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

Systematic Heuristic Evaluation of Computerized Consultation Order Templates: Clinicians’ and Human Factors Engineers’ Perspectives

We assessed the usability of consultation order templates and identified problems to prioritize in design efforts for improving referral communication. With a sample of 26 consultation order templates, three evaluators performed a usability heuristic evaluation. The evaluation used 14 domain-independent heuristics and the following three supplemental references: 1 new domain-specific heuristic, 6 usability goals, and coded clinicians’ statements regarding ease of use for 10 sampled templates. Evaluators found 201 violations, a mean of 7.7 violations per template. Minor violations outnumbered major violations almost twofold, 115 (57%) to 62 (31%). Approximately 68% of violations were linked to 5 heuristics: aesthetic and minimalist design (17%), error prevention (16%), consistency and standards (14%), recognition rather than recall (11%), and meet referrers’ information needs (10%). Severe violations were attributed mostly to meet referrers’ information needs and recognition rather than recall. Recorded violations yielded potential negative consequences for efficiency, effectiveness, safety, learnability, and utility. Evaluators and clinicians demonstrated 80% agreement in usability assessment. Based on frequency and severity of usability heuristic violations, the consultation order templates reviewed may impede clinical efficiency and risk patient safety. Results support the following design considerations: communicate consultants’ requirements, facilitate information seeking, and support communication. While the most frequent heuristic violations involved interaction design and presentation, the most severe violations lacked information desired by referring clinicians. Violations related to templates’ inability to support referring clinicians’ information needs had the greatest potential negative impact on efficiency and safety usability goals. Heuristics should be prioritized in future design efforts

Missing links: challenges in engaging the underserved with health information and communication technology

We sought to understand underserved patients' preferences for health information technology (HIT) and examine the current use of personal health records (PHRs) in Community Health Centers (CHCs) serving low-income, uninsured, and underinsured patients. Forty-three patients and 49 clinic staff, administrators, and providers from these CHC systems were interviewed using open-ended questions assessing patient experience, perceptions of the CHC, access barriers, strategies used to overcome access barriers, technology access and use, and clinic operations and workflow. All seven CHC systems were at some stage of implementing PHRs, with two clinics having already completed implementation. Indiana CHCs have experienced barriers to implementing and using PHRs in a way that provides value for patients or providers/staff There was a general lack of awareness among patients regarding the existence of PHRs, their benefits and a lack of effective promotion to patients. Most patients have access to the internet, primarily through mobile phones, and desire greater functionality in order to communicate with CHCs and manage their health conditions. Despite decades of research, there remain barriers to the adoption and use of PHRs. Novel approaches must be developed to achieve the desired impact of PHRs on patient engagement, communication and satisfaction. Our findings provide a roadmap to greater engagement of patients via PHRs by expanding functionality, training both patients and clinic providers/staff, and incorporating adult learning strategies

Multihospital Infection Prevention Collaborative: Informatics Challenges and Strategies to Prevent MRSA

We formed a collaborative to spread effective MRSA prevention strategies. We conducted a two-phase, multisite, quasi-experimental study of seven hospital systems (11 hospitals) in IN, MT, ME and Ontario, Canada over six years. Patients with prior MRSA were identified at admission using regional health information exchange data. We developed a system to return an alert message indicating a prior history of MRSA, directed to infection preventionists and admissions. Alerts indicated the prior anatomic site, and the originating institution. The combined approach of training and coaching, implementation of MRSA registries, notifying hospitals on admission of previously infected or colonized patients, and change strategies was effective in reducing MRSA infections over 80%. Further research and development of electronic surveillance tools is needed to better integrate the varied data source and support preventing MRSA infections. Our study supports the importance of hospitals collaborating to share data and implement effective strategies to prevent MRSA

“Anybody on this list that you're more worried about?” Qualitative analysis exploring the functions of questions during end of shift handoffs

