Characteristics of High Versus Low-Performing Hospitals for Very Preterm Infant Morbidity and Mortality.

Objective: To ascertain organizational attributes, policies, and practices that differentiate hospitals with high versus low risk-adjusted rates of very preterm neonatal morbidity and mortality (NMM). Methods: Using a positive deviance research framework, we conducted qualitative interviews of hospital leadership and frontline clinicians from September-October 2018 in 4 high-performing and 4 low-performing hospitals in New York City, based on NMM measured in previous research. Key interview topics included NICU physician and nurse staffing, professional development, standardization of care, quality measurement and improvement, and efforts to measure and report on racial/ethnic disparities in care and outcomes for very preterm infants. Interviews were audiotaped, professionally transcribed, and coded using NVivo software. In qualitative content analysis, researchers blinded to hospital performance identified emergent themes, highlighted illustrative quotes, and drew qualitative comparisons between hospital clusters. Results: The following features distinguished high-performing facilities: 1) stronger commitment from hospital leadership to diversity, quality, and equity; 2) better access to specialist physicians and experienced nursing staff; 3) inclusion of nurses in developing clinical policies and protocols, and 4) acknowledgement of the influence of racism and bias in healthcare on racial-ethnic disparities. In both clusters, areas for improvement included comprehensive family engagement strategies, care standardization, and reporting of quality data by patient sociodemographic characteristics. Conclusions and relevance: Our findings suggest specific organizational and cultural characteristics, from hospital leadership and clinician perspectives, that may yield better patient outcomes, and demonstrate the utility of a positive deviance framework to center equity in quality initiatives for high-risk infant care.

Distinguishing High-Performing From Low-Performing Hospitals for Severe Maternal Morbidity: A Focus on Quality and Equity.

OBJECTIVE: To investigate which organizational factors, policies, and practices distinguish hospitals with high compared with low risk-adjusted rates of severe maternal morbidity (SMM). METHODS: Using a positive deviance approach, this qualitative study included 50 semistructured interviews with health care professionals (obstetrics and gynecology chairs, labor and delivery medical directors, nurse managers, frontline nurses, physicians or nurses responsible for quality and safety, and chief medical officers) in four low-performing and four high-performing hospitals in New York City. Hospital performance was based on risk-adjusted morbidity metrics from previous research. Major topics explored were structural characteristics (eg, staffing, credentialing), organizational characteristics (eg, culture, leadership, communication, use of data), labor and delivery practices (eg, use of standardized, evidence-based practices, teamwork), and racial and ethnic disparities in SMM. All interviews were audiotaped, professionally transcribed, and coded using NVivo software. Researchers blinded to group assignment conducted qualitative content analysis. Researchers wrote analytic memos to identify key themes and patterns emerging from the interviews, highlight illustrative quotes, and draw qualitative comparisons between the two hospital clusters with different (but unrevealed) performance levels. RESULTS: Six themes distinguished high-performing from low-performing hospitals. High-performing hospitals were more likely to have: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. CONCLUSION: Organizational factors, policies, and practices at multiple levels distinguish high-performing from low-performing hospitals for SMM. Findings illustrate the potential for targeted quality initiatives to improve maternal health and reduce obstetric disparities arising from delivery in low-performing hospitals.

Racial and Ethnic Disparities in Severe Maternal Morbidity: A Qualitative Study of Women's Experiences of Peripartum Care.

INTRODUCTION: Racial and ethnic disparities in rates of maternal morbidity and mortality in the United States are striking and persistent. Despite evidence that variation in the quality of care contributes substantially to these disparities, we do not sufficiently understand how experiences of perinatal care differ by race and ethnicity among women with severe maternal morbidity. METHODS: We conducted focus groups with women who experienced a severe maternal morbidity event in a New York City hospital during their most recent pregnancy (n = 20). We organized three focus groups by self-identified race/ethnicity ([1] Black, [2] Latina, and [3] White or Asian) to detect any within- and between-group differences. Discussions were audiotaped and transcribed. The research team coded the transcripts and used content analysis to identify key themes and to compare findings across racial and ethnic groups. RESULTS: Participants reported distressing experiences and lasting emotional consequences after having a severe childbirth complication. Many women appreciated the life-saving care they received. However, poor continuity of care, communication gaps, and a perceived lack of attentiveness to participants' physical and emotional needs led to substantial concern and disappointment in care. Black and Latina women in particular emphasized these themes. CONCLUSIONS: This study highlights missed opportunities for improved clinician communication and continuity of care to address emotional trauma when severe obstetric complications occur, particularly for Black and Latina women. Enhancing communication to ensure that women feel heard and informed throughout the birth process and addressing implicit bias, as a part of the more systemic issue of institutionalized racism, could both decrease disparities in obstetric care quality and improve the patient experience for women of all races and ethnicities.

