Assessment of patient safety research from an organizational ergonomics and structural perspective.

The aim of this study is to review patient safety improvement initiatives within a conceptual framework that builds upon principles of organizational ergonomics and emphasizes structural factors that influence patient safety. The literature review included 131 English language published studies of patient safety improvement strategies extracted using Medline, Ovid Healthstar, PubMed and CINAHL searches. Keywords for the search included: 'patient safety'; 'medical errors'; 'adverse event'; 'iatrogenic'; and truncated options for 'improve'. The multilevel, hierarchical framework offered in this paper integrates quality management principles and organizational ergonomics theory and organizes patient safety initiatives according to sociotechnical system elements within three structural levels: health policies and associated health care organizations; health care delivery organizations; and health care microsystems. Utilizing the conceptual framework, this review of patient safety improvement initiatives highlights the need for consideration of the impact of all improvement proposals on each structural component within health care systems. The review also supports the need for patient safety research to evolve from exploratory, 1-D reporting to multi-level, integrated research.

Interdisciplinary health professional education: a historical review.

A historical review was conducted to examine the advances made, nationally and internationally, in interdisciplinary health professional education since the mid-1960s. One hundred and nineteen articles were reviewed and divided by decade into the following subheadings: models, courses, communication/group process issues, and international perspectives. Twenty-seven articles, categorized as models, defined the conceptual field, described curriculum and program development, or provided a framework for evaluation. Thirty-two articles dealt with interdisciplinary courses, focusing on objectives, content areas, or innovative methods. Nine articles contributed content on interdisciplinary communication and group process issues, from which guidelines were abstracted. Fifty-one articles contributed an international perspective, leading to the recognition that interdisciplinary health professional education, practice, and research is a global movement.

Issues in the assessment of continuous quality improvement implementation in health care organizations.

OBJECTIVE: This paper has two primary aims. First, it examines the need for improved assessment of continuous quality improvement implementation. Second, it analyzes current worldwide measures and studies of continuous quality improvement implementation. METHOD: A comprehensive literature review was conducted which included all published (English language) studies of organization-wide continuous quality improvement implementation. RESULTS: Analysis of the content and research methods incorporated into current measures of continuous quality improvement implementation used worldwide supports a strong consensus regarding the major criteria that need to be addressed. However, there are still promising areas for future research, namely increased use of criteria other than the Baldrige categories, increased focus upon financial variables, improved measures of implementation stage/phase and the use of different types of respondents from multiple organizational levels. CONCLUSION: Increased understanding of the empirical benefits and costs of continuous quality improvement in health care organizations is heavily contingent upon the continued development and improvement of measures of continuous quality improvement implementation.

Facilitating factors for, barriers to, and outcomes of interdisciplinary education projects in the health sciences.

Appropriate collaboration and communication among health professionals is viewed as increasingly important in meeting the challenges of today's health care system. Student socialization to interdisciplinary practice is thought to be facilitated through interdisciplinary academic and clinical learning experiences during the educational program. The purpose of this article is to identify factors commonly cited as facilitating and inhibiting interdisciplinary education, to provide insight for the development of successful interdisciplinary education projects.

International health services management education: an overview of major efforts and lessons learned during the 1990s.

In this paper, the authors examine select major pedagogical and methodological issues concerning health care management executive training and academic program development in the former Soviet sphere of influence during the 1990s. Experience from programs offered during the 1990s has direct implications for the continued development of health care management programs and faculty in the United States. In essence, each of the nations that were involved represented an experimental setting for the introduction and improvement of management skills in the health care sector and the development of professional health care managers. Evaluative findings should help to inform future efforts to construct and deliver effective international and domestic management educational programs.

The impact of socio-cultural and clinical factors on health-related quality of life reports among Hispanic and African-American cancer patients.

A hierarchical multiple linear regression approach (N = 761) was used to identify pertinent factors which influence health-related quality of life (HRQL) reports among Hispanic and African-American cancer patients. The independent variables include: performance status, disease site, disease stage, mode of administration, socio-economic status (SES), gender, age, living arrangement, race/ethnicity, religious affiliation, insurance status, and spiritual beliefs. The outcome measures, five subscales of HRQL (physical well-being, social well-being, satisfaction with treatment, emotional well-being, functional well-being) and overall HRQL (sum of the five subscales), were estimated using the Functional Assessment of Cancer Therapy (FACT) Scales. This study identified performance status and spiritual beliefs as consistent predictors of overall HRQL. This study also found no significant effects of SES, mode of administration, gender age, living arrangement and insurance status on the reporting of overall HRQL. Spiritual beliefs and performance status are important determinants of HRQL across a diverse group of cancer patients.

