Amanda L. Brewster

A Comparison of Pan Trap and Intensive Net Sampling Techniques for Documenting a Bee (Hymenoptera: Apiformes) Fauna

Recent interest in pollinator sampling, often motivated by concerns about pollinator decline, has led to the increased use of standardized sampling protocols based on passive insect traps. Compared with netting insects at host plants, these protocols have the potential to limit some types of sampling bias, such as those associated with a researchers observational and netting skills. The most commonly deployed recent protocol is the use of colored pan traps (bowls) filled with soapy water (Aguiar and Sharkov, 1997; Calbuig, 2001; Cane et al, 2000; Leong and Thorp, 1999; Toler et al, 2005). Insects approach the bowls, land on the water, and drown. The method is particularly good at catching numerous species of bees, but can also be effective for capturing various flower-visiting flies, skippers and a wide range of other insect taxa. As a bee sampling device, pan traps have several known biases: they catch bumble bees, honey bees and bees in the genus Colletes much less frequently than expected by their perceived abundance (e.g., Toler et al, 2005). Pan traps are especially good at catching halictid bees (Family Halictidae). Because of these biases, researchers sometimes use a modest amount of net collecting on flowers to accompany pan traps. Other potential biases remain to be studied, such as whether the effectiveness of pan traps is inversely related to flower abundance, a bias suspected by several researchers but not yet studied. Based on their pan-trapping study, Toler et al (2005) concluded that the predominant flower color in the plant community did not influence the relative attractiveness of particular pan trap colors, but they did not study the effect of floral abundance per se. Depending on a researchers interest in deploying pan traps, these biases may or may not generate concern. Pan traps seem very well suited to testing for the presence of particular bee species in the community (Leong and Thorp, 1999), including many parasitic bee species that are seldom caught at flowers. They also provide a very valuable tool for augmenting other collecting methods, especially when there are few host plants to sample (e.g., early spring). Work by Cane et al. (2000) included a comparison of pan traps versus intensive netting to sample the very diverse and well known flower-visiting insect fauna of creosote bush. These workers concluded that pan trapping was of limited use in detecting the creosote bush fauna because of numerous species caught by netting but not by pan traps. Pan traps did catch many bee species not netted at creosote bush, however. Because netting in that study was restricted to creosote bush, there was no basis to compare the relative effectiveness of netting versus pan trapping for sampling a local bee fauna in the wider flower-rich community. In 2002 in northern Virginia, we carried out an intensive netting/observational survey of floral visitors within one hectare plots at Blandy Experimental Farm, an ecological experiment station of the University of Virginia. The sampled habitat was an open field and the sampling protocol comprised net sampling on the six most prominent plant species in the community from 8:00-16:00 hrs Eastern Daylight Time. Each plant species was surveyed for a total of 2.25 hrs, spread equally across the sampling period. Each of three researchers sampled all plant species in succession, one species at a time, three times across the sampling period (8:00-10:00, 11:00-13:00, 14:00-16:00). Survey periods lasted 15 mins per plant species per researcher, with researchers moving through the entire plot during that period. Bee species that could be recognized on the wing (e.g., Apis mellifera) were noted but not captured. To compare the effectiveness of pan trapping to such an intensive netting protocol at one of our sites, we placed a line of 30 pan traps (6 oz Solo bowls painted fluorescent blue, fluorescent yellow, or left white) in a diagonal line across the plot,

Leadership Development Programs for Physicians: A Systematic Review

BackgroundPhysician leadership development programs typically aim to strengthen physicians’ leadership competencies and improve organizational performance. We conducted a systematic review of medical literature on physician leadership development programs in order to characterize the setting, educational content, teaching methods, and learning outcomes achieved.MethodsArticles were identified through a search in Ovid MEDLINE from 1950 through November 2013. We included articles that described programs designed to expose physicians to leadership concepts, outlined teaching methods, and reported evaluation outcomes. A thematic analysis was conducted using a structured data entry form with categories for setting/target group, educational content, format, type of evaluation and outcomes.ResultsWe identified 45 studies that met eligibility criteria, of which 35 reported on programs exclusively targeting physicians. The majority of programs focused on skills training and technical and conceptual knowledge, while fewer programs focused on personal growth and awareness. Half of the studies used pre/post intervention designs, and four studies used a comparison group. Positive outcomes were reported in all studies, although the majority of studies relied on learner satisfaction scores and self-assessed knowledge or behavioral change. Only six studies documented favorable organizational outcomes, such as improvement in quality indicators for disease management. The leadership programs examined in these studies were characterized by the use of multiple learning methods, including lectures, seminars, group work, and action learning projects in multidisciplinary teams.DiscussionPhysician leadership development programs are associated with increased self-assessed knowledge and expertise; however, few studies have examined outcomes at a system level. Our synthesis of the literature suggests important gaps, including a lack of programs that integrate non-physician and physician professionals, limited use of more interactive learning and feedback to develop greater self-awareness, and an overly narrow focus on individual-level rather than system-level outcomes.

