7199136 DOI: 10.2196/14476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 11/19/2019] [Accepted: 01/27/2020] [Indexed: 01/21/2023] Open
Abstract
Background Practice-based research is essential to generate the data necessary to understand outcomes in ambulatory oncology care. Although there is an increased interest in studying ambulatory oncology care, given the rising patient volumes and complexity in those settings, little guidance is available on how best to recruit ambulatory oncology practices for research. Objective This paper aimed to describe the facilitators and barriers to recruiting ambulatory oncology practices into a large multisite study. Methods Using a mixed methods design, we sought to recruit 52 ambulatory oncology practices that have participated in a state-wide quality improvement collaborative for the quantitative phase. We used 4 domains of the Consolidated Framework for Implementation Research (CFIR) to describe facilitators and barriers to recruitment. Results We successfully recruited 28 of the 52 collaborative-affiliated practices, collecting survey data from 2223 patients and 297 clinicians. Intervention attributes included multimodal outreach and training activities to assure high fidelity to the data collection protocol. The implementation process was enhanced through interactive training and practice-assigned champions responsible for data collection. External context attributes that facilitated practice recruitment included partnership with a quality improvement collaborative and the inclusion of a staff member from the collaborative in our team. Key opinion leaders within each practice who could identify challenges to participation and propose flexible solutions represented internal context attributes. We also reported lessons learned during the recruitment process, which included navigating diverse approaches to human subjects protection policies and understanding that recruitment could be a negotiated process that took longer than anticipated, among others. Conclusions Our experience provides other researchers with challenges to anticipate and possible solutions for common issues. Using the CFIR as a guide, we identified numerous recruitment barriers and facilitators and devised strategies to enhance recruitment efforts. In conclusion, researchers and clinicians can partner effectively to design and implement research protocols that ultimately benefit patients who are increasingly seeking care in ambulatory practices.
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Affiliation(s)
| | - Louise Bedard
- Michigan Oncology Quality Consortium, Ann Arbor, MI, United States
| | - Jennifer J Griggs
- Michigan Oncology Quality Consortium, Ann Arbor, MI, United States.,Hematology & Oncology Division, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
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Quinn M, Ameling JM, Forman J, Krein SL, Manojlovich M, Fowler KE, King EA, Meddings J. Persistent Barriers to Timely Catheter Removal Identified from Clinical Observations and Interviews. Jt Comm J Qual Patient Saf 2019; 46:99-108. [PMID: 31879072 DOI: 10.1016/j.jcjq.2019.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 09/23/2019] [Accepted: 10/15/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Indwelling urinary and vascular catheters are valuable devices in patient care, but prolonged or unnecessary use increases the risk of infectious and noninfectious catheter harms. METHODS To understand persistent barriers to detecting and removing unnecessary catheters, researchers conducted a multimethod qualitative study that included observations and in-person interviews with clinicians working on a progressive care unit of a large hospital. Observations consisted of shadowing nurses during shift change and while admitting patients, and observing physicians during morning rounds. Observational data were gathered using unstructured field notes. Interviews were conducted using a semistructured guide, audio-recorded, and transcribed. Qualitative content analysis was conducted to identify main themes. RESULTS Barriers to timely removal identified during 19 interviews with clinicians and 133 hours of field observations included physicians not routinely reviewing catheter necessity during rounds, catheters going unnoticed or hidden under clothing, common use of "Do Not Remove" orders, and little or no discussion of catheters among clinicians. Five overall themes emerged: (1) Catheter data are hard to find, not accurate, or not available; (2) Catheter removal is not a priority; (3) Confusion exists about who has authority to remove catheters; (4) There is a lack of agreement on, and awareness of, standard protocols and indications for removal; and (5) Communication barriers among clinicians create challenges. CONCLUSION To address barriers and facilitate detection and timely removal, clinicians need ready access to accurate catheter data, more clearly delineated clinician roles for prompting removal, effective tools to facilitate discussions about catheter use, and standardized catheter removal protocols.
