Yu Fang Li

Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework.

BackgroundThe Promoting Action on Research Implementation in Health Services, or PARIHS, framework is a theoretical framework widely promoted as a guide to implement evidence-based clinical practices. However, it has as yet no pool of validated measurement instruments that operationalize the constructs defined in the framework. The present article introduces an Organizational Readiness to Change Assessment instrument (ORCA), organized according to the core elements and sub-elements of the PARIHS framework, and reports on initial validation.MethodsWe conducted scale reliability and factor analyses on cross-sectional, secondary data from three quality improvement projects (n = 80) conducted in the Veterans Health Administration. In each project, identical 77-item ORCA instruments were administered to one or more staff from each facility involved in quality improvement projects. Items were organized into 19 subscales and three primary scales corresponding to the core elements of the PARIHS framework: (1) Strength and extent of evidence for the clinical practice changes represented by the QI program, assessed with four subscales, (2) Quality of the organizational context for the QI program, assessed with six subscales, and (3) Capacity for internal facilitation of the QI program, assessed with nine subscales.ResultsCronbachs alpha for scale reliability were 0.74, 0.85 and 0.95 for the evidence, context and facilitation scales, respectively. The evidence scale and its three constituent subscales failed to meet the conventional threshold of 0.80 for reliability, and three individual items were eliminated from evidence subscales following reliability testing. In exploratory factor analysis, three factors were retained. Seven of the nine facilitation subscales loaded onto the first factor; five of the six context subscales loaded onto the second factor; and the three evidence subscales loaded on the third factor. Two subscales failed to load significantly on any factor. One measured resources in general (from the context scale), and one clinical champion role (from the facilitation scale).ConclusionWe find general support for the reliability and factor structure of the ORCA. However, there was poor reliability among measures of evidence, and factor analysis results for measures of general resources and clinical champion role did not conform to the PARIHS framework. Additional validation is needed, including criterion validation.

Assessing an organizational culture instrument based on the Competing Values Framework: Exploratory and confirmatory factor analyses

BackgroundThe Competing Values Framework (CVF) has been widely used in health services research to assess organizational culture as a predictor of quality improvement implementation, employee and patient satisfaction, and team functioning, among other outcomes. CVF instruments generally are presented as well-validated with reliable aggregated subscales. However, only one study in the health sector has been conducted for the express purpose of validation, and that study population was limited to hospital managers from a single geographic locale.MethodsWe used exploratory and confirmatory factor analyses to examine the underlying structure of data from a CVF instrument. We analyzed cross-sectional data from a work environment survey conducted in the Veterans Health Administration (VHA). The study population comprised all staff in non-supervisory positions. The survey included 14 items adapted from a popular CVF instrument, which measures organizational culture according to four subscales: hierarchical, entrepreneurial, team, and rational.ResultsData from 71,776 non-supervisory employees (approximate response rate 51%) from 168 VHA facilities were used in this analysis. Internal consistency of the subscales was moderate to strong (α = 0.68 to 0.85). However, the entrepreneurial, team, and rational subscales had higher correlations across subscales than within, indicating poor divergent properties. Exploratory factor analysis revealed two factors, comprising the ten items from the entrepreneurial, team, and rational subscales loading on the first factor, and two items from the hierarchical subscale loading on the second factor, along with one item from the rational subscale that cross-loaded on both factors. Results from confirmatory factor analysis suggested that the two-subscale solution provides a more parsimonious fit to the data as compared to the original four-subscale model.ConclusionThis study suggests that there may be problems applying conventional CVF subscales to non-supervisors, and underscores the importance of assessing psychometric properties of instruments in each new context and population to which they are applied. It also further highlights the challenges management scholars face in assessing organizational culture in a reliable and comparable way. More research is needed to determine if the emergent two-subscale solution is a valid or meaningful alternative and whether these findings generalize beyond VHA.

The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level.

