The Value of Outdoor Behavioral Healthcare for Adolescent Substance Users with Comorbid Conditions.

The damage inflicted on our society by mental health and substance use issues is reaching epidemic proportions with few signs of abating. One new and innovative strategy for addressing these comorbid issues has been the development of outdoor behavioral healthcare (OBH). This study compared the effectiveness of three post-acute adolescent substance use situations: OBH, treatment as usual (TAU), and no structured treatment (NST). The simulated target population was 13-17 years old with comorbid substance use and mental health issues. When costs were adjusted for actual completion rates of 94% in OBH, 37% in TAU, and $0 for NST, the actual treatment costs per person were $27 426 for OBH and $31 113 for TAU. OBH also had a cost-benefit ratio of 60.4% higher than TAU, an increased Quality in Life Years (QALY) life span, societal benefits of an additional $36 100, and 424% better treatment outcomes as measured by the Youth Outcome Questionnaire (YOQ) research instrument.

Family Enrichment Adventure Therapy: A Mixed Methods Study Examining the Impact of Trauma-Informed Adventure Therapy on Children and Families Affected by Abuse.

Child abuse is epidemic in the United States and has dire long-term consequences. Innovative interventions are needed to address the negative cognitive, affective and behavioral effects of child abuse. This mixed-method study examined if adventure therapy is 1) an effective mental health intervention for child and adolescent survivors of abuse and neglect, and 2) an effective intervention for families affected by abuse and neglect. The effectiveness of the adventure therapy intervention was measured by a reduction in child trauma symptoms and improved family functioning, as reported via the Trauma Symptom Checklist for Children (TSCC), the Family Assessment Device (FAD), as well as qualitative data gathered via family focus groups. Findings showed that trauma-informed adventure therapy with youth and families affected by abuse reduces trauma symptomology in youth and improves family functioning, particularly in the areas of communication, closeness and problem-solving skills.

Erratum to: Family Enrichment Adventure Therapy: A Mixed Methods Study Examining the Impact of Trauma-Informed Adventure Therapy on Children and Families Affected by Abuse.

[This corrects the article DOI: 10.1007/s40653-017-0133-4.].

Nudging Healthier Choices in a Hospital Cafeteria: Results From a Field Study.

More than two thirds of adults and one third of children are overweight or obese in the United States. These trends have led to initiatives to provide information that supports informed choices. Traffic light labeling has been shown to increase consumer awareness and encourage healthy selections. This article contributes to the literature on healthy choices by comparing the additional contribution of a number of interventions used in combination with traffic light labeling. We conducted a 21-month field study in a workplace cafeteria. We analyzed cash register receipts, focusing on sales of beverages and chips. We found that the traffic light system was effective. The addition of caloric information to traffic light labeling had a positive effect on the purchase of healthy chips. However, other interventions appeared to produce more harm than good, essentially wiping out the benefits from traffic light labeling. These findings suggest that although it is possible to improve on traffic light labeling with selective interventions, caution is in order as some interventions may trigger compensatory behavior that results in the purchase of unhealthy items.

The impact of middle manager affective commitment on perceived improvement program implementation success.