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Meddings J, Manojlovich M, Fowler KE, Ameling JM, Greene L, Collier S, Bhatt J, Saint S. A Tiered Approach for Preventing Catheter-Associated Urinary Tract Infection. Ann Intern Med 2019; 171:S30-S37. [PMID: 31569226 DOI: 10.7326/m18-3471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jennifer Meddings
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., S.S.)
| | | | - Karen E Fowler
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (K.E.F.)
| | | | - Linda Greene
- University of Rochester Highland Hospital, Rochester, New York (L.G.)
| | - Sue Collier
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.C., J.B.)
| | - Jay Bhatt
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.C., J.B.)
| | - Sanjay Saint
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., S.S.)
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36
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Meddings J, Manojlovich M, Ameling JM, Olmsted RN, Rolle AJ, Greene MT, Ratz D, Snyder A, Saint S. Quantitative Results of a National Intervention to Prevent Hospital-Acquired Catheter-Associated Urinary Tract Infection: A Pre-Post Observational Study. Ann Intern Med 2019; 171:S38-S44. [PMID: 31569231 DOI: 10.7326/m18-3534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many hospitals struggle to prevent catheter-associated urinary tract infection (CAUTI). OBJECTIVE To evaluate the effect of a multimodal initiative on CAUTI in hospitals with high burden of health care-associated infection (HAI). DESIGN Prospective, national, nonrandomized, clustered, externally facilitated, pre-post observational quality improvement initiative, for 3 cohorts active between November 2016 and May 2018. SETTING Acute care, long-term acute care, and critical access hospitals, including intensive care and non-intensive care wards. PARTICIPANTS Target hospitals had a high burden of Clostridioides difficile infection plus central line-associated bloodstream infection, CAUTI, or hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection, defined as cumulative attributable differences above the first tertile in the Targeted Assessment for Prevention (TAP) strategy. Some additional nonrecruited hospitals also joined. INTERVENTION Multimodal intervention, including Practice Change Assessment tool to identify infection prevention and control (IPC) and HAI prevention gaps; Web-based, on-demand modules involving onboarding, foundational IPC practices, HAI-specific 2-tiered approach to prioritize and implement interventions, and TAP resources; monthly webinars; state partner-led in-person meetings; and feedback. State partners made site visits to at least 50% of their enrolled hospitals, to support self-assessments and coach. MEASUREMENTS Rates of CAUTI and urinary catheter device utilization ratio. RESULTS Of 387 participating hospitals from 23 states and the District of Columbia, 361 provided CAUTI data. Over the study period, the unadjusted CAUTI rate was low and relatively stable, decreasing slightly from 1.12 to 1.04 CAUTIs per 1000 catheter-days. Catheter utilization decreased from 21.46 to 19.83 catheter-days per 100 patient-days from the pre- to the postintervention period. LIMITATIONS The intervention period was brief, with no assessment of fidelity. Baseline CAUTI rates were low. Patient characteristics were not assessed. CONCLUSION This multimodal intervention yielded no substantial improvements in CAUTI or urinary catheter utilization. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.
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Affiliation(s)
- Jennifer Meddings
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., M.T.G., S.S.)
| | | | - Jessica M Ameling
- University of Michigan Medical School, Ann Arbor, Michigan (J.M.A., A.S.)
| | - Russell N Olmsted
- Integrated Clinical Services Team, Trinity Health, Livonia, Michigan (R.N.O.)
| | - Andrew J Rolle
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (A.J.R.)
| | - M Todd Greene
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., M.T.G., S.S.)
| | - David Ratz
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (D.R.)
| | - Ashley Snyder
- University of Michigan Medical School, Ann Arbor, Michigan (J.M.A., A.S.)
| | - Sanjay Saint
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (J.M., M.T.G., S.S.)
