Learning from patients: The impact of using patients' narratives on patient experience scores

BACKGROUND

Enthusiasm has grown about using patients' narratives-stories about care experiences in patients' own words-to advance organizations' learning about the care that they deliver and how to improve it, but studies confirming association have not been published.

PURPOSE

We assessed whether primary care clinics that frequently share patients' narratives with their staff have higher patient experience survey scores.

APPROACH

We conducted a 1-year study of 5,545 adult patients and 276 staff affiliated with nine clinics in one health system. We used multilevel models to analyze survey data from patients about their experiences and from staff about exposure to useful narratives. We examined staff confidence in own knowledge as a moderator because confidence can influence use of new information sources.

RESULTS

Frequency of sharing useful narratives with staff was associated with patient experience scores for all measures, conditional on staff confidence in own knowledge ( p < .01). For operational measures (e.g., care coordination), increased sharing correlated with subsequently higher performance for more confident staff and lower performance or no difference for less confident staff, depending on measure. For relational measures (e.g., patient-provider communication), increased sharing correlated with higher scores for less confident staff and lower scores for more confident staff.

CONCLUSION

Sharing narratives with staff frequently is associated with better patient experience survey scores, conditional on confidence in knowledge.

PRACTICE IMPLICATIONS

Frequently sharing useful patient narratives should be encouraged as an organizational improvement strategy. However, organizations need to address how narrative feedback interacts with their staff's confidence to realize higher experience scores across domains.

A systematic review of research on empathy in health care

OBJECTIVE

To summarize the predictors and outcomes of empathy by health care personnel, methods used to study their empathy, and the effectiveness of interventions targeting their empathy, in order to advance understanding of the role of empathy in health care and facilitate additional research aimed at increasing positive patient care experiences and outcomes.

DATA SOURCE

We searched MEDLINE, MEDLINE In-Process, PsycInfo, and Business Source Complete to identify empirical studies of empathy involving health care personnel in English-language publications up until April 20, 2021, covering the first five decades of research on empathy in health care (1971-2021).

STUDY DESIGN

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

DATA COLLECTION/EXTRACTION METHODS

Title and abstract screening for study eligibility was followed by full-text screening of relevant citations to extract study information (e.g., study design, sample size, empathy measure used, empathy assessor, intervention type if applicable, other variables evaluated, results, and significance). We classified study predictors and outcomes into categories, calculated descriptive statistics, and produced tables to summarize findings.

PRINCIPAL FINDINGS

Of the 2270 articles screened, 455 reporting on 470 analyses satisfied the inclusion criteria. We found that most studies have been survey-based, cross-sectional examinations; greater empathy is associated with better clinical outcomes and patient care experiences; and empathy predictors are many and fall into five categories (provider demographics, provider characteristics, provider behavior during interactions, target characteristics, and organizational context). Of the 128 intervention studies, 103 (80%) found a positive and significant effect. With four exceptions, interventions were educational programs focused on individual clinicians or trainees. No organizational-level interventions (e.g., empathy-specific processes or roles) were identified.

CONCLUSIONS

Empirical research provides evidence of the importance of empathy to health care outcomes and identifies multiple changeable predictors of empathy. Training can improve individuals' empathy; organizational-level interventions for systematic improvement are lacking.

Association of women leaders in the C-suite with hospital performance

BACKGROUND

Women comprise 50% of the healthcare workforce, but only about 25% of senior leadership positions in the USA. No studies to our knowledge have investigated the performance of hospitals led by women versus those led by men to evaluate the potential explanation that the inequity reflects appropriate selection due to skill or performance differences.

METHODS

We conducted a descriptive analysis of the gender composition of hospital senior leadership (C-suite) teams and cross-sectional, regression-based analyses of the relationship between gender composition, hospital characteristics (eg, location, size, ownership), and financial, clinical, safety, patient experience and innovation performance metrics using 2018 data for US adult medical/surgical hospitals with >200 beds. C-suite positions examined included chief executive officer (CEO), chief financial officer (CFO) and chief operating officer (COO). Gender was obtained from hospital web pages and LinkedIn. Hospital characteristics and performance were obtained from American Hospital Directory, American Hospital Association Annual Hospital Survey, Healthcare Cost Report Information System and Hospital Consumer Assessment of Healthcare Providers and Systems surveys.

