Safe Surgery Checklist Implementation: Associations of Management Practice and Safety Culture Change.

Designing and developing safe systems has been a persistent challenge in health care, and in surgical settings in particular. In efforts to promote safety, safety culture, i.e., shared values regarding safety management, is considered a key driver of high-quality, safe healthcare delivery. However, changing organizational culture so that it emphasizes and promotes safety is often an elusive goal. The Safe Surgery Checklist is an innovative tool for improving safety culture and surgical care safety, but evidence about Safe Surgery Checklist effectiveness is mixed. We examined the relationship between changes in management practices and changes in perceived safety culture during implementation of safe surgery checklists. Using a pre-posttest design and survey methods, we evaluated Safe Surgery Checklist implementation in a national sample of 42 general acute care hospitals in a leading hospital network. We measured perceived management practices among managers (n = 99) using the World Management Survey. We measured perceived preoperative safety and safety culture among clinical operating room personnel (N = 2,380 (2016); N = 1,433 (2017)) using the Safe Surgical Practice Survey. We collected data in two consecutive years. Multivariable linear regression analysis demonstrated a significant relationship between changes in management practices and overall safety culture and perceived teamwork following Safe Surgery Checklist implementation.

The association between care integration and care quality.

OBJECTIVE: The study aims to analyze the relationship between care integration and care quality, and to examine if the relationship varies by patient risk. DATA SOURCES AND STUDY SETTING: The key independent variables used validated measures derived from a provider survey of functional (i.e., administrative and clinical systems) and social (i.e., patient integration, professional cooperation, professional coordination) integration. Survey responses represented data from a stratified sample of 59 practice sites from 17 health systems. Dependent variables included three quality measures constructed from patient-level Medicare data: colorectal cancer screening among patients at risk, patient-level 30-day readmission, and a practice-level Healthcare Effectiveness Data and Information Set (HEDIS) composite measure of publicly reported, individual measures of ambulatory clinical quality performance. DATA COLLECTION/EXTRACTION METHOD: We obtained quality- and beneficiary-level covariate data for the 41,966 Medicare beneficiaries served by the 59 practices in our survey sample. STUDY DESIGN: We estimated hierarchical linear models to examine the association between care integration and care quality and the moderating effect of patients' clinical risk score. We graphically visualized the moderating effects at ±1 standard deviation of our z-standardized independent and moderating variables and performed simple slope tests. PRINCIPAL FINDINGS: Our analyses uncovered a strong positive relationship between social integration, specifically patient integration, and the quality of care a patient receives (e.g., a 1-point increase in a practice's patient integration was associated with 0.31-point higher HEDIS composite score, p < 0.01). Further, we documented positive and significant associations between aspects of social and functional integration on quality of care based on patient risk. CONCLUSIONS: The findings suggest social integration matters for improving the quality of care and that the relationship of integration to quality is not uniform for all patients. Policymakers and practitioners considering structural integrations of health systems should direct attention beyond structure to consider the potential for social integration to impact outcomes and how that might be achieved.

High-performing primary care clinics across high-need, high-cost Medicare populations.

BACKGROUND: To reduce spending and improve quality, some primary care clinics in the USA have focused on high-need, high-cost (HNHC) Medicare beneficiaries, which include clinically distinct subpopulations: older adults with frailty, adults under 65 years with disability and beneficiaries with major complex chronic conditions. Nationally, the extent to which primary care clinics are high-performing 'Bright Spots'-clinics that achieve favourable outcomes at lower costs across HNHC beneficiary subpopulations-is not known. OBJECTIVE: To determine the prevalence of primary care clinics that perform highly on commonly used cost or quality measures for HNHC subpopulations. DESIGN AND PARTICIPANTS: Cross-sectional study using Medicare claims data from 2014 to 2015. MAIN MEASURES: Annual spending, avoidable hospitalisations for ambulatory care-sensitive conditions, treat-and-release emergency department visits, all-cause 30-day unplanned hospital readmission rates and healthy days at home. Clinics were high performing when they ranked in the top quartile of performance for ≥4 measures for an HNHC subpopulation. 'Bright Spot' clinics were in the top quartile of performance for ≥4 measures across all the HNHC subpopulations. KEY RESULTS: A total of 2770 primary care clinics cared for at least 10 beneficiaries from each of the three HNHC subpopulations (adults under 65 with disability, older adults with frailty and beneficiaries with major complex chronic conditions). Less than 4% of clinics were high performing for each HNHC subpopulation; <0.5% of clinics were in the top quartile for all five measures for a given subpopulation. No clinics met the definition of a primary care 'Bright Spot'. CONCLUSIONS: High-performing primary care clinics that achieved favourable health outcomes or lower costs across subpopulations of HNHC beneficiaries in the Medicare programme in 2015 were rare. Efforts are needed to support primary care clinics in providing optimal care to HNHC subpopulations.