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Manojlovich M, Ameling JM, Forman J, Judkins S, Quinn M, Meddings J. Contextual Barriers to Communication Between Physicians and Nurses About Appropriate Catheter Use. Am J Crit Care 2019; 28:290-298. [PMID: 31263012 DOI: 10.4037/ajcc2019372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Indwelling urinary and vascular catheters are a common cause of health care-associated infections. Interventions designed to reduce catheter use can be ineffective if they are not integrated into the workflow and communication streams of busy clinicians. OBJECTIVES To characterize communication barriers between physicians and nurses and to understand how these barriers affect appropriate use and removal of indwelling urinary and vascular catheters. METHODS Individual and small-group semistructured interviews were conducted with physicians and nurses in a progressive care unit of an academic hospital. Common themes were identified, analyzed, and then organized using a conceptual framework of contextual barriers to communication: organizational, cognitive, and social complexity. RESULTS Several barriers to communication between physicians and nurses contributed to inappropriate use and delayed removal of catheters. Workflow misalignment between clinicians was a barrier associated with organizational complexity, issues with electronic medical records and pagers were associated with cognitive complexity, and strained relationships between clinicians and rigid hierarchies were associated with social complexity. CONCLUSIONS Communication is contextual, and improving physician-nurse communication about appropriate catheter use may require innovations that address the identified contextual barriers.
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Affiliation(s)
- Milisa Manojlovich
- Milisa Manojlovich is a professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor. Jessica M. Ameling is a project manager, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor. Jane Forman is a senior qualitative methodologist, Center for Clinical Management Research, Veterans Affairs Ann Arbor Health-care System, Ann Arbor, Michigan. Samantha Judkins is a clinical nursing supervisor, Michigan Medicine, Ann Arbor. Martha Quinn is a senior qualitative research area specialist, Center for Managing Chronic Disease, University of Michigan School of Public Health, Ann Arbor. Jennifer Meddings is an associate professor, Department of Internal Medicine and Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and a researcher, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System.
| | - Jessica M Ameling
- Milisa Manojlovich is a professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor. Jessica M. Ameling is a project manager, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor. Jane Forman is a senior qualitative methodologist, Center for Clinical Management Research, Veterans Affairs Ann Arbor Health-care System, Ann Arbor, Michigan. Samantha Judkins is a clinical nursing supervisor, Michigan Medicine, Ann Arbor. Martha Quinn is a senior qualitative research area specialist, Center for Managing Chronic Disease, University of Michigan School of Public Health, Ann Arbor. Jennifer Meddings is an associate professor, Department of Internal Medicine and Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and a researcher, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System
| | - Jane Forman
- Milisa Manojlovich is a professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor. Jessica M. Ameling is a project manager, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor. Jane Forman is a senior qualitative methodologist, Center for Clinical Management Research, Veterans Affairs Ann Arbor Health-care System, Ann Arbor, Michigan. Samantha Judkins is a clinical nursing supervisor, Michigan Medicine, Ann Arbor. Martha Quinn is a senior qualitative research area specialist, Center for Managing Chronic Disease, University of Michigan School of Public Health, Ann Arbor. Jennifer Meddings is an associate professor, Department of Internal Medicine and Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and a researcher, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System
| | - Samantha Judkins
- Milisa Manojlovich is a professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor. Jessica M. Ameling is a project manager, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor. Jane Forman is a senior qualitative methodologist, Center for Clinical Management Research, Veterans Affairs Ann Arbor Health-care System, Ann Arbor, Michigan. Samantha Judkins is a clinical nursing supervisor, Michigan Medicine, Ann Arbor. Martha Quinn is a senior qualitative research area specialist, Center for Managing Chronic Disease, University of Michigan School of Public Health, Ann Arbor. Jennifer Meddings is an associate professor, Department of Internal Medicine and Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and a researcher, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System
| | - Martha Quinn
- Milisa Manojlovich is a professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor. Jessica M. Ameling is a project manager, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor. Jane Forman is a senior qualitative methodologist, Center for Clinical Management Research, Veterans Affairs Ann Arbor Health-care System, Ann Arbor, Michigan. Samantha Judkins is a clinical nursing supervisor, Michigan Medicine, Ann Arbor. Martha Quinn is a senior qualitative research area specialist, Center for Managing Chronic Disease, University of Michigan School of Public Health, Ann Arbor. Jennifer Meddings is an associate professor, Department of Internal Medicine and Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and a researcher, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System
| | - Jennifer Meddings
- Milisa Manojlovich is a professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor. Jessica M. Ameling is a project manager, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor. Jane Forman is a senior qualitative methodologist, Center for Clinical Management Research, Veterans Affairs Ann Arbor Health-care System, Ann Arbor, Michigan. Samantha Judkins is a clinical nursing supervisor, Michigan Medicine, Ann Arbor. Martha Quinn is a senior qualitative research area specialist, Center for Managing Chronic Disease, University of Michigan School of Public Health, Ann Arbor. Jennifer Meddings is an associate professor, Department of Internal Medicine and Department of Pediatrics and Communicable Diseases, University of Michigan Medical School and a researcher, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System
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Umberfield E, Ghaferi AA, Krein SL, Manojlovich M. Using Incident Reports to Assess Communication Failures and Patient Outcomes. Jt Comm J Qual Patient Saf 2019; 45:406-413. [PMID: 30935883 PMCID: PMC6590519 DOI: 10.1016/j.jcjq.2019.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/07/2019] [Accepted: 02/11/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes. METHODS Incident reports filed during fiscal year 2015-2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test. RESULTS Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes. CONCLUSION It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.
