Robin R. Gillies

THE PERFORMANCE OF INTENSIVE CARE UNITS : DOES GOOD MANAGEMENT MAKE A DIFFERENCE ?

A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention “leverage points” for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.

Organizational assessment in intensive care units (ICUs): construct development, reliability, and validity of the ICU nurse-physician questionnaire.

Health Services Research has a growing need for reliable and valid measures of managerial practices and organizational processes. A national study of 42 intensive care units involving over 1,700 respondents provides evidence for the reliability and validity of a comprehensive set of measures related to leadership, organizational culture, communication, coordination, problem solving-conflict management and team cohesiveness. The data also support the appropriateness of aggregating individual respondent data to the unit level. Implications for further research are discussed.

Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients.

OBJECTIVES To assess the impact of total quality management (TQM) and organizational culture on a comprehensive set of endpoints of care for coronary artery bypass graft surgery (CABG) patients, including risk-adjusted adverse outcomes, clinical efficiency, patient satisfaction, functional health status, and cost of care. METHODS Prospective cohort study of 3,045 eligible CABG patients from 16 hospitals using risk-adjusted clinical outcomes, functional health status, patient satisfaction, and cost measures. Implementation of TQM was measured by a previously validated instrument based on the Baldridge national quality award criteria. Organizational culture was measured by a previously validated 20-item instrument. Generalized estimating equations were used to control for potential selection bias, repeated measures, and intraclass correlation. RESULTS A 2- to 4-fold difference in all major clinical CABG care endpoints was observed among the 16 hospitals, but little of this variation was associated with TQM or organizational culture. Patients receiving CABG from hospitals with high TQM scores were more satisfied with their nursing care (P = 0.005) but were more likely to have lengths of stay >10 days (P = 0.0003). A supportive group culture was associated with shorter postoperative intubation times (P = 0.01) but longer operating room times (P = 0.004). A supportive group culture was also associated with higher patient physical (P = 0.005) and mental (P = 0.01) functional health status scores 6 months after CABG. CONCLUSIONS There was little effect of TQM and organizational culture on multiple endpoints of care for CABG patients. There is a need to examine further the relationships among individual professional skills and motivations, group and microsystem team processes, specifically tailored interventions, and organization-wide culture, decision support processes, and incentives. Assessing the impact of such multifaceted approaches is an important area for further research.

Improving intensive care : observations based on organizational case studies in nine intensive care units : a prospective, multicenter study

To examine organizational practices associated with higher and lower intensive care unit (ICU) outcome performance. Design:Prospective multicenter study. On-site organizational analysis; prospective inception cohort. Setting:Nine ICUs (one medical, two surgical, six medical-surgical) at five teaching and four nonteaching hospitals. Participants:A sample of 3,672 ICU admissions; 316 nurses and 202 physicians. Materials and Methods:Interviews and direct observations by a team of clinical and organizational researchers. Demographic, physiologic, and outcome data for an average of 408 admissions per ICU; and questionnaires on ICU structure and organization. The ratio of actual/predicted hospital death rate was used to measure ICU effectiveness; the ratio of actual/predicted length of ICU stay was used to assess efficiency. Measurements and Main Results:ICUs with superior risk-adjusted survival could not be distinguished by structural and organizational questionnaires or by global judgment following on-site analysis. Superior organizational practices among these ICUs were related to a patient-centered culture, strong medical and nursing leadership, effective communication and coordination, and open, collaborative approaches to solving problems and managing conflict. Conclusions:The best and worst organizational practices found in this study can be used by ICU leaders as a checklist for improving ICU management. (Crit Care Med 1993; 21:1443–1451)

Value and cost of teaching hospitals: a prospective, multicenter, inception cohort study.

