Investing in Skilled Specialists to Grow Hospital Infrastructure for Quality Improvement.

OBJECTIVES: Hospitals can reduce labor costs by hiring lowest skill possible for the job, stretching clinical hours, and reducing staff not at bedside. However, these labor constraints designed to reduce costs may paradoxically increase costs. Specialty staff, such as board-certified clinicians, can redesign health systems to evaluate the needs of complex patients and prevent complications. The aim of the study was to evaluate whether investing in skilled specialists for supporting hospital quality infrastructure improves value and performance. METHODS: We evaluated pressure injury rates as an indicator of performance in a retrospective observational cohort of 55 U.S. academic hospitals from the Vizient clinical database between 2007 and 2012. Pressure injuries were defined by U.S. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 3 (PSI-03) for stage 3, 4, and unstageable pressure injuries not present on admission in hospitalized adults. We compared ratios of board-certified wound care nurses per 1000 hospital beds to hospital-acquired pressure injury rates in these hospitals using mixed-effects regression of hospital quarters. RESULTS: High-performing hospitals invested in prevention infrastructure with skilled specialists and observed performance improvements. Regression indicated that by adding one board-certified wound care nurse per 1000 hospital beds, hospitals had associated decreases in pressure injury rates by -17.7% relative to previous quarters, controlling for other interruptions. Highest performers supplied fewer skilled specialists and achieve improved outcomes. CONCLUSIONS: Skilled specialists bring important value to health systems as a representation of investment in infrastructure, and the proportion of these specialists could be scaled relative to the hospital's patient capacity. Policy should support hospitals to make investments in infrastructure to drive down patient costs and improve quality

Validity and usefulness of members reports of implementation progress in a quality improvement initiative: findings from the Team Check-up Tool (TCT)

<p>Abstract</p> <p>Background</p> <p>Team-based interventions are effective for improving safety and quality of healthcare. However, contextual factors, such as team functioning, leadership, and organizational support, can vary significantly across teams and affect the level of implementation success. Yet, the science for measuring context is immature. The goal of this study is to validate measures from a short instrument tailored to track dynamic context and progress for a team-based quality improvement (QI) intervention.</p> <p>Methods</p> <p>Design: Secondary cross-sectional and longitudinal analysis of data from a clustered randomized controlled trial (RCT) of a team-based quality improvement intervention to reduce central line-associated bloodstream infection (CLABSI) rates in intensive care units (ICUs).</p> <p>Setting: Forty-six ICUs located within 35 faith-based, not-for-profit community hospitals across 12 states in the U.S.</p> <p>Population: Team members participating in an ICU-based QI intervention.</p> <p>Measures: The primary measure is the Team Check-up Tool (TCT), an original instrument that assesses context and progress of a team-based QI intervention. The TCT is administered monthly. Validation measures include CLABSI rate, Team Functioning Survey (TFS) and Practice Environment Scale (PES) from the Nursing Work Index.</p> <p>Analysis: Temporal stability, responsiveness and validity of the TCT.</p> <p>Results</p> <p>We found evidence supporting the temporal stability, construct validity, and responsiveness of TCT measures of intervention activities, perceived group-level behaviors, and barriers to team progress.</p> <p>Conclusions</p> <p>The TCT demonstrates good measurement reliability, validity, and responsiveness. By having more validated measures on implementation context, researchers can more readily conduct rigorous studies to identify contextual variables linked to key intervention and patient outcomes and strengthen the evidence base on successful spread of efficacious team-based interventions. QI teams participating in an intervention should also find data from a validated tool useful for identifying opportunities to improve their own implementation.</p

The impact of open versus closed format ICU admission practices on the outcome of high risk surgical patients: a cohort analysis

<p>Abstract</p> <p>Background</p> <p>In the year 2000, the organizational structure of the ICU in the Zaandam Medical Centre (ZMC) changed from an open to a closed format ICU. The objective of this study was to evaluate the effect of this organizational change on outcome in high risk surgical patients.</p> <p>Methods</p> <p>The medical records of all consecutive high risk surgical patients admitted to the ICU from 1996 to 1998 (open format) and from 2003 to 2005 (closed format), were reviewed. High-risk patients were defined according to the Identification of Risk in Surgical patients (IRIS) score. Parameters studied were: mortality, morbidity, ICU length of stay (LOS) and hospital LOS.</p> <p>Results</p> <p>Mortality of ICU patients was 25.7% in the open format group and 15.8% in the closed format group (p = 0.01). Morbidity decreased from 48.6% to 46.1% (p = 0.6). The average length of hospital stay was 17 days in the open format group, and 21 days in the closed format group (p = 0.03).</p> <p>Conclusions</p> <p>High risk surgical patients in the ICU are patients that have undergone complex and often extensive surgery. These patients are in need of specialized treatment and careful monitoring for maximum safety and optimal care. Our results suggest that closed format is a more favourable setting than open format to minimize the effects of high risk surgery, and to warrant safe outcome in this patient group.</p

Changing the narratives for patient safety

Mary Dixon-Woods is supported by a Wellcome Trust Senior Investigator award (WT097899)

Validity and reliability of Turkish version of "Hospital Survey on Patient Safety Culture" and perception of patient safety in public hospitals in Turkey

<p>Abstract</p> <p>Background</p> <p>The Hospital Survey on Patient Safety Culture (HSOPS) is used to assess safety culture in many countries. Accordingly, the questionnaire has been translated into Turkish for the study of patient safety culture in Turkish hospitals. The aim of this study is threefold: to determine the validity and reliability of the translated form of HSOPS, to evaluate physicians' and nurses' perceptions of patient safety in Turkish public hospitals, and to compare finding with U.S. hospital settings.</p> <p>Methods</p> <p>Physicians and nurses working in all public hospitals in Konya, a large city in Turkey, were asked to complete a self-administrated patient safety culture survey (n = 309). Data collection was carried out using the Turkish version of HSOPS, developed by Agency for Healthcare Research and Quality (AHRQ). Data were summarized as percentages, means, and SD values. Factor analysis, correlation coefficient, Cronbach's alpha, ANOVA, and t tests were employed in statistical analyses. Items on patient safety were categorized into 10 factors. Factor loadings and internal consistencies of dimension items were high.</p> <p>Results</p> <p>Most of the scores related to dimensions, and the overall patient safety score (44%) were lower than the benchmark score. "Teamwork within hospital units" received the highest score (70%), and the lowest score belonged to the "frequency of events reported" (15%). The study revealed that more than three quarters of the physicians and nurses were not reporting errors.</p> <p>Conclusion</p> <p>The Turkish version of HSOPS was found to be valid and reliable in determining patient safety culture. This tool will be helpful in tracking improvements and in heightening awareness on patient safety culture in Turkey.</p