What Works in Readmissions Reduction: How Hospitals Improve Performance.

Background:Hospitals across the United States are pursuing strategies to reduce avoidable readmissions but the evidence on how best to accomplish this goal is mixed, with no specific clinical practice shown to reduce readmissions consistently. Changes to hospital organizational practices, a key component of context, also may be critical to improving performance on readmissions, but this has not been studied. Objective:The aim of this study was to understand how high-performing hospitals improved risk-stratified readmission rates, and whether their changes to clinical practices and organizational practices differed from low-performing hospitals. Design:This was a qualitative study of 10 hospitals in which readmission rates had decreased (n=7) or increased (n=3). Participants:A total of 82 hospital staff drawn from hospitals that had participated in the State Action on Avoidable Readmissions quality improvement initiative. Results:High-performing hospitals were distinguished by several organizational practices that facilitated readmissions reduction, that is, collective habits of action or interpretation shared by organization members. First, high-performing hospitals reported focused efforts to improve collaboration across hospital departments. Second, they helped postacute providers improve care by sharing the hospital’s clinical and quality improvement expertise and data. Third, high performers enthusiastically engaged in trial and error learning to reduce readmissions. Fourth, they emphasized that readmissions represented bad outcomes for patients, de-emphasizing the role of financial penalties. Both high-performing and low-performing hospitals had implemented most clinical practice changes commonly recommended to reduce readmissions. Conclusions:Our findings highlight several organizational practices that hospitals may be able to use to enhance the effectiveness of their readmissions reduction efforts.

Organizational culture change in U.S. hospitals: a mixed methods longitudinal intervention study

BackgroundImproving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospital leadership, clinicians, and policymakers. Evidence suggests links between hospital organizational culture and hospital performance; however, few studies have attempted to shift organizational culture in order to improve performance, fewer have focused on patient outcomes, and none have addressed mortality for patients with AMI. We sought to address this gap through a novel longitudinal intervention study, Leadership Saves Lives (LSL).MethodsThis manuscript describes the methodology of LSL, a 2-year intervention study using a concurrent mixed methods design, guided by open systems theory and the Assess, Innovate, Develop, Engage, Devolve (AIDED) model of diffusion, implemented in 10 U.S. hospitals and their peer hospital networks. The intervention has three primary components: 1) annual convenings of the ten intervention hospitals; 2) semiannual workshops with guiding coalitions at each hospital; and 3) continuous remote support across all intervention hospitals through a web-based platform. Primary outcomes include 1) shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) in-hospital AMI mortality. Quantitative data include annual surveys of guiding coalition members in the intervention hospitals and peer network hospitals. Qualitative data include in-person, in-depth interviews with all guiding coalition members and selective observations of key interactions in care for patients with AMI, collected at three time points. Data integration will identify patterns and major themes in change processes across all intervention hospitals over time.ConclusionsLSL is novel in its use of a longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This paper adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change.

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

Background Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced. Methods This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services. Results We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011–2014 and 2012–2015. Conclusions Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.

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

Background Quality collaboratives are widely endorsed as a potentially effective method for translating and spreading best practices for acute myocardial infarction (AMI) care. Nevertheless, hospital success in improving performance through participation in collaboratives varies markedly. We sought to understand what distinguished hospitals that succeeded in shifting culture and reducing 30-day risk-standardised mortality rate (RSMR) after AMI through their participation in the Leadership Saves Lives (LSL) collaborative. Procedures We conducted a longitudinal, mixed methods intervention study of 10 hospitals over a 2-year period; data included surveys of 223 individuals (response rates 83%–94% depending on wave) and 393 in-depth interviews with clinical and management staff most engaged with the LSL intervention in the 10 hospitals. We measured change in culture and RSMR, and key aspects of working related to team membership, turnover, level of participation and approaches to conflict management. Main findings The six hospitals that experienced substantial culture change and greater reductions in RSMR demonstrated distinctions in: (1) effective inclusion of staff from different disciplines and levels in the organisational hierarchy in the team guiding improvement efforts (referred to as the ‘guiding coalition’ in each hospital); (2) authentic participation in the work of the guiding coalition; and (3) distinct patterns of managing conflict. Guiding coalition size and turnover were not associated with success (p values>0.05). In the six hospitals that experienced substantial positive culture change, staff indicated that the LSL learnings were already being applied to other improvement efforts. Principal conclusions Hospitals that were most successful in a national quality collaborative to shift hospital culture and reduce RSMR showed distinct patterns in membership diversity, authentic participation and capacity for conflict management.