RESULTS

Of the 526 hospitals studied, 22% had a woman CEO, 26% a woman CFO and 36% a woman COO. While 55% had at least one woman in the C-suite, only 15.6% had more than one. Of the 1362 individuals who held one of the three C-suite positions, 378 were women (27%). Hospital performance on 27 of 28 measures (p>0.05) was similar between women and men-led hospitals. Hospitals with a woman CEO performed significantly better than men-led hospitals on one financial metric, days in accounts receivable (p=0.04).

CONCLUSION

Hospitals with women in the C-suite have comparable performance to those without, yet inequity in the gender distribution of leaders remains. Barriers to women's advancement should be recognised and efforts made to rectify this inequity, rather than underusing an equally skilled pool of potential women leaders.

Development and Testing of a Survey Measure of Organizational Perinatal Patient‐Centered Care Culture

OBJECTIVE

To develop and test a measure of patient-centered care (PCC) culture in hospital-based perinatal care.

DATA SOURCES

Data were obtained from US perinatal hospitals: one provided survey development data and 14 contributed data for survey testing.

STUDY DESIGN

We used qualitative and quantitative methods to develop the mother-infant centered care (MICC) culture survey. Qualitative methods included observation, focus group, interviews, and expert consultations to adapt items from other settings and create new items capturing dimensions of PCC articulated by The Commonwealth Fund. We quantitatively assessed survey psychometric properties using reliability (Cronbach's α and Pearson correlation coefficients) and validity (exploratory and confirmatory factor analysis [CFA]) statistics, and refined the survey. After confirming aggregation suitability (ICCs), we calculated "MICC culture scores" at the individual, unit, and hospital level and assessed associations between scores and survey-collected, staff-reported outcomes to evaluate concurrent validity.

DATA COLLECTION

Survey development included 12 site-visit observations, one semi-structured focus group (five participants), two semi-structured interviews, five cognitive interviews, and three expert consultations. Survey testing used online surveys administered to obstetric and neonatal unit staff (N = 316).

PRINCIPAL FINDINGS

Using responses from 10 hospitals with ≥4 responses from both units (n = 240), the 20-item MICC culture survey demonstrated reliability (Cronbach's α = 0.95) while capturing all PCC dimensions (subscale Cronbach's α = 0.72-0.87). CFA showed validity through goodness-of-fit (overall chi-square = 214 [p-value = 0.012], SRMR = 0.056, RMSEA = 0.041, CFI = 0.97, and TLI = 0.96). Aggregation statistics (ICCs < 0.05) justify unit- and hospital-level aggregation. Demonstrating preliminary validity, individual-, unit-, and hospital-level MICC culture scores were associated with all outcomes (satisfaction with care provided, within-unit team effectiveness, and relational coordination [RC] between units) (p-values < 0.05), except for neonatal unit scores and RC (p-value = 0.11).

CONCLUSIONS

The MICC culture survey is a psychometrically sound measure of PCC culture for hospital-based perinatal care. Survey scores are associated with staff-reported outcomes. Future studies with patient outcomes will aid identification of improvement opportunities in perinatal care.