Context:Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units. Objective:To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA). Design, Settings, and Patients:A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals. Methods:We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission. Main Outcome Measure:In-hospital mortality. Results:Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99–1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86–0.96). RN education was not significantly associated with mortality. Conclusions:Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

Depression Diagnosis and Antidepressant Treatment among Depressed VA Primary Care Patients

This study examined the extent to which 3559 VA primary care patients with depression symptomatology received depression diagnoses and/or antidepressant prescriptions. Symptomatology was classified as mild (13%), moderate (42%) or severe (45%) based on SCL-20 scores. Diagnosis and treatment was related to depression severity and other patient characteristics. Overall, 44% were neither diagnosed nor treated. Only 22% of those neither diagnosed nor treated for depression received treatment for other psychopathology. Depression treatment performance measures dependent on diagnoses and antidepressant prescriptions from administrative databases exclude undiagnosed patients with significant, treatable, symptomatology.

Nurse staffing and patient outcomes in Veterans Affairs hospitals.

Objective: To assess characteristics and perceptions of nurses working in the Veterans Health Administration (VHA), comparing types of nursing personnel, to benchmark to prior studies across healthcare systems. Background: Prior studies have shown relationships between positive registered nurse (RN) perceptions of the practice environment and patient outcomes. To date, no study has reported the comparison of RN perceptions of the practice environment in hospital nursing with those of non-RN nursing personnel. This study is the first to offer a more comprehensive look at perceptions of practice environment from the full range of the nursing work force and may shed light on issues such as the relationship of skill mix to nurse and patient outcomes. Methods: Cross-sectional observational study with a mailed survey administered to all nursing personnel in 125 VA Medical Centers between February and June 2003. Results: Compared with other types of nursing personnel in the VHA, RNs are generally less positive about their practice environments. However, compared with RNs in other countries and particularly with other RNs in the United States (Pennsylvania), VHA RNs are generally more positive about their practice environment and express more job satisfaction. Conclusions: The nursing work force of the VHA has some unique characteristics. The practice environment for nurses in the VHA is relatively positive, and may indicate that the VHA, as a system, provides an environment that is more like magnet hospitals. This is significant for a public sector hospital system.

Implementing electronic clinical reminders for lipid management in patients with ischemic heart disease in the veterans health administration: QUERI Series

BackgroundIschemic heart disease (IHD) affects at least 150,000 veterans annually in the United States. Lowering serum cholesterol has been shown to reduce coronary events, cardiac death, and total mortality among high risk patients. Electronic clinical reminders available at the point of care delivery have been developed to improve lipid measurement and management in the Veterans Health Administration (VHA). Our objective was to report on a hospital-level intervention to implement and encourage use of the electronic clinical reminders.MethodsThe implementation used a quasi-experimental design with a comparison group of hospitals. In the intervention hospitals (N = 3), we used a multi-faceted intervention to encourage use of the electronic clinical reminders. We evaluated the degree of reminder use and how patient-level outcomes varied at the intervention and comparison sites (N = 3), with and without adjusting for self-reported reminder use.ResultsThe national electronic clinical reminders were implemented in all of the intervention sites during the intervention period. A total of 5,438 patients with prior diagnosis of ischemic heart disease received care in the six hospitals (3 intervention and 3 comparison) throughout the 12-month intervention. The process evaluation showed variation in use of reminders at each site. Without controlling for provider self-report of use of the reminders, there appeared to be a significant improvement in lipid measurement in the intervention sites (OR 1.96, 95% CI 1.34, 2.88). Controlling for use of reminders, the amount of improvement in lipid measurement in the intervention sites was even greater (OR 2.35, CI 1.96, 2.81). Adjusting for reminder use demonstrated that only one of the intervention hospitals had a significant effect of the intervention. There was no significant change in management of hyperlipidemia associated with the intervention.ConclusionThere may be some benefit to focused effort to implement electronic clinical reminders, although reminders designed to improve relatively simple tasks, such as ordering tests, may be more beneficial than reminders designed to improve more complex tasks, such as initiating or titrating medications, because of the less complex nature of the task. There is value in monitoring the process, as well as outcome, of an implementation effort.