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O'Leary KJ, Johnson JK, Manojlovich M, Goldstein JD, Lee J, Williams MV. Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems. BMC Health Serv Res 2019; 19:293. [PMID: 31068161 PMCID: PMC6505207 DOI: 10.1186/s12913-019-4116-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/22/2019] [Indexed: 11/25/2022] Open
Abstract
Background A number of challenges impede our ability to consistently provide high quality care to patients hospitalized with medical conditions. Teams are large, team membership continually evolves, and physicians are often spread across multiple units and floors. Moreover, patients and family members are generally poorly informed and lack opportunities to partner in decision making. Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of a single intervention. We believe these interventions represent complementary and mutually reinforcing components of a redesigned clinical microsystem. Our specific objective for this study is to implement a set of evidence-based complementary interventions across a range of clinical microsystems, identify factors and strategies associated with successful implementation, and evaluate the impact on quality. Methods The RESET project uses the Advanced and Integrated MicroSystems (AIMS) interventions. The AIMS interventions consist of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities. Four hospital sites were chosen to receive guidance and resources as they implement the AIMS interventions. Each study site has assembled a local leadership team, consisting of a physician and nurse, and receives mentorship from a physician and nurse with experience in leading similar interventions. Primary outcomes include teamwork climate, assessed using the Safety Attitudes Questionnaire, and adverse events using the Medicare Patient Safety Monitoring System (MPSMS). RESET uses a parallel group study design and two group pretest-posttest analyses for primary outcomes. We use a multi-method approach to collect and triangulate qualitative data collected during 3 visits to study sites. We will use cross-case comparisons to consider how site-specific contextual factors interact with the variation in the intensity and fidelity of implementation to affect teamwork and patient outcomes. Discussion The RESET study provides mentorship and resources to assist hospitals as they implement complementary and mutually reinforcing components to redesign the clinical microsystems caring for medical patients. Our findings will be of interest and directly applicable to all hospitals providing care to patients with medical conditions. Trial registration NCT03745677. Retrospectively registered on November 19, 2018. Electronic supplementary material The online version of this article (10.1186/s12913-019-4116-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 E. Ontario Street, Suite 700, Chicago, IL, 60611, USA.