Background Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of questions during handoff has been less well explored and understood. Objective To investigate questions and the functions they serve in nursing and medicine handoffs. Research design Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs. Subjects Twenty-seven nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. Results Our analysis revealed that the vast majority of questions were asked by the Incoming Providers. Although topics varied widely, the bulk of Incoming Provider questions requested information that would best help them understand individual patient conditions and plan accordingly. Other question types sought consensus on clinical reasoning or framing and alignment between the two professionals. Conclusions Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of questions during end of shift handoffs provides insights into the interface between the technical context in which information is transferred and the social context in which meaning is created

Inside help: An integrative review of champions in healthcare-related implementation

Background/aims: The idea that champions are crucial to effective healthcare-related implementation has gained broad acceptance; yet the champion construct has been hampered by inconsistent use across the published literature. This integrative review sought to establish the current state of the literature on champions in healthcare settings and bring greater clarity to this important construct. Methods: This integrative review was limited to research articles in peer-reviewed, English-language journals published from 1980 to 2016. Searches were conducted on the online MEDLINE database via OVID and PubMed using the keyword "champion." Several additional terms often describe champions and were also included as keywords: implementation leader, opinion leader, facilitator, and change agent. Bibliographies of full-text articles that met inclusion criteria were reviewed for additional references not yet identified via the main strategy of conducting keyword searches in MEDLINE. A five-member team abstracted all full-text articles meeting inclusion criteria. Results: The final dataset for the integrative review consisted of 199 unique articles. Use of the term champion varied widely across the articles with respect to topic, specific job positions, or broader organizational roles. The most common method for operationalizing champion for purposes of analysis was the use of a dichotomous variable designating champion presence or absence. Four studies randomly allocated of the presence or absence of champions. Conclusions: The number of published champion-related articles has markedly increased: more articles were published during the last two years of this review (i.e. 2015-2016) than during its first 30 years (i.e. 1980-2009).The number of champion-related articles has continued to increase sharply since the year 2000. Individual studies consistently found that champions were important positive influences on implementation effectiveness. Although few in number, the randomized trials of champions that have been conducted demonstrate the feasibility of using experimental design to study the effects of champions in healthcare

Comparing the Costs and Acceptability of Three Fidelity Assessment Methods for Assertive Community Treatment

Successful implementation of evidence-based practices requires valid, yet practical fidelity monitoring. This study compared the costs and acceptability of three fidelity assessment methods: on-site, phone, and expert-scored self-report. Thirty-two randomly selected VA mental health intensive case management teams completed all fidelity assessments using a standardized scale and provided feedback on each. Personnel and travel costs across the three methods were compared for statistical differences. Both phone and expert-scored self-report methods demonstrated significantly lower costs than on-site assessments, even when excluding travel costs. However, participants preferred on-site assessments. Remote fidelity assessments hold promise in monitoring large scale program fidelity with limited resources

Persuasive health educational materials for colorectal cancer screening

This paper describes an effort to design and evaluate persuasive educational materials for colorectal cancer (CRC) screening. Although CRC screening is highly effective, screening rates in the US remain low. Educational materials represent one strategy for educating patients about screening options and increasing openness to screening. We developed a one-page brochure, leveraging factual information from the Centers for Disease Control and Prevention (CDC) and national guidelines, and strategies for persuasion from the human factors and behavioral economics literatures. We evaluated the resulting brochure with adults over the age of 50. Findings suggest that the educational brochure increases knowledge of CRC and screening options, and increases openness to screening. Furthermore, no significant difference was found between the new one-page brochure and an existing multi-page Screen for Life brochure recommended by the CDC. We interpret these findings as indication that the more practical and potentially less intimidating one-page brochure is as effective as the existing multi-page Screen for Life brochure

The Relationship Between Provider Competence, Content Exposure, and Consumer Outcomes in Illness Management and Recovery Programs

Provider competence may affect the impact of a practice. The current study examined this relationship in sixty-three providers engaging in Illness Management and Recovery with 236 consumers. Improving upon previous research, the present study utilized a psychometrically validated competence measure in the ratings of multiple Illness Management and Recovery sessions from community providers, and mapped outcomes onto the theory underlying the practice. Provider competence was positively associated with illness self-management and adaptive coping. Results also indicated baseline self-management skills and working alliance may affect the relationship between competence and outcomes