Establishing a culture of perinatal safety in a community hospital

While unsafe behavior of frontline hospital staff, primarily physicians and nurses, is sometimes the proximal cause of adverse events, the critical importance of system‐wide, hospital organizational factors is now being acknowledged(1,2). These organizational factors create the “safety culture” that influences the occurrence of these proximal failures.(3) The concept of safety culture originated in high‐reliability organization theory, which was largely developed by a group of social scientists at the University of California at Berkeley who studied high‐risk organizations that have achieved very low accident and error rates, for example, aircraft carrier flight decks, nuclear power plants and air‐traffic control systems.(4–6) Safety culture refers to the enduring and shared beliefs and practices of organization members regarding the organization's willingness to detect and learn from errors.(7)     

What are we without risk? The physician organization at a crossroads

The managed care market in Chicago is experiencing rapid change. As health maintenance organization (HMO) enrollment flattens or even declines, and capitation becomes less sustainable for many, physician organizations are reevaluating their continued participation in risk-based contracts and are struggling to define their future roles. Physician organizations are looking for new ways to provide value to their physician members. Physician hospital organizations (PHOs) in particular are reassessing how the organization can continue to serve the interests of both the physicians and their hospital partners. To better understand the concerns of physician organizations, The Lowell Group surveyed Chicago area provider executives on their top issues. Three major concerns emerged: (1) protecting the financial health of the organization; (2) predicting the future of the managed care industry; and (3) evolving the physician organization to meet changing market conditions. Ultimately, physician organizations must make business decisions that support their true goals-serving patients and purchasers of care, physician members, and the organization's owners.     

Primary care gatekeepers in HMOs

The most pressing issue in health care delivery today is inflationary cost increases. The gatekeeping role of primary care physicians, particularly family physicians, may lower health care costs through a more judicious use of specialty referrals, expensive tests, and hospitalization. The study of such an impact is most readily carried out in the practice setting of health maintenance organizations (HMOs), where there is a defined patient population. Incomplete data and lack of sensitive indicators of the gatekeeping effect are limitations of this preliminary study. The results show, however, that the internal organization of an HMO does not influence hospital and ambulatory care utilization rates, with the exception that HMOs staffed by a group of salaried physicians (staff HMOs) reported higher ambulatory care utilization. No significant differences were demonstrated in hospital or ambulatory care utilization rates among the HMOs using more primary care physicians or family physicians than others. The results indicate that ambulatory care utilization rates are proportional to the number of physicians per 1,000 members. The results also suggest that there may be an inverse relationship between hospital utilization rates and the number of primary care physicians, especially if they are family physicians. Further studies need more specific indicators to evaluate the effect of the gatekeeping role in health care delivery.     

Impact of critical care outreach services on the delivery and organization of hospital care

OBJECTIVES: To evaluate the impact of critical care outreach services on the delivery and organization of hospital care from the perspective of staff working in acute hospitals. METHODS: One hundred semi-structured interviews were undertaken with hospital staff who were either members of, or who came into contact with, the outreach service in eight hospitals in England. RESULTS: Outreach services had two main impacts on the delivery and organization of hospital care, reflecting the organizational and educational aims of the policy. First, on the organization of patient care: it was suggested that care was more timely, there were fewer referrals to the intensive care unit (ICU) and ICUs felt more able to discharge patients to hospital wards. There were also perceived to be improved links between ward nurses and medical teams and improved morale among ICU nurses. Second, on the confidence and skills of ward staff (nurses and junior doctors): increased contact on the wards resulted in more opportunities to share critical care skills. However, there remained concerns about the sustainability of improved skills and some respondents felt that junior doctors were becoming de-skilled. CONCLUSION: Critical care outreach services have had a positive impact on the delivery and organization of hospital care. In attempting to share critical care skills, however, these services can experience a tension between the aims of service delivery and education - a tension which is partly resolved by sharing skills in the clinical and organizational context of direct patient care.     