Nurse executive and staff nurse perceptions of the effects of reorganization in Veterans Health Administration hospitals

Objective: To examine nurse executive perceptions of effects of service line reorganization on nurse executive roles, nursing staff and patient care, and compare nurse executive responses to staff nurse reports of job satisfaction and quality of care in the same types of Veterans Health Administration facilities. Background: Although a growing body of research focuses on the association between nurse staffing structures, nurse satisfaction, and patient outcomes, relatively little attention has been paid to the effects of hospital restructuring on nursing management and nursing staff. Methods: Data on hospital and nursing service organization and nurse executive perceptions were collected through structured interviews with 125 nurse executives conducted from December 2002 through May 2003. Staff nurse data were derived from a survey of Veterans Health Administration nursing staff conducted from February through June 2003 at the same facilities. Results: Nurse executives in Veterans Health Administration described significant changes in the nurse executive role, and new challenges for managing nursing practice and achieving consistent quality of nursing care. Although nursing management perceived differences in the overall effects of restructuring on nursing staff depending on the type of reorganization, staff nurses reported significant differences in perceived quality of patient care across organization types.

Organizational factors associated with decreased mortality among veterans affairs patients with an ICU Stay

In-hospital mortality rates associated with an ICU stay are high and vary widely among units. This variation may be related to organizational factors such as staffing patterns, ICU structure, and care processes. We aimed to identify organizational factors associated with variation in in-hospital mortality for patients with an ICU stay. This was a retrospective observational cross-sectional study using administrative data from 34 093 patients from 171 ICUs in 119 Veterans Health Administration hospitals. Staffing and patient data came from Veterans Health Administration national databases. ICU characteristics came from a survey in 2004 of ICUs within the Veterans Health Administration. We conducted multilevel multivariable estimation with patient-, unit-, and hospital-level data. The primary outcome was in-hospital mortality. Of 34 093 patients, 2141 (6.3%)died in the hospital. At the patient level, risk of complications and having a medical diagnosis were significantly associated with a higher risk of mortality. At the unit level, having an interface with the electronic medical record was significantly associated with a lower risk of mortality. The finding that electronic medical records integrated with ICU information systems are associated with lower in-hospital mortality adds support to existing evidence on organizational characteristics associated with in-hospital mortality among ICU patients.

Underuse of cardioprotective medications in patients prior to acute myocardial infarction