Emergent Homecare Models Are Shaping Care in England: An Ethnographic Study of Four Distinct Homecare Models

This chapter addresses the grand challenge of an aging society and the subsequent growing demand for in-home care for the elderly - often referred to as homecare. It examines how emergent homecare models in England differ from the "time and task" model and how they are shaping the care market. These models offer new approaches regarding what, how, and when care is delivered at home. Homecare providers face rising demand driven not only by population aging but also by market demand for personalized care, choice, continuity of care, and real-time availability. The landscape presents an opportunity for innovative models to become established, by offering a more inducing service design and value propositions that respond to customers' needs. Using the "business model canvas" to guide data collection, this study presents an ethnographic case analysis of four homecare organizations with distinct emergent homecare models. The study includes 14 months of field observation and 33 in-depth interviews. It finds that providers are becoming increasingly aware of evolving customer needs, establishing models such as the "uberization," "community-based," "live-in," and "preventative" described in the chapter. These models are becoming more pervasive and are mostly market-driven; however, some of their innovations are market shaping. The major innovations are in their value propositions, partnership arrangements, and customer segments. Their value propositions focus on well-being outcomes, including choice and personalization for care users; their workforces are perceived to be a major stakeholder segment, and their networks of partners offer access to complementary services, investments, and specialist knowledge.

Even Superheroes Need Rest: A Guide to Facilitating Recovery from Work for Health-care Workers during COVID-19 and beyond

The COVID-19 pandemic burdens health-care workers (HCWs) worldwide. Amid high-stress conditions and unprecedented needs for crisis management, organizations face the grand challenge of supporting the mental health and well-being of their HCWs. The current literature on mental health and well-being primarily focuses on improving personal resilience among HCWs. However, this puts the responsibility for coping with COVID-19-related stress almost fully on the individual. This chapter discusses an important alternative framing of this issue - how health-care organizations (HCOs) can facilitate recovery from work processes (i.e., returning to a baseline level by engaging in nonwork activities after work) for their workers. Based on a narrative review of the occupational health psychology literature, we provide practical strategies for supporting the four key recovery experiences of detachment, control, mastery, and relaxation, as well as present general recommendations about how to promote recovery. These strategies can help HCOs facing the grand challenge of sustaining worker well-being and functioning during the COVID-19 pandemic, as well as during future pandemics and for workers facing high work pressure in general.

Aligning Health Care and Social Services for Patients with Complex Needs: The Multiple Roles of Interorganizational Relationships

Leading health care institutions have recommended greater alignment among health care and social services organizations as a strategy to improve population health. Deepening our understanding of how interorganizational relationships among health care and social service organizations influence care for people with complex needs could improve the design of interventions aimed at aligning these organizations to achieve health goals. Accordingly, we used qualitative methods to (1) elucidate the functions performed by health care and social service organizations caring for older adults and (2) investigate corresponding relationship forms. In-depth interviews with 175 representatives of health care and social service organizations in 10 communities were analyzed. Three distinct interorganizational relationships functions emerged: First, interorganizational relationships gave organizations a deeper and more accurate understanding of how their work was interdependent with the work of other organizations in the community. This function was achieved through coalitions that loosely tied large numbers of organizations and allowed information to flow among them. Second, interorganizational relationships allowed organizations to take joint action toward a shared goal, a function achieved in the form of pairs or small groups of organizations working closely together. Third, interorganizational relationships fostered accountability, with one organization advocating for the needs of clients or patients with another organization. Our results suggest that initiatives to promote regional alignment among health care and social services organizations may benefit from flexible models that anticipate a narrowing of partners to achieve tangible outcomes. Initiatives also need to accommodate low-level conflict that routinely exists among organizations in these sectors.

Technological Change and Frontline Care Delivery Work: Toward the Quadruple Aim

The COVID-19 pandemic stressed the health care sector's longstanding pain points, including the poor quality of frontline work and the staffing challenges that result from it. This has renewed interest in technology-centered approaches to achieving not only the "Triple Aim" of reducing costs while raising access and quality but also the "Quadruple Aim" of doing so without further squeezing wages and abrading job quality for frontline workers. How can we leverage technology toward the achievement of the Quadruple Aim? I view this as a "grand challenge" for health care managers and policymakers. Those looking for guidance will find that most analyses of the workforce impact of technological change consider broad classes of technology such as computers or robots outside of any particular industry context. Further, they typically predict changes in work or labor market outcomes will come about at some ill-defined point in the medium to long run. This decontextualization and detemporization proves markedly problematic in the health care sector: the nonmarket, institutional factors driving technology adoption and implementation loom especially large in frontline care delivery, and managers and policymakers understandably must consider a well-defined, near-term, i.e., 5-10-year, time horizon. This study is predicated on interviews with hospital and home health agency administrators, union representatives, health care information technology (IT) experts and consultants, and technology developers. I detail the near-term drivers and anticipated workforce impact of technological changes in frontline care delivery. With my emergent prescriptions for managers and policymakers, I hope to guide sectoral actors in using technology to address the "grand challenge" inherent to achieving the Quadruple Aim.

