Jason P. Richter

The influence of organizational factors on patient safety: Examining successful handoffs in health care.

BACKGROUND Although patient handoffs have been extensively studied, they continue to be problematic. Studies have shown poor handoffs are associated with increased costs, morbidity, and mortality. No prior research compared perceptions of management and clinical staff regarding handoffs. PURPOSE Our aims were (a) to determine whether perceptions of organizational factors that can influence patient safety are positively associated with perceptions of successful patient handoffs, (b) to identify organizational factors that have the greatest influence on perceptions of successful handoffs, and (c) to determine whether associations between perceptions of these factors and successful handoffs differ for management and clinical staff. METHODOLOGY/APPROACH A total of 515,637 respondents from 1,052 hospitals completed the Hospital Survey on Patient Safety Culture that assessed perceptions about organizational factors that influence patient safety. Using weighted least squares multiple regression, we tested seven organizational factors as predictors of successful handoffs. We fit three separate models using data collected from (a) all staff, (b) management only, and (c) clinical staff only. FINDINGS We found that perceived teamwork across units was the most significant predictor of perceived successful handoffs. Perceptions of staffing and management support for safety were also significantly associated with perceived successful handoffs for both management and clinical staff. For management respondents, perceptions of organizational learning or continuous improvement had a significant positive association with perceived successful handoffs, whereas the association was negative for clinical staff. Perceived communication openness had a significant association only among clinical staff. PRACTICE IMPLICATIONS Hospitals should prioritize teamwork across units and strive to improve communication across the organization in efforts to improve handoffs. In addition, hospitals should ensure sufficient staffing and management support for patient safety. Different perceptions between management and clinical staff with respect to the importance of organizational learning are noteworthy and merit additional study.

Limited Use of Price and Quality Advertising Among American Hospitals

Background Consumer-directed policies, including health savings accounts, have been proposed and implemented to involve individuals more directly with the cost of their health care. The hope is this will ultimately encourage providers to compete for patients based on price or quality, resulting in lower health care costs and better health outcomes. Objective To evaluate American hospital websites to learn whether hospitals advertise directly to consumers using price or quality data. Methods Structured review of websites of 10% of American hospitals (N=474) to evaluate whether price or quality information is available to consumers and identify what hospitals advertise about to attract consumers. Results On their websites, 1.3% (6/474) of hospitals advertised about price and 19.0% (90/474) had some price information available; 5.7% (27/474) of hospitals advertised about quality outcomes information and 40.9% (194/474) had some quality outcome data available. Price and quality information that was available was limited and of minimal use to compare hospitals. Hospitals were more likely to advertise about service lines (56.5%, 268/474), access (49.6%, 235/474), awards (34.0%, 161/474), and amenities (30.8%, 146/474). Conclusions Insufficient information currently exists for consumers to choose hospitals on the basis of price or quality, making current consumer-directed policies unlikely to realize improved quality or lower costs. Consumers may be more interested in information not related to cost or clinical factors when choosing a hospital, so consumer-directed strategies may be better served before choosing a provider, such as when choosing a health plan.

Evaluating the Effect of Safety Culture on Error Reporting A Comparison of Managerial and Staff Perspectives

Although medical error reporting has been studied, underreporting remains pervasive. The study aims were to identify the organizational factors with the greatest perceived effect on error reporting and to determine whether associations differ for management and clinical staff. A total of 515 637 respondents from 1052 hospitals completed the Hospital Survey on Patient Safety Culture. Nine organizational factors were tested as predictors of error reporting using weighted least-squares multiple regression. Error feedback was perceived as the most significant predictor, while organizational learning was another significant factor. It also was found that although management support for patient safety was significantly related to error reporting among clinical staff, this association was not significant among management. This difference is relevant because managers may not be aware that their failure to demonstrate support for safety leads to underreporting by frontline clinical staff. Findings from this study can inform hospitals’ efforts to increase error reporting.

Patient experience and hospital profitability: Is there a link?