The ambiguity of "we": Perceptions of teaming in dynamic environments and their implications.

In healthcare, organizations increasingly call on clinicians and staff to team up fluidly to deliver integrated services across disciplines and settings. Yet little is known about how clinicians and staff perceive of team membership in healthcare environments where team boundaries are often ambiguous and continually shifting. We draw on the context of primary care in the United States, where fluid multi-disciplinary teamwork is commonly exhorted, to investigate the extent to which clinicians and staff perceive of various roles (e.g., physician, front desk) as members in their teams, and to identify potential implications. Using a survey fielded within 59 clinics (n = 828), we find substantial variation in individuals' perceptions of the roles they consider as team members during an episode of care (e.g., mean team size = 10.60 roles; standard deviation = 5.09). Perceiving more expansive sets of roles as team members exhibits a positive association with performance as measured by care quality (b = 0.02; p < .01) but a curvilinear association with job satisfaction. Separating an individual's perceived core (roles always perceived as part of the team) and periphery (roles sometimes perceived as part of the team), perceiving a larger core is positively associated with performance (b = 0.03 p < .01). In contrast, perceiving a larger periphery is marginally negatively associated with performance (b = -0.02, p < .10). This appears to be driven by divergence from the norm perception of the core, i.e., when individuals attribute to the periphery the roles that are considered by most others to be core. Our findings suggest that individuals viewing the roles they must team with more expansively may generate higher quality output but experience a personal toll. Delivering on the ideal of team-based care in dynamic environments may require helping team members gain clarity about their teammates and implementing policies that attend to job satisfaction as team boundaries shift and expand.

The dynamics of integration and integrated care: An exploratory study of physician organizations.

BACKGROUND: Substantial variation exists in how well health care is integrated, even across similarly structured organizations, yet research about what physician organizations (POs) do that enables or inhibits integrated care is limited. PURPOSE: The aim of this study was to explore the dynamics that enable POs to integrate care. METHODOLOGY/APPROACH: We ranked a stratified sample of POs according to patient perceptions of integrated care, as measured in a survey. We interviewed professionals, patients, and family members in 10 higher and 3 lower ranked POs about the process of caring for patients with complex conditions. We derived integration-related themes from the interview data and quantified their prevalence. Using a quasi-statistical approach, we explored relationships among themes and their associations with patient perceptions of integrated care. RESULTS: From 6,104 coded references, we derived a set of themes representing integration perspectives, integration engagement mechanisms, and integration failures. POs experienced frequent integration failures. Higher ranked POs experienced these failures less often because of a combination of functional, interpersonal, and stakeholder engagement mechanisms, which appear to complement one another. Integration perspectives, including both people-oriented and systems-oriented mindsets, appear to play a role in generating these integration dynamics. CONCLUSION: Delivering integrated care depends on a PO's ability to limit integration failures, keeping provider attention focused on patients. Building on the attention-based view, we present a framework suggesting that this ability is a function of both integration perspectives and integration engagement mechanisms. PRACTICE IMPLICATIONS: POs interested in delivering more integrated care should employ a variety of complementary integration engagement mechanisms and facilitate these efforts by nurturing both people-oriented and system-oriented mindsets among PO decision-makers.

Patients' Perceptions of Integrated Care Among Medicare Beneficiaries by Level of Need for Health Services.

