Health Care Management Review最新文献

Background: Although trust and psychological safety (PS) are critical for improving patient safety and medical error reporting, little is known about how they work together and how health care systems promote PS.

Purpose: This study examined how leadership for self-worth, inclusion, and trust may work together to foster PS and how this influences medical error reporting.

Approach: Data were collected in 2019 from 373 employees (24% response rate) in 85 hospital departments (54% response rate) in a nonprofit health care system in the eastern United States. Constructs were operationalized at the department level.

Results: Negative binomial path model results found several direct effects. Leadership for self-worth was positively associated with inclusion, inclusion was positively associated with trust and PS, trust was positively associated with reported medical errors, and PS was negatively associated with reported medical errors. Indirect effects uncovered leadership for self-worth was positively associated with PS by enhancing inclusion. In addition, leadership for self-worth increased inclusion, which increased trust and ultimately encouraged PS. Leadership for self-worth was associated with fewer reported medical errors through increasing inclusion, trust, and PS.

Practical implications: Trust encourages the formal reporting of medical errors whereas PS encourages learning from mistakes and improving care to reduce future errors (and consequently the number of reported errors). Leaders who understand employees' unique needs, express confidence in employees' abilities, and encourage employees to share their ideas, create inclusive and trusting work environments that encourage PS and ultimately help reduce reported medical errors.

Background: Skilled nursing facilities' (SNFs) ability to provide optimal post-acute care depends on effective receipt of information from hospitals ("information continuity"). Little is known about how SNFs perceive information continuity and how it may relate to upstream information sharing processes, organizational context, and downstream outcomes.

Purpose: First, this study aims to identify how SNF perceptions of information continuity may be shaped by hospital information sharing practices, including measures of completeness, timeliness, and usability, as well as characteristics of the transitional care environment (i.e., integrated care relationships and/or consistency of information sharing practices across different hospital partners). Second, we analyze which of these characteristics are associated with quality of transitional care (measured by 30-day readmissions).

Approach: A cross-sectional analysis of nationally representative SNF survey ( N = 212) linked to Medicare claims was performed.

Results: SNF perceptions of information continuity are strongly and positively associated with hospital information sharing practices. Adjusting for actual information sharing practices, SNFs that experienced discordance across hospitals reported lower perceptions of continuity (β = -0.73, p = .022); evidence of stronger relationships with a given hospital partner appears to help facilitate resources and communication that helps to close this gap. Perceptions of information continuity, more so than the upstream information sharing processes reported, exhibited a more reliable and significant association with rates of readmissions as an indicator of transitional care quality.

Conclusion: SNF perceptions of information continuity are strongly associated with patient outcomes and are reflective of both hospital information sharing practices as well as characteristics of the transitional care environment that can mitigate or amplify the cognitive and administration challenge of their work.

Practice implications: Improving transitional care quality requires that hospitals improve information sharing behaviors but also invest in capacity for learning and process improvement in the SNF environment.

Background: The introduction of electronic health records (EHRs) has contributed considerably to EHR work outside work (WOW) hours for physicians. Prior research has identified the pressures associated with stress resulting from EHR WOW, yet developing a nuanced understanding of how physicians appraise and respond to this stress, and the resulting impacts, remains absent from the literature.

Purpose: Grounded in the technostress model, this study takes a qualitative approach to explore both the pressures and opportunities associated with EHR WOW.

Methods: Thematic analysis of data from semistructured interviews was utilized to examine the pressures and opportunities associated with EHR WOW among primary care pediatricians (n = 15) affiliated with a large Midwestern pediatric health system.

Results: The physicians in this study regularly spent time working in the EHR outside work hours. They felt the EHR contributed to their documentation burden, which ultimately increased their EHR WOW, and reported a sense of burden from ubiquitous EHR availability. Conversely, they appreciated the flexibility the EHR provided in terms of work-life balance. Suggestions for improvement under the direct purview of practice management included enhanced EHR usability, improvements in workflow during work hours to free up time to document, and more training on both EHR documentation strategies and ongoing software upgrades.

Conclusion: Physicians perceive that the EHR exerts certain pressures while affording new opportunities and conveniences. This study provides evidence of both the pressures and opportunities of EHR WOW and their effect on physician well-being.

Practice implications: Specific opportunities are identified for health administrators to enable physicians to better manage EHR WOW.