ObjectiveTo examine variations in case-mix, structure, resource use, and outcome performance among teaching and nonteaching intensive care units (ICU). Design:Prospective inception cohort study. Patients: Aconsecutive sample of 15,297 patients at 35 hospitals, which compared 8,269 patients admitted to 20 teaching ICUs at 18 hospitals vs. 7,028 patients admitted to 17 non-teaching ICUs at 17 hospitals. Interventions:None. Measurements:We selected demographic, physiologic, and treatment information for an average of 415 patients at each ICU, and collected data on hospital and ICU structure. Outcomes were compared using ratios of observed to risk-adjusted predicted hospital death rates, ICU length of stay, and resource use. Main Results:When compared to nonteaching ICUs, teaching ICUs had twice the number of physicians who regulary provided services and cared for significantly younger and more severely ill (p < .001) patients. Risk-adjusted ICU length of stay was similar, but resource use was significantly (p < .001) greater in teaching ICUs, with

As good as it gets? Chronic care management in nine leading US physician organisations.

3,000 (10.5%) of estimated total costs for an average ICU admission related to increased use of diagnostic testing and invasive procedures in teaching ICUs. Risk-adjusted hospital death rates were not significantly different (p = .1) between all teaching and nonteaching ICUs, but were significantly (p < .05) better in four teaching ICUs, but in only one nonteaching ICU. The 14 hospitals that were members of the Council of Teaching Hospitals had significantly better risk-adjusted outcome in their 16 ICUs than all others (odds ratio = 1.21, confidence interval 1.06 to 1.38, p = .004). Conclusions:Teaching ICUs care for more complex patients in a substantially more complicated organizational setting. The best risk-adjusted survival rates occur at teaching ICUs, but production cost is higher in teaching units, secondary to increased testing and therapy. Teaching ICUs are also successfully transferring knowledge to trainees who, after their training, are achieving equivalent results at slightly lower cost in nonteaching ICUs. (Crit Care Med 1993; 21:1432–1442)

Small And Medium-Size Physician Practices Use Few Patient-Centered Medical Home Processes

Innovations in care management processes have improved the care of patients with chronic illnesses, but many patients still do not receive these benefits. The authors have studied the barriers and facilitators to implementing these improvements in leading US physician practices About 125 million of the 276 million people living in the United States have some type of chronic illness (table 1).1 Four chronic conditions affect nearly half of Americans with a chronic disease: asthma, depression, and diabetes each affect about 15 million,2–4 while five million have congestive heart failure.5 In 1999 these four chronic diseases were directly responsible for 140 000 deaths in the United States6 and generated at least

Measuring The Medical Home Infrastructure In Large Medical Groups

173bn (£108bn, €170bn) in medical and other costs. 5 7–9 Over the past decade the effectiveness of care for patients with these and other major chronic illnesses has been improved by innovations in care management processes such as the use of guidelines, disease management techniques, case management, and patient education to improve self management of chronic disease.10 However, many patients are not benefiting from these advances. Recent studies indicate that fewer than half of US patients with asthma, depression, and diabetes receive appropriate treatment.11–13 Organisational characteristics of physician practices associated with effective chronic disease care include the use of patient care teams, supportive information systems, and a high volume of patients.14 Hence, we expect that in the United States moderate and large sized, well organised, multispecialty practices are likely to offer chronic disease care that is as good as it gets and provide other physician organisations with benchmarks against which performance can be measured. #### Summary points

Implementing evidence-based medicine: The role of market pressures, compensation incentives, and culture in physician organizations

The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,344 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patient-centered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.

An Empirical Assessment of High-Performing Medical Groups: Results from a National Study:

The patient-centered medical home is taking center stage in discussions of primary care innovation as a new delivery model that provides comprehensive, coordinated care across the lifespan. Although the medical home is widely discussed by policymakers, payers, and other stakeholders, the extent to which physician practices have the infrastructure in place to function as medical homes is not known. Using data from the 2006-07 National Study of Physician Organizations, we examine the extent of adoption of medical home infrastructure components among large primary care and multispecialty medical groups and their association with medical group size and ownership.