Nathalie McIntosh

Multilevel Interventions: Measurement and Measures

BACKGROUND Multilevel intervention research holds the promise of more accurately representing real-life situations and, thus, with proper research design and measurement approaches, facilitating effective and efficient resolution of health-care system challenges. However, taking a multilevel approach to cancer care interventions creates both measurement challenges and opportunities. METHODS One-thousand seventy two cancer care articles from 2005 to 2010 were reviewed to examine the state of measurement in the multilevel intervention cancer care literature. Ultimately, 234 multilevel articles, 40 involving cancer care interventions, were identified. Additionally, literature from health services, social psychology, and organizational behavior was reviewed to identify measures that might be useful in multilevel intervention research. RESULTS The vast majority of measures used in multilevel cancer intervention studies were individual level measures. Group-, organization-, and community-level measures were rarely used. Discussion of the independence, validity, and reliability of measures was scant. DISCUSSION Measurement issues may be especially complex when conducting multilevel intervention research. Measurement considerations that are associated with multilevel intervention research include those related to independence, reliability, validity, sample size, and power. Furthermore, multilevel intervention research requires identification of key constructs and measures by level and consideration of interactions within and across levels. Thus, multilevel intervention research benefits from thoughtful theory-driven planning and design, an interdisciplinary approach, and mixed methods measurement and analysis.

Organizational predictors of coordination in inpatient medicine.

Background: As the care of hospitalized patients becomes more complex, intraprofessional coordination among nurses and among physicians, and interprofessional coordination between these groups are likely to play an increasingly important role in the provision of hospital care. Purpose: The purpose of this study was to identify the independent effects of organizational factors on provider ratings of overall coordination in inpatient medicine (OCIM). Methodology/Approach: This was an exploratory cross-sectional, descriptive study. Primary data were collected between June 2010 and September 2011 through surveys of inpatient medicine nurse managers, physicians, and chiefs of medicine at 36 Veterans Health Administration medical centers. Secondary data from the 2011 Veterans Health Administration national survey of nurses were also used. Individual-level data were aggregated and analyzed at the facility level. Multivariate linear regression models were used to assess the relationship between 55 organizational factors and provider ratings of OCIM. Findings: Organizational factors that were common across models and associated with better provider ratings of OCIM included provider perceptions that the goals of senior leadership are aligned with those of the inpatient service and that the facility is committed to the highest quality of patient care, having resources and staff that enable clinicians to do their jobs, and use of strategies that enhance interactions and communication among and between nurses and physicians. Practice Implications: To improve intraprofessional and interprofessional coordination and, consequently, patient care, facilities should consider making patient care quality a more important strategic organizational priority; ensuring that providers have the staffing, training, supplies, and other resources they need to do their jobs; and implementing strategies that improve interprofessional communication and working relationships, such as multidisciplinary rounding.

Impact of provider coordination on nurse and physician perceptions of patient care quality.

The objective of this study was to assess the role of provider coordination on nurse manager and physician perceptions of care quality, while controlling for organizational factors. Findings indicated that nurse-nurse coordination was positively associated with nurse manager perceptions of care quality; neither physician-physician nor physician-nurse coordination was associated with physician perceptions. Organizational factors associated with positive perceptions of care quality included facility support of education for nurses and physicians, and the use of multidisciplinary rounding.

Hospital Public–Private Partnerships in Low Resource Settings: Perceptions of How the Lesotho PPP Transformed Management Systems and Performance

Abstract—Public–private partnerships (PPPs) seek to expand access to quality health services in ways that best leverage the capacities and resources of both sectors. There are few examples of PPPs in the hospital sector in developing countries, and little is known about how the involvement of the private sector transforms the delivery of health services in this context. In 2006, the government of Lesotho adopted a PPP approach for the health sector, contracting out to design, build, and operate a hospital network in its capital district. This case study examines differences between a government-run hospital and the PPP-run hospital that replaced it, using in-depth interviews with key informants, observation of management systems, and document review. Key informants emphasized changes in infrastructure, communication, human resource management, and organizational culture that improved quality and demand for services. Important drivers of improved performance included better defined policies and procedures, empowerment and training of managers and staff, and increased accountability. Well-functioning support systems kept the hospital clean and equipment functioning, reduced stock-outs, and allowed staff to do the jobs they were trained to do. The Lesotho PPP model provides insight into the mechanisms by which public–private partnerships may increase access and quality of care.

Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration

OBJECTIVE To examine factors associated with 0- to 7-day admission after outpatient surgery in high-volume specialties: general surgery, orthopedics, urology, ear/nose/throat, and podiatry. STUDY DESIGN We calculated rates and assessed diagnosis codes for 0- to 7-day admission after outpatient surgery for Centers for Medicare and Medicaid Services (CMS) and Veterans Health Administration (VA) dually enrolled patients age 65 and older. We also estimated separate multilevel logistic regression models to compare patient, procedure, and facility characteristics associated with postoperative admission. DATA COLLECTION 2011-2013 surgical encounter data from the VA Corporate Data Warehouse; geographic data from the Area Health Resources File; CMS enrollment and hospital admission data. PRINCIPAL FINDINGS Among 63,585 outpatient surgeries in 124 facilities, 0- to 7-day admission rates ranged from 5 percent (podiatry) to 28 percent (urology); nearly 66 percent of the admissions occurred on the day of surgery. Only 97 admissions were detected in the CMS data (1 percent). Surgical complications were diagnosed in 4 percent of admissions. Procedure complexity, measured by relative value units or anesthesia risk score, was associated with admission across all specialties. CONCLUSION As many as 20 percent of VA outpatient surgeries result in an admission. Complex procedures are more likely to be followed by admission, but more evidence is required to determine how many of these reflect potential safety or quality problems.

A Qualitative Study of Participation in Cardiac Rehabilitation Programs in an Integrated Health Care System

INTRODUCTION Despite strong incentives to use cardiac rehabilitation (CR), patient participation is low in the Veterans Health Administration (VHA). This is paradoxical given that VHA is an integrated health care system that offers a range of CR programs which should logically reduce barriers to access to CR participation. The purpose of this study was to better understand the contextual factors that influence patient participation in CR and how patients consider factors together when making decisions about CR participation. MATERIALS AND METHODS Using a qualitative study design we examined patient and provider perceptions of CR across six VHA medical centers with high- and low-enrollment rates between December 2014 and October 2015. We conducted semistructured interviews with CR eligible patients who had both enrolled and not enrolled in CR (n = 16), cardiology providers who could refer patients to CR and CR staff who provided CR services (n = 15). Data were analyzed using grounded thematic techniques. RESULTS We identified program and patient-specific factors related to CR participation. The four program factors were: program responsiveness to patient needs, CR schedule, specialized CR program equipment, and the CR program social environment. Program factors were primarily discussed by individuals associated with sites that had high CR enrollment rates. The patient-specific factor that promoted participation was patient perceptions of CR benefits. Disincentives to participation included competing conditions or obligations, logistical/cost challenges, convenience, and fear of exercise. CR participation entailed a complex process in which patients balanced factors that reinforced patient perceptions that CR was beneficial against factors that acted as disincentives to participation. CONCLUSIONS CR participation was influenced by both program and patient factors. Patients weighed factors that fostered perceptions that CR was beneficial against factors that served as disincentives to CR participation when considering CR participation. High-enrollment sites may be better at countering disincentives to participate and/or improve patient perceptions of CR. Actionable ways to improve CR participation include encouraging providers to strongly and frequently endorse CR, educating patients about the importance and benefits of CR, emphasizing how exercises are individualized, supervised and monitored, educating patients about how CR is safe and effective, how CR offers peer support, and structuring CR programs to be responsive to patient needs in terms of duration, frequency, schedule, and location.

Building Systemwide Improvement Capability: Does an Organization's Strategy for Quality Improvement Matter?

Objectives: Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organizations improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning. Methods: Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results. Results: We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at &agr; = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success. Conclusions: This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.

organizational Factors Associated With Perceived Quality of Patient Care in Closed Intensive Care Units

Background Improving patient care quality in intensive care units is increasingly important as intensive care unit services account for a growing proportion of hospital services. Organizational factors associated with quality of patient care in such units have been identified; however, most were examined in isolation, making it difficult to assess the relative importance of each. Furthermore, though most intensive care units now use a closed model, little research has been done in this specific context. Objectives To examine the relative importance of organizational factors associated with patient care quality in closed intensive care units. Method In a national exploratory, cross‐sectional study focused on intensive care units at US Veterans Health Administration acute care hospitals, unit directors were surveyed about nurse and physician staffing, work resources and training, patient care coordination, rounding, and perceptions of patient care quality. Administrative records yielded data on patient volume and facility teaching status. Descriptive statistics, bivariate analyses, and regression modeling were used for data analysis. Results Sixty‐nine completed surveys from directors of closed intensive care units were returned. Regression model results showed that better patient care coordination (&bgr; = 0.43; P = .01) and having adequate work resources (&bgr; = 0.26; P = .02) were significantly associated with higher levels of patient care quality in such units (R2 = 0.22). Conclusions Augmenting work resources and/or focusing limited hospital resources on improving patient care coordination may be the most productive ways to improve patient care quality in closed intensive care units. (American Journal of Critical Care. 2017;26:401‐407)