Cheryl Rathert

Patient-Centered Care and Outcomes: A Systematic Review of the Literature

Patient-centered care (PCC) has been studied for several decades. Yet a clear definition of PCC is lacking, as is an understanding of how specific PCC processes relate to patient outcomes. We conducted a systematic review of the PCC literature to examine the evidence for PCC and outcomes. Three databases were searched for all years through September 2012. We retained 40 articles for the analysis. Results found mixed relationships between PCC and clinical outcomes, that is, some studies found significant relationships between specific elements of PCC and outcomes but others found no relationship. There was stronger evidence for positive influences of PCC on satisfaction and self-management. Future research should examine specific dimensions of PCC and how they relate to technical care quality, particularly some dimensions that have not been studied extensively. Future research also should identify moderating and mediating variables in the PPC–outcomes relationship.

Linking physician burnout and patient outcomes: Exploring the dyadic relationship between physicians and patients

Background: Although patient outcomes of hospital stays have been widely explored, particularly patient satisfaction, there is a dearth of research linking health care provider burnout and patient outcomes at a dyadic level. In this article, we develop and test a model to explain the relationship between dimensions of burnout and patient outcomes, including patient satisfaction and recovery time. Purpose: The purpose of this article is to explore the relationship between physician burnout and patient satisfaction and the time required to regain normal functioning after hospital discharge. Methods: This study was based upon a survey of 178 matched pairs of patients and physicians. The patients were people who had been hospitalized within the previous year. Results: We found support for the notion that the depersonalization dimension of physician burnout was associated with patient outcomes of lower satisfaction and longer post discharge recovery time (after controlling for severity of illness and other demographic factors). Implications for Practice: The findings suggest that physician burnout has an impact on patient outcomes. Although this is a preliminary study, it suggests that organizations that take proactive steps to reduce burnout through system wide intervention programs will see greater benefits in terms of patient satisfaction and recovery.

Health care work environments, employee satisfaction, and patient safety: Care provider perspectives.

BACKGROUND Experts continue to decry the lack of progress made in decreasing the alarming frequency of medical errors in health care organizations (Leape, L. L., & Berwick, D. M. (2005). Five years after to err is human: What have we learned?. Journal of the American Medical Association, 293(19), 2384-2390). At the same time, other experts are concerned about the lack of job satisfaction and turnover among nurses (. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press). Research and theory suggest that a work environment that facilitates patient-centered care should increase patient safety and nurse satisfaction. PURPOSES The present study began with a conceptual model that specifies how work environment variables should be related to both nurse and patient outcomes. Specifically, we proposed that health care work units with climates for patient-centered care should have nurses who are more satisfied with their jobs. Such units should also have higher levels of patient safety, with fewer medication errors. METHODOLOGY/APPROACH We examined perceptions of nurses from three acute care hospitals in the eastern United States. FINDINGS Nurses who perceived their work units as more patient centered were significantly more satisfied with their jobs than were those whose units were perceived as less patient centered. Those whose work units were more patient centered reported that medication errors occurred less frequently in their units and said that they felt more comfortable reporting errors and near-misses than those in less patient-centered units. PRACTICE IMPLICATIONS Patients and quality leaders continue to call for delivery of patient-centered care. If climates that facilitate such care are also related to improved patient safety and nurse satisfaction, proactive, patient-centered management of the work environment could result in improved patient, employee, and organizational outcomes.

The role of continuous quality improvement and psychological safety in predicting work-arounds.

Background: Work-arounds are work procedures that are undertaken to address a block in work flow. Although there has been extensive interest in the health care literature concerning work-arounds, there is a dearth of literature exploring the factors that predict work-arounds. Purpose: The purpose of this article is to examine the role of continuous quality improvement and psychological safety as predictors of work-arounds in health care organizations. Specifically, we hypothesized that continuous quality improvement and psychological safety predicted work-arounds such that psychological safety mediated the relationship between continuous quality improvement and work-arounds. Methodology: This study was part of a larger cross-sectional field study exploring workforce issues among cancer registrars working in acute care hospitals who report tumor data to a state cancer registry in the Midwest. Eighty-three employees of cancer registries responded to telephone survey items assessing continuous quality improvement (personal influence and management style), psychological safety, and work-arounds. Findings: Using mediated multiple regression (with findings confirmed with a Sobel test), we found partial support for the hypothesized mediated relationship between personal influence, management style, psychological safety, and work-arounds. The exception to this pattern concerned personal influence. Because personal influence is a dimension of continuous quality improvement, it would be negatively associated with work-arounds; we found the opposite to be true in this study. Practice Implications: To avoid problems with work-arounds, our findings suggest that organizations need to commit to continuous improvement at a strategic level. In addition, culture and management behaviors need to shift away from reinforcement of individual first-order problem solving (manifest as work-arounds) toward second-order problem-solving approaches.

Improving work environments in health care: test of a theoretical framework.