The role of nursing in bridging the gap between managers and physicians in hospitals

Tension between hospital managers and physicians is at an all-time high. This article builds on a previous work on the culture of managers and physicians and suggests that nurses can play an instrumental role in bridging the gap between these 2 cultures. Several similarities appear between managers' and nurses' cultures, other similarities can be found between physicians' and nurses' cultures, whereas nurses' culture seems to fall somewhat in the middle of the continuum on some other cultural aspects. Therefore, we suggest that nursing can and should play a crucial role in bridging the gap between the worlds of management and medicine. In a way, nurses can act as "translators," who can explain physicians' views to managers and vice versa. Practically, this will mean a better-defined role for nurses in key hospital committees and task forces, a more active role of the chief nursing officer in the Chief Executive Officer-Chief Medical Officer, and, more importantly, better representation of nurses on hospital boards that already have physician members.     

Full clinical departments of family practice: their relationship to hospital privileges in university hospitals

All 52 family practice residency programs that hospitalize patients at a university hospital were surveyed to determine how many have full clinical departments of family practice and what effect having a full clinical department has on hospital privileges. A full clinical department is defined as one in which all hospital privileges for family physicians are reviewed and recommended by the family practice department without need for review by other specialties, even when the requested privileges overlap with another specialty. Responses were received from 100 percent of the surveyed hospitals. At 16 hospitals (30.8 percent) there is a full clinical department of family practice. When these hospitals were compared with the 36 (69.2 percent) at which there is no full clinical department, it was found that in every area of patient care, hospital privileges for family physicians are more extensive at hospitals with full clinical departments. The American Academy of Family Physicians is currently promoting the formation of full clinical departments of family practice as a method for improving hospital privileges for its members. The results of this study suggest that promoting the formation of full clinical departments will be an effective intervention.     

Magnetic direction

In April 2005, the American Nurses Association (ANA) awarded St. Joseph Hospital, Nashua, NH, its highest honor for excellence in nursing: "Magnet Recognition." The Magnet Recognition Program was developed by the ANA's American Nurses Credentialing Center in the early 1980s to recognize health care organizations that provide the best in nursing care and uphold the tradition of excellence in professional nursing practice. St. Joseph began pursuing Magnet status more than three years ago, starting with a number of enhancements to nursing practices. The hospital worked hard to improve nurse-to-patient staffing and included many of its nurses on the nursing quality council, division advisory, and cultural diversity committees. Magnet program appraisers visited the hospital this January to conduct an intensive, on-site three-day examination. They interviewed patients, staff nurses, physicians, hospital employees, administrators, board members, and nursing leadership to evaluate St. Joseph's nursing care, services, and delivery of care to patients and their families. Soon after, Magnet status was bestowed.     

The silent organizational pathology of insidious intimidation

While organizations are valiantly striving to address acts of disruption among physicians and nurses, a silent and yet equally disruptive pathology is spreading through the veins of the organization. This behavior is found among all ranks and responsibilities, from the C‐suite to the housekeeping staff. It occurs daily and is rarely reported. It continues because its nature is such that it is difficult to measure, the victims often feel helpless, and the perpetrators are often those in positions that are not normally perceived to be as essential to the flow of patient care. Nonetheless, this insidious intimidation chills communication, reduces morale, and ultimately harms patients. Organizations that desire a culture of safety and comfort must address this behavior through individual coaching, education of all staff, a willingness to tackle system frustrations that amplify and perpetuate the behavior, and establish processes for dealing fairly and firmly with the behavior.     

