The impact of job control on employee perception of management commitment to safety.

Background: Employees self-reporting low job control may perceive management as not being committed to employee safety. Objective: Assess the relationship between self-reported job control and management commitment to safety while controlling for categorical variables. Method: A 31-item survey was used in a cross-sectional study to assess the relationship between self-reported job control scores (JCS) and management commitment to safety scores (MCS). Descriptive statistics (means and frequencies), and an ANACOVA (analysis of covariance) were performed on a saturated model. Results: Study had 71 percent response rate. Results indicate a statistically significant association between MCS and JCS when controlling for job position [F (5, 690) = 206.97, p < 0.0001, adjusted R-square = 0.60]. Conclusion: Employees with low job control have poor perceptions of management's commitment to safety when controlling for job position.

Interorganizational Collaboration in Emergency Cardiovascular Care.

BACKGROUND: Interorganizational collaboration management theory contends that cooperation between distinct but related organizations can yield innovation and competitive advantage to the participating organization. Yet, it is unclear if a multi-institutional collaborative can improve quality outcomes across communities. METHODS: We developed a large regional collaborative network of 15 hospitals and 24 emergency medical service agencies surrounding Dallas, Texas, and collected patient-level data on treatment times for acute myocardial infarctions. Using a pre-/posttest research design, we applied median tests of differences to explore outcome changes between groups and over the 6-year period, using data extracted from participating hospital electronic health records. RESULTS: We analyzed temporal trends and changes in treatment times for 2302 patients with ST-elevation myocardial infarction between the pre- and posttest groups. We found a statistically significant 19-minute median reduction in the key outcome metric (total ischemic time, the time difference between the patient's first reported symptoms and the definitive opening of the artery). This represents a 10.8% community-wide improvement over time. CONCLUSIONS: Interorganizational collaboration focused on quality improvement can impact population health across a community. This study provides a basis for broader understanding and participation by health care organizations in multi-institutional community change efforts.

Journal Rankings by Health Management Faculty Members: Are There Differences by Rank, Leadership Status, or Area of Expertise?

Health administration (HA) faculty members publish in a variety of journals, including journals focused on management, economics, policy, and information technology. HA faculty members are evaluated on the basis of the quality and quantity of their journal publications. However, it is unclear how perceptions of these journals vary by subdiscipline, department leadership role, or faculty rank. It is also not clear how perceptions of journals may have changed over the past decade since the last evaluation of journal rankings in the field was published. The purpose of the current study is to examine how respondents rank journals in the field of HA, as well as the variation in perception by academic rank, department leadership status, and area of expertise. Data were drawn from a survey of HA faculty members at U.S. universities, which was completed in 2012. Different journal ranking patterns were noted for faculty members of different subdisciplines. The health management-oriented journals (Health Care Management Review and Journal of Healthcare Management) were ranked higher than in previous research, suggesting that journal ranking perceptions may have changed over the intervening decade. Few differences in perceptions were noted by academic rank, but we found that department chairs were more likely than others to select Health Affairs in their top three most prestigious journals (ß = 0.768; p < .01). Perceived journal prestige varied between a department chair and untenured faculty in different disciplines, and this perceived difference could have implications for promotion and tenure decisions.

Improving Capacity Management in the Emergency Department: A Review of the Literature, 2000-2012.

Capacity management (CM) is a critical component of maintaining and improving healthcare quality and patient safety. One particular area for concern has been the emergency department and the growing issues of patient overcrowding, boarding, and ambulance diversion, which can result in poor patient care and less efficient operations. This study provides a review of the current and most relevant academic literature on capacity management directly related to hospital emergency departments, identifies strengths and weaknesses of the approaches discussed in the literature, and provides practical recommendations for health services administrators implementing CM in their organizations. An extensive literature search was conducted using several search engines and scholarly databases. Articles were identified based on a combination of keywords and then were reviewed and selected for inclusion in the study in adherence to specified criteria. The CM literature includes a great divergence of themes, topics, and definitions. Twenty-two articles were selected for their relevance to emergency department CM with a focus on operations management concepts. A categorization scheme was used, resulting in four thematic groups of articles: problems, solutions, outcomes, and metrics. Healthcare managers wishing to implement solutions to CM problems have a wide variety of operations literature to draw on that can address scheduling and patient throughput, but there are also a number of studies that consider electronic and technological solutions to CM problems. All of these solutions have the potential to positively influence the quality of patient care, including satisfaction.

