Jochen Profit

Burnout in the NICU setting and its relation to safety culture

Background Burnout is widespread among healthcare providers and is associated with adverse safety behaviours, operational and clinical outcomes. Little is known with regard to the explanatory links between burnout and these adverse outcomes. Objectives (1) Test the psychometric properties of a brief four-item burnout scale, (2) Provide neonatal intensive care unit (NICU) burnout and resilience benchmarking data across different units and caregiver types, (3) Examine the relationships between caregiver burnout and patient safety culture. Research design Cross-sectional survey study. Subjects Nurses, nurse practitioners, respiratory care providers and physicians in 44 NICUs. Measures Caregiver assessments of burnout and safety culture. Results Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. The percentage of respondents in each NICU reporting burnout ranged from 7.5% to 54.4% (mean=25.9%, SD=10.8). The four-item burnout scale was reliable (α=0.85) and appropriate for aggregation (intra-class correlation coefficient-2=0.95). Burnout varied significantly between NICUs, p<0.0001, but was less prevalent in physicians (mean=15.1%, SD=19.6) compared with non-physicians (mean=26.9%, SD=11.4, p=0.0004). NICUs with more burnout had lower teamwork climate (r=−0.48, p=0.001), safety climate (r=−0.40, p=0.01), job satisfaction (r=−0.64, p<0.0001), perceptions of management (r=−0.50, p=0.0006) and working conditions (r=−0.45, p=0.002). Conclusions NICU caregiver burnout appears to have ‘climate-like’ features, is prevalent, and associated with lower perceptions of patient safety culture.

Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care A Randomized Trial

IMPORTANCE Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory. OBJECTIVE To test the effect of explicit financial incentives to reward guideline-recommended hypertension care. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists). INTERVENTIONS Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports. MAIN OUTCOMES AND MEASURES Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension. RESULTS Mean (SD) total payments over the study were

The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU

4270 (

Neonatal intensive care unit safety culture varies widely.

459),

Postnatal growth failure in very low birthweight infants born between 2005 and 2012

2672 (

Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis.

153), and

Improving benchmarking by using an explicit framework for the development of composite indicators: an example using pediatric quality of care

1648 (

Implementing pay-for-performance in the neonatal intensive care unit.

248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout. CONCLUSIONS AND RELEVANCE Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00302718.

Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout

Background Neonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unit setting make the SAQ an attractive tool for comparing clinical performance between hospitals. Little information is available on the use of the SAQ for this purpose in the NICU setting. Objectives To determine whether the dimensions of safety culture measured by the SAQ give consistent results when used as a NICU performance measure. Methods Cross-sectional survey of caregivers in 12 NICUs, using the six scales of the SAQ: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions. NICUs were ranked by quantifying their contribution to overall risk-adjusted variation across the scales. Spearman rank correlation coefficients were used to test for consistency in scale performance. The authors then examined whether performance in the top four NICUs in one scale predicted top four performance in others. Results There were 547 respondents in 12 NICUs. Of 15 NICU-level correlations in performance ranking, two were >0.7, seven were between 0.4 and 0.69, and the six remaining were <0.4. The authors found a trend towards significance in comparing the distribution of performance in the top four NICUs across domains with a binomial distribution p=0.051, indicating generally consistent performance across dimensions of safety culture. Conclusion A culture of safety permeates many aspects of patient care and organisational functioning. The SAQ may be a useful tool for comparative performance assessments among NICUs.

Formal selection of measures for a composite index of NICU quality of care: Baby-MONITOR

Background Variation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture. Objective To describe NICU care giver assessments of safety culture, explore variability within and between NICUs on safety culture domains, and test for association with care giver characteristics. Methods NICU care givers in 12 hospitals were surveyed using the Safety Attitudes Questionnaire (SAQ), which has six scales: teamwork climate, safety climate, job satisfaction, stress recognition, perception of management and working conditions. Scale means, SDs and percent positives (percent agreement) were calculated for each NICU. Results There was substantial variation in safety culture domains among NICUs. Composite mean score across the six domains ranged from 56.3 to 77.8 on a 100-point scale and NICUs in the top four NICUs were significantly different from the bottom four (p<0.001). Across the six domains, respondent assessments varied widely, but were least positive on perceptions of management (3%–80% positive; mean 33.3%) and stress recognition (18%–61% positive; mean 41.3%). Comparisons of SAQ scale scores between NICUs and a previously published adult ICU cohort generally revealed higher scores for NICUs. Composite scores for physicians were 8.2 (p=0.04) and 9.5 (p=0.02) points higher than for nurses and ancillary personnel. Conclusion There is significant variation and scope for improvement in safety culture among these NICUs. The NICU variation was similar to variation in adult ICUs, but NICU scores were generally higher. Future studies should validate whether safety culture measured with the SAQ correlates with clinical and operational outcomes in NICUs.