Background: Academic medical centers (AMCs) are well recognized for their innovations that enhance frontline care, but there is little study of their innovation management processes, which is key for advancing theory regarding the effectiveness of innovation efforts to improve care.

Purpose: We aimed to identify organizational models used for frontline innovation by AMCs in the United States, core activities within models, and factors that influence innovation success.

Methods: We conducted a qualitative study of 12 AMCs using data from semistructured interviews with centers' innovation leaders. Inclusion required satisfying two of three criteria in 2021 (only met by 35 AMCs nationally): listed in the professional association of innovation leaders (Council of 33), Becker's review of most innovative hospitals, and/or top 20 U.S. News and World Report best hospitals honor roll. We analyzed the interview data using the constant comparative method.

Results: Innovative AMCs pursue innovation through innovation centers (using a centralized or multicenter model) or within clinical departments (department-level model). All three models emphasize seven activities, although performed differently: sourcing ideas, developing ideas, implementing innovations, fundraising, managing partnerships, measuring success, and managing mindset. Several factors influenced success: role performance, operational challenges, technology, public policy, customer clarity, stakeholder buy-in, diversity of input, and focus. The centralized model struggled less with standardization and coordination issues.

Conclusion: AMCs have options for structuring their innovation efforts. However, there are consistent activities for successful innovation management and factors that they must manage.

Practice implications: AMCs can select among innovation models to fit their circumstances but likely need to perform seven activities well for success.

Background: The COVID-19 pandemic is a profound change event for U.S. primary care physicians and their medical practices.

Purpose: We examined how a group of U.S. primary care physicians and their medical practices used resiliency-based strategies, tactics, and mindsets to navigate pandemic-related change over the time period early 2020 through mid-2021.

Methodology: A 15-month longitudinal qualitative study of the same 10 physicians interviewed a total of 42 times at four time intervals during the 2020-2021 COVID-19 pandemic. Data were analyzed using a systematic coding approach consisting of first- and second-order code categories feeding into an overall interpretive framework of resiliency-based adaptations.

Results: Primary care physicians and their practices engaged in two main resiliency-based strategic adaptations during the pandemic. These adaptations were labeled "keeping the business afloat" and "keeping primary care relevant for patients." Each consisted of different strategies and tactics that shared common features including proactiveness, innovativeness, and pragmatism. Specific resiliency-based mindsets were identified that helped physicians both initially engage in needed strategies and tactics while continuing to engage in them over time.

Conclusions: The results demonstrate how physicians use resiliency-based adaptation in response to profound change in their environments, defined by behavioral variety and motivated by self-interested and patient-centered imperatives.

Practice implications: Physicians are proactive and possess multiple adaptive capabilities. Seen in this more positive light, health care organizations should focus on greater engagement of their physician-employees in implementing innovation in care delivery and managing change, that is, as responsible partners rather than resistors to meeting organizational imperatives.

Background: Perioperative nursing units are described as one of the most challenging practice environments, characterized by a distinct hierarchal culture and rapid pace. These dynamics create challenges for creating a culture of safety, where meso-level nurse leaders (MLNLs) must operate in the space between the micro level of direct patient care and the macro-level administrative priorities.

Purpose: Guided by complexity leadership theory, we sought to understand the strategies MLNLs used to facilitate a culture of safety in perioperative settings.

Methodology: A qualitative descriptive study with semistructured interviews was conducted. Inductive thematic analysis was used to analyze content from the interviews, and several techniques (audit trail, reflexivity, peer debriefing) were used to ensure rigor.

Results: Seventeen MLNLs completed an interview, and analysis identified four strategies that MLNLs reported to foster safety as meso-leaders in perioperative environments: (a) recognizing the unique perioperative management environment, (b) learning not to take interactions personally, (c) developing "super meso-level nurse leader" skills, and (d) appealing to policies and patient safety.

Conclusion: Perioperative environments require MLNLs to use multifaceted strategies to keep the peace among many stakeholders and foster patient safety.

Practice implications: Our study shows how clear organizational policies and procedures can serve as a vital tool-moving attention away from a feeling of individual "policing" and toward joint discussion about shared patient safety goals-and ultimately support MLNLs in challenging perioperative work environments. Perioperative environments create unique challenges, and organizations should consider perioperative-specific leadership training to prepare MLNLs for these roles.