Improving Training Motivation and Transfer in Hospitals: Extension of a Conceptual Model

Health-care professionals undergo numerous training programs each year in order to fulfill licensure requirements and organizational obligations. However, evidence suggests that a substantial amount of what is taught during training is never learned or transferred back to routine work. A major contributor to this issue is low training motivation. Prior conceptual models on training transfer in the organizational sciences literature consider this deficit, yet do not account for the unique conditions of the hospital setting. This chapter seeks to close this gap by adapting conceptual models of training transfer to this setting that are grounded in organizational science. Based on theory and supplemented by semistructured key informant interviews (i.e., organizational leaders and program directors), we introduce an applied model of training motivation to facilitate training transfer in the hospital setting. In this model, training needs analysis is positioned as a key antecedent to ensure support for training, relevant content, and perceived utility of training. We posit that these factors, along with training design and logistics, enhance training motivation in hospital environments. Further, we suggest that training motivation subsequently impacts learning and transfer, with elements of the work environment also serving as moderators of the learning-transfer relationship. Factors such as external support for training content (e.g., from accrediting bodies) and allocation of time for training are emphasized as facilitators. The proposed model suggests there are factors unique to the hospital work setting that impact training motivation and transfer that should be considered when developing and implementing training initiatives in this setting.

Effects of affiliation network membership on hospital quality and financial performance

OBJECTIVE

To examine the effects of hospital membership in affiliation networks-franchise-like networks sponsored by high-quality health systems in which affiliate hospitals pay an annual fee for access to sponsor's operational and clinical resources-on clinical quality, patient experience ratings, and financial performance of affiliates and their competitors.

DATA SOURCES

Network membership data from press releases and websites of four sponsors (Mayo Clinic, Cleveland Clinic, MD Anderson, Memorial Sloan Kettering), American Hospital Association's Annual Survey, Centers for Medicare & Medicaid Services' Hospital Compare, and Healthcare Cost Report Information System, all for 2005-2016.

STUDY DESIGN

We used a quasi-experimental design and estimated hospital-level regressions with hospital-fixed effects. Dependent variables were measures of clinical quality, patient experience, and financial performance. Independent variables included an indicator for affiliate versus nonaffiliate and fixed effects for hospital characteristics and year. To analyze effects on competitors, we repeated analyses by comparing hospitals in the same county as an affiliate to nonaffiliated, noncompetitor hospitals.

DATA COLLECTION

Membership was obtained through press releases and network websites then linked across datasets by name and Medicare's identification number.

PRINCIPAL FINDINGS

Across networks, affiliates (N = 199) experienced insignificant clinical quality changes but increased net income by $38,500 and operating margin by 6.6% (p values = 0.01-0.08) compared to nonaffiliates. Multispecialty affiliates improved on no measures. Cancer-specific affiliates improved their net income ($96,900) and operating margin (3.6%; p-values < 0.05). Affiliates' competitors experienced mixed changes in clinical measures relative to hospitals without affiliates in market (p-value < 0.05) but no financial effects. Affiliation was not associated with patient experience ratings for affiliates nor competitors.

CONCLUSIONS

Despite quality-focused missions, affiliation networks are not guaranteed to improve public measures of quality in affiliated hospitals, although hospitals in these communities improve financially. Future research should assess the conditions and mechanisms by which affiliation improves quality consistently and which forms of quality.