Requirements for integrating care across providers, settings, and over time increase with patients' needs. Health care providers' ability to offer care that patients experience as integrated may vary among patients with different levels of need. We explore the variation in patients' perceptions of integrated care among Medicare beneficiaries based on the beneficiary's level of need using ordinary least square regression for each of four high-need groups: beneficiaries (a) with complex chronic conditions, (b) with frailties, (c) below 65 with disability, and (d) with any (of the first three) high needs. We control for beneficiary demographics and other factors affecting integrated care, and we conduct sensitivity analyses controlling for multiple individual chronic conditions. We find significant positive associations with level of need for provider support for self-directed care and medication and home health management. Controlling for multiple individual chronic conditions reduces effect sizes and number of significant relationships.

Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration.

More is known about the structural features of health system integration than the social features-elements of normative integration (alignment of norms) and interpersonal integration (collaboration among professionals and with patients). We surveyed practice managers and 1,360 staff and physicians at 59 practice sites within 17 health systems (828 responses; 61%). Building on prior theory, we developed and established the psychometric properties of survey measures describing normative and interpersonal integration. Normative and interpersonal integration were both consistently related to better provider experience, perceived care quality, and clinical integration (e.g., a 1-point increase in a practice's normative integration was associated with 0.53-point higher job satisfaction and 0.77-point higher perceived care quality in the practice, measured on 1 to 5 scales, p < .01). Variation in social features of integration may help explain why some health systems better integrate care, pointing to normative and interpersonal integration as potential resources for improvement.

Impact of COVID-19 on Primary Care Practice Sites and Their Vulnerable Patients.

Purpose: While COVID-19 has upended lives, it has also catalyzed innovation with potential to advance health delivery. Yet, we know little about how the delivery system, and primary care in particular, has responded and how this has impacted vulnerable patients. We aimed to understand the impact of COVID-19 on primary care practice sites and their vulnerable patients and to identify explanations for variation. Approach: We developed and administered a survey to practice managers and physician leaders from 173 primary care practice sites, October-November 2020. We report and graphically depict results from univariate analysis and examine potential explanations for variation in practices' process innovations in response to COVID-19 by assessing bivariate relationships between seven dependent variables and four independent variables. Findings: Among 96 (55.5%) respondents, primary care practice sites on average took more safety (8.5 of 12) than financial (2.5 of 17) precautions in response to COVID-19. Practice sites varied in their efforts to protect patients with vulnerabilities, providing care initially postponed, and experience with virtual visits. Financial risk, practice size, practitioner age, and emergency preparedness explained variation in primary care practices' process innovations. Many practice sites plan to sustain virtual visits, dependent mostly on patient and provider preference and continued reimbursement. Value: While findings indicate rapid and substantial innovation, conditions must enable primary care practice sites to build on and sustain innovations, to support care for vulnerable populations, including those with multiple chronic conditions and socio-economic barriers to health, and to prepare primary care for future emergencies.

Even Superheroes Need Rest: A Guide to Facilitating Recovery from Work for Health-care Workers during COVID-19 and beyond.

The COVID-19 pandemic burdens health-care workers (HCWs) worldwide. Amid high-stress conditions and unprecedented needs for crisis management, organizations face the grand challenge of supporting the mental health and well-being of their HCWs. The current literature on mental health and well-being primarily focuses on improving personal resilience among HCWs. However, this puts the responsibility for coping with COVID-19-related stress almost fully on the individual. This chapter discusses an important alternative framing of this issue - how health-care organizations (HCOs) can facilitate recovery from work processes (i.e., returning to a baseline level by engaging in nonwork activities after work) for their workers. Based on a narrative review of the occupational health psychology literature, we provide practical strategies for supporting the four key recovery experiences of detachment, control, mastery, and relaxation, as well as present general recommendations about how to promote recovery. These strategies can help HCOs facing the grand challenge of sustaining worker well-being and functioning during the COVID-19 pandemic, as well as during future pandemics and for workers facing high work pressure in general.

Differences in patient perceptions of integrated care among black, hispanic, and white Medicare beneficiaries.

