Patient and Family Engagement in Addressing Hospital Patient Safety Concerns: Experiences, Attitudes and Patient Safety Engagement Comfort Levels of Recently Hospitalized Patients

Introduction Patient engagement involves the behaviors of patients, family members, and health professionals (i.e., doctors, nurses, and other healthcare staff) in a collaborative partnership to improve health and healthcare. It also constitutes organizational structures policies and procedures designed to foster and promote the active inclusion of patients and family members in health services delivery. Patient engagement is associated with enriched patient experience, patient safety and clinical effectiveness. An evidence base is essential for its translation from a conceptual framework to tangible programs that can be pragmatically implemented in healthcare delivery systems. However, little is known about how individual level factors, healthcare staff behaviors within hospital work systems and hospital characteristics support engagement, influence patients’ engagement comfort, and the impact on patients’ experience of care. The intent of this doctoral dissertation is to perform a secondary analysis of the Consumers Union Patient and Family Engagement Survey to examine three key research questions: Which aggregated patient and hospital characteristics are associated with hospital staff behaviors that support patient engagement? Which aggregated patient and hospital characteristics are associated with patients’ level of comfort with engagement around safety issues during their hospital stay? What are the effects of hospital professional patient engagement behaviors and patients’ level of comfort with engagement around safety issues during their hospital stay on the patients’ experience of care? Literature Review The Multidimensional Framework for Patient and Family Engagement in Health and Healthcare, developed by Carman et al., delineates the levels at which engagement can and should take place. This includes direct care, organizational design and governance across an engagement continuum that includes consultation, involvement as well as partnership and shared leadership. Patient engagement behaviors are rooted in self-efficacy (i.e., activation) but also in perceived norms and consequences. They are also influenced by organizational, socio-demographic, socio-cultural, and task-related factors. Patient experience of care is shown to be positively associated with varied degrees of technical quality, patient safety, clinical effectiveness, patient-provider communication and treatment adherence. This doctoral dissertation focuses on the direct care level of engagement and studies the experiences, attitudes and patient engagement comfort of recently hospitalized patients. Methods I completed a secondary analysis of the probability-based, nationally representative Consumers Union Patient and Family Engagement Survey final data set. The study sample included non-institutionalized individuals’, age 25 to 75 residing in the United States who had at least one hospitalization in the last six months. I used the weighted sample of individual respondents in the secondary analysis to represent the population of interest in the United States. I used exploratory factor analysis as a data reduction technique to examine outcomes of interest. I explored the underlying factor structure of the 22 observed variables (i.e., 11 hospital staff behaviors and patients’ engagement comfort with those same 11 behaviors), and the correlation between the observed variables and the factors (i.e., factor loadings). I analyzed factor loadings, the proportion of variance explained by each factor, and any common factors. Principal component analysis was used to assess the amount of variance in the observed hospital staff behaviors and patient engagement comfort variables. Outcome variable selection included hospital professional pain assessment and patient identification behaviors, patient engagement comfort with pain assessment and patient identification, and patients’ likelihood to recommend the hospital to a family member or friend. Logistic and ordinal logistic regression analyses were used to assess outcome variable relationships while controlling for each independent variable of interest. Complex survey data techniques and unvariate, bivariate and regression analyses were completed using SAS software. Results The sample was fairly evenly split between male (47%) and females (53%). The mean age was 53 and median was 50 years. Greater than 60% of respondents were White, non-Hispanic, 53% were married. Most were hospitalized in metropolitan, non-teaching hospitals with greater than 100 beds. Greater than 50% were hospitalized for a surgical admission and 56% had more than one previous hospitalization. The majority of respondents reported hospital professionals performed pain assessment and patient identification rather routinely. Higher proportions of these behaviors were reported by older patients, age 45 years plus, white, non-Hispanic, married, college educated patients who had advocate support during hospitalization. Logistic regression analysis showed that having a high school education was associated with a 0.31 odds of reporting pain assessment hospital engagement compared to those with a Bachelor’s degree or higher (p=0.02). Being admitted for a medical admission was associated with a 0.37 odds of reporting pain assessment hospital engagement compared to those admitted for surgery (p=0.02). These results were statistically significant in the logistic regression model (p\u3c0.05). Most respondents indicated they were comfortable with patient engagement. Greater than 80% of patients reported they were either very comfortable or comfortable with pain assessment and patient identification engagement. Most were older age, 45 plus years, married, and college educated. Ordinal logistic regression analysis showed having three previous hospital admissions was associated with a 0.55 odds of reporting feeling comfortable with pain assessment engagement compared to those with four or more previous hospital admissions (p=0.04). Results were statistically significant (p\u3c0.05). The following results were also statistically significant in the patient identification ordinal logistic regression model. Being female was associated with a 0.55 odds of reporting feeling comfortable with patient identification engagement compared to males (p=\u3c0.01). Having improved health status was associated with a 1.89 odds of reporting feeling comfortable with patient identification engagement compared to those whose health status worsened in the past year (p=0.05). Greater than 80% of patients indicated they would definitely recommend the hospital to a family member or friend. The majority of these patients were older, 55 plus years, married, had advocate support during hospitalization, and had not experienced a medical error during their most recent hospitalization. Ordinal logistic regression analysis showed not having experienced one or more medical errors during the index (i.e., most recent hospitalization) was associated with a 2.00 odds of reporting they would recommend the hospital to a family member or friend compared to patients who reported they had experienced one or more medical errors during their most recent hospitalization (p=\u3c0.01). Results were statistically significant in the ordinal logistic regression model (p\u3c0.05). Conclusion This doctoral study attempted to fill an evidence gap around factors that influence comfort with patient engagement, measurement of hospital professional behaviors that support engagement and their impact on the patient experience of care. Study findings provide supporting evidence that patents perceive hospital professionals often proactively engage patients in pain assessment and patient identification. The analysis reinforced the role socio-demographic factors play in patient engagement. Logistic regression analysis showed that having a medical (i.e., non-surgical) hospital admission was positively associated with patient’s comfort with pain assessment engagement. Having only a high school education was negatively associated feeling comfortable with pain assessment engagement. With regard to gender, female and improved health status in the past 12 months, were positively associated with patient’s comfort with patient identification engagement. It also confirmed the statistically significant medical error experience on patients’ overall experience of care. Findings also support that patients’ admission type matters, particularly to pain assessment. Ultimately these findings can be used to identify opportunities to improve the nature of the patient-health professional relationship toward greater degrees of collaboration and engagement, particularly related to safety and quality of care. It addresses limited evidence as to what precisely patients’ feel comfortable doing when it comes to patient engagement. Future patient engagement research should focus on actual patient engagement behaviors, characteristics of engagement and continued evidence around measure development