BACKGROUND: Recent literature suggests that middle manager affective commitment (emotional attachment, identification, and involvement) to an improvement program may influence implementation success. However, less is known about the interplay between middle manager affective commitment and frontline worker commitment, another important driver of implementation success. PURPOSE: We contribute to this research by surveying middle managers who directly manage frontline workers on nursing units. We assess how middle manager affective commitment is related to their perceptions of implementation success and whether their perceptions of frontline worker support mediate this relationship. We also test whether a set of organizational support factors foster middle manager affective commitment. METHODOLOGY: We adapt survey measures of manager affective commitment to our research context of hospitals. We surveyed 67 nurse managers from 19 U.S. hospitals. We use hierarchical linear regression to assess relationships among middle manager affective commitment to their units' falls reduction program and their perceptions of three constructs related to the program: frontline worker support, organizational support, and implementation success. RESULTS: Middle manager affective commitment to their unit's falls reduction program is positively associated with their perception of implementation success. This relationship is mediated by their perception of frontline worker support for the falls program. Moreover, middle managers' affective commitment to their unit's falls program mediates the relationship between perceived organizational support for the program and perceived implementation success. CONCLUSION: We, through this research, offer an important contribution by providing empirical support of factors that may influence successful implementation of an improvement program: middle manager affective commitment, frontline worker support, and organizational support for an improvement program. PRACTICE IMPLICATIONS: Increasing levels of middle manager affective commitment to an improvement program could strengthen program implementation success by facilitating frontline worker support for the program. Furthermore, providing the organizational support items in our survey construct may bolster middle manager affective commitment.

Applying Organizational Learning Research to Accountable Care Organizations.

To accomplish the goal of improving quality of care while simultaneously reducing cost, Accountable Care Organizations (ACOs) need to find new and better ways of providing health care to populations of patients. This requires implementing best practices and improving collaboration across the multiple entities involved in care delivery, including patients. In this article, we discuss seven lessons from the organizational learning literature that can help ACOs overcome the inherent challenges of learning how to work together in radically new ways. The lessons involve setting expectations, creating a supportive culture, and structuring the improvement efforts. For example, with regard to setting expectations, framing the changes as learning experiences rather than as implementation projects encourages the teams to utilize helpful activities, such as dry runs and pilot tests. It is also important to create an organizational culture where employees feel safe pointing out improvement opportunities and experimenting with new ways of working. With regard to structure, stable, cross-functional teams provide a powerful building block for effective improvement efforts. The article concludes by outlining opportunities for future research on organizational learning in ACOs.

Designed for workarounds: a qualitative study of the causes of operational failures in hospitals.

Frontline care clinicians and staff in hospitals spend at least 10% of their time working around operational failures: situations in which information, supplies, or equipment needed for patient care are insufficient. However, little is known about underlying causes of operational failures and what hospitals can do to reduce their occurrence. To address this gap, we examined the internal supply chains at 2 hospitals with the aim of discovering organizational factors that contribute to operational failures. We conducted in-depth qualitative research, including observations and interviews of more than 80 individuals from 4 nursing units and the ancillary support departments that provide equipment and supplies needed for patient care. We found that a lack of interconnectedness among interdependent departments' routines was a major source of operational failures. The low levels of interconnectedness occurred because of how the internal supply chains were designed and managed rather than because of employee error or a shortfall in training. Thus, we propose that the time that hospital staff members spend on workarounds can be reduced through deliberate efforts to increase interconnectedness among hospitals' internal supply departments. Four dimensions of interconnectedness include: 1) hospital-level-rather than department-level-performance measures; 2) internal supply department routines that respond to specific patients' needs rather than to predetermined stocking routines; 3) knowledge that is necessary for efficient handoffs of materials that is translated across departmental boundaries; and 4) cross-departmental collaboration mechanisms that enable improvement in the flow of materials across departmental boundaries.

Effect of in-water iodine supplementation on weight gain, diarrhea and oral and dental health of nursery pigs.