| | - Julie K Johnson
- Department of Surgery and the Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Milisa Manojlovich
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Jenna D Goldstein
- Center for Hospital Innovation and Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Jungwha Lee
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark V Williams
- Center for Health Services Research, University of Kentucky College of Medicine, Lexington, KY, USA
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Patel MR, Friese CR, Mendelsohn-Victor K, Fauer AJ, Ghosh B, Bedard L, Griggs JJ, Manojlovich M. Clinician Perspectives on Electronic Health Records, Communication, and Patient Safety Across Diverse Medical Oncology Practices. J Oncol Pract 2019; 15:e529-e536. [PMID: 31009284 DOI: 10.1200/jop.18.00507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We know little about how increased technological sophistication of clinical practices affects safety of chemotherapy delivery in the outpatient setting. This study investigated to what degree electronic health records (EHRs), satisfaction with technology, and quality of clinician-to-clinician communication enable a safety culture. METHODS We measured actions consistent with a safety culture, satisfaction with practice technology, and quality of clinician communication using validated instruments among 297 oncology nurses and prescribers in a statewide collaborative. We constructed an index to reflect practice reliance on EHRs (1 = "all paper" to 5 = "all electronic"). Linear regression models (with robust SEs to account for clustering) examined relationships between independent variables of interest and safety. Models were adjusted for clinician age. RESULTS The survey response rate was 68% (76% for nurses and 59% for prescribers). The mean (standard deviation) safety score was 5.3 (1.1), with a practice-level range of 4.9 to 5.4. Prescribers reported fewer safety actions than nurses. Higher satisfaction with technology and higher-quality clinician communication were significantly associated with increased safety actions, whereas increased reliance on EHRs was significantly associated with lower safety actions. CONCLUSION Practices vary in their performance of patient safety actions. Supporting clinicians to integrate technology and strengthen communication are promising intervention targets. The inverse relationship between reliance on EHRs and safety suggests that technology may not facilitate clinicians' ability to attend to patient safety. Efforts to improve cancer care quality should focus on more seamless integration of EHRs into routine care delivery and emphasize increasing the capacity of all care clinicians to communicate effectively and coordinate efforts when administering high-risk treatments in ambulatory settings.
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Affiliation(s)
- Minal R Patel
- 1 University of Michigan School of Public Health, Ann Arbor, MI.,2 University of Michigan Rogel Cancer Center, Ann Arbor, MI
| | - Christopher R Friese
- 1 University of Michigan School of Public Health, Ann Arbor, MI.,2 University of Michigan Rogel Cancer Center, Ann Arbor, MI.,3 University of Michigan School of Nursing, Ann Arbor, MI
| | | | - Alex J Fauer
- 3 University of Michigan School of Nursing, Ann Arbor, MI
| | - Bidisha Ghosh
- 3 University of Michigan School of Nursing, Ann Arbor, MI
| | - Louise Bedard
- 4 Michigan Oncology Quality Consortium, Ann Arbor, MI
| | - Jennifer J Griggs
- 1 University of Michigan School of Public Health, Ann Arbor, MI.,2 University of Michigan Rogel Cancer Center, Ann Arbor, MI.,4 Michigan Oncology Quality Consortium, Ann Arbor, MI.,5 University of Michigan, Ann Arbor, MI
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Gupta A, Harrod M, Quinn M, Manojlovich M, Fowler KE, Singh H, Saint S, Chopra V. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. ACTA ACUST UNITED AC 2018; 5:151-156. [PMID: 30007056 DOI: 10.1515/dx-2018-0014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/18/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Traditionally, research has examined systems- and cognitive-based sources of diagnostic error as individual entities. However, half of all errors have origins in both domains.
Methods
We conducted a focused ethnography of inpatient physicians at two academic institutions to understand how systems-based problems contribute to cognitive errors in diagnosis. Medicine teams were observed on rounds and during post-round work after which interviews were conducted. Field notes related to the diagnostic process and the work system were recorded, and findings were organized into themes. Using deductive content analysis, themes were categorized based on a published taxonomy to link systems-based contributions and cognitive errors such as faulty data gathering, information processing, data verification and errors associated with multiple domains.
Results
Observations, focus groups and interviews of 10 teams were conducted between January 2016 and April 2017. The following themes were identified: (1) challenges with interdisciplinary communication and communication within the electronic medical record (EMR) contributed to faulty data gathering; (2) organizational structures such as the operation of consulting services in silos promoted faulty information processing; (3) care handoffs led to faulty data verification and (4) interruptions, time constraints and a cluttered physical environment negatively influenced multiple cognitive domains.
Conclusions
Systems-based factors often facilitate and promote cognitive problems in diagnosis. Linking systems-based contributions to downstream cognitive impacts and intervening on both in tandem may help prevent diagnostic errors.