OBJECTIVE: This study sought to identify potential disparities among racial/ethnic groups in patient perceptions of integrated care (PPIC) and to explore how methodological differences may influence measured disparities. DATA SOURCE: Data from Medicare beneficiaries who completed the 2015 Medicare Current Beneficiary Survey (MCBS) and were enrolled in Part A benefits for an entire year. STUDY DESIGN: We used 4-point measures of eight dimensions of PPIC and assessed differences in dimensions among racial/ethnic groups. To estimate differences, we applied a "rank and replace" method using multiple regression models in three steps, balancing differences in health status among racial groups and adjusting for differences in socioeconomic status. We reran all analyses with additional SES controls and using standard multiple variable regression. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: We found several significant differences in perceived integrated care between Black versus White (three of eight measures) and Hispanic versus White (one of eight) Medicare beneficiaries. On average, Black beneficiaries perceived more integrated support for self-care than did White beneficiaries (mean difference = 0.14, SE = 0.06, P =.02). Black beneficiaries perceived more integrated specialists' knowledge of past medical history than did White beneficiaries (mean difference = 0.12, SE = 0.06, P =.01). Black and Hispanic beneficiaries also each reported, on average, 0.18 more integrated medication and home health management than did White beneficiaries (P <.01 and P <.01). These findings were robust to sensitivity analyses and model specifications. CONCLUSIONS: There exist some aspects of care for which Black and Hispanic beneficiaries may perceive greater integrated care than non-Hispanic White beneficiaries. Further studies should test theories explaining why racial/ethnic groups perceive differences in integrated care.

Development and Psychometric Analysis of the Revised Patient Perceptions of Integrated Care Survey.

This article describes the development and psychometric testing of the Patient Perceptions of Integrated Care (PPIC 2.1) survey, which we administered to 12,364 Medicare beneficiaries who received treatment from 150 randomly selected physician organizations, receiving 3,067 responses (26%). Psychometric analyses, performed using two methods to adjust for respondent inherent optimism (as a measure of response tendency), supported a 6-factor, 22-item model with excellent fit. These factors were (1) Staff Knowledge about the Patient's Medical History, (2) Provider Support for the Patient's Self-Directed Care, (3) Test Result Communication, (4) Provider Knowledge of the Patient, (5) Provider Support for Medication Adherence and Home Health Management, and (6) Specialist Knowledge about the Patient's Medical History. Per Spearman-Brown prophesy calculations, reliability would exceed 0.7 for all factors at 33 or more responses per organization. The PPIC 2.1 survey can distinguish six dimensions of integrated patient care with high physician organization-level reliability at reasonable sample sizes.

Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-for-Service.

BACKGROUND: Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare. OBJECTIVE: To characterize patient experiences of integrated care within Medicare and identify whether MA or ACO beneficiaries perceive greater integration than FFS beneficiaries. DESIGN: Retrospective cross-sectional analysis of the 2015 Medicare Current Beneficiary Survey. SUBJECTS: Nationally representative sample of 11,978 Medicare beneficiaries. MEASURES: Main outcomes included 8 previously derived domains of patient-perceived integrated care (PPIC), measured on a scale of 1-4. RESULTS: The final sample was 55% female with a mean (SD) age of 71.1 (11.3). In unadjusted analyses, we observed considerable variation across PPIC domains in the full sample, but little variation across subsamples defined by coverage type within a given PPIC domain. In linear models adjusting for a rich set of patient characteristics, we observe no significant benefits of ACOs nor MA relative to FFS, a finding which is robust to alternative specifications and adjustment for multiple comparisons. We similarly observed no benefits in subgroup analyses restricted to states with relatively high market penetration of ACOs or MA. CONCLUSIONS: Despite characteristics of ACOs and MA that theoretically promote integrated care, we find that PPIC is largely similar across coverage types in Medicare.

Care integration within and outside health system boundaries.

OBJECTIVE: Examine care integration-efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them-to understand whether and at which organizational level health systems impact care quality and staff experience. DATA SOURCES: Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017-2019). STUDY DESIGN: We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression. PRINCIPAL FINDINGS: Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems-up to 38 percentage points (pp) lower (P < .001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2-pp) increase in use of evidence-based care related to 6.4-pp and 8.9-pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5-pp increase in staff job satisfaction; one SD (9.7-pp) increase in integration of social services and community resources related to a 7.0-pp increase in perceived quality of care by health systems; one SD (6.9-pp) increase in patient engagement related to a 6.4-pp increase in job satisfaction and a 4.6-pp decrease in burnout; and one SD (10.6-pp) increase in integration of diabetic eye examinations related to a 5.5-pp increase in job satisfaction (all P < .05). CONCLUSIONS: Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems.

