Health Care Management Review最新文献

Background: Care coordination is central to accountable care organizations (ACOs), especially in Medicaid where many patients have complex medical and social needs. Little is known about how to best organize care coordination resources in this context, particularly whether to centralize them. We examined how care coordinators' location, management, and colocation of both (within ACO headquarters, practice sites, or other organizations) relate to care quality and coordination.

Methods: We conducted a cross-sectional analysis of surveys administered to a sample of practice sites covering all 17 Medicaid ACOs in Massachusetts ( n = 225, response rate = 64%). We applied controlled, cluster-robust regressions, adjusting the significance threshold for the number of ACO clusters, to assess how clinical information sharing across settings, care quality improvement, knowledge of social service referral, and cross-resource coordination (i.e., the ability of multiple resources to work well together) relate to where care coordinators were physically located and/or managed.

Results: Centralizing care coordinators at ACO headquarters was associated with greater information sharing. Embedding care coordinators in practices was associated with greater care quality improvement. Embedding coordinators at other organizations was associated with less information sharing and care quality improvement. Managing coordinators at practice sites and other organizations were associated with better care quality improvement and cross-resource coordination, respectively. Colocating the two functions showed no significant differences.

Practice implications: Choosing care coordinators' locations may present trade-offs. ACOs may strategically choose embedding care coordinators at practice sites for enhanced care quality versus centralizing them at the ACO to facilitate information sharing.

Background: An important element of value-based health care (VBHC) is interprofessional collaboration in integrated practice units (IPUs) for the delivery of the complete cycle of care. High levels of interprofessional collaboration between clinical and nonclinical staff in IPUs are assumed rather than proven. Factors that may stimulate interprofessional collaboration in the context of VBHC are underresearched.

Purpose: The aim of this study was to examine relational coordination (RC) in VBHC and its antecedents.

Approach: A questionnaire was used to examine the association of both team practices and organizational conditions with interprofessional collaboration in IPUs. Gittell's Relational Coordination Survey was drawn upon to measure interprofessional collaboration by capturing the relational dynamics in coordinated working. The questionnaire also included measures of team practices (team meetings and boundary spanning behavior) and organizational conditions (task interdependence and time constraints).

Results: The number of different professional groups participating in team meetings is positively associated with RC in IPUs. Boundary spanning behavior, task interdependence, and time constraints are not associated with RC.

Conclusions: In IPUs, the diversity within interprofessional team meetings is important for establishing high-quality communication and relationships.

Practice implications: Hospital managers should prioritize facilitating and encouraging shared meetings to enhance RC levels among professional groups in IPUs.

Background: Tobacco screening interventions have demonstrated effectiveness at improving population health, yet many people who want to quit using tobacco lack access to professional assistance. One way to address this gap is to train members of the clinical team as tobacco treatment specialists (TTSs).

Purpose: The purpose of this study was to understand how TTSs have been used across a variety of health care organizations implementing health systems change for tobacco treatment and examine the sustainability of TTSs as a health systems change innovation for tobacco cessation.

Methodology: This study used qualitative interviews ( n = 25) to identify themes related to implementing TTSs as a health systems change innovation and examined these themes within the constructs of the theory of innovation implementation.

Results: Insights about implementing TTSs as an innovation primarily aligned with four theoretical constructs: implementation policies and practices, implementation climate, innovation-values fit, and implementation effectiveness. Specific themes were perceived to facilitate the sustainability of TTSs including team-based TTS efforts, widespread awareness of TTS roles, leadership buy-in, and recognized value of TTS services. Barriers to sustainability included inadequate resources (e.g., time and staff), lack of tracking outcomes, inappropriate referrals, and lack of reimbursement.

Practice implications: Health care organizations planning to implement health systems change for tobacco cessation can encourage committed use of TTSs as an innovation by considering the insights provided in this study. These primarily related to five overarching implementation considerations: staff selection and training, tracking and dissemination of impacts, adequate resources, referrals and workflow, and billing and reimbursement.