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Affiliation(s)
- Ashwin Gupta
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105-2303, USA.,University of Michigan Medical School, Ann Arbor, MI 48109-0624, USA
| | - Molly Harrod
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Martha Quinn
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | - Sanjay Saint
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vineet Chopra
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
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Manias E, Gray K, Wickramasinghe N, Manojlovich M. Using electronic medical records to create big data and to communicate with patients—Is there room for both? Collegian 2018. [DOI: 10.1016/j.colegn.2018.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Al-Hamdan Z, Banerjee T, Manojlovich M. Communication With Physicians as a Mediator in the Relationship Between the Nursing Work Environment and Select Nurse Outcomes in Jordan. J Nurs Scholarsh 2018; 50:714-721. [PMID: 30043513 DOI: 10.1111/jnu.12417] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To test whether communication mediated relationships among nurses' work environments and nurse outcomes of job satisfaction and intent to stay. DESIGN This study used a cross-sectional, quantitative survey design to query 650 nurses who worked in three hospitals in Jordan. METHODS We used Arabic versions of valid, reliable instruments measuring the nursing work environment, nurse perceptions of communication with physicians, intent to stay, and job satisfaction. Mediation analysis was used to test hypotheses. FINDINGS A total of 582 questionnaires were returned (89.5% response rate). Nurse perceptions of communication with physicians mediated the relationship between the nursing work environment and job satisfaction in medical, surgical, and critical care units. Nurse perceptions of communication with physicians mediated the relationship between the nursing work environment and intent to stay in all but maternity and "other" units. CONCLUSIONS Depending on the nurse outcome, communication was a significant mediator for various unit types. These results may be related to the type of work that is done in each unit and the influence of patient care. Communication is one of many mechanisms that can specify how a positive nursing work environment can contribute to nurses' job satisfaction and intent to stay. CLINICAL RELEVANCE A potential solution to the nursing shortage in Jordan emerges by identifying communication with physicians as a mediator in the relationship between the work environment and selected nurse outcomes.
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Affiliation(s)
- Zaid Al-Hamdan
- Jordan University of Science and Technology, Faculty of Nursing, Irbid, Jordan
| | - Tanima Banerjee
- University of Michigan, Institute of Healthcare Policy and Innovation Ann Arbor, MI, USA
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Manojlovich M, Frankel RM, Harrod M, Heshmati A, Hofer T, Umberfield E, Krein S. Formative evaluation of the video reflexive ethnography method, as applied to the physician-nurse dyad. BMJ Qual Saf 2018; 28:160-166. [PMID: 30007915 DOI: 10.1136/bmjqs-2017-007728] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/30/2018] [Accepted: 06/24/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite decades of research and interventions, poor communication between physicians and nurses continues to be a primary contributor to adverse events in the hospital setting and a major challenge to improving patient safety. The lack of progress suggests that it is time to consider alternative approaches with greater potential to identify and improve communication than those used to date. We conducted a formative evaluation to assess the feasibility, acceptability and utility of using video reflexive ethnography (VRE) to examine, and potentially improve, communication between nurses and physicians. METHODS We begin with a brief description of the institutional review boardapproval process and recruitment activities, then explain how we conducted the formative evaluation by describing (1) the VRE process itself; (2) our assessment of the exposure to the VRE process; and (3) challenges encountered and lessons learnt as a result of the process, along with suggestions for change. RESULTS Our formative evaluation demonstrates that it is feasible and acceptable to video-record communication between physicians and nurses during patient care rounds across many units at a large, academic medical centre. The lessons that we learnt helped to identify procedural changes for future projects. We also discuss the broader application of this methodology as a possible strategy for improving other important quality and safety practices in healthcare settings. CONCLUSIONS The VRE process did generate increased reflection in both nurse and physician participants. Moreover, VRE has utility in assessing communication and, based on the comments of our participants, can serve as an intervention to possibly improve communication, with implications for patient safety.