[Lessons that health care can and should learn from the COVID-19 pandemic]. / De lessen die de zorg kán en móét leren van de COVID-19-pandemie.

The COVID-19 pandemic presents healthcare organizations with substantial challenges. Four main themes can be distinguished in the way healthcare organizations organize the necessary preconditions for their professionals to provide high quality care in this crisis. These include: keeping professionals employable, implementing a wide range of digital solutions, collaborating with organizations in and outside of healthcare at a large scale and rapid pace, and interacting with national and regional policy, which can either serve as a barrier or facilitator. It is essential to learn from these approaches and rapidly disseminate the associated best practices.

Can Organisational Culture of Teams Be a Lever for Integrating Care? An Exploratory Study.

INTRODUCTION: Organisational culture is believed to be an important facilitator for better integrated care, yet how organisational culture impacts integrated care remains underspecified. In an exploratory study, we assessed the relationship between organisational culture in primary care centres as perceived by primary care teams and patient-perceived levels of integrated care. THEORY AND METHODS: We analysed a sample of 2,911 patient responses and 17 healthcare teams in four primary care centres. We used three-level ordered logistic regression models to account for the nesting of patients within health care teams within primary care centres. RESULTS: Our results suggest a non-linear relationship between organisational culture at the team level and integrated care. A combination of different culture types-including moderate levels of production-oriented, hierarchical and team-oriented cultures and low or high levels of adhocracy cultures-related to higher patient-perceived levels of integrated care. CONCLUSIONS AND DISCUSSION: Organisational culture at the level of healthcare teams has significant associations with patient-perceived integrated care. Our results may be valuable for primary care organisations in their efforts to compose healthcare teams that are predisposed to providing better integrated care.

Cross-Cultural Validation of the Patient Perception of Integrated Care Survey.

OBJECTIVE: To test the cross-cultural validity of the U.S. Patient Perception of Integrated Care (PPIC) Survey in a Dutch sample using a standardized procedure. DATA SOURCES: Primary data collected from patients of five primary care centers in the south of the Netherlands, through survey research from 2014 to 2015. STUDY DESIGN: Cross-sectional data collected from patients who saw multiple health care providers during 6 months preceding data collection. DATA COLLECTION: The PPIC survey includes 59 questions that measure patient perceived care integration across providers, settings, and time. Data analysis followed a standardized procedure guiding data preparation, psychometric analysis, and included invariance testing with the U.S. dataset. PRINCIPAL FINDINGS: Latent scale structures of the Dutch and U.S. survey were highly comparable. Factor "Integration with specialist" had lower reliability scores and noninvariance. For the remaining factors, internal consistency and invariance estimates were strong. CONCLUSIONS: The standardized cross-cultural validation procedure produced strong support for comparable psychometric characteristics of the Dutch and U.S. surveys. Future research should examine the usability of the proposed procedure for contexts with greater cultural differences.

Translating the Patient Perception of Integrated Care Survey to Measure Integrated Care in the Netherlands: Combining Equivalence and Contextualization Approaches for Optimal Results.

INTRODUCTION: An increase in initiatives to improve integration of care provides the need for instruments that assess the degree of integrated care as perceived by patients across cultural contexts. This article aims to explain the relevance of equivalence and contextualization approaches in translating and adapting the Patient Perception of Integrated Care Survey developed in the US for use in the Netherlands. THEORY AND METHODS: The World Health Organization guidelines guided the translation and adaptation, including a forward-backward translation and patient-feedback through informal contacts (N4) and cognitive interviews (N14). RESULTS: The forward-backward translation produced a Dutch version of the Patient Perception of Integrated Care Survey with minor adaptations. Patients evaluated the survey as very relevant. Alterations resulted from structural and cultural differences and specificities of patients with chronic conditions. CONCLUSIONS AND DISCUSSION: A context-sensitive translation process is key to developing instruments for cross-cultural health research. Our results show that equivalence- and contextualization methods provide equally relevant, yet substantially different contributions to the translation outcome and should both be incorporated when translating instruments for different cultural contexts. The results support the applicability of the Patient Perception of Integrated Care Survey in the Netherlands and are promising for its adoption in other cultural contexts.