A Systematic Review of Surveys for Measuring Patient-centered Care in the Hospital Setting

BACKGROUND

Patient-centered care (PCC) is a core component of quality care and its measurement is fundamental for research and improvement efforts. However, an inventory of surveys for measuring PCC in hospitals, a core care setting, is not available.

OBJECTIVE

To identify surveys for assessing PCC in hospitals, assess PCC dimensions that they capture, report their psychometric properties, and evaluate applicability to individual and/or dyadic (eg, mother-infant pairs in pregnancy) patients.

RESEARCH DESIGN

We conducted a systematic review of articles published before January 2019 available on PubMed, Web of Science, and EBSCO Host and references of extracted papers to identify surveys used to measure "patient-centered care" or "family-centered care." Surveys used in hospitals and capturing at least 3 dimensions of PCC, as articulated by the Picker Institute, were included and reviewed in full. Surveys' descriptions, subscales, PCC dimensions, psychometric properties, and applicability to individual and dyadic patients were assessed.

RESULTS

Thirteen of 614 articles met inclusion criteria. Nine surveys were identified, which were designed to obtain assessments from patients/families (n=5), hospital staff (n=2), and both patients/families and hospital staff (n=2). No survey captured all 8 Picker dimensions of PCC [median=6 (range, 5-7)]. Psychometric properties were reported infrequently. All surveys applied to individual patients, none to dyadic patients.

CONCLUSIONS

Multiple surveys for measuring PCC in hospitals are available. Opportunities exist to improve survey comprehensiveness regarding dimensions of PCC, reporting of psychometric properties, and development of measures to capture PCC for dyadic patients.

Who Joins the Franchise, Affiliation Model of Hospital Networks? An Analysis of Hospital and Market Characteristics of Members

Joining nonownership based, organization-driven networks and alliances is a common strategy for hospitals to pursue yet little is known about what types of hospitals join these collaborations, due in part to challenges in identifying members. One novel network form that has recently emerged, and made identification feasible, is franchise-like "affiliation networks" in which affiliate hospitals pay an annual membership fee that allows access to the clinical expertise and resources of high-status, nationally ranked sponsor hospitals. Affiliation networks and their members publicize affiliation. Using 2006-2015 data on United States' hospitals, we find hospitals with higher patient acuity, teaching hospitals, and hospitals located in areas of higher utilization intensity were more likely to join an affiliation network. Joining affiliation networks does not appear to be in response to highly competitive markets because hospitals in less competitive environments are more likely to join and hospitals with higher net incomes are more likely to join.

A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers

Background

Recognition that coordination among healthcare providers is associated with better quality of care and lower costs has increased interest in interventions designed to improve care coordination. One intervention is to add care coordination to nurses’ role in a formal way. Little is known about effects of this approach, which tends to be pursued by small organizations and those in lower-resource settings. We assessed effects of this approach on care experiences of high-risk patients (those most in need of care coordination) and clinician teamwork during the first 6 months of use.

Methods

We conducted a quasi-experimental study using a clustered, controlled pre-post design. Changes in staff and patient experiences at six community health center practice locations that introduced the added-role approach for high-risk patients were compared to changes in six locations without the program in the same health system. In the pre-period (6 months before intervention training) and post-period (about 6 months after intervention launch, following 3 months of training), we surveyed clinical staff (N = 171) and program-qualifying patients (3007 pre-period; 2101 post-period, including 113 who were enrolled during the program’s first 6 months). Difference-in-differences models examined study outcomes: patient reports about care experiences and clinician-reported teamwork. We assessed frequency of patient office visits to validate access and implementation, and contextual factors (training, resources, and compatibility with other work) that might explain results.

Results

Patient care experiences across all high-risk patients did not improve significantly (p > 0.05). They improved somewhat for program enrollees, 5% above baseline reports (p = 0.07). Staff-perceived teamwork did not change significantly (p = 0.12). Office visits increased significantly for enrolled patients (p < 0.001), affirming program implementation (greater accessing of care). Contextual factors were not reported as problematic, except that 41% of nurses reported incompatibility between care coordination and other job demands. Over 75% of nurses reported adequate training and resources.

