David Pryor

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Background:The Joint Commission on Accreditation of Healthcare Organizations is proposing that hospitals measure culture beginning in 2007. However, a reliable and widely used measurement tool for the operating room (OR) setting does not currently exist. Methods:OR personnel in 60 US hospitals were surveyed using the Safety Attitudes Questionnaire. The teamwork climate domain of the survey uses six items about difficulty speaking up, conflict resolution, physician–nurse collaboration, feeling supported by others, asking questions, and heeding nurse input. To justify grouping individual-level responses to a single score at each hospital OR level, the authors used a multilevel confirmatory factor analysis, intraclass correlations, within-group interrater reliability, and Cronbach’s &agr;. To detect differences at the hospital OR level and by caregiver type, the authors used multivariate analysis of variance (items) and analysis of variance (scale). Results:The response rate was 77.1%. There was robust evidence for grouping individual-level respondents to the hospital OR level using the diverse set of statistical tests, e.g., Comparative Fit Index = 0.99, root mean squared error of approximation = 0.05, and acceptable intraclasss correlations, within-group interrater reliability values, and Cronbach’s &agr; = 0.79. Teamwork climate differed significantly by hospital (F59, 1,911 = 4.06, P < 0.001) and OR caregiver type (F4, 1,911 = 9.96, P < 0.001). Conclusions:Rigorous assessment of teamwork climate is possible using this psychometrically sound teamwork climate scale. This tool and initial benchmarks allow others to compare their teamwork climate to national means, in an effort to focus more on what excellent surgical teams do well.

More quality measures versus measuring what matters: a call for balance and parsimony

External groups requiring measures now include public and private payers, regulators, accreditors and others that certify performance levels for consumers, patients and payers. Although benefits have accrued from the growth in quality measurement, the recent explosion in the number of measures threatens to shift resources from improving quality to cover a plethora of quality-performance metrics that may have a limited impact on the things that patients and payers want and need (ie, better outcomes, better care, and lower per capita costs). Here we propose a policy that quality measurement should be: balanced to meet the need of end users to judge quality and cost performance and the need of providers to continuously improve the quality, outcomes and costs of their services; and parsimonious to measure quality, outcomes and costs with appropriate metrics that are selected based on end-user needs.

The Quality ‘Journey’ At Ascension Health: How We’ve Prevented At Least 1,500 Avoidable Deaths A Year—And Aim To Do Even Better

A decade ago the Institute of Medicine estimated that 44,000-98,000 preventable deaths occur each year in US hospitals. The leaders of Ascension Health-one of the nations largest health care delivery networks, with sixty-nine hospitals in twenty states and the District of Columbia-dedicated themselves to preventing equivalent numbers of deaths in their system. In 2003 they set a goal of reducing preventable deaths by 900 each year by 2008. By fiscal year 2010 Ascension Health had reduced preventable deaths by more than 1,500 people annually and, by some calculations, by more than 5,000 people annually, compared to 2004. Ascension Health had also achieved important improvements in preventing birth trauma and reducing rates of pressure ulcers and hospital-acquired infections. The health care system could achieve even greater results by adopting the safety principles used in high-reliability entities such as the nuclear power industry. The adoption of such principles can lead to impressive improvements in health care quality.