Perinatal care experiences among racially and ethnically diverse mothers whose infants required a NICU stay.

OBJECTIVE: To learn how diverse mothers whose babies required a neonatal intensive care unit (NICU) stay evaluate their obstetric and neonatal care. STUDY DESIGN: We conducted three focus groups stratified by race/ethnicity (Black, Latina, White, and Asian women, n = 20) who delivered infants at <32 weeks gestation or <1500 g with a NICU stay. We asked women to assess perinatal care and applied classic qualitative analysis techniques to identify themes and make comparisons across groups. RESULTS: Predominant themes were similar across groups, including thoroughness and consistency of clinician communication, provider attentiveness, and barriers to closeness with infants. Care experiences were largely positive, but some suggested poorer communication and responsiveness toward Black and Latina mothers. CONCLUSION: Feeling consulted and included in infant care is critical for mothers of high-risk neonates. Further in-depth research is needed to remediate differences in hospital culture and quality that contribute to disparities in neonatal care and outcomes.

Positive Deviance to Address Health Equity in Quality and Safety in Obstetrics.

Racial/ethnic disparities persist in obstetrical outcomes. In this paper, we ask how research in obstetrical quality can go beyond a purely quantitative approach to tackle the challenge of health inequity in quality and safety. This overview debriefs the use of positive deviance and mixed methods in others areas of medicine, describes the shortcomings of quantitative methods in obstetrics and presents qualitative studies carried out in obstetrics as well as the insights provided by this method. The article concludes by proposing positive deviance as a mixed methods approach to generate new knowledge for addressing racial and ethnic disparities in maternal outcomes.

An informed public's views on reducing antibiotic overuse.

OBJECTIVE: To understand public attitudes about and recommendations to address antibiotic overuse by employing public deliberation (a method for eliciting informed input on value-laden issues). DATA SOURCES/STUDY SETTING: Participants in 24 Community Deliberation groups (CD; n = 263), four Citizens' Panel groups (CP; n = 96), and a control group (n = 348). Data were collected in 2012 in four U.S. STUDY DESIGN: Using mixed methods, we analyzed quantitative and qualitative data from a randomized control trial. DATA COLLECTION/EXTRACTION METHODS: Using pre/postdeliberation surveys, we compared CD and CP participant attitude changes regarding antibiotic use to the control group. We analyzed deliberation transcripts using qualitative techniques to provide context for survey results. PRINCIPAL FINDINGS: Compared to control group participants, CD and CP participants had a larger postdeliberation shift in attitudes toward support of government limits on when doctors can prescribe antibiotics. Participants described unawareness about antibiotic overuse and called for education. When discussing prescription limits, participants debated tensions between preserving patient/doctor autonomy and protecting society from antibiotic-related harms. Participants saw patient, physician, and government roles in antibiotic stewardship policies/programs. CONCLUSION: When informed about individual and social consequences of antibiotic overuse, patients may be more receptive to antibiotic prescription limits. Community-physician-government partnerships are needed to create solutions.

Using the Taxonomy and the Metrics: What to Study When and Why Comment on "Metrics and Evaluation Tools for Patient Engagement in Healthcare Organization- and System-Level Decision-Making: A Systematic Review".

Dukhanin and colleagues' taxonomy of metrics for patient engagement at the organizational and system levels has great potential for supporting more careful and useful evaluations of this ever-growing phenomenon. This commentary highlights the central importance to the taxonomy of metrics assessing the extent of meaningful participation in decision-making by patients, consumers and community members; discusses how the purpose of an evaluation and the organizational relationships among key evaluation stakeholders is likely to influence the choice of metrics in important ways; and suggests a recasting of the metrics in the form of a logic model that supports the selection of metrics that are appropriate for a program given its stage of development and the purposes of the study.