Conclusions

There were some positive effects of adding care coordination to nurses’ role within 6 months of implementation, suggesting value in this improvement strategy. Addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.

Professionalizing Healthcare Management: A Descriptive Case Study

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

Moving Toward Improved Teamwork in Cancer Care: The Role of Psychological Safety in Team Communication

Effective communication is a requirement in the teamwork necessary for improved coordination to deliver patient-centered, value-based cancer care. Communication is particularly important when care providers are geographically distributed or work across organizations. We review organizational and teams research on communication to highlight psychological safety as a key determinant of high-quality communication within teams. We first present the concept of psychological safety, findings about its communication effects for teamwork, and factors that affect it. We focus on five factors applicable to cancer care delivery: familiarity, clinical hierarchy–related status differences, geographic dispersion, boundary spanning, and leader behavior. To illustrate how these factors facilitate or hinder psychologically safe communication and teamwork in cancer care, we review the case of a patient as she experiences the treatment-planning process for early-stage breast cancer in a community setting. Our analysis is summarized in a key principle: Teamwork in cancer care requires high-quality communication, which depends on psychological safety for all team members, clinicians and patients alike. We conclude with a discussion of the implications of psychological safety in clinical care and suggestions for future research.

Psychometric Evaluation of an Instrument for Measuring Organizational Climate for Quality: Evidence From a National Sample of Infection Preventionists

In recent years, there has been increased interest in measuring the climate for infection prevention; however, reliable and valid instruments are lacking. This study tested the psychometric properties of the Leading a Culture of Quality for Infection Prevention (LCQ-IP) instrument measuring the infection prevention climate in a sample of 972 infection preventionists from acute care hospitals. An exploratory principal component analysis showed that the instrument had structural validity and captured 4 factors related to the climate for infection prevention: Psychological Safety, Prioritization of Quality, Supportive Work Environment, and Improvement Orientation. LCQ-IP exhibited excellent internal consistency, with a Cronbach α of .926. Criterion validity was supported with overall LCQ-IP scores, increasing with the number of evidence-based prevention policies in place (P = .047). This psychometrically sound instrument may be helpful to researchers and providers in assessing climate for quality related to infection prevention.

Applying Organizational Learning Research to Accountable Care Organizations

To accomplish the goal of improving quality of care while simultaneously reducing cost, Accountable Care Organizations (ACOs) need to find new and better ways of providing health care to populations of patients. This requires implementing best practices and improving collaboration across the multiple entities involved in care delivery, including patients. In this article, we discuss seven lessons from the organizational learning literature that can help ACOs overcome the inherent challenges of learning how to work together in radically new ways. The lessons involve setting expectations, creating a supportive culture, and structuring the improvement efforts. For example, with regard to setting expectations, framing the changes as learning experiences rather than as implementation projects encourages the teams to utilize helpful activities, such as dry runs and pilot tests. It is also important to create an organizational culture where employees feel safe pointing out improvement opportunities and experimenting with new ways of working. With regard to structure, stable, cross-functional teams provide a powerful building block for effective improvement efforts. The article concludes by outlining opportunities for future research on organizational learning in ACOs.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Innovating in Health Care Management Education: Development of an Accelerated MBA and MPH Degree Program at Yale

Increasingly, there is recognition of the need for individuals with expertise in both management and public health to help health care organizations deliver high-quality and cost-effective care.

The Yale School of Public Health and Yale School of Management began offering an accelerated Master of Business Administration (MBA) and Master of Public Health (MPH) joint degree program in the summer of 2014. This new program enables students to earn MBA and MPH degrees simultaneously from 2 fully accredited schools in 22 months. Students will graduate with the knowledge and skills needed to become innovative leaders of health care organizations.