PDCA循环管理在提高儿科护士人文关怀能力中的作用

目的研究PDCA循环管理在提高儿科护士人文关怀能力中的作用。方法选取2018年1-6月在该院儿科住院的患儿100例为对照组,实施普通儿科护理常规。2018年7-12月在该院儿科住院的患儿100例为观察组,实施PDCA循环管理模式。患者出院时对比两组患儿护理质量、患儿家属满意度及护士人文关怀能力。结果出院时护士关怀能力、患儿家属满意度、护理质量均有显著提高。结论 PDCA管理模式用于提高儿科护士人文关怀能力效果明显,利于提高护理质量及患儿家长的满意度,值得推广。     

Motivational patterns of management team members in a large hospital

Management teams have been introduced as a means of solving conflicts and providing highly required co-ordination between professional groups, sub-units and their individual leaders in large, complex organizations such as hospitals. This study examines the motivational patterns of the three members of management teams of four clinical departments at a large university hospital. A strong professionalism was the dominant motivational orientation of all nurse managers (nursing directors of the clinics) and to a great extent also of the physician managers (head physicians of the clinics). The business managers' dominant motivational pattern was hierarchy in two out of the four teams, and professionalism in two teams. The respective comparison groups had rather similar motivational patterns in common with their leaders: ordinary physicians and nurses had a professional and administrative staff hierarchic orientation. The comparison group of mid-level managers from private firms was also hierarchically oriented, although task orientation was also often high in their motivational pattern. The results are consistent with the educational background and differences in the tasks of the groups studied. The role of different professional cultures in determining and designing efficiently functioning management teams is an important task for further research.     

Comparisons of nurses and physicians on an operational measure of empathy

In view of many changes taking place in today's health care marketplace, the theme of empathy in health provider-patient relations needs to be revisited. It has been proposed that patients benefit when all members of the health care team provide empathic care. Despite the role of empathy in patient outcomes, empirical research on empathy among health professionals is scarce partly because of a lack of a psychometrically sound tool to measure it. In this study, we briefly describe the development and validation of the Jefferson Scale of Physician Empathy (JSPE), an instrument that was specifically developed to measure empathy among health professionals (20 Likert-type items). The purpose of this study was to compare nurses and physicians on their responses to the JSPE. Study participants were 56 female registered nurses and 42 female physicians in the Internal Medicine postgraduate medical education program at Thomas Jefferson University Hospital. The reliability coefficients (Chronbach's coefficient alpha) were 0.87 for the nurses and 0.89 for physicians. Results of t test showed no significant difference between nurses and physicians on total scores of the JSPE; however, multivariate analyses of variance indicated statistically significant differences between the two groups on 5 of 20 items of the JSPE. Findings suggest that the JSPE is a reliable research tool that can be used to assess empathy among health professionals including nurses.     

Organisationskultur als Wettbewerbsfaktor im Krankenhaus?

Focusing on organizational culture as a “soft” factor, the authors pursue the question of how the hospital can increase its competitiveness. They attempt to determine which characteristics are present in an organizational culture that enhances the organizational members’ willingness to change and thereby increases the ability to innovate as a competitive factor. The distinction between an open and a closed organizational culture (Gebert/ Boerner 1999) serves as the basis for developing the hypothesis that a relatively open organizational culture promotes the organizational members’ willingness to change and an organization’s innovativeness and can be interpreted as a response to competitive pressure. This hypothesis is empirically tested on organizations outside the realm of hospitals. The authors then seek to find the extent to which a relatively open organizational culture is salient to innovativeness and competitiveness in hospitals as well and try to ascertain the current degree of openness in hospitals. The results of the investigation are used to draw conclusions for hospital management.     