Best practices to promote occupational safety and satisfaction: a comparison of three North American hospitals.

PURPOSE: Hospitals in North America consistently have employee injury rates ranking among the highest of all industries. Organizations that mandate workplace safety training and emphasize safety compliance tend to have lower injury rates and better employee safety perceptions. However, it is unclear if the work environment in different national health care systems (United States vs. Canada) is associated with different employee safety perceptions or injury rates. This study examines occupational safety and workplace satisfaction in two different countries with employees working for the same organization. METHODOLOGY/APPROACH: Survey data were collected from environmental services employees (n = 148) at three matched hospitals (two in Canada and one in the United States). The relationships that were examined included: (1) safety leadership and safety training with individual/unit safety perceptions; (2) supervisor and coworker support with individual job satisfaction and turnover intention; and (3) unit turnover, labor usage, and injury rates. FINDINGS: Hierarchical regression analysis and ANO VA found safety leadership and safety training to be positively related to individual safety perceptions, and unit safety grade and effects were similar across all hospitals. Supervisor and coworker support were found to be related to individual and organizational outcomes and significant differences were found across the hospitals. Significant differences were found in injury rates, days missed, and turnover across the hospitals. ORIGINALITY/VALUE: This study offers support for occupational safety training as a viable mechanism to reduce employee injury rates and that a codified training program translates across national borders. Significant differences were found.between the hospitals with respect to employee and organizational outcomes (e.g., turnover). These findings suggest that work environment differences are reflective of the immediate work group and environment, and may reflect national health care system differences.

Reassessing After-Hour Arrival Patterns and Outcomes in ST-Elevation Myocardial Infarction.

INTRODUCTION: Differences in after-hours capability or performance of ST-elevation myocardial infarction (STEMI) centers has the potential to impact outcomes of patients presenting outside of regular hours. METHODS: Using a prospective observational study, we analyzed all 1,247 non-transfer STEMI patients treated in 15 percutaneous coronary intervention (PCI) facilities in Dallas, Texas, during a 24-month period (2010-2012). Controlling for confounding factors through a variety of statistical techniques, we explored differences in door-to-balloon (D2B) and in-hospital mortality for those presenting on weekends vs. weekdays and business vs. after hours. RESULTS: Patients who arrived at the hospital on weekends had larger D2B times compared to weekdays (75 vs. 65 minutes; KW=48.9; p<0.001). Patients who arrived after-hours had median D2B times >16 minutes longer than those who arrived during business hours and a higher likelihood of mortality (OR 2.23, CI [1.15-4.32], p<0.05). CONCLUSION: Weekends and after-hour PCI coverage is still associated with adverse D2B outcomes and in-hospital mortality, even in major urban settings. Disparities remain in after-hour STEMI treatment.

The use of six sigma in health care management: are we using it to its full potential?

Popular quality improvement tools such as Six Sigma (SS) claim to provide health care managers the opportunity to improve health care quality on the basis of sound methodology and data. However, it is unclear whether this quality improvement tool is being used correctly and improves health care quality. The authors conducted a comprehensive literature review to assess the correct use and implementation of SS and the empirical evidence demonstrating the relationship between SS and improved quality of care in health care organizations. The authors identified 310 articles on SS published in the last 15 years. However, only 55 were empirical peer-reviewed articles, 16 of which reported the correct use of SS. Only 7 of these articles included statistical analyses to test for significant changes in quality of care, and only 16 calculated defects per million opportunities or sigma level. This review demonstrates that there are significant gaps in the Six Sigma health care quality improvement literature and very weak evidence that Six Sigma is being used correctly to improve health care quality.

Building the case for quality improvement in the health care industry: a focus on goals and training.