Background: Health care professionals face greater uncertainty in their careers as traditional jobs wither and new, organizationally controlled jobs proliferate, reducing economic security and professional autonomy.

Purpose: We apply psychological contract and self-efficacy theory to examine the career agency of early-career physicians. We ask the following: (a) What are the unfulfilled expectations and emotions experienced by young physicians at the training and early career stages? (b) What are the forms of career agency exhibited by young physicians in response to unfulfillment?

Methodology: We conducted a study on 48 U.K. early-career primary care physicians, known as general practitioners. The sample comprised both trainees as well as newly qualified physicians. Data were collected through in-depth interviews and focus group discussions.

Results: Physicians interpreted their early-career experiences based on predominantly ideological expectations around what it means to be a successful professional. However, the realities of practice resulted in highly emotional experiences of violation that were associated with a "reactive" agency and job behaviors that were more transactional and less relational.

Conclusion: This study identifies the expectations of early career professionals, which helps understand how and why psychological contract violations occur. It also expands the conceptualization of career agency from a positively framed aspect of professional behavior to one that includes haphazard and self-serving elements.

Practice implications: Our study highlights several implications of the shifts in physician career agency for primary care practice. It discusses the potential effects of the purposeful self-interest among doctors on professional identity and power, as well as patient care.

Purpose: The purpose of this study was to examine the effects of psychological capital on the relationship between physical violence and mental health issues of nurses and personal care assistants (PCAs) working in aged care using the job demands-resources theory.

Methodology: Data were collected from 254 nurses and PCAs of the Australian Nursing Midwifery Federation located in Victoria, Australia. The study takes a quantitative approach and tests the hypotheses through regression analyses.

Findings: The results indicate that experiencing physical violence increases levels of stress, depression, and anxiety. This, in turn, increases nurses' and PCAs' intention to leave. However, increased psychological capital can assist nurses and PCAs in dealing with physical violence.

Research implications: The study acknowledges that physical violence is a factor in nurses' intention to leave. The significant finding is that psychological capital plays a protective role in ameliorating the negative impact of physical violence on individual well-being and intentions to leave. We note, however, that this is a cross-section study, and more longitudinal research needs to be undertaken.

Practical implications: There are clear implications for managers to create a supportive organization that cultivates hope, self-efficacy, and resilience, thereby increasing psychological capital. Leadership development programs could build a supportive foundation for nurses to seek support and build resilience. Job construction should be focused on protecting nurses from risk by utilizing manageable workloads to limit stress, depression, and anxiety.

Originality: Our study extends research on retention of these skilled and important health care workers in a demanding environment that has largely been absent from the literature. Specifically, physical violence is often considered part of nursing work, but its impact on mental health, well-being, and intention to leave are underexplored in this sector, as well as the effectiveness of specific measures that bolster the negative impact of physical violence on nurses.

Background: Research suggests that changes in nurse roles can compromise perceived organizational safety. However, over the past 15 years, many infusion tasks have been reallocated from specialty nurse infusion teams to individual generalist nurses-a process we call infusion task reallocation . These changes purportedly benefit employees by allowing care providers to practice at the "top of their license." However, job demands-resources theory suggests that changing core task arrangements can either enrich or merely enlarge jobs depending on their effects on demands and resources, with corresponding consequences for performance (e.g., safety). There is relatively little research directly exploring these effects and their mechanisms.

Purpose: This study examines the relationship between infusion task reallocation and perceptions of organizational safety. We also explore the extent to which this relationship may be mediated by infusion-related resources and psychological safety.

Methodology: Data were collected through a survey of 623 nurses from 580 U.S. hospitals. The relationship between infusion task reallocation and perceptions of organizational safety, as well as the potential mediating roles of infusion-related resources and psychological safety, was examined using structural equation modeling.

Results: Infusion task reallocation was negatively associated with respondents' perceptions of organizational safety, with nurses working in organizations without an infusion team indicating lower perceptions of organizational safety than nurses working in organizations with an infusion team. This relationship was mediated by nurse perceptions of psychological safety within the organization, but not by infusion-related resources, suggesting that task reallocation is associated with lower perceived organizational safety because nurses feel less psychologically safe rather than because of perceived technical constraints.

Practice implications: The results indicate that, although infusion task reallocation may be a cost-reducing approach to managing clinical responsibilities, it enlarges rather than enriches the job through higher demands and fewer resources for nurses and, in turn, lower perceived organizational safety.