Psychiatric morbidity and emotional exhaustion among hospital physicians and nurses: association with perceived job-related factors

The objective of this study was to evaluate psychiatric morbidity and emotional exhaustion among physicians and nurses of a general hospital in central Italy, examining the association with perceived job-related factors. Anonymous questionnaires were distributed to all 323 hospital physicians and 609 nurses of a nonprofit health organization in Rome, Italy. Standardized instruments were used to evaluate psychiatric morbidity (General Health Questionnaire), burnout (Maslach Burnout Inventory), and perceived job-related factors. Logistic regression was used to examine the association between job-related factors, psychiatric morbidity, and burnout, controlling for demographic factors. Questionnaires were returned by 155 physicians and 216 nurses (overall response rate 40%). Estimated prevalence of psychiatric morbidity was 25% among physicians and 36.9% among nurses. Burnout on the emotional exhaustion scale affected 38.7% of physicians and 46.4% of nurses. Personnel with emotional exhaustion was at higher risk of psychiatric morbidity (p < .001). The likelihood of psychiatric morbidity among physicians was increased by perceived insufficient recognition of personal commitments by the unit's head (odds ratio [OR] = 4.21; 95% confidence interval [CI] 1.2-15.1; p = .027), insufficient managerial ability of the unit's head (OR = 3.45; 95% CI 1.2-10.1; p = .023), and unsatisfactory communication (OR = 5.30; 95% CI 1.6-17.6; p = .006). Among nurses, psychiatric morbidity was associated with insufficient ability of the unit's head to solve conflicts, insufficient decisional power in relation to responsibilities, insufficient economic rewards and career possibilities, and working in surgery. Similar job-related factors were associated also with emotional exhaustion. Psychiatric morbidity and emotional exhaustion were relatively high, particularly among nurses. Specific job-related factors were associated with psychiatric morbidity and burnout. Improving these aspects is important for the well-being of hospital staff and the quality of patient care.     

The Representation of Health Professionals on Governing Boards of Health Care Organizations in New York City

The Representation of Health Professionals on Governing Boards of Health Care Organizations in New York City. The heightened importance of processes and outcomes of care—including their impact on health care organizations’ (HCOs) financial health—translate into greater accountability for clinical performance on the part of HCO leaders, including their boards, during an era of health care reform. Quality and safety of care are now fiduciary responsibilities of HCO board members. The participation of health professionals on HCO governing bodies may be an asset to HCO governing boards because of their deep knowledge of clinical problems, best practices, quality indicators, and other issues related to the safety and quality of care. And yet, the sparse data that exist indicate that physicians comprise more than 20 % of the governing board members of hospitals while less than 5 % are nurses and no data exist on other health professionals. The purpose of this two-phased study is to examine health professionals’ representations on HCOs—specifically hospitals, home care agencies, nursing homes, and federally qualified health centers—in New York City. Through a survey of these organizations, phase 1 of the study found that 93 % of hospitals had physicians on their governing boards, compared with 26 % with nurses, 7 % with dentists, and 4 % with social workers or psychologists. The overrepresentation of physicians declined with the other HCOs. Only 38 % of home care agencies had physicians on their governing boards, 29 % had nurses, and 24 % had social workers. Phase 2 focused on the barriers to the appointment of health professionals to governing boards of HCOs and the strategies to address these barriers. Sixteen health care leaders in the region were interviewed in this qualitative study. Barriers included invisibility of health professionals other than physicians; concerns about “special interests”; lack of financial resources for donations to the organization; and lack of knowledge and skills with regard to board governance, especially financial matters. Strategies included developing an infrastructure for preparing and getting appointed various health professionals, mentoring, and developing a personal plan of action for appointments.     

Creating a culture for health care quality and safety

Approximately 67% of hospital quality indicators require some type of laboratory testing to monitor compliance. Unfortunately, in many hospitals, laboratory data information systems remain an untapped resource in eliminating medical errors and improving patient safety. Using case scenarios, this article demonstrates potential consequences for patient safety and quality of care when information sharing between medical technologists and nurses is not a part of a hospital's culture. The outcome for this patient could have been avoided if a more inclusive health care quality and safety culture existed. Creating a culture for health care quality and safety requires consensus building by clinical and administrative leaders. Consensus building occurs by managing relationships among and between a team of independent, autonomous physicians, nurses, allied health professionals, and health care administrators. These relationships are built on mutual respect and effective communication. Creating a quality culture is a challenging but necessary prerequisite for eliminating medical errors and ensuring patient safety. Physician leaders promoting and advancing cultural change in clinical care from one of exclusive decision making authority to a culture that is based on shared decision making are a necessary first step. Shared decision making requires mutual respect, trust, confidentiality, responsiveness, empathy, effective listening, and communication among all clinical team members. Physician and administrative leaders with a focus on patient safety and a willingness to change will ensure a culture of health care quality and safety.     