An analysis of the impact of demographic, clinical, and social factors on health-related quality of life.

This study investigated the impact of demographic, social, and clinical factors on cancer patients' self-ratings of health-related quality of life (HRQL). The sample consisted of 1342 ethnically diverse individuals in treatment at four member institutions of the Eastern Cooperative Oncology Group (ECOG). Multivariable regression analyses were employed to determine the relationship between demographic variables (age, gender, race/ethnicity, socio-economic status (SES), living arrangement), clinical factors (performance status rating (PSR), disease type, disease stage), and social characteristics (spiritual beliefs, religious affiliation, relationship with physician) and five outcome measures of HRQL. The dependent variables, four dimensions of HRQL and overall HRQL, were measured by the Functional Assessment of Cancer Therapy-General (FACT-G) Quality of Life Measurement System. The results indicated that the full set of predictor variables accounted for 45% of the variance in patients' reporting of overall HRQL, 25% of the variance in physical well-being, 27% of the variance in social well-being, 30% of the variance in emotional well-being, and 41% of the variance in the area of functional well-being. The findings suggest that there are multiple factors that influence an individual's assessment of their HRQL and that these factors need to be considered in the management and treatment of culturally diverse cancer patients.

Training future leaders of academic medicine: internal programs at three academic health centers.

The authors review the need for internal programs for leadership training at academic health centers and then describe in detail three programs of this type that have operated during the 1990s: (1) the Allegheny Leadership Institute, founded by the Allegheny Health, Education and Research Foundation, Pittsburgh, Pennsylvania; (2) the Physician Executive Management Development Program (PEMDP) of Saint Louis University School of Medicine; and (3) the University of Nebraska Medical Center Leadership Institute. Educational elements common to these programs include having a small class size and participants from many areas of academic medicine and health care, focusing on educational strategies that draw on participants' experiences and training, conducting the training away from the participants' institutions, having short sessions, using faculty from both within and outside the participants' institutions, and creating strategies to reinforce learning. Lessons learned reflect the unique context of each institution; the authors list the major lessons learned by each of the three programs they surveyed (e.g., leaders of the Saint Louis University PEMDP program believe that it is important to help participants implement desired changes in their work areas once they return to work, and are investigating how to do this). The authors conclude with an extensive list of recommendations to optimize the effects of leadership development training carried out in AHCs' internal programs (e.g., "Focus on specific skills that can be learned, and link the learning experiences to real work situations in health care and higher education") and explain why they think internal leadership institutes have at least three distinct advantages over external programs.

The emerging role of the client in the delivery of primary care to older Americans.

OBJECTIVE: To address the likely influences, on options faced by older clients, of specific changes in the delivery system and several possible responses to these changes and the changed options, by older persons in the aggregate. STUDY DESIGN: Four specific topics are discussed at length: (1) the probable altered role for the older healthcare client brought on by organizational changes; (2) findings from research on elderly health maintenance behavior and reasons for the increased importance of this issue; (3) the effectiveness of the conventional approach to explaining health services utilization in population studies; and (4) recommendations for future research into the direct or indirect influence of organizational changes in the primary healthcare system on the health-related decisions and behaviors of older persons.

The influence of personal expectations on cancer patients' reports of health-related quality of life.

The role of personal expectations on reports of health-related quality of life (HRQL) in the context of a set of other variables commonly thought to affect patient report of HRQL was examined. The complete set of predictor variables included: (1) patient factors including age, gender, race, education, income, insurance type, living arrangement and expectations; and (2) clinical factors namely performance status rating (PSR), diagnosis and disease stage. The outcome measures included five dimensions of HRQL (relationship with physician, physical, social, emotional and functional well being) and an overall measure of HRQL. Five variables (PSR, expectation rating, age, living arrangement and managed care enrollment) exerted significant effects on the summated rating of HRQL. Older cancer patients, those living with others, those enrolled in managed care organizations and those who report better-than-expected experience are more likely to have a higher overall HRQL. In addition to treating the disease itself, quality of life can possibly be enhanced by narrowing the disparities between individuals' expectations and what actually occurs. Patients would likely therefore benefit from being encouraged to set and maintain realistic goals concerning their cancer prognosis and treatment process.