Background: In light of high levels of staff turnover and variability in the quality of health care, much attention is currently being paid to the health care work environment and how it potentially relates to staff, patient, and organizational outcomes. Although some attention has been paid to staffing variables, more attention must be paid to improving the work environment for patient care. Purposes: The purpose of this study was to empirically explore a theoretical model linking the work environment in the health care setting and how it might relate to work engagement, organizational commitment, and patient safety. This study also explored how the work environment influences staff psychological safety, which has been show to influence several variables important in health care. Methodology: Clinical care providers at a large metropolitan hospital were surveyed using a mail methodology. The overall response rate was 42%. This study analyzed perceptions of staff who provided direct care to patients. Findings: Using structural equation modeling, we found that different dimensions of the work environment were related to different outcome variables. For example, a climate for continuous quality improvement was positively related to organizational commitment and patient safety, and psychological safety partially mediated these relationships. Patient-centered care was positively related to commitment but negatively related to engagement. Practice Implications: Health care managers need to examine how organizational policies and practices are translated into the work environment and how these influence practices on the front lines of care. It appears that care provider perceptions of their work environments may be useful to consider for improvement efforts.

Hospital ethical climate and teamwork in acute care: the moderating role of leaders.

Background: Health care delivery teams have received much attention in recent years from researchers and practitioners. Recent empirical research has demonstrated that objective and subjective outcomes tend to be improved when care teams function smoothly and efficiently. However, little is known about how the work environment, or care context, influences team processes that lead to better outcomes. Purpose: The purposes of this study were to explore acute care staffs perceptions of how two components of the work environment, the ethical climate and continuous quality improvement leadership, influence teamwork and to begin to identify actionable approaches for improving teamwork. Although ethical climate influences have been studied in several sectors, research is lacking in health care. Methodology/Approach: A cross-sectional field study explored how the ethical climate impacted teamwork in an acute care setting and how continuous quality improvement leadership behaviors moderated the relationship between the ethical climate and teamwork. Findings: Results indicated that clinicians who perceived the ethical climate to be benevolent were significantly more likely to say that teamwork was better. Furthermore, we found that continuous quality improvement leadership styles moderated the relationship between the ethical climate and teamwork. Practice Implications: Although a benevolent ethical climate appears to be associated with effective teamwork, it appears that the proximate continuous quality improvement behaviors exhibited by leaders have a significant impact as well, above and beyond the climate. Implications for research and practice are discussed.

Acute care patients discuss the patient role in patient safety.

Background: Patient safety has been a highly researched topic in health care since the year 2000. One strategy for improving patient safety has been to encourage patients to take an active role in their safety during their health care experiences. However, little research has shed light on how patients view their roles. Purpose: This study attempted to address this deficit by inductively exploring the results of a qualitative study in which patients reported their ideas about what they believe their roles should be. Methodology: Patients with an overnight stay in the previous 90 days at one of three hospitals were surveyed using a mailing methodology. Of 1,040 respondents, 491 provided an open-ended response regarding what they believe the patient role should be. Findings: Qualitative analysis found several prominent themes. The largest proportion of responses (23%) suggested that patients should follow instructions given by care providers. Other prominent themes were that patients should ask questions and become informed about their conditions and treatments, and many implied that they should expect competent care. Our results suggest that patients believe they should be able to trust that they are being provided competent care, as opposed to assuming a leadership role in their safety. Practice Implications: Our results suggest that engaging patients in safety efforts may be complex, requiring a variety of strategies. Managers must provide environments conducive to staff and patient interactions to support patients in this effort. Different types of patients may require different engagement strategies.

Putting the ‘patient’ in patient safety: a qualitative study of consumer experiences

Background  Although patient safety has been studied extensively, little research has directly examined patient and family (consumer) perceptions. Evidence suggests that clinicians define safety differently from consumers, e.g. clinicians focus more on outcomes, whereas consumers may focus more on processes. Consumer perceptions of patient safety are important for several reasons. First, health‐care policy leaders have been encouraging patients and families to take a proactive role in ensuring patient safety; therefore, an understanding of how patients define safety is needed. Second, consumer perceptions of safety could influence outcomes such as trust and satisfaction or compliance with treatment protocols. Finally, consumer perspectives could be an additional lens for viewing complex systems and processes for quality improvement efforts.

Patient perceptions of patient-centred care: empirical test of a theoretical model

Patient perception measures are gaining increasing interest among scholars and practitioners. The aim of this study was to empirically examine a conceptual model of patient‐centred care using patient perception survey data.

Emotional exhaustion and workarounds in acute care: Cross sectional tests of a theoretical framework

BACKGROUND As health care organizations strive to improve their work processes, attention is being paid to workarounds in the clinical setting. Some research has found a link between burnout and workarounds. Other research shows that the clinical work environment can influence burnout levels in clinical workers, particularly emotional exhaustion. OBJECTIVE Underpinned by Conservation of Resources theory, we examined a conceptual model linking the work environment with workarounds in acute care nurses and other clinicians, and hypothesized that burnout, specifically emotional exhaustion, would mediate these relationships. STUDY DESIGN AND SETTING A cross sectional survey study was conducted in a large tertiary hospital in North America. PARTICIPANTS All clinical care providers in the hospitals medical units were invited to participate. The response rate was 45%, with nurses comprising 85% of respondents. METHOD Questionnaires were mailed to employee homes using a two-wave methodology. RESULTS Hypotheses were examined using structural equation modeling. Time pressure was positively related to exhaustion, and autonomy was negatively related. Exhaustion was positively related to workarounds, and mediated the time pressure and autonomy to workarounds relationships. Contrary to expectations, the physical environment was directly and negatively related to workarounds. CONCLUSION Our findings suggest that the work environment may influence more than individual clinician well-being and exhaustion, it also may influence workaround behaviors that could lead to harm for patients and/or the organization. More attention should be paid to the mechanisms that influence workarounds.