Setting Boundaries: Public Views on Limiting Patient and Physician Autonomy in Health Care Decisions.

We obtained and qualitatively analyzed input from more than nine hundred citizens during seventy-six public deliberation sessions about patient and physician autonomy in decision making, setting health care boundaries, and the tensions among competing social values. Generally, participants resisted interference with the patient-physician relationship and believed strongly in the freedom of patient and physician to control individual medical decisions. However, during deliberation participants identified two situations where boundaries and regulations in health care were more acceptable: protecting people from harm and allocating limited resources. The core value of individual freedom was tempered in varying degrees by the values of concern for the greater good and fairness in allocating resources. Where tensions between values emerged, participants used different concepts-including accountability, transparency, trust, personal responsibility, and moral obligation-to navigate trade-offs. Fairly balancing the public's desire to protect individual freedom with their sense of responsibility for protecting the common good may be the key to developing acceptable, workable policies that promote evidence-based medical practice.

Understanding An Informed Public's Views On The Role Of Evidence In Making Health Care Decisions.

Policy makers and practitioners increasingly believe that medical evidence plays a critical role in improving care and health outcomes and lowering costs. However, public understanding of the role of evidence-based care may be different. Public deliberation is a process that convenes diverse citizens and has them learn about and consider ethical or values-based dilemmas and weigh alternative views. The Community Forum Deliberative Methods Demonstration project, sponsored by the Agency for Healthcare Research and Quality, obtained informed public views on the role of evidence in health care decisions through seventy-six deliberative groups involving 907 people overall, in the period August-November 2012. Although participants perceived evidence as being essential to high-quality care, they also believed that personal choice or clinical judgment could trump evidence. They viewed doctors as central figures in discussing evidence with patients and key arbiters of whether to follow evidence in individual cases. They found evidence of harm to individuals or the community to be more compelling than evidence of effectiveness. These findings indicate that increased public understanding of evidence can play an important role in advancing evidence-based care by helping create policies that better reflect the needs and values of the public.

Understanding Consumer Perceptions and Awareness of Hospital-Based Maternity Care Quality Measures.

OBJECTIVE: To explore factors that may influence use of comparative public reports for hospital maternity care. DATA SOURCES: Four focus groups conducted in 2013 with 41 women and preintervention survey data collected in 2014 to 2015 from 245 pregnant women in North Carolina. STUDY DESIGN: As part of a larger randomized controlled trial, we conducted qualitative formative research to develop an intervention that will be evaluated through pre- and postintervention surveys. DATA EXTRACTION METHODS: Analysis of focus group transcripts examined participants' perceptions of high-quality maternity care and the importance of different quality measures. Quantitative analysis included descriptive results of the preintervention survey and subgroup analyses to examine the impact of race, education, and being a first-time mom on outcomes. PRINCIPAL FINDINGS: When describing high-quality maternity care, participants focused on interactions with providers, including respect for preferences and communication. The importance of quality measures was influenced by the extent to which they focused on babies' health, were perceived as the hospital's responsibility, and were perceived as representing "standard care." At baseline, 28 percent of survey respondents had used quality information to choose a hospital. Survey respondents were more aware of some quality measures (e.g., breastfeeding support) than others (e.g., episiotomy rates). CONCLUSIONS: Public reporting efforts could help increase relevance of maternity care quality measures by creating measures that reflect women's concerns, clearly explaining the hospital's role in supporting quality care, and showing how available quality measures can inform decisions about childbirth.

Effectiveness of public deliberation methods for gathering input on issues in healthcare: Results from a randomized trial.