Information Management during Care Transitions of Older Adults receiving Skilled Home Healthcare Services after Hospital Discharge

Background: Older adults who require skilled home health care (SHHC) services following hospital discharge are among those at highest risk of experiencing suboptimal outcomes during care transitions. Information management (IM) refers to the ability of skilled home healthcare providers (SHHCP) to collect, organize, and communicate older adults’ care plans to key stakeholders. Optimal IM is critical to ensure patient safety during a care transition from hospital to home, yet little is known about IM during this care transition. Human factors engineering (HFE), a systems science that investigates factors affecting human performance, may be used to understand risks and outcomes experienced by older adults receiving SHHC services after hospital discharge. Objectives: We used a HFE approach to: 1) identify key components of IM from the perspectives of SHHCPs directly responsible for executing older adults’ transitions; and 2) describe IM-related process failures during the SHHC admissions process and initial home visit after hospital discharge. Methods: This was a qualitative study primarily guided by the HFE-informed Information Chaos framework, which groups IM-related process failures (i.e., information problems that may contribute to errors) that contribute to suboptimal IM into five categories: information overload (too much information), information underload (too little information), information scatter (information in many places), information conflict (information not matching other information), and erroneous information (incorrect information). We interviewed 33 SHHC administrative staff to obtain contextual information about the SHHC admissions process (~24 hours after hospital discharge) and initial home visit (~48-72 hours after hospital discharge). We directly observed interactions among SHHCPs, older adults, and informal caregivers during the initial home visit after hospital discharge (n=60 visits). Following each visit, we interviewed the older adults (n=60), informal caregivers (n=40), and SHHCPs (n=46) involved. Participants were admitted to SHHC at five sites associated with three SHHC agencies in rural and urban sites across the US. Both field notes and audiotapes of interviews were transcribed, coded, and analyzed. Themes, subthemes, and information flow diagrams were generated. Results: We identified four action steps involved in the flow of information during the SHHC admissions process primarily taking place in the hospital and at the SHHC agency: 1) prepare referral and inform agency; 2) verify insurance; 3) contact older adult; and 4) review case to schedule visit. We subsequently identified four action steps involved in the flow of information during the initial start-of-care (SOC) home visit: 1) assess appropriateness for SHHC and obtain consent for treatment; 2) manage expectations; 3) ensure safety; and 4) develop contingency plans and recovery scenarios. Within each of these action steps, we identified examples of IM-related process failures: too much information for older adults to process upon hospital discharge (information overload); SHHCPs without access to complete information during the SOC visit (information underload); SHHC coordinators needing to access information from multiple places to prepare the initial referral (information scatter); older adult and informal caregivers’ mismatched expectations regarding what SHHC services they will actually receive, compared with what they were told in the hospital (information conflict); and SHHCPs encountering wrong diagnoses or medication lists during the SOC visit (erroneous information). We also identified important characteristics of IM during hospital/SHHC transitions: overlap among roles, tasks, information sources, and information targets; propagation of IM-related process failures over time; and variation in IM across study sites. Conclusions: Understanding IM during hospital/SHHC transitions elicited factors influencing the quality of care delivered during this particularly high-risk transition. IM required a high reliance on others (e.g., hospital staff, SHHC staff, older adults, informal caregivers) for success to reduce the risk of propagating IM-related process failures throughout the care transition. However, SHHCP often did not have access to complete and correct information during the SOC visit, nor did they have easy access to the sources of that information. This suggests that clinical and organizational infrastructure was not in place to adequately support IM during the hospital/SHHC transition