We discuss the rationale for the program, the developmental process, the curriculum, benefits of the program, and potential challenges.

Deliberate learning in health care: the effect of importing best practices and creative problem solving on hospital performance improvement

This article examines the effect on quality improvement of two common but distinct approaches to organizational learning: importing best practices (an externally oriented approach rooted in learning by imitating others' best practices) and internal creative problem solving (an internally oriented approach rooted in learning by experimenting with self-generated solutions). We propose that independent and interaction effects of these approaches depend on where organizations are in their improvement journey - initial push or later phase. We examine this contingency in hospitals focused on improving treatment time for patients with heart attacks. Our results show that importing best practices helps hospitals achieve initial phase but not later phase improvement. Once hospitals enter the later phase of their efforts, however, significant improvement requires creative problem solving as well. Together, our results suggest that importing best practices delivers greater short-term improvement, but continued improvement depends on creative problem solving.

Behaviors of successful interdisciplinary hospital quality improvement teams

BACKGROUND

Although interdisciplinary hospital quality improvement (QI) teams are both prevalent and associated with success of (QI) efforts, little is known about the behaviors of successful interdisciplinary QI teams.

OBJECTIVE

We examined the specific behaviors of interdisciplinary QI teams in hospitals that successfully redesigned care for patients with ST-elevation myocardial infarction (STEMI) and reduced door-to-balloon times.

DESIGN

Qualitative study.

PARTICIPANTS

Researchers interviewed 122 administrators, providers, and staff in 11 hospitals with substantial improvements in door-to-balloon times.

MEASUREMENTS

Using data from the in-depth qualitative interviews, the authors identified themes that described the behaviors of interdisciplinary QI teams in successful hospitals.

RESULTS

Teams focused on 5 behaviors: (1) motivating involved hospital staff toward a shared goal, (2) creating opportunities for learning and problem-solving, (3) addressing the impact of changes to care processes on staff, (4) protecting the integrity of the new care processes, and (5) representing each involved clinical discipline effectively.

CONCLUSIONS

The behaviors observed may enhance a QI team's ability to motivate the various disciplines involved, understand the care process they must change, be responsive to front-line concerns while maintaining control over the improvement process, and share information across all levels of the hospital hierarchy. Teams in successful hospitals did not avoid interdisciplinary conflict, but rather allowed each discipline to contribute to the team from its own perspective. Successful QI teams addressed the concerns of each involved discipline, modified protocols guided by clinical outcomes, and became conduits of information on changes to care processes to both executive managers and front-line staff.

Understanding the use and impact of the online community in a national quality improvement campaign

BACKGROUND

National quality campaigns often sponsor online communities; however, little is known about whether and how organisations use these communities, and the impact of their use.

METHODS

We conducted a longitudinal study of the D2B Online Community, which was sponsored by the D2B Alliance, a campaign to improve heart attack care. We examined community use, helpfulness, and impact on care for 731 Alliance-hospitals. Our data sources were a hospital survey, the archive of messages sent and the National Cardiovascular Data Registry's time-to-treatment data.

RESULTS

About 52% of hospitals (n=378/731) studied used the online community, with 27% of hospitals (n=195) contributing messages to the online community, while 25% (n=183) were silent users. Silent users were hospitals that reported staff use of the online community, but their staff did not send any messages. In the vast majority of contributing hospitals, only one individual contributed messages to the community. Contributing individuals, mostly nurses (70%), sent a total of 1155 messages, with 36% of messages sent by 11 high-volume users (5%). Messages discussed techniques for improving performance, performance measurement issues, location and interpretation of expert guidance and how to manage staff role changes. We found no statistical association between community use and improved time-to-treatment; however, many users rated the community highly for helpfulness.

CONCLUSION

Many organisations used the online community for information exchange and found it helpful, despite its lack of association with performance improvement, suggesting what benefits there are may not directly link to performance.

What is the experience of national quality campaigns? Views from the field

OBJECTIVE

To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements.