Background: The unprecedented use of travel and temporary nurses in recent years requires further investigation of the impact on patient care.

Purpose: We conducted a systematic review of empirical research investigating the relationship between travel nurses and patient care to identify if consistent significant associations exist and how structural and process variables may influence such associations.

Methods: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of six databases resulted in the identification of 21 relevant articles.

Results: The existing research of travel nurse use differs widely in terms of the definition of travel nurse, study design, and included controls. The literature has failed to establish a consistent relationship between travel nurses and patient outcomes. Adverse associations between travel nursing and patient care may reflect staffing levels or work environments rather than the specific care by the travel nurses themselves.

Practice implications: Underlying structural and process variables, such as staffing levels and the practice work environment, may be confounding associations between travel nurse usage and quality patient care. Administrators and managers are urged to assess staffing and the work environment when employing travel nurses.

Background: Communication is an essential organizational process for responding to adversity. Managers are often advised to communicate frequently and redundantly during crises. Nonetheless, systematic investigation of how information receivers perceive organizational communication amid crises has remained lacking.

Purpose: The aim of this study was to characterize features of effective internal crisis communication by examining how information-sharing processes unfolded during the initial stage of the COVID-19 pandemic.

Methodology: Between June and August 2020, we conducted 55 semistructured interviews with emergency department workers practicing in a variety of roles. We analyzed interview transcripts following constructivist constant comparative methods.

Results: Our findings revealed that at the onset of COVID-19 pandemic response, emergency department workers struggled with immense fear and anxiety amid high uncertainty and equivocality. Frequent and redundant communication, however, resulted in information delivery and uptake problems, worsening anxiety, and interpersonal tension. These problems were ameliorated by the emergence of contextual experts who centralized and democratized communication. Centralization standardized information received across roles, work schedules, and settings while decoupling internal communication from turbulence in the environment. Democratization made information accessible in a way that all could understand. It also ensured information senders' receptiveness to feedback from information receivers. Centralization and democratization together worked to reduce sensed uncertainty and equivocality, which reduced anxiety and interpersonal tension.

Conclusion: Establishing frequent and redundant communication strategies does not necessarily address the anxiety and interpersonal tension produced by uncertainty and equivocality in crises.

Practice implications: Centralization and democratization of crisis communication can reduce anxiety, improve coordination, and promote a safer workplace and patient care environment.

Background: Increasingly, hospitals are expected to provide patient-centered care that attends to patients' health needs, including spiritual care needs. Chaplaincy services help to meet patients' spiritual care needs, which have been shown to have a positive impact on health outcomes. Variation in the provision of chaplaincy services suggests hospitals do not uniformly conform to the expectation of making chaplaincy services available.

Purpose: The aim of this study was to examine the availability and factors that influence hospitals' provision of chaplaincy services.

Methodology: Data were combined from the American Hospital Association annual surveys with the Area Health Resource File at the county level from 2010 to 2019. Observations on general, acute-care community hospitals were analyzed (45,384 hospital-year observations) using logistic regression that clustered standard errors at the hospital level.

Results: Hospitals with Joint Commission accreditation, more staffed beds, nonprofit and government ownership, teaching status, one or more intensive care units, a higher percentage of Medicare inpatient days, church affiliation, and system membership were more likely to provide chaplaincy services than their counterparts. Certification as a trauma hospital and market competition showed no influence on the provision of chaplaincy services.

Conclusion: The lack of chaplaincy services in many hospitals may be due to limited resources, workforce shortage, or a lack of consensus on scope and nature of chaplaincy services.

Practice implications: Chaplaincy services are an underutilized resource that influences patient experience, clinician burnout and turnover, and the goal of ensuring care is patient-centered. Administrators should consider stronger partnerships where services are provided; researchers and policymakers should consider how the lack of these services in some hospitals may reinforce existing health disparities.

Background: Given that emotional exhaustion and nurse engagement have significant implications for nurse well-being and organizational performance, determining how to increase nurse engagement while reducing nurse exhaustion is of value.