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

Background— Because organizational culture is increasingly understood as fundamental to achieving high performance in hospital and other healthcare settings, the ability to measure this nuanced concept empirically has gained importance. Aside from measures of patient safety culture, no measure of organizational culture has been widely endorsed in the medical literature, limiting replication of previous findings and broader use in interventional studies. Methods and Results— We sought to develop and assess the validity and reliability of a scale for assessing organizational culture in the context of hospitals’ efforts to reducing 30-day risk-standardized mortality after acute myocardial infarction. The 31-item scale was completed by 147 individuals representing 10 hospitals during August and September 2014. The resulting organizational culture scale demonstrated high level of construct validity and internal consistency. Factor analyses indicated that the 31 items loaded well (loading values 0.48–0.90), supporting distinguishable domains of (1) learning environment, (2) psychological safety, (3) commitment to the organization, (4) senior management support, and (5) time for improvement efforts. Cronbach &agr; coefficients were 0.94 for the scale and ranged from 0.77 to 0.88 for the subscales. The scale displayed reasonable convergent validity and statistically significant variability across hospitals, with hospital identity accounting for 11.3% of variance in culture scores across respondents. Conclusions— We developed and validated a relatively easy-to-administer survey that was able to detect substantial variability in organizational culture across different hospitals and may be useful in measuring hospital culture and evaluating changes in culture over time as part performance improvement efforts.

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

OBJECTIVE To understand how health care providers and social services providers coordinate their work in communities that achieve relatively low health care utilization and costs for older adults. STUDY SETTING Sixteen Hospital Service Areas (HSAs) in the United States. STUDY DESIGN We conducted a qualitative study of HSAs with performance in the top or bottom quartiles nationally across three key outcomes: ambulatory care sensitive hospitalizations, all-cause risk-standardized readmission rates, and average reimbursements per Medicare beneficiary. We selected 10 higher performing HSAs and six lower performing HSAs for inclusion in the study. DATA COLLECTION To understand patterns of collaboration in each community, we conducted site visits and in-depth interviews with a total of 245 representatives of health care organizations, social service agencies, and local government bodies. PRINCIPAL FINDINGS Organizations in higher performing communities regularly worked together to identify challenges faced by older adults in their areas and responded through collective action-in some cases, through relatively unstructured coalitions, and in other cases, through more hierarchical configurations. Further, hospitals in higher performing communities routinely matched patients with needed social services. CONCLUSIONS The collaborative approaches used by higher performing communities, if spread, may be able to improve outcomes elsewhere.

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

Background: Despite evidence that enrollment with hospice services has the potential to reduce hospital readmission rates, previous research has not examined exactly how hospitals may promote the appropriate use of hospice and palliative care for their discharged patients. Therefore, we sought to explore the strategies used by hospitals to increase the use of hospice and palliative care for patients at risk of readmission. Methods: We conducted a secondary analysis of qualitative data from a study of hospitals that were participating in the State Action on Avoidable Readmissions (STAAR) initiative, a quality improvement collaborative. We used data attained from 46 in-depth interviews conducted during 10 hospital site visits using a standard discussion guide and protocol. We used a grounded theory approach using the constant comparative method to generate recurrent and unifying themes. Results: We found that a positive effect for hospitals participating in the STAAR initiative was enhanced engagement in efforts to promote greater use of hospice and palliative care as a possible method of reducing unplanned readmissions, the central goal of the STAAR initiative. Hospital staff described strategies to increase the use of hospice and palliative care that included (1) designing and implementing tracking systems to identify patients most at risk of being readmitted, (2) providing education about hospice and palliative care to family, internal and external clinical groups, and (3) establishing closer links to posthospital settings. Conclusion: National efforts to reduce rehospitalizations may result in improved integration of hospice and palliative care for patients who are at risk of readmission.

Strategies to reduce hospital 30-day risk-standardized mortality rates for patients with acute myocardial infarction: a cross-sectional and longitudinal survey

BackgroundSurvival rates after acute myocardial infarction (AMI) vary markedly across U.S. hospitals. Although substantial efforts have been made to improve hospital performance, we lack contemporary evidence about changes in hospital strategies and features of organizational culture that might contribute to reducing hospital AMI mortality rates. We sought to describe current use of several strategies and features of organizational culture linked to AMI mortality in a national sample of hospitals and examine changes in use between 2010 and 2013.MethodsWe conducted a cross-sectional survey of 543 hospitals (70% response rate) in 2013, and longitudinal analysis of a subsample of 107 hospitals that had responded to a survey in 2010 (67% response rate).ResultsBetween 2010 and 2013, the use of many strategies increased, but the use of only two strategies increased significantly: the percentage of hospitals providing regular training to Emergency Medical Service (EMS) providers about AMI care increased from 36% to 71% (P-value < 0.001) and the percentage of hospitals using computerized assisted physician order entry more than doubled (P-value < 0.001). Most, but not all, hospitals reported having environments conducive to communication, coordination and problem solving.ConclusionsWe found few significant changes between 2010 and 2013 in hospital strategies or in key features of organizational culture that have been associated with lower AMI mortality rates. Findings highlight several opportunities to help close remaining performance gaps in AMI mortality among hospitals.