Variation in Hospital Length of Stay: Do Physicians Adapt Their Length of Stay Decisions to What Is Usual in the Hospital Where They Work?

OBJECTIVE: To test the hypothesis that physicians who work in different hospitals adapt their length of stay decisions to what is usual in the hospital under consideration. DATA SOURCES: Secondary data were used, originating from the Statewide Planning and Research Cooperative System (SPARCS). SPARCS is a major management tool for assisting hospitals, agencies, and health care organizations with decision making in relation to financial planning and monitoring of inpatient and ambulatory surgery services and costs in New York state. STUDY DESIGN: Data on length of stay for surgical interventions and medical conditions (a total of seven diagnosis-related groups [DRGs]) were studied, to find out whether there is more variation between than within hospitals. Data (1999, 2000, and 2001) from all hospitals in New York state were used. The study examined physicians practicing in one hospital and physicians practicing in more than one hospital, to determine whether average length of stay differs according to the hospital of practice. Multilevel models were used to determine variation between and within hospitals. A t-test was used to test whether length of stay for patients of each multihospital physician differed from the average length of stay in each of the two hospitals. PRINCIPAL FINDINGS: There is significantly (p<.05) more variation between than within hospitals in most of the study populations. Physicians working in two hospitals had patient lengths of stay comparable with the usual practice in the hospital where the procedure was performed. The proportion of physicians working in one hospital did not have a consistent effect for all DRGs on the variation within hospitals. CONCLUSION: Physicians adapt to their colleagues or to the managerial demands of the particular hospital in which they work. The hospital and broader work environment should be taken into account when developing effective interventions to reduce variation in medical practice.     

Low catheter sepsis rate in a hospital-wide nutrition support service

Four hundred and seventy-nine catheters were inserted into 471 patients over a 6 year period for the administration of total parenteral nutrition. Catheter insertion was carried out only by surgical members of the nutrition support service. Complications were recorded prospectively and stored, with all other details of treatment, on a microcomputer. The mechanical complication rate was 6.4% of catheters used and the incidence of catheter related sepsis (CRS) 2.9%. Catheters which grew organisms, but were not associated with CRS, occurred in 3.7% of catheters used. Catheter care was performed by nurses throughout the hospital under the supervision of the nutrition nurse. The results of our work indicate that restriction of catheter care to specialised nurses is unnecessary providing there is staff education and support. In addition, the value of routine catheter tip culture in patients, not suspected of having infection, is questionable.     

Satisfaction with hospitalization: a comparative analysis of three types of services

A study of patient's satisfaction with hospital services was undertaken. The purpose of the study was to explore whether and to what extent patients' satisfaction with three types of hospital services (medical, nursing and supportive) is differentially explained by patient's sociodemographic, psychosocial, situational and attitudinal characteristics. To achieve this, 476 patients were interviewed. The results of the analysis of their general satisfaction with hospitalization and a comparative analysis of satisfaction with the three types of services are presented. The best predictors of satisfaction with all three types of services (in order of their importance) are found to be: perceived improvement in health, size of social networks, satisfaction with organizations in the past, and age. The type of ward (medical vs surgical) is found to be a powerful predictor of satisfaction with physicians and nurses only. Ward effect is also interactive--improvement in one's health predicts significantly more satisfaction with medical services in medical wards than in surgical wards. The findings of this study suggest that when clients perceive that their main goal has been achieved (i.e. improvement in health), they tend to attach little importance to deficiencies in the process of achieving it (i.e. the provision of services).