UNLABELLED: Public deliberation elicits informed perspectives on complex issues that are values-laden and lack technical solutions. This Deliberative Methods Demonstration examined the effectiveness of public deliberation for obtaining informed public input regarding the role of medical evidence in U.S. healthcare. We conducted a 5-arm randomized controlled trial, assigning participants to one of four deliberative methods or to a reading materials only (RMO) control group. The four deliberative methods reflected important differences in implementation, including length of the deliberative process and mode of interaction. The project convened 76 groups between August and November 2012 in four U.S. LOCATIONS: Chicago, IL; Sacramento, CA; Silver Spring, MD; and Durham, NC, capturing a sociodemographically diverse sample with specific attention to ensuring inclusion of Hispanic, African-American, and elderly participants. Of 1774 people recruited, 75% participated: 961 took part in a deliberative method and 377 participants comprised the RMO control group. To assess effectiveness of the deliberative methods overall and of individual methods, we evaluated whether mean pre-post changes on a knowledge and attitude survey were statistically different from the RMO control using ANCOVA. In addition, we calculated mean scores capturing participant views of the impact and value of deliberation. Participating in deliberation increased participants' knowledge of evidence and comparative effectiveness research and shifted participants' attitudes regarding the role of evidence in decision-making. When comparing each deliberative method to the RMO control group, all four deliberative methods resulted in statistically significant change on at least one knowledge or attitude measure. These findings were underscored by self-reports that the experience affected participants' opinions. Public deliberation offers unique potential for those seeking informed input on complex, values-laden topics affecting broad public constituencies.

Deliberation: obtaining informed input from a diverse public.

OBJECTIVES: Health care decision makers require public input to incorporate diverse values into programs and policies. Deliberation, one method for obtaining input, seeks to apply inclusive principles wherein diverse groups provide perspectives to inform decisions. We evaluate whether participants of different racial, ethnic, and educational backgrounds show differences in the effect of deliberation and the value placed on deliberation participation. METHODS: We surveyed 907 participants before and after deliberation. Regression models examined associations between demographics and change in knowledge and attitudes, and perceived impact. RESULTS: Changes in knowledge about using medical evidence in decision-making were not associated with race, ethnicity, or education. Changes in attitudes were not associated with these characteristics with one exception. African American, Hispanic, and participants with lower educational attainment reported more perceived impact. CONCLUSION: Similar results across demographic groups suggest deliberation's promise for obtaining input from a diverse public to inform health programs and policies.

Improving the quality of geriatric nursing care: enduring outcomes from the geriatric nursing education consortium.

The nation's aging demography, few nursing faculty with gerontological nursing expertise, and insufficient geriatric content in nursing programs have created a national imperative to increase the supply of nurses qualified to provide care for older adults. Geriatric Nursing Education Consortium (GNEC), a collaborative program of the John A. Hartford Foundation, the American Association of Colleges of Nursing, and the New York University (NYU) Nursing Hartford Institute for Geriatric Nursing, was initiated to provide faculty with the necessary skills, knowledge, and competency to implement sustainable curricular innovations in care of older adults. This article describes the background, step-by-step process approach to the development of GNEC evidence-based curricular materials, and the dissemination of these materials through 6-, 2-, and a half-day national Faculty Development Institutes (FDIs). Eight hundred eight faculty, representing 418 schools of nursing, attended. A total of 479 individuals responded to an evaluation conducted by Baruch College that showed faculty feasibility to incorporate GNEC content into courses, confidence in teaching and incorporating content, and overall high rating of the GNEC materials. The impact of GNEC is discussed along with effects on faculty participants over 2 years. Administrative- and faculty-level recommendations to sustain and expand GNEC are highlighted.

Patient and family engagement: a framework for understanding the elements and developing interventions and policies.

Patient and family engagement offers a promising pathway toward better-quality health care, more-efficient care, and improved population health. Since definitions of patient engagement and conceptions of how it works vary, we propose a framework. We first present the forms engagement can take, ranging from consultation to partnership. We discuss the levels at which patient engagement can occur across the health care system, from the direct care setting to incorporating patient engagement into organizational design, governance, and policy making. We also discuss the factors that influence whether and to what extent engagement occurs. We explore the implications of our multidimensional framework for the development of interventions and policies that support patient and family engagement, and we offer a research agenda to investigate how such engagement leads to improved outcomes.

An experiment shows that a well-designed report on costs and quality can help consumers choose high-value health care.