Health care organizations are under intense pressure to improve the efficiency and effectiveness of care delivery and, increasingly, they are using quality improvement teams to identify and target projects to improve performance outcomes. This raises the question of what factors actually drive the performance of these projects in a health care environment. Using data from a survey of health care professionals acting as informants for 244 patient care, clinical-administrative, and nonclinical administrative quality improvement project types in 93 health care organizations, we focus on 2 factors--goal setting and quality training--as potential drivers of quality improvement project performance. We find that project-level goals and quality training have positive associations with process quality, while organizational-level goals have no impact. In addition, the relationship between project-level goals and process quality is stronger for patient care projects than for administrative projects. This indicates that the motivational and cognitive effects of goal setting are greater for projects that involve interactions with clinicians than for ones that involve interactions with other staff. Although project-level goal setting is beneficial for improving process quality overall, our findings suggest the importance of being especially attentive to goal setting for projects that impact direct patient care.

Barriers and disparities in emergency medical services 911 calls for stroke symptoms in the United States adult population: 2009 BRFSS Survey.

INTRODUCTION: This study examines barriers and disparities in the intentions of American citizens, when dealing with stroke symptoms, to call 911. This study hypothesizes that low socioeconomic populations are less likely to call 911 in response to stroke recognition. METHODS: The study is a cross-sectional design analyzing data from the Centers for Disease Control's 2009 Behavioral Risk Factor Surveillance Survey, collected through a telephone-based survey from 18 states and the District of Columbia. The study identified the 5 most evident stroke-warning symptoms based on those given by the American Stroke Association. We conducted appropriate weighting procedures to account for the complex survey design. RESULTS: A total of 131,988 respondents answered the following question: "If you thought someone was having a heart attack or a stroke, what is the first thing you would do?" A majority of those who said they would call 911 were insured (85.1%), had good health (84.1%), had no stroke history (97.3%), had a primary care physician (PCP) (81.4%), and had no burden of medical costs (84.9%). Those less likely to call 911 were found in the following groups: 65 years or older, men, other race, unmarried, less than or equal to high school degree, less than $25,000 family income, uninsured, no PCP, burden of medical costs, fair/poor health, previous history of strokes, or interaction between burden of medical costs and less than $50,000 family income (p<0.0001 by X(2) tests). The only factors significantly associated with "would call 911" were age, sex, race/ethnicity, marital status, and previous history of strokes. CONCLUSION: Barriers and disparities exist among subpopulations of different socioeconomic statuses. This study suggests that some potential stroke victims could have limited access to EMS services. Greater effort targeting certain populations is needed to motivate citizens to call 911.

The joint relationship between organizational design factors and HR practice factors on direct care workers' job satisfaction and turnover intent.

BACKGROUND: Human resource (HR) practices, such as training and communication, have been linked to positive employee job commitment and lower turnover intent for direct care workers (DCWs). Not many studies have looked at the combined interaction of HR practices and organizational structure. PURPOSE: The aim of this study is to examine the relationship between organizational structure (centralization, formalization, and span of control) and HR practices (training, horizontal communication, and vertical communication) on DCW's job satisfaction and turnover intent. METHODOLOGY: Data were collected from 58 long-term care facilities in five states. We used latent class analysis to group facility characteristics into three sets of combinations: "organic," "mechanistic," and "minimalist." We used multivariate regression to test the relationship of each of these groups on DCW's job satisfaction and turnover intent. FINDINGS: After controlling for state, organizational, and individual covariates, the organic group, which represents decentralized and less formalized structures and high levels of job training and communication, was positively related to job satisfaction and negatively related to intent to leave. On the other hand, the minimalist group, which is characterized by low levels of job-related training and communication, showed no significant differences from the mechanistic group (referent) on job satisfaction and intent to leave. PRACTICE IMPLICATIONS: These findings imply that managers in long-term care facilities may want to consider adopting organic, decentralized structures and HR practices to retain DCWs.

A business planning model to identify new safety net clinic locations.

PURPOSE: Community health clinics serving the poor and underserved are geographically expanding due to changes in U.S. health care policy. This paper describes the experience of a collaborative alliance of health care providers in a large metropolitan area who develop a conceptual and mathematical decision model to guide decisions on expanding its network of community health clinics. DESIGN/METHODOLOGY/APPROACH: Community stakeholders participated in a collaborative process that defined constructs they deemed important in guiding decisions on the location of community health clinics. This collaboration also defined key variables within each construct. Scores for variables within each construct were then totaled and weighted into a community-specific optimal space planning equation. This analysis relied entirely on secondary data available from published sources. FINDINGS: The model built from this collaboration revolved around the constructs of demand, sustainability, and competition. It used publicly available data defining variables within each construct to arrive at an optimal location that maximized demand and sustainability and minimized competition. PRACTICAL IMPLICATIONS: This is a model that safety net clinic planners and community stakeholders can use to analyze demographic and utilization data to optimize capacity expansion to serve uninsured and Medicaid populations. ORIGINALITY/VALUE: Communities can use this innovative model to develop a locally relevant clinic location-planning framework.