BACKGROUND Patient experience has had a direct financial impact on hospitals since value-based purchasing was instituted by the Centers for Medicare & Medicaid Services in 2013 as a method to reward or punish hospitals based on performance on various measures, including patient experience. Although other industries have shown an indirect impact of customer experience on overall profitability, that link has not been well established in the health care industry. Return-to-provider rate and perceptions of health quality have been associated with profitability in the health care industry. PURPOSE Our aims were to assess whether, independent of a direct financial impact, a more positive patient experience is associated with increased profitability and whether a more negative patient experience is associated with decreased profitability. METHODOLOGY/APPROACH We used a sample of 19,792 observations from 3767 hospitals over the 6-year period 2007-2012. The data were sourced from Centers for Medicare & Medicaid Services and Hospital Consumer Assessment of Healthcare Providers and Systems. Using generalized estimating equations to account for repeated measures, we fit four separate models for three dependent variables: net patient revenue, net income, and operating margin. Each model included one of the following independent variables of interest: percentage of patients who definitely recommend the hospital, percentage of patients who definitely would not recommend the hospital, percentage of patients who rated the hospital 9 or 10, and percentage of patients who rated the hospital 6 or lower. FINDINGS We identified that a positive patient experience is associated with increased profitability and a negative patient experience is even more strongly associated with decreased profitability. PRACTICE IMPLICATIONS Management should have greater justification for incurring costs associated with bolstering patient experience programs. Improvements in training, technology, and staffing can be justified as a way to improve not only quality but now profitability as well.

The Effects of Nursing Satisfaction and Turnover Cognitions on Patient Attitudes and Outcomes: A Three-Level Multisource Study

OBJECTIVE To explore antecedents and outcomes of nurse self-reported job satisfaction and dissatisfaction-based turnover cognitions, theorizing (using Self-Determination Theory) that leaders can foster work conditions that help fulfill innate needs, thereby fostering satisfaction of nurses and patients, and reducing adverse events. DATA SOURCES/STUDY SETTING Primary and secondary data were collected within a 4-month period in 2015, from 2,596 nurses in 110 Army treatment facilities (hospitals and clinics) across 35 health care systems. DATA COLLECTION/EXTRACTION We collected individual nurse responses to the Practice Environment Scale-Nursing Work Index, in addition to aggregated archival data from the same timeframe, including both facility-level patient satisfaction records (the Army Provider Level Satisfaction Survey) and health care system-level adverse events records (provided by the Army Programming, Analysis, and Evaluation office). PRINCIPAL FINDINGS Five predictors of nurse satisfaction and turnover cognitions emerged-supportive leadership, staffing levels, nurse-physician teamwork, adoption of nursing care practice, and advancement opportunities. Aggregated nurse satisfaction was the most consistent predictor of both patient satisfaction and adverse events. CONCLUSION These findings provide evidence of the importance of nurse attitudes in improving perceived and actual performance across facilities and health care systems; in addition to practical steps, managers can take to improve satisfaction and retention.

Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections.

Background: Approximately 250,000 central line-associated bloodstream infections (CLABSIs) occur annually in the United States, with 30,000 related deaths. CLABSIs are largely preventable, and the Comprehensive Unit-Based Safety Program (CUSP) is a proven sustainable model that can be used to reduce CLABSIs. CUSP is a resource intensive program that, although widely used, has not been universally adopted. Purpose: The purpose of this study is to identify the significant factors of safety culture prior to CUSP implementation associated with a reduction or elimination of CLABSIs. By identifying these factors, hospitals can target CUSP to those units expected to have the greatest odds of reducing CLABSIs. Methodology/Approach: Using logistic and negative binomial regressions, we analyzed 649 hospital units that completed the national On the CUSP: Stop BSI study between May 2009 and June 2012. Hospital units provided CLABSI rates and staff survey responses on perceptions of factors of safety culture prior to CUSP implementation and CLABSI rates for six quarters thereafter. Findings: We found that hospital units reduced infection rates in the six quarters following CUSP implementation from 1.95 to 1.04 CLABSIs per 1,000 central line days. Most of the improvement occurred within the first two quarters following implementation. Hospitals with a stronger preimplementation safety culture had lower CLABSI rates at conclusion of the study. We found communication openness, staffing, organizational learning, and teamwork to be significantly associated with zero or reduced CLABSI rates. Practice Implications: CUSP appears to have a greater impact on CLABSI rates when implemented by units with a strong existing safety culture. Targeted implementation allows hospitals to optimize success, maximize scarce resources, and alleviate some of the CUSP program’s cost concerns if CUSP cannot be implemented in all units. To enhance the impact of CUSP, hospitals should improve safety culture prior to implementation in units that poorly exhibit it.