A farm trial was conducted to evaluate the effect of in-water iodine on piglet growth, the incidence of diarrhea, and the development of deleterious oral and dental conditions. A total of 208 weaned piglets were included in the study. Piglets were weighed 3 times: within 24 h of weaning, and 3 wk and 6 wk after weaning. A concentration of 1 ppm iodine was provided in their drinking water. Swabs were taken from all water nipples and water lines and pooled fecal samples were collected from all pen floors. Fecal samples were also collected from sows at weaning. The swabs and fecal samples were tested for the presence of Salmonella and Escherichia coli. Within 24 h of each weighing, a complete oral examination was performed on each piglet. No significant difference in growth (P > 0.05) or dental conditions (P > 0.05) was found among treatment groups during the period that iodine was added to the drinking water. After weaning, all deleterious oral conditions increased (oral lesions from weaning to 6 wk, staining and caries from weaning to 3 wk, gingivitis from 3 wk to 6 wk; P < 0.05). Only gingivitis was found to be negatively associated with piglet weight (P < 0.05). Salmonella was cultured only twice from fecal samples and never from water nipples. Only 1 sow tested positive for Salmonella and E. coli O139: K82 and O157:K"V17 were cultured only rarely from the water nipples. No signs of diarrhea were noted throughout the study. Adding an aqueous iodine supplement to nursery pigs, therefore, did not provide an advantage for either growth or oral condition. Deleterious oral conditions do increase after weaning, with gingivitis being associated with lower piglet weight.

Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems.

OBJECTIVE: To contrast the safety-related concerns raised by front-line staff about hospital work systems (operational failures) with national patient safety initiatives. DATA SOURCES: Primary data included 1,732 staff-identified operational failures at 20 U.S. hospitals from 2004 to 2006. STUDY DESIGN: Senior managers observed front-line staff and facilitated open discussion meetings with employees about their patient safety concerns. DATA COLLECTION: Hospitals submitted data on the operational failures identified through managers' interactions with front-line workers. Data were analyzed for type of failure and frequency of occurrence. Recommendations from staff were compared with recommendations from national initiatives. PRINCIPAL FINDINGS: The two most frequent categories of operational failures, equipment/supplies and facility issues, posed safety risks and diminished staff efficiency, but have not been priorities in national initiatives. CONCLUSIONS: Our study suggests an underutilized strategy for improving patient safety and staff efficiency: leveraging front-line staff experiences with work systems to identify and address operational failures. In contrast to the perceived tradeoff between safety and efficiency, fixing operational failures can yield benefits for both. Thus, prioritizing improvement of work systems in general, rather than focusing more narrowly on specific clinical conditions, can increase safety and efficiency of hospitals.

Operational failures and interruptions in hospital nursing.

OBJECTIVE: To describe the work environment of hospital nurses with particular focus on the performance of work systems supplying information, materials, and equipment for patient care. DATA SOURCES: Primary observation, semistructured interviews, and surveys of hospital nurses. STUDY DESIGN: We sampled a cross-sectional group of six U.S. hospitals to examine the frequency of work system failures and their impact on nurse productivity. DATA COLLECTION: We collected minute-by-minute data on the activities of 11 nurses. In addition, we conducted interviews with six of these nurses using questions related to obstacles to care. Finally, we created and administered two surveys in 48 nursing units, one for nurses and one for managers, asking about the frequency of specific work system failures. PRINCIPAL FINDINGS: Nurses we observed experienced an average of 8.4 work system failures per 8-hour shift. The five most frequent types of failures, accounting for 6.4 of these obstacles, involved medications, orders, supplies, staffing, and equipment. Survey questions asking nurses how frequently they experienced these five categories of obstacles yielded similar frequencies. For an average 8-hour shift, the average task time was only 3.1 minutes, and in spite of this, nurses were interrupted mid-task an average of eight times per shift. CONCLUSIONS: Our findings suggest that nurse effectiveness can be increased by creating improvement processes triggered by the occurrence of work system failures, with the goal of reducing future occurrences. Second, given that nursing work is fragmented and unpredictable, designing processes that are robust to interruption can help prevent errors.

A case study of operational failure in home healthcare.

Examination of operational failures in home healthcare could yield important insights into improving patient safety. This article presents a case study of work system breakdowns observed in the home healthcare setting. The findings suggest that the biggest areas of opportunity are failures stemming from (a) insufficient support from home health agencies and (b) inadequate coordination with patients and their families. Factors that impede organizations from learning from employees' experiences with operational failures and steps that managers may take to overcome these hurdles are discussed.