Emergency medical services as a strategy for improving ST-elevation myocardial infarction system treatment times.

BACKGROUND: Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival. STUDY OBJECTIVE: We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI. METHODS: We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics-hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times. RESULTS: We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001). CONCLUSION: Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

Growth in percutaneous coronary intervention capacity relative to population and disease prevalence.

BACKGROUND: The access to and growth of percutaneous coronary intervention (PCI) has not been fully explored with regard to geographic equity and need. Economic factors and timely access to primary PCI provide the impetus for growth in PCI centers, and this is balanced by volume standards and the benefits of regionalized care. METHODS AND RESULTS: Geospatial and statistical analyses were used to model capacity, growth, and access of PCI hospitals relative to population density and myocardial infarction (MI) prevalence at the state level. Longitudinal data were obtained for 2003-2011 from the American Hospital Association, the U.S. Census, and the Centers for Disease Control and Prevention (CDC) with geographical modeling to map PCI locations. The number of PCI centers has grown 21.2% over the last 8 years, with 39% of all hospitals having interventional cardiology capabilities. During the same time, the US population has grown 8.3%, from 217 million to 235 million, and MI prevalence rates have decreased from 4.0% to 3.7%. The most densely concentrated states have a ratio of 8.1 to 12.1 PCI facilities per million of population with significant variability in both MI prevalence and average distance between PCI facilities. CONCLUSIONS: Over the last decade, the growth rate for PCI centers is 1.5× that of the population growth, while MI prevalence is decreasing. This has created geographic imbalances and access barriers with excess PCI centers relative to need in some regions and inadequate access in others.

The use of six sigma in health care management: are we using it to its full potential?

Popular quality improvement tools such as Six Sigma (SS) claim to provide health care managers the opportunity to improve health care quality on the basis of sound methodology and data. However, it is unclear whether this quality improvement tool is being used correctly and improves health care quality. The authors conducted a comprehensive literature review to assess the correct use and implementation of SS and the empirical evidence demonstrating the relationship between SS and improved quality of care in health care organizations. The authors identified 310 articles on SS published in the last 15 years. However, only 55 were empirical peer-reviewed articles, 16 of which reported the correct use of SS. Only 7 of these articles included statistical analyses to test for significant changes in quality of care, and only 16 calculated defects per million opportunities or sigma level. This review demonstrates that there are significant gaps in the Six Sigma health care quality improvement literature and very weak evidence that Six Sigma is being used correctly to improve health care quality.

Developing an ST-elevation myocardial infarction system of care in Dallas County.

BACKGROUND: The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI. METHODS: Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression. RESULTS: Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P < .001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P < .001), from a median time of 195 to 162 minutes. CONCLUSION: The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies.

A transition strategy for becoming a baby-friendly hospital: exploring the costs, benefits, and challenges.

The objectives of this study were to provide an economic assessment as well as a calculated projection of the costs that typical U.S. tertiary-care hospitals would incur through policy reconfiguration and implementation to achieve the UNICEF/World Health Organization Baby-Friendly® Hospital designation and to examine the associated challenges and benefits of becoming a Baby-Friendly Hospital. We analyzed hospital resource utilization, focusing on formula use and staffing profiles at one U.S. urban tertiary-care teaching hospital, as well as conducted an online survey and telephone interviews with a selection of Baby-Friendly Hospitals to obtain their perspective on costs, challenges, and benefits. Findings indicate that added costs for a new Baby-Friendly Hospital will approximate $148 per birth, but these costs sharply decrease over time as breastfeeding rates increase in a Baby-Friendly environment.

Do EHR investments lead to lower staffing levels?

