Mindy E. Flanagan

Major trauma in geriatric patients.

Contemporary trauma to the elderly, its severity and associated mortality and morbidity in 111 United States and Canadian trauma centers are described. Three-thousand eight-hundred thirty-three (3,833) trauma patients age 65 years or older are compared to 42,944 injured patients under age 65. Although both groups had equivalent measures of injury severity, the older group had higher case fatality and complication rates and longer hospital stays. The results raise important questions regarding the triage, acute care, accurate prediction of outcome, and hospital reimbursement for the elderly injured patient, with implications for care evaluation, quality assurance, and the long-term viability of trauma centers and systems of care.

You and me and the computer makes three: variations in exam room use of the electronic health record.

Challenges persist on how to effectively integrate the electronic health record (EHR) into patient visits and clinical workflow, while maintaining patient-centered care. Our goal was to identify variations in, barriers to, and facilitators of the use of the US Department of Veterans Affairs (VA) EHR in ambulatory care workflow in order better to understand how to integrate the EHR into clinical work. We observed and interviewed 20 ambulatory care providers across three geographically distinct VA medical centers. Analysis revealed several variations in, associated barriers to, and facilitators of EHR use corresponding to different units of analysis: computer interface, team coordination/workflow, and organizational. We discuss our findings in the context of different units of analysis and connect variations in EHR use to various barriers and facilitators. Findings from this study may help inform the design of the next generation of EHRs for the VA and other healthcare systems.

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions

BACKGROUND Healthcare professionals develop workarounds rather than using electronic health record (EHR) systems. Understanding the reasons for workarounds is important to facilitate user-centered design and alignment between work context and available health information technology tools. OBJECTIVE To examine both paper- and computer-based workarounds to the use of EHR systems in three benchmark institutions. METHODS Qualitative data were collected in 11 primary care outpatient clinics across three healthcare institutions. Data collection methods included direct observation and opportunistic questions. In total, 120 clinic staff and providers and 118 patients were observed. All data were analyzed using previously developed workaround categories and examined for potential new categories. Additionally, workarounds were coded as either paper- or computer-based. RESULTS Findings corresponded to 10 of 11 workaround categories identified in previous research. All 10 of these categories applied to paper-based workarounds; five categories also applied to computer-based workarounds. One new category, no correct path (eg, a desired option did not exist in the computer interface, precipitating a workaround), was identified for computer-based workarounds. The most consistent reasons for workarounds across the three institutions were efficiency, memory, and awareness. CONCLUSIONS Consistent workarounds across institutions suggest common challenges in outpatient clinical settings and failures to accommodate these challenges in EHR design. An examination of workarounds provides insight into how providers adapt to limiting EHR systems. Part of the design process for computer interfaces should include user-centered methods particular to providers and healthcare settings to ensure uptake and usability.

Context, culture and (non-verbal) communication affect handover quality

Background Transfers of care, also known as handovers, remain a substantial patient safety risk. Although research on handovers has been done since the 1980s, the science is incomplete. Surprisingly few interventions have been rigorously evaluated and, of those that have, few have resulted in long-term positive change. Researchers, both in medicine and other high reliability industries, agree that face-to-face handovers are the most reliable. It is not clear, however, what the term face-to-face means in actual practice. Objectives We studied the use of non-verbal behaviours, including gesture, posture, bodily orientation, facial expression, eye contact and physical distance, in the delivery of information during face-to-face handovers. Methods To address this question and study the role of non-verbal behaviour on the quality and accuracy of handovers, we videotaped 52 nursing, medicine and surgery handovers covering 238 patients. Videotapes were analysed using immersion/crystallisation methods of qualitative data analysis. A team of six researchers met weekly for 18 months to view videos together using a consensus-building approach. Consensus was achieved on verbal, non-verbal, and physical themes and patterns observed in the data. Results We observed four patterns of non-verbal behaviour (NVB) during handovers: (1) joint focus of attention; (2) ‘the poker hand’; (3) parallel play and (4) kerbside consultation. In terms of safety, joint focus of attention was deemed to have the best potential for high quality and reliability; however, it occurred infrequently, creating opportunities for education and improvement. Conclusions Attention to patterns of NVB in face-to-face handovers coupled with education and practice can improve quality and reliability.

The next-generation electronic health record: perspectives of key leaders from the US Department of Veterans Affairs

The rapid change in healthcare has focused attention on the necessary development of a next-generation electronic health record (EHR) to support system transformation and more effective patient-centered care. The Department of Veterans Affairs (VA) is developing plans for the next-generation EHR to support improved care delivery for veterans. To understand the needs for a next-generation EHR, we interviewed 14 VA operational, clinical and informatics leaders for their vision about system needs. Leaders consistently identified priorities for development in the areas of cognitive support, information synthesis, teamwork and communication, interoperability, data availability, usability, customization, and information management. The need to reconcile different EHR initiatives currently underway in the VA, as well as opportunities for data sharing, will be critical for continued progress. These findings may support the VAs effort for evolutionary change to its information system and draw attention to necessary research and development for a next-generation information system and EHR nationally.