Quality Indicators Associated With the Level of NCQA Accreditation

The National Committee for Quality Assurance (NCQA) is the most widely used accrediting body of health plans, but no study has explored how differences in health quality affect the accreditation level. Consumers may benefit as they guide health insurance purchasing decisions toward a cost-quality evaluation. The authors conducted a multinomial logistic regression analysis using data from the 2015 NCQA Quality Compass of 351 health plans. This study’s outcome variable represented NCQA accreditation at 3 levels: accredited, commendable, and excellent. The authors examined the relationship of patient satisfaction, monitoring and prevention activities, appropriate care, and readmission rates on accreditation level. Satisfaction and monitoring and prevention activities were significantly associated with higher levels of accreditation in all analyses, but readmission was not. The expanded coverage of the Affordable Care Act provides an opportunity for health plans to market to consumers the benefits of accreditation to foster higher quality care.

Fix These First: How the World’s Leading Companies Point the Way Toward High Reliability in the Military Health System

EXECUTIVE SUMMARY The 2014 Military Health System Review calls for healthcare system leaders to implement effective strategies used by other high-performing organizations. The authors state, “ the [military health system] MHS can create an optimal healthcare environment that focuses on continuous quality improvement where every patient receives safe, high-quality care at all times” (Military Health System, 2014, p. 1). Although aspirational, the document does not specify how a highly reliable health system is developed or what systemic factors are necessary to sustain highly reliable performance. Our work seeks to address this gap and provide guidance to MHS leaders regarding how high-performing organizations develop exceptional levels of performance. The authors’ expectation is that military medicine will draw on these lessons to enhance leadership, develop exceptional organizational cultures, onboard and engage employees, build customer loyalty, and improve quality of care. Leaders from other segments of the healthcare field likely will find this study valuable given the size of the military healthcare system (9.6 million beneficiaries), the United States’ steady progression toward population-based health, and the increasing need for highly reliable systems and performance.

Doing Well by Doing Good: Evaluating the Influence of Patient Safety Performance on Hospital Financial Outcomes

Background: As financial pressures on hospitals increase because of changing reimbursement structures and heightened focus on quality and value, the association between patient safety performance and financial outcomes remains unclear. Purpose: The purpose of this study is to investigate if hospitals with higher patient safety performance are associated with higher levels of profitability than those with lower safety performance. Methodology/Approach: Using multinomial logistic regression, we analyzed data from the spring 2014 Leapfrog Hospital Safety Score and the 2014 American Hospital Association to determine the association between Leapfrog Hospital Safety Score performance and three dimensions of organizational profitability: operating margin, net patient revenue, and operating income. Results: Our findings suggest that improved hospital safety scores are associated with a relative risk of being in the top versus bottom quartile of financial performance: 5.41 times greater (p < .001) for operating margin, 10.98 times greater (p < .001) for net patient revenue, and 4.03 times greater (p < .001) for operating income. Practice Implications: Our findings suggest that improved patient safety performance, as evaluated within the Leapfrog Hospital Safety Score, is associated with improved financial performance at the hospital level. Targeted focus on patient safety may allow hospitals to improve financial performance, maximize scarce resources, and generate additional capital to continue to positively evolve care.