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Affiliation(s)
| | - Richard M Frankel
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Molly Harrod
- Center for Clinical Management Research, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | | | - Timothy Hofer
- Center for Clinical Management Research, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Sarah Krein
- Center for Clinical Management Research, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Patel MR, Friese CR, Mendelsohn-Victor K, Fauer AJ, Ghosh B, Ramakrishnan A, Bedard L, Griggs JJ, Manojlovich M. Clinician perspectives on electronic health records, communication, and patient safety across diverse medical oncology practices. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.6549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Louise Bedard
- University of Michgian Comprehensive Cancer Center, Ann Arbor, MI
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Friese CR, Patel MR, Mendelsohn-Victor K, Fauer AJ, Ghosh B, Ramakrishnan A, Bedard L, Griggs JJ, Manojlovich M. Patterns of patient-reported chemotherapy toxicities across twenty-eight ambulatory oncology settings. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e18721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Louise Bedard
- University of Michgian Comprehensive Cancer Center, Ann Arbor, MI
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Liu X, Zhu T, Manojlovich M, Cohen HW, Tsilimingras D. Racial/ethnic disparity in the associations of smoking status with uncontrolled hypertension subtypes among hypertensive subjects. PLoS One 2017; 12:e0182807. [PMID: 28793323 PMCID: PMC5549965 DOI: 10.1371/journal.pone.0182807] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/25/2017] [Indexed: 01/13/2023] Open
Abstract
Background Racial/ethnic differences in the associations of smoking with uncontrolled blood pressure (BP) and its subtypes (isolated uncontrolled systolic BP (SBP), uncontrolled systolic-diastolic BP, and isolated uncontrolled diastolic BP (DBP)) have not been investigated among diagnosed hypertensive subjects. Methods A sample of 7,586 hypertensive patients aged ≥18 years were selected from the National Health and Nutrition Examination Survey 1999–2010. Race/ethnicity was classified into Hispanic, non-Hispanic white, and non-Hispanic black. Smoking was categorized as never smoking, ex-smoking, and current smoking. Uncontrolled BP was determined as SBP≥140 or DBP≥90 mm Hg. Isolated uncontrolled SBP was defined as SBP≥140 and DBP<90 mm Hg, uncontrolled SDBP as SBP≥140 and DBP≥90 mm Hg, and isolated uncontrolled DBP as SBP<140 and DBP≥90 mm Hg. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of uncontrolled BP and its subtypes were calculated using weighted logistic regression models. Results The interaction effect of race and smoking was significant after adjustment for the full potential confounding covariates (Adjusted p = 0.0412). Compared to never smokers, current smokers were 29% less likely to have uncontrolled BP in non-Hispanic whites (OR = 0.71, 95% CI = 0.56–0.90), although the likelihood for uncontrolled BP is the same for smokers and never smokers in Hispanics and non-Hispanic blacks. Current smokers were 26% less likely than never smokers to have isolated uncontrolled SBP in non-Hispanic whites (OR = 0.74, 95% CI = 0.58–0.95). However, current smoking is associated with an increased likelihood of uncontrolled systolic-diastolic BP in non-Hispanic blacks, and current smokers in this group were 70% more likely to have uncontrolled systolic-diastolic BP than never smokers (OR = 1.70, 95% CI = 1.10–2.65). Conclusion The associations between current smoking and uncontrolled BP differed over race/ethnicity. Health practitioners may need to be especially vigilant with non-Hispanic black smokers with diagnosed hypertension.
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Affiliation(s)
- Xuefeng Liu
- Department of Systems, Population, and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, United States of America
- Frankel Cardiovascular Center, University of Michigan School of Medicine, Ann Arbor, MI, United States of America
- * E-mail:
| | - Tinghui Zhu
- Department of Systems, Population, and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, United States of America
| | - Milisa Manojlovich
- Department of Systems, Population, and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, United States of America
| | - Hillel W. Cohen
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Dennis Tsilimingras
- Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, United States of America
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Costa DK, White MR, Ginier E, Manojlovich M, Govindan S, Iwashyna TJ, Sales AE. Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review. Chest 2017; 152:304-311. [PMID: 28438605 DOI: 10.1016/j.chest.2017.03.054] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation. METHODS We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved. RESULTS Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination). CONCLUSIONS We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.