Surgical inpatient satisfaction: What are the real drivers?

BACKGROUND Inpatient satisfaction is a key element of hospital pay-for-performance programs. Communication and pain management are known to influence results, but additional factors may affect satisfaction scores. We tested the hypothesis that patient factors and outcome parameters not considered previously are clinically important drivers of inpatient satisfaction. METHODS Medical records were reviewed for 1,340 surgical patients who returned nationally standardized inpatient satisfaction questionnaires. These patients were managed by 41 surgeons in seven specialties at two academic medical centers. Thirty-two parameters based on the patient, surgeon, outcomes, and survey were measured. Univariate and multivariable analyses were performed. RESULTS Inpatients rated their overall experience favorably 75.7% of the time. Less-satisfied patients were more likely to be female, younger, less ill, taking outpatient narcotics, and admitted via the emergency department (all P < .02). Less-satisfied patients also were more likely to have unresected cancer (P < .001) or a postoperative complication (P < .001). The most relevant independent predictors of dissatisfaction in multivariable analyses were younger age, admission via the emergency department, preoperative narcotic use, lesser severity of illness, unresected cancer, and postoperative morbidity (all P < .01). CONCLUSION Several patient factors, expectations of patients with cancer, and postoperative complications are important and clinically relevant drivers of surgical inpatient satisfaction. Programs to manage expectations of cancer patient expectations and decrease postoperative morbidity should improve surgical inpatient satisfaction. Further efforts to risk-adjust patient satisfaction scores should be undertaken.

Healthcare Team Vitality Instrument (HTVI): developing a tool assessing healthcare team functioning.

AIM This paper is a report of a study conducted to refine, shorten and validate the Healthcare Team Vitality Instrument. BACKGROUND The Healthcare Team Vitality Instrument was developed to assess team vitality of nurses as well as other licensed and unlicensed personnel working as part of healthcare teams in inpatient hospital units. This instrument was necessary for two reasons. First, other commonly used instruments assess characteristics of Registered Nurses or perceptions about and characteristics of the organizations in which they work, but not these factors in combination with critical factors of interdisciplinary team functioning and collaboration. Second, a short tool for repeated, regular measurement of team vitality was needed to track the impact of changes to improve work environments. METHOD Revisions to the Healthcare Team Vitality Instrument occurred in two phases. Phase 1 entailed collecting preliminary data and conducting cognitive interviews to refine the initial items. During Phase 2, the factor structure of the Healthcare Team Vitality Instrument was identified and a brief form developed and validated. Data were collected in 2006 and 2007. FINDINGS Exploratory factor analyses suggested a four-factor solution with the following dimensions: (1) support structures, (2) engagement and empowerment, (3) patient care transitions and (4) team communication. CONCLUSION The Healthcare Team Vitality Instrument can contribute both to better management practices and advancing knowledge to promote retention of nurses, and to some extent other healthcare professionals, as well as efforts to transform the acute healthcare work environment.

The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance

BackgroundThe effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs.MethodsSurveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models.ResultsFor all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used.ConclusionProvider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.

Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation

BackgroundBased on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administrations (VHAs) colorectal cancer (CRC) screening clinical reminder to compare against the VHAs current CRC reminder.MethodsIn a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs.ResultsDesign enhancements to the VHAs existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further.ConclusionsThis study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice.

Clinicians’ Perceptions of How Burnout Affects Their Work

OBJECTIVE The aim of this mixed-methods study was to identify ways that professional burnout may affect clinical work and consumer outcomes. METHODS Clinicians (N=120) participating in a burnout intervention trial completed a survey before the intervention, rating their level of burnout and answering open-ended questions about how burnout may affect their work. Responses were analyzed with team-based content analysis. RESULTS Clinicians reported specific ways that burnout affects work, including empathy, communication, therapeutic alliance, and consumer engagement. Clinicians acknowledged negative impacts on outcomes, although few consumer outcomes were specified. Clinicians with higher levels of depersonalization were more likely to report that burnout affects how staff work with consumers (r=.21, p<.05); however, emotionally exhausted clinicians were less likely to report an impact on consumer outcomes (r=-.24, p=.01). CONCLUSIONS Reducing professional burnout may have secondary gains in improving quality of services and consumer outcomes; findings point to specific aspects of care and outcome domains that could be targeted.