DATA SOURCES

In-depth interviews, hospital surveys, and Health Quality Alliance data.

STUDY DESIGN

We conducted a qualitative study using in-depth interviews with clinical and administrative staff (N = 99) at hospitals reporting strong influence (n = 6) as well as hospitals reporting limited influence (n = 6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data.

DATA COLLECTION METHODS

In-depth, open-ended interviews; hospital survey.

PRINCIPAL FINDINGS

Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes.

CONCLUSIONS

The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals.

Blueprint for the dissemination of evidence-based practices in health care

Aimed at fostering the broad adoption of effective health care interventions, this report proposes a blueprint for improving the dissemination of best practices by national quality improvement campaigns. The blueprint's eight key strategies are to: 1) highlight the evidence base and relative simplicity of recommended practices; 2) align campaigns with strategic goals of adopting organizations; 3) increase recruitment by integrating opinion leaders into the enrollment process; 4) form a coalition of credible campaign sponsors; 5) generate a threshold of participating organizations that maximizes network exchanges; 6) develop practical implementation tools and guides for key stakeholder groups; 7) create networks to foster learning opportunities; and 8) incorporate monitoring and evaluation of milestones and goals. The impact of quality campaigns also depends on contextual factors, including the nature of the innovation itself, external environmental incentives, and features of adopting organizations.

National efforts to improve door-to-balloon time results from the Door-to-Balloon Alliance

OBJECTIVES

The purpose of this study was to determine if enrollment in the Door-to-Balloon (D2B) Alliance, a national quality campaign sponsored by the American College of Cardiology and 38 partner organizations, was associated with increased likelihood of patients who received primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) being treated within 90 min of hospital presentation.

BACKGROUND

The D2B Alliance, launched in November 2006, sought to achieve the goal of having 75% of patients with STEMI treated within 90 min of hospital presentation.

METHODS

We conducted a longitudinal study of D2B times in 831 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, April 1, 2005, to March 31, 2008.

RESULTS

By March 2008, >75% of patients had D2B times of < or = 90 min, compared with only about one-half of patients with D2B times within 90 min in April 2005. Trends since the launch of the D2B Alliance showed that patients treated in hospitals enrolled in the D2B Alliance for at least 3 months were significantly more likely than patients treated in nonenrolled hospitals to have D2B times within 90 min, although the magnitude of the difference was modest (odds ratio: 1.16; 95% confidence interval: 1.07 to 1.27).

CONCLUSIONS

The D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by 2008.

Research in action: using positive deviance to improve quality of health care

Background

Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality.

Methods

We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction.

Results

The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices.

Conclusion

The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality.

Learning and improving in quality improvement collaboratives: which collaborative features do participants value most?

OBJECTIVE

To understand participants' views on the relative helpfulness of various features of collaboratives, why each feature was helpful and which features the most successful participants viewed as most central to their success.

DATA SOURCES

Primary data collected from 53 teams in four 2004-2005 Institute for Healthcare Improvement (IHI) Breakthrough Series collaboratives; secondary data from IHI and demographic sources.

STUDY DESIGN

Cross-sectional analyses were conducted to assess participants' views of 12 features, and the relationship between their views and performance improvement.

DATA COLLECTION METHODS

Participants' views on features were obtained via self-administered surveys and semi-structured telephone interviews. Performance improvement data were obtained from IHI and demographic data from secondary sources.

PRINCIPAL FINDINGS

Participants viewed six features as most helpful for advancing their improvement efforts overall and knowledge acquisition in particular: collaborative faculty, solicitation of their staff's ideas, change package, Plan-Do-Study-Act cycles, Learning Session interactions, and collaborative extranet. These features also provided participants with motivation, social support, and project management skills. Features enabling interorganizational learning were rated higher by teams whose organizations improved significantly than by other teams.

CONCLUSIONS

Findings identify features of collaborative design and implementation that participants view as most helpful and highlight the importance of interorganizational features, at least for those organizations that most improve.