Improving Accessible and Personalized Airway Protective Rehabilitation in Neurodegenerative Disease

Utilization of airway protective rehabilitation among individuals with neurodegenerative disease is astoundingly low. Yet, due to progressive decline in airway protective function and resulting health consequences such as aspiration pneumonia, the need for rehabilitation is clear. Moreover, a growing literature supports the benefit of airway protective rehabilitation in neurodegenerative populations. Therefore, it is a healthcare priority to increase treatment utilization in order to improve health and quality of life for individuals with neurodegenerative disease. Improving treatment accessibility and relevance are two approaches that have the potential to improve utilization. Despite the need to increase treatment accessibility and the growing evidence base to support the use of telehealth to increase access, a significant gap remains in our understanding of the feasibility and acceptability of telehealth to manage dysphagia in neurodegenerative disease. Moreover, little is known about patient perspectives which are critical to refine person-centered models of care that are relevant to patient’s needs. To address this important clinical research gap, this dissertation includes a series of three research studies aimed at improving accessible and relevant rehabilitation for airway protective dysfunction in neurodegenerative disease. Chapter 1 will provide an overview of the current literature as it relates to airway protective dysfunction in neurodegenerative disease, existing rehabilitation approaches, telehealth to manage dysphagia, and the need for personalized care. Chapter 2 will examine the feasibility of rehabilitating airway protection via telehealth in individuals with neurodegenerative movement disorders. Chapter 3 will then explore speech language pathologists’ (SLPs) perspectives and experiences using telehealth to manage dysphagia. Chapter 4 will characterize patient perspectives on airway protective dysfunction and treatment experience following cough skill training (CST). I will conclude (Chapter 5) by synthesizing the findings from chapters 2-4 and suggesting directions for future research

Navigating the Patient Room: Critical Care Nurses' Interaction with the Designed Physical Environment

abstract: The physical environment influences the physiology, psychology, and the societal interactions of those who experience it. The environment can also influence human behavior. Critical care nurses are in constant interaction with the physical environment surrounding their patients. High acuity ICU patients are vulnerable and at risk for harm, infection, and poor outcomes while the physical and cognitive workload of nurses presents a demanding and continuous challenge. The goal of this qualitative study was to explore and understand the way critical care nurses navigate within the patient room and interact with its features. The study of critical care nurses interacting with the patient room environment was conducted in five critical care units at three tertiary care institutions in the Eastern United States, along with another unit in the pilot study at a community hospital in the Southwest United States. Nurses were observed in their typical work environment as they performed normal tasks and patient care activities for entire day and night shifts. The study involved ethnographic field observations, individual semi-structured participant interviews, and examination of photographs and floor plans. The exploratory study resulted in a comprehensive model for nurse navigation that includes both cognitive and action components, along with a conceptual framework for nurse behavioral activity. Repetitive patterns of nurse movement were identified and named. The findings produced recommendations for nurses’ effective use of space and architectural design of ICU patient rooms to improve patient outcomes.Dissertation/ThesisDoctoral Dissertation Nursing and Healthcare Innovation 201