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Affiliation(s)
| | | | - Emily Ginier
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI
| | | | - Sushant Govindan
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Anne E Sales
- VA Center for Clinical Management Research, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
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49
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Holmgren AJ, Pfeifer E, Manojlovich M, Adler-Milstein J. A Novel Survey to Examine the Relationship between Health IT Adoption and Nurse-Physician Communication. Appl Clin Inform 2016; 7:1182-1201. [PMID: 27999841 DOI: 10.4338/aci-2016-08-ra-0145] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/04/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND As EHR adoption in US hospitals becomes ubiquitous, a wide range of IT options are theoretically available to facilitate physician-nurse communication, but we know little about the adoption rate of specific technologies or the impact of their use. OBJECTIVES To measure adoption of hardware, software, and telephony relevant to nurse-physician communication in US hospitals. To assess the relationship between non-IT communication practices and hardware, software, and telephony adoption. To identify hospital characteristics associated with greater adoption of hardware, software, telephony, and non-IT communication practices. METHODS We conducted a survey of 105 hospitals in the National Nursing Practice Network. The survey captured adoption of hardware, software, and telephony to support nurse-physician communication, along with non-IT communication practices. We calculated descriptive statistics and then created four indices, one for each category, by scoring degree of adoption of technologies or practices within each category. Next, we examined correlations between the three technology indices and the non-IT communication practices index. We used multivariate OLS regression to assess whether certain types of hospitals had higher index scores. RESULTS The majority of hospitals surveyed have a range of hardware, software, and telephony tools available to support nurse-physician communication; we found substantial heterogeneity across hospitals in non-IT communication practices. More intensive non-IT communication was associated with greater adoption of software (r=0.31, p=0.01), but was not correlated with hardware or telephony. Medium-sized hospitals had lower adoption of software (r =-1.14,p=0.04) in comparison to small hospitals, while federally-owned hospitals had lower software (r=-2.57, p=0.02) and hardware adoption (r=-1.63, p=0.01). CONCLUSIONS The positive relationship between non-IT communication and level of software adoption suggests that there is a complementary, rather than substitutive, relationship. Our results suggest that some technologies with the potential to further enhance communication, such as CPOE and secure messaging, are not being utilized to their full potential in many hospitals.
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50
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Al-Hamdan Z, Manojlovich M, Tanima B. Jordanian Nursing Work Environments, Intent to Stay, and Job Satisfaction. J Nurs Scholarsh 2016; 49:103-110. [PMID: 27899008 DOI: 10.1111/jnu.12265] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to examine associations among the nursing work environment, nurse job satisfaction, and intent to stay for nurses who practice in hospitals in Jordan. DESIGN A quantitative descriptive cross-sectional survey design was used. METHODS Data were collected through survey questionnaires distributed to 650 registered nurses (RNs) who worked in three hospitals in Jordan. The self-report questionnaire consisted of three instruments and demographic questions. The instruments were the Practice Environment Scale of the Nursing Work Index (PES-NWI), the McCain Intent to Stay scale, and Quinn and Shepard's (1974) Global Job Satisfaction survey. Descriptive statistics were calculated for discrete measures of demographic characteristics of the study participants. Multivariate linear regression models were used to explore relationships among the nursing work environment, job satisfaction, and intent to stay, adjusting for unit type. FINDINGS There was a positive association between nurses' job satisfaction and the nursing work environment (t = 6.42, p < .001). For each one-unit increase in the total score of the PES-NWI, nurses' average job satisfaction increased by 1.3 points, controlling for other factors. Overall, nurses employed in public hospitals were more satisfied than those working in teaching hospitals. The nursing work environment was positively associated with nurses' intent to stay (t = 4.83, p < .001). The Intent to Stay score increased by 3.6 points for every one-unit increase in the total PES-NWI score on average. The highest Intent to Stay scores were reported by nurses from public hospitals. CONCLUSIONS The work environment was positively associated with nurses' intent to stay and job satisfaction. More attention should be paid to create positive work environments to increase job satisfaction for nurses and increase their intent to stay. CLINICAL RELEVANCE Hospital and nurse managers and healthcare policymakers urgently need to create satisfactory work environments supporting nursing practice in order to increase nurses' job satisfaction and intent to stay.
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Affiliation(s)
- Zaid Al-Hamdan
- Xi Alpha, Associate Professor, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Milisa Manojlovich
- Rho, Associate professor, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Banerjee Tanima
- Statistician, School of Nursing, University of Michigan, Ann Arbor, MI, USA
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