Advocates of health reform continue to pursue policies and tools that will make information about comparative costs and resource use available to consumers. Reformers expect that consumers will use the data to choose high-value providers-those who offer higher quality and lower prices-and thus contribute to the broader goal of controlling national health care spending. However, communicating this information effectively is more challenging than it might first appear. For example, consumers are more interested in the quality of health care than in its cost, and many perceive a low-cost provider to be substandard. In this study of 1,421 employees, we examined how different presentations of information affect the likelihood that consumers will make high-value choices. We found that a substantial minority of the respondents shied away from low-cost providers, and even consumers who pay a larger share of their health care costs themselves were likely to equate high cost with high quality. At the same time, we found that presenting cost data alongside easy-to-interpret quality information and highlighting high-value options improved the likelihood that consumers would choose those options. Reporting strategies that follow such a format will help consumers understand that a doctor who provides higher-quality care than other doctors does not necessarily cost more.

Building Academic Geriatric Nursing Capacity: results after the first 10 years and implications for the future.

In 2000, the John A. Hartford Foundation launched a multi-million dollar investment in Building Academic Geriatric Nursing Capacity (BAGNC) at the American Academy of Nursing (AAN). After a decade of focused support to increase scholarship, research, leadership, and institutional collaboration, is there evidence this program is successful in achieving its goals? Equally important, as the need for quality geriatric nursing care increases with the expanding aging population and associated complex health conditions, how does the experience and outcomes of this program inform nursing's future? To address both questions, the authors first provide an overview of geriatric nursing prior to and up to the time the BAGNC program began, then review results of an external evaluation of the BAGNC program, and finally propose goals and strategies for the next 20 years of academic geriatric nursing.

From patient education to patient engagement: implications for the field of patient education.

OBJECTIVE: Advances in health care require that individuals participate knowledgeably and actively in their health care to realize its full benefit. Implications of these changes for the behavior of individuals and for the practice of patient education are described. METHODS: An "engagement behavior framework" (EBF) was compiled from literature reviews and key informant interviews. To assess the focus of research and interventions on the identified engagement behaviors, the EBF was used to code scientific sessions in professional conferences relevant to patient education in the US in 2006-2007. RESULTS: Many specific behaviors constitute engagement. Professional conferences on patient education show only modest attention to the full range of relevant behaviors. CONCLUSION: People must make informed choices about insurance and clinicians, coordinate communications among providers and manage complex treatments on their own. Not doing so risks preventable illness, suboptimal outcomes and wasted resources. PRACTICE IMPLICATIONS: Increased responsibilities of individuals, sick and well, to find and actively participate in high quality health care provides an opportunity for patient education researchers and clinicians to improve health outcomes by developing innovative strategies to support all individuals to effectively participate in their care to the extent possible.

Addressing the need for public reporting of comparative hospice quality: a focus group study.

BACKGROUND: Standardized measures are available to assess hospice quality across multiple domains, but no information on hospice quality is available to the public. A study was conducted in 2006 to explore the public's knowledge, beliefs, and attitudes about hospice care and their responses to the idea of a public report on comparative hospice quality. METHODS: Six focus groups were conducted, two with individuals with direct hospice care experience and four with people without experience. Focus groups were videotaped, transcribed, and analyzed for themes and patterns of convergence and divergence. RESULTS: Focus group participants without hospice experience knew of hospice but had little accurate information about hospices services, who could benefit, or how it is financed. Even some with hospice experience were unaware of services such as bereavement support. Participants saw hospice as appropriate only when the family could no longer provide care. They wanted a public report to include information about hospice, help in comparing hospice to other kinds of end-of-life care, details on accreditation, staff and services of individual hospices, quality comparisons, and decision support. Hospice was viewed as providing a broad range of services to the family as well as the patient. DISCUSSION: This research will provide guidance for the development of an evidence-based model report on hospice quality that includes substantial educational material. It also supports the selection of measures for such a report that would resonate with the public, which makes the use of a comparative quality report more likely. The next step in this research is to develop and formatively test such a report, so that it can be pilot tested with willing hospices in a community offering a choice of providers. Considerable additional work is needed to ensure that hospice becomes more understandable and transparent to the public.

Quality improvement in small office settings: an examination of successful practices.

BACKGROUND: Physicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives. METHODS: We undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities. RESULTS: Physicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers. CONCLUSION: These findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.