Measuring Patient-Reported Shared Decision-Making to Promote Performance Transparency and Value-Based Payment: Assessment of collaboRATE's Group-Level Reliability.

Shared decision-making (SDM) between clinicians and patients is a key component of patient experience, but measurement efforts have been hampered by a lack of valid and reliable measures that are feasible for routine use. In this study, we aim to investigate collaboRATE's reliability, calculate required sample sizes for reliable measurement, and compare Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience survey items to collaboRATE. CollaboRATE's provider group-level reliability reached acceptable reliability at 190 patient reports, while the CAHPS SDM measure demonstrated similar reliability at a sample size of 124. The CAHPS communication measure reached acceptable reliability with 55 patient reports. A strong correlation was observed between collaboRATE and CAHPS communication measures (r = 0.83). As a reliable measure of SDM, collaboRATE may be useful for both building payment models that support shared clinical decision-making and encouraging data transparency with regard to provider group performance.

Do collaboRATE Scores Reflect Differences in Perceived Shared Decision-Making Across Diverse Patient Populations? Evidence From a Large-Scale Patient Experience Survey in the United States.

Patient characteristics have been linked to prevalence and quality of shared decision-making (SDM) behaviors across diverse studies of varied size and focus. We aim to evaluate the extent to which patient characteristics are associated with patient-rated SDM scores as measured by collaboRATE and whether or not collaboRATE varies at the provider group level. We used the 2017 California Patient Assessment Survey data set, which included adult patients of 153 California-based medical groups receiving services between January and October 2016. Mixed-effects logistic regression evaluated relationships between collaboRATE scores and patient characteristics. We analyzed 31 265 total survey responses. Among included covariates, patients' health status, race, primary language, and mode of survey response were significantly associated with collaboRATE scores. Case-mix adjustment is common in healthcare quality measurement and can be useful in pay-for-performance systems. For those use cases, we recommend adjusting collaboRATE scores by patients' age, health status, gender, race, and language spoken at home, and survey response mode. However, when case-mix adjustment is not required, we suggest highlighting observed disparities across diverse patient populations to improve attention to inequities in patient experience.

Finding your way through EOL challenges in the ICU using Adaptive Leadership behaviours: A qualitative descriptive case study.

OBJECTIVE: Using the Adaptive Leadership framework, we describe behaviours that providers used while interacting with family members facing the challenges of recognising that their loved one was dying in the ICU. RESEARCH METHODOLOGY: In this prospective pilot case study, we selected one ICU patient with end-stage illness who lacked decision-making capacity. Participants included four family members, one nurse and two physicians. The principle investigator observed and recorded three family conferences and conducted one in-depth interview with the family. Three members of the research team independently coded the transcripts using a priori codes to describe the Adaptive Leadership behaviours that providers used to facilitate the family's adaptive work, met to compare and discuss the codes and resolved all discrepancies. FINDINGS: We identified behaviours used by nurses and physicians that facilitated the family's ability to adapt to the impending death of a loved one. Examples of these behaviours include defining the adaptive challenges for families and foreshadowing a poor prognosis. CONCLUSIONS: Nurse and physician Adaptive Leadership behaviours can facilitate the transition from curative to palliative care by helping family members do the adaptive work of letting go. Further research is warranted to create knowledge for providers to help family members adapt.

Studying the clinical encounter with the Adaptive Leadership framework.

In this paper we discuss the concept of leadership as a personal capability, not contingent on one's position in a hierarchy. This type of leadership allows us to reframe both the care-giving and organizational roles of nurses and other front-line clinical staff. Little research has been done to explore what leadership means at the point of care, particularly in reference to the relationship between health care practitioners and patients and their family caregivers. The Adaptive Leadership framework, based on complexity science theory, provides a useful lens to explore practitioners' leadership behaviors at the point of care. This framework proposes that there are two broad categories of challenges that patients face: technical and adaptive. Whereas technical challenges are addressed with technical solutions that are delivered by practitioners, adaptive challenges require the patient (or family member) to adjust to a new situation and to do the work of adapting, learning, and behavior change. Adaptive leadership is the work that practitioners do to mobilize and support patients to do the adaptive work. The purpose of this paper is to describe this framework and demonstrate its application to nursing research. We demonstrate the framework's utility with five exemplars of nursing research problems that range from the individual to the system levels. The framework has the potential to guide researchers to ask new questions and to gain new insights into how practitioners interact with patients at the point of care to increase the patient's ability to tackle challenging problems and improve their own health care outcomes. It is a potentially powerful framework for developing and testing a new generation of interventions to address complex issues by harnessing and learning about the adaptive capabilities of patients within their life contexts.

Adaptive leadership and the practice of medicine: a complexity-based approach to reframing the doctor-patient relationship.

RATIONALE, AIMS AND OBJECTIVES: This paper applies the concepts of 'adaptive leadership', as developed by Ron Heifetz, MD, to the practice of medicine. METHODS: Literature review and theory development. RESULTS: Patients are complex adaptive systems facing both adaptive and technical health challenges. Technical health challenges are amenable to the simple or complicated expert-mediated technical interventions that are common in modern medicine, but complex adaptive challenges can only be addressed by patients doing the adaptive work to learn new attitudes, beliefs and behaviours. In medicine, we often make the mistake of offering technical interventions in lieu of supporting patients' adaptive work. This error can result in poor clinical outcomes and wasted resources. Expecting simple or complicated technical 'solutions' to resolve complex adaptive health challenges is a failure of adaptive leadership and violates Ashby's law of requisite variety. Adaptive leadership behaviours correspond to and complement doctor practices that have been shown to improve health outcomes and doctor-patient communication. CONCLUSIONS: Adopting an adaptive leadership framework in the practice of medicine will require adaptive work on our part, but it promises to improve the doctor-patient relationship, increase our effectiveness as healers and reduce unnecessary health care utilization.

Use and costs of care in retail clinics versus traditional care sites.

Retail clinics have generated much interest, promising convenient, lower-cost service for the treatment of minor conditions than conventional care sites can offer. Using health plan claims data, we describe utilization trends, patient mix, and cost per episode of care for the five conditions most frequently treated at a retail clinic chain in the Minneapolis-St. Paul area, as compared with other care settings. Retail clinic use for these conditions is increasing at about 3 percent per year and offers savings of $50-$55 per episode. However, it accounts for only 6 percent of such episodes, and the impact on overall cost and quality remains undetermined.