A study used FTE employees per adjusted occupied bed (FTE/AOB) as a measure to ascertain the effect of EHR investments on labor productivity. The study focused on three primary questions: Do FTE/AOB decline as the number of EHR applications used in a hospital increases? Is impact on FTE/AOB greater with some EHR applications than with others? Do FTE/AOB decline overtime, as the hospital continues to use the EHR application?

Cost comparison of baby friendly and non-baby friendly hospitals in the United States.

OBJECTIVES: The objectives of this study were to provide an economic assessment of the incremental costs associated with obtaining the World Health Organization and United Nations International Children's Emergency Fund designation as a Infant-Friendly hospital. We hypothesized that baby-friendly hospitals will have higher costs than similar non-baby-friendly hospitals. METHODS: Data from the 2007 American Hospital Association and the 2007 Centers for Medicare and Medicaid Cost Reports were used to compare labor and delivery costs in baby-friendly and non-baby-friendly hospitals. Operational costs per delivery were calculated using a matched-pairs analysis of a sample of baby-friendly and non-baby-friendly hospitals in the United States. Costs associated with labor-and-delivery diagnosis-related codes were analyzed for each baby-friendly hospital and compared with the mean and median costs incurred by non-baby-friendly hospitals. RESULTS: Nursery plus labor-and-delivery costs for the baby-friendly sites were $2205 per delivery, compared with $2170 for the non-baby-friendly matched pair. Baby-friendly facilities have slightly higher costs than non-baby-friendly facilities, ranging from 1.6% to 5%, but these costs were not statistically significant (P > .05). CONCLUSIONS: These results suggest that becoming baby-friendly is relatively cost-neutral for a typical acute care hospital. Although the overall expense of providing baby-friendly hospital nursery services is greater than nursery service costs of non-baby-friendly hospitals, the cost difference was not statistically significant. Additional research is needed to compare the economic impact of maternal and infant health benefits from breastfeeding versus the incremental expenses of becoming a baby-friendly hospital.

Organizing for performance: what does the empirical literature reveal about the influence of organizational factors on hospital financial performance?

This chapter reviews and integrates the empirical literature on the influence of organizational factors on hospital financial performance. Five categories of organizational characteristics that research has addressed are identified and examined as part of the review: ownership, governance, integration, management strategy, and quality. With some exceptions, our review reveals a general lack of consistency and conclusiveness across studies in each area. Exceptions were found in the areas of governance (e.g., physician participation and board processes) and integration (e.g., horizontal system centralization). Despite the lack of conclusive findings across studies, our review suggests substantial opportunities for future work, including opportunities for qualitative and exploratory work. Additional implications for theory and management are discussed.

Perception is reality: How patients contribute to poor workplace safety perceptions.

BACKGROUND: Nurses and aides are among the occupational subgroups with the highest injury rates and workdays lost to illness and injury in North America. Many studies have shown that these incidents frequently happen during provision of patient care. Moreover, health care workplaces are a source of numerous safety risks that contribute to worker injuries. These findings identify health care as a high-risk occupation for employee injury or illness. PURPOSE: The purpose of this study was to examine the relationships among patient care, employee safety perceptions, and employee stress. Using the National Institute for Occupational Safety and Health Model of Job Stress and Health as a foundation, we developed and tested a conceptual workplace safety climate-stress model that explicates how caring for high-risk patients is a safety stressor that has negative outcomes for health care providers, including poor workplace safety perceptions and increasing stress levels. We introduced the concept of "high-risk patients" and define them as those who put providers at greater risk for injury or illness. METHODOLOGY: Using a nonexperimental survey design, we examined patient types and safety perceptions of health care providers (nurses, aides, and allied health) in an acute care hospital. FINDINGS: Health care providers who care for high-risk patients more frequently have poor safety climate perceptions and higher stress levels. Safety climate was found to mediate the relationship between high-risk patients and stress. PRACTICE IMPLICATIONS: These findings bring insight into actions health care organizations can pursue to improve health care provider well-being. Recognizing that different patients present different risks and pursuing staffing, training, and equipment to minimize employee risk of injury will help reduce the staggering injury rates experienced by these employees. Moreover, minimizing employee stress over poor workplace safety is achievable through comprehensive workplace safety climate programs that include supervisor, management, and organizational commitment to safety enhancement.