Purpose: Resource loss and gain cycles, as theorized in conservation of resources theory, are examined using the experience of emotional exhaustion to evaluate loss cycles and work engagement to evaluate gain cycles. Furthermore, we integrate conservation of resources theory with regulatory focus theory to examine how the ways in which individuals approach work goals serves as a facilitator to the acceleration and deceleration of both of these cycles.

Methodology/approach: Using data from nurses working in a hospital in the Midwest United States at six time points spanning over 2 years, we demonstrate the accumulation effects of the cycles over time using latent change score modeling.

Results: We found that prevention focus was associated with the accelerated accumulation effects of emotional exhaustion and that promotion focus was associated with the accelerated accumulation effects of work engagement. Furthermore, prevention focus attenuated the acceleration of engagement, but promotion did not influence the acceleration of exhaustion.

Conclusion: Our findings suggest that individual factors such as regulatory focus are key to helping nurses to better control their resource gain and loss cycles.

Practice implications: We provide implications for nurse managers and health care administrators to help encourage promotion focus and suppress prevention focus in the workplace.

Background: Performance-based budgeting (PBB) is a variation of pay for performance that has been used in government hospitals but could be applicable to any integrated system. It works by increasing or decreasing funding based on preestablished performance thresholds, which incentivizes organizations to improve performance. In late 2006, the U.S. Army implemented a PBB program that tied hospital-level funding decisions to performance on key cost and quality-related metrics.

Purpose: The aim of this study was to estimate the impact of PBB on quality improvement in U.S. Army health care facilities.

Approach: This study used a retrospective difference-in-differences analysis of data from two Defense Health Agency data repositories. The merged data set encompassed administrative, demographic, and performance information about 428 military health care facilities. Facility-level performance data on quality indicators were compared between 187 Army PBB facilities and a comparison group of 241 non-PBB Navy and Air Force facilities before and after program implementation.

Results: The Army's PBB programs had a positive impact on quality performance. Relative to comparison facilities, facilities that participated in PBB programs increased performance for over half of the indicators under investigation. Furthermore, performance was either sustained or continued to improve over 5 years for five of the six performance indicators examined long term.

Conclusion: Study findings indicate that PBB may be an effective policy mechanism for improving facility-level performance on quality indicators.

Practice implications: This study adds to the extant literature on pay for performance by examining the specific case of PBB. It demonstrates that quality performance can be influenced internally through centralized budgeting processes. Though specific to military hospitals, the findings might have applicability to other public and private sector hospitals who wish to incentivize performance internally in their organizational subunits through centralized budgeting processes.

Background: A large volume of literature identifies positive, rejuvenating benefits associated with giving compassion to others. However, the relationship between giving compassion and feelings of exhaustion remains underexplored. Understanding when giving compassion can potentially lead to feelings of emotional exhaustion is particularly important for nurses who are called upon to provide high levels of compassion to suffering patients in their daily work. We suggest that by engaging in transformational leadership behaviors, frontline supervisors can help nurses realize the positive benefits associated with giving compassion.

Purpose: The aim of this study was to examine the impact of nurses' perceptions of transformational leadership offered by their supervisors on the relationship between the levels of compassionate behaviors nurses report engaging in with patients and feelings of emotional exhaustion and job satisfaction.

Methodology/approach: A time-lagged field survey was conducted across two waves of 112 full-time employed inpatient nurses within the United States.

Results: Providing high levels of compassionate behavior to patients was associated with reduced (increased) perceptions of emotional exhaustion and increased (decreased) job satisfaction when supervisors engaged in higher (lower) levels of transformational leadership.

Discussion: Transformational leadership serves as an important resource to help caregivers such that nurses feel invigorated and satisfied, as opposed to drained or fatigued, when engaging in high levels of compassionate behaviors toward suffering patients.

Practice implications: For nurses to fully reap the established positive benefits associated with providing compassion to patients, frontline supervisors should be encouraged to engage in behaviors reflective of transformational leadership.