Marjorie L. Pearson

The Role of Perceived Team Effectiveness in Improving Chronic Illness Care

Background/Objectives:The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. Study Setting and Methods:Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care. Results:A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made. Conclusions:The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.

CESAREAN CHILDBIRTH AND PSYCHOSOCIAL OUTCOMES : A META-ANALYSIS

A comprehensive literature review with meta-analysis examines the differences between vaginal and cesarean delivery on 23 psychosocial outcomes of childbirth. The most robust findings suggest that cesarean mothers, compared with mothers who delivered vaginally, expressed less immediate and long-term satisfaction with the birth, were less likely ever to breast-feed, experienced a much longer time to first interaction with their infants, had less positive reactions to them after birth, and interacted less with them at home. Some differences were also found between unplanned and planned cesarean sections; none were found between birthing methods for maternal confidence for infant caretaking soon after birth, maternal anxiety in the hospital and at home, maternal stress at home, maternal return to work, and continuation of breast-feeding once begun. Implications of these findings for theory, research, and childbirth practice are discussed.

Information Content and Clarity of Radiologists' Reports for Chest Radiography

RATIONALE AND OBJECTIVES We systematically characterized the information provided by chest radiography reports on a nationally representative sample of 822 elderly patients hospitalized in 297 acute-care hospitals in five states who had an admission diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia. METHODS We studied the content of radiography reports, including mention of the type or adequacy of radiography; the presence or absence of a prior radiograph; comments about bones, the aorta, the mediastinum, and pleura and notation of the laterality of findings; and the presence of diagnosis. Two physicians reviewed each patients report, and a third assigned the final rating when they disagreed. RESULTS Our analysis found wide variation in content of chest radiography reports, extensive variation in terms used to identify the presence or absence of abnormal findings, and a large degree of uncertainty in what was found. CONCLUSION With most hospitals introducing new information systems in response to technological advances and the need to generate more formal hospitalwide reports, the time is right to improve the quality of chest radiography reporting.

Motivation to change chronic illness care: results from a national evaluation of quality improvement collaboratives.

Abstract: This article examines the motivation of health care professionals to improve quality of chronic illness care using the Chronic Care Model and Plan-Do-Study-Act cycles. The findings suggest that organizational attempts to redesign care require support of activities initiated by practitioners and managers and an organizational commitment to quality improvement.

Structured Implicit Review: A New Method for Monitoring Nursing Care Quality

Background.Nurses’ independent decisions about assessment, treatment, and nursing interventions for hospitalized patients are important determinants of quality of care. Physician peer implicit review of medical records has been central to Medicare quality management and is considered the gold standard for reviewing physician care, but peer implicit review of nursing processes of care has not received similar attention. Objective.The objective of this study was to develop and evaluate nurse structured implicit review (SIR) methods. Research Design.We developed SIR instruments for rating the quality of inpatient nursing care for congestive heart failure (CHF) and cerebrovascular accident (CVA). Nurse reviewers used the SIR form to rate a nationally representative sample of randomly selected medical records for each disease from 297 acute care hospitals in 5 states (collected by the RAND-HCFA Prospective Payment System study). Subjects.The study subjects were elderly Medicare inpatients with CHF (n = 291) or CVA (n = 283). Measures.We developed and tested scales reflecting domains of nursing process, evaluated interrater and interitem reliability, and assessed the extent to which items and scales predicted overall ratings of the quality of nursing care. Results.Interrater reliability for 14 of 16 scales (CHF) or 10 of 16 scales (CVA) was ≥0.40. Interitem reliability was >0.80 for all but 1 scale (both diseases). Functional Assessment, Physical Assessment, and Medication Tracking ratings were the strongest predictors of overall nursing quality ratings (P <0.001 for each). Conclusions.Nurse peer review with SIR has adequate interrater and excellent scale reliabilities and can be a valuable tool for assessing nurse performance.

The influence of integrated electronic medical records and computerized nursing notes on nurses' time spent in documentation.

We investigated nurses’ time spent in documentation as it relates to the use of electronic charting. A cross-sectional analysis was completed using time and motion data collected during a nursing process improvement initiative for 105 units in 55 hospitals. Ordinary least squares regression with a cluster adjustment revealed very little difference in time spent in documentation with or without the use of electronic medical records or computerized nursing notes. Nurses spent 19% of their time completing documentation, regardless of electronic charting usage, compared with all other categories of care. These findings suggest that integrated electronic medical records and computerized nursing notes do not appear to increase the time nurses spend documenting.

Participation of Unit Nurses

Front-line implementation on TCAB pilot units.

Evaluating quality of nursing care: the gap between theory and practice.

The purpose of this article is to determine whether nursing practice, as judged by nurse peer reviewers, varies by type or location of hospital and to assess which aspects of practice tend to be most at variance with nursing theory. This article provides a framework of continued quality assessment and improvement that is based on prior research. Trained nurse peer reviewers carried out structured implicit review, which utilized their professional judgment to evaluate the process of nursing care for patients admitted to acute hospitals with heart failure or cerebrovascular accident. Findings show significant variations in the quality of nursing care and support the continued development of nursing quality assessment and improvement initiatives directed at reducing the gap between nursing theory and practice.

Changes Over Time in the Use of Do Not Resuscitate Orders and the Outcomes of Patients Receiving Them

OBJECTIVES Do not resuscitate (DNR) orders are increasingly common, though there has been little evaluation of their changing use. The authors contrasted the use and outcomes of DNR orders for nationally representative samples of Medicare patients hospitalized with specific diagnoses in 1981 to 1982 and 1985 to 1986. METHODS Using ordinary least squares regression to adjust for patient and hospital characteristics, the authors compared use, timing and predictors of DNR orders, and survival to hospital discharge of patients with DNR orders between the two time periods. RESULTS After adjustment for sickness at admission and for patient and hospital factors, more patients received DNR orders in 1985 to 1986 than in 1981 to 1982 (13% versus 10%, P < 0.001), with most of the increase among patients with the greatest sickness at admission. Disparity in DNR order use by age, diagnosis, functional status, preadmission residence, and gender found in 1981 to 1982 was still present in 1985 to 1986. DNR orders were written earlier in hospitalization during the latter time period. Patients with DNR orders were more likely to survive to hospital discharge in 1985 to 1986 than in 1981 to 1982 (44% versus 36%, P = 0.001), but their 30-day survival did not differ. CONCLUSIONS Although use increased, disparities in DNR order assignment persisted in these 1980s data. Examination is needed into whether these differences persist and whether they reflect patient preferences. Systems should be developed to preserve and review the preferences of the increasing number of patients discharged after in-hospital DNR orders.

Overall Effect of TCAB on Initial Participating Hospitals

Evaluation at 13 pilot facilities.