An analysis of the adoption of managerial innovation: cost accounting systems in hospitals.

The adoption of new medical technologies has received significant attention in the hospital industry, in part, because of its observed relation to hospital cost increases. However, few comprehensive studies exist regarding the adoption of non-medical technologies in the hospital setting. This paper develops and tests a model of the adoption of a managerial innovation, new to the hospital industry, that of cost accounting systems based upon standard costs. The conceptual model hypothesizes that four organizational context factors (size, complexity, ownership and slack resources) and two environmental factors (payor mix and interorganizational dependency) influence hospital adoption of cost accounting systems. Based on responses to a mail survey of hospitals in the Chicago area and AHA annual survey information for 1986, a sample of 92 hospitals was analyzed. Greater hospital size, complexity, slack resources, and interorganizational dependency all were associated with adoption. Payor mix had no significant influence and the hospital ownership variables had a mixed influence. The logistic regression model was significant overall and explained over 15% of the variance in the adoption decision.

Improving hospital performance: issues in assessing the impact of TQM activities.

Despite numerous published reports of the need for TQM activities in health care organizations and their widespread diffusion within the health care industry, whether they make a difference remains an unresolved issue. In this article, we discuss the major reasons why the impacts of TQM should be assessed, what needs to be measured during assessment activities, and significant methodological issues that can confound the evaluation of TQM effects. An audit framework is described that can be used to depict the types of effects that TQM may have on the performance of health care organizations. Assessment guidelines are offered that will hopefully benefit the future efforts of institutional managers and health services researchers in their attempts to determine whether TQM activities do in fact make a significant difference.

Determinants of patient satisfaction with outpatient surgery.

To help understand the determinants of patient satisfaction following outpatient surgery, the authors developed a written survey instrument and administered it to more than 200 patients. The significant predictors of overall satisfaction were the courtesy of the staff and clinical quality. Overall satisfaction was also found to be a significant predictor of intent to recommend.

Examining the relationship between health locus of control and the use of medical care services.

Health locus of control, the extent to which one believes he or she can affect his or her health status, usually is viewed as one of the factors that predisposes individuals to use medical services. However, some social theorists outside the area of utilization studies suggest that locus of control beliefs also are consequences of health-related behaviors and events such as utilization. The authors address this issue by investigating the relationship between health locus of control and utilization of medical services in a sample of 298 elderly community-dwellers surveyed at three points in time. They found that health locus of control was affected by serious medical care encounters and that, for two dimensions of health locus of control, there was a reciprocal relationship between control beliefs and utilization.

An analysis of physician utilization by elderly persons: systematic differences between self-report and archival information.

Elderly persons may over- or underreport their utilization of services, and systematic variance in this discrepancy may bias research findings. Therefore, this study analyzed the discrepancy between archival and self-report measures of physician utilization and examined the association of that discrepancy with health status and sociodemographic variables. Each older person underreported physician utilization by a net of .35 visits, but the total discrepancy was nearly two visits per person, or 65 percent of the number of self-reported visits. The multivariate findings indicate that underreports of utilization are smaller for those elderly persons with lower health status (as measured by disease history) and larger for those with higher levels of utilization. Those in poor health tend to overreport physician visits, and those with greater levels of utilization tend to have greater proportional reporting error. Self-reported measures of physician utilization should be considered in the context of the net error and the systematic nature of that error.

Elderly health beliefs, attitudes, and maintenance.

BACKGROUND: Why older persons engage in varying amounts of health maintenance activity is becoming both an increasingly important policy issue and a topic of interest to health services researchers. Such activity may help the elderly to delay the onset of the health-related problems associated with aging, maintain if not improve their functional abilities, and perhaps improve their quality of life. METHODS: Using a conceptual model largely based upon the health belief model, this study sought to examine predictors of variability of health maintenance activity among older persons. The project included cross-sectional data drawn from the first phase of a multiyear panel study of elderly community residents. RESULTS: Results of ordinary least-squares and logistic regression analyses of seven types of health maintenance activity suggest that health beliefs are an important consideration but that other variables, namely, type of insurance plan and select sociodemographic factors, also had significant impacts. Another consistent finding was that each of the types of health maintenance activity was associated with different types of predictor variables. CONCLUSION: These findings suggest that in order for levels of health maintenance activity to be increased, intervention programs need to be targeted toward specific types of health beliefs and need to take into account the importance of social differences.