S prevention in coronary heart disease (CHD) improves survival and reduces recurrent events.1–4 National clinical guidelines and organizational performance measures recommend the use of hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), blockers, angiotensin-converting enzyme (ACE) inhibitors, and aspirin in most patients after acute myocardial infarction (AMI).5–8 However, many high-risk patients do not receive them.9,10 We sought to determine whether patients with known CHD admitted for AMI to hospitals in the Veterans Administration (VA) system had indications for pharmacologic secondary prevention before admission and the extent to which these therapies were begun in the period immediately after discharge from the hospital. • • • We conducted a before–after study of patients with documented CHD who had an AMI to compare their cardioprotective medications during the 6 months before admission for AMI and during the 3 months after hospital discharge. We identified established male patients who had a diagnosis of CHD registered from April 1 to June 30, 2000, and were admitted with a primary diagnosis of AMI between July 1, 2000, and June 30, 2001, to any of the 8 VA medical centers in the Veterans Integrated Service Network (VISN) 20. A diagnosis of CHD was defined as an in-patient primary discharge diagnosis or an outpatient diagnosis for any of the following International Classification of Diseases, 9th revision (ICD9-CM) codes: 410 (AMI), 411 (unstable angina pectoris), 412 (past AMI), and 414 (coronary atherosclerosis). We defined an established patient as having visited a VA primary or specialty care clinic (including internal medicine, primary care, geriatric, cardiology, endocrinology, diabetes, hypertension, pulmonary, and mental health) between April 1, 2000, and June 30, 2000, and having made at least 1 visit within 13 to 24 months before April 1, 2000. Only patients who were alive on June 30, 2000, and alive at discharge were included. Patient, pharmacy, co-morbidity, and laboratory data were extracted from the VISN 20 data warehouse (CHIPS). CHIPS is a relational database that contains data from the clinical information systems of each of the 8 VA medical facilities in VISN 20 of the Veterans Health Administration. The main variables of interest were prescriptions dispensed for 4 drug classes: statins, blockers, ACE inhibitors/angiotensin II receptor blockers (ARBs), and aspirin. We included ARBs because a growing body of published reports supports treatment with ARBs in patients intolerant to ACE inhibitors.11,12 Drug data were extracted for from January 1, 2000, to September 30, 2001. We compared the proportion of CHD patients with filled prescriptions of each drug class 6 months before the AMI admission date and 3 months after hospital discharge. We also compared the proportion of prescription fills for each of the 4 drug classes based on the history of cardiac risk factors before admission. Risk factors included ICD9-CM documentation of hypertension, diabetes, and congestive heart failure, and laboratory documentation of elevated low-density lipoprotein (LDL) cholesterol. Data on risk factors were extracted from January 1, 1990, to June 30, 2001. We defined an LDL cholesterol 120 mg/dl (3.11 mmol/L) as elevated based on the Veterans Health Administration guidelines for management of dyslipidemia. LDL cholesterol data were extracted for 15 months before the admission date. The most recent documented LDL cholesterol before admission was used in our analyses. We used McNemar’s test to assess the statistical significance of the changes in the proportion of patients with medication fills before admission and after discharge. We identified 13,767 male veterans with a history of CHD during April 1 and June 30, 2000. Of these men, 239 were admitted to a VISN 20 facility with a primary diagnosis of AMI from July 1, 2000, to June 30, 2001. Eight patients died in the hospital and were excluded from study. The remaining 231 patients (mean age 69 years) were predominantly white (94%) and married (55%). Cardiac risk factors were common (Table 1). After discharge for AMI, we observed significant (p 0.05) increases in the percentage of patients receiving a prescription for 3 of the 4 drug classes: from 50% to 68% for statins, from 53% to 82% for blockers, and from 50% to 66% for ACE inhibitors/ARBs (Table 2). The amount of increase From Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System, Seattle; and the Departments of Health Services and Medicine, University of Washington, Seattle, Washington. This work was funded by VA HSR & D Grant IHD 98-001 from the VA Health Services Research and Development Service, Seattle, Washington. Dr. Miller’s address is: HSR & D Center of Excellence, VA Puget Sound Health Care System (152), 1660 South Columbian Way, Seattle, Washington 98108. E-mail: Rosalie.Miller@med.va.gov. Manuscript received January 30, 2003; revised manuscript received and accepted April 3, 2003.

Nurse staffing and patient care costs in acute inpatient nursing units.

ObjectiveStudies suggest that a business case for improving nurse staffing can be made to increase registered nurse (RN) skill mix without changing total licensed nursing hours. It is unclear whether a business case for increasing RN skill mix can be justified equally among patients of varying health needs. This study evaluated whether nursing hours per patient day (HPPD) and skill mix are associated with higher inpatient care costs within acute medical/surgical inpatient units using data from the Veterans Health Administration. MethodsRetrospective cross-sectional study, including 139,360 inpatient admissions to 292 acute medical/surgical units at 125 Veterans Health Administration medical centers between February and June 2003, was conducted. Dependent variables were inpatient costs per admission and costs per patient day. ResultsThe average costs per surgical and medical admission were