Objective. To investigate organizational facilitators and barriers to patient-centered care in US health care institutions renowned for improving the patient care experience. Design. A qualitative study involving interviews of senior staff and patient representatives. Semi-structured interviews focused on organizational processes, senior leadership, work environment, measurement and feedback mechanisms, patient engagement and information technology and access. Setting. Eight health care organizations across the USA with a reputation for successfully promoting patient-centered care. Participants. Forty individuals, including chief executives, quality directors, chief medical officers, administrative directors and patient committee representatives. Results. Interviewees reported that several organizational attributes and processes are key facilitators for making care more patient-centered: (i) strong, committed senior leadership, (ii) clear communication of strategic vision, (iii) active engagement of patient and families throughout the institution, (iv) sustained focus on staff satisfaction, (v) active measurement and feedback reporting of patient experiences, (vi) adequate resourcing of care delivery redesign, (vii) staff capacity building, (viii) accountability and incentives and (ix) a culture strongly supportive of change and learning. Interviewees reported that changing the organizational culture from a ‘provider-focus’ to a ‘patient-focus’ and the length of time it took to transition toward such a focus were the principal barriers against transforming delivery for patient-centered care.

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Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience.

Background: The main purpose of this study was to identify factors that influence healthcare quality in the Iranian context. 

Methods: Exploratory in-depth individual and focus group interviews were conducted with 222 healthcare stakeholders including healthcare providers, managers, policy-makers, and payers to identify factors affecting the quality of healthcare services provided in Iranian healthcare organisations. 

Results: Quality in healthcare is a production of cooperation between the patient and the healthcare provider in a supportive environment. Personal factors of the provider and the patient, and factors pertaining to the healthcare organisation, healthcare system, and the broader environment affect healthcare service quality. Healthcare quality can be improved by supportive visionary leadership, proper planning, education and training, availability of resources, effective management of resources, employees and processes, and collaboration and cooperation among providers. 

Conclusion: This article contributes to healthcare theory and practice by developing a conceptual framework that provides policy-makers and managers a practical understanding of factors that affect healthcare service quality.

https://www.ijhpm.com/article_2864_2639694b52ee2d50badb65bd92c90d7d.pdf

Factors Influencing Healthcare Service Quality

Objectives: To review the empirical literature to identify the activities, time spent and engagement of hospital managers in quality of care. Design: A systematic review of the literature. Methods: A search was carried out on the databases MEDLINE, PSYCHINFO, EMBASE, HMIC. The search strategy covered three facets: management, quality of care and the hospital setting comprising medical subject headings and key terms. Reviewers screened 15 447 titles/abstracts and 423 full texts were checked against inclusion criteria. Data extraction and quality assessment were performed on 19 included articles. Results: The majority of studies were set in the USA and investigated Board/senior level management. The most common research designs were interviews and surveys on the perceptions of managerial quality and safety practices. Managerial activities comprised strategy, culture and data-centred activities, such as driving improvement culture and promotion of quality, strategy/goal setting and providing feedback. Significant positive associations with quality included compensation attached to quality, using quality improvement measures and having a Board quality committee. However, there is an inconsistency and inadequate employment of these conditions and actions across the sample hospitals. Conclusions: There is some evidence that managers’ time spent and work can influence quality and safety clinical outcomes, processes and performance. However, there is a dearth of empirical studies, further weakened by a lack of objective outcome measures and little examination of actual actions undertaken. We present a model to summarise the conditions and activities that affect quality performance.

https://bmjopen.bmj.com/content/bmjopen/4/9/e005055.full.pdf

The role of hospital managers in quality and patient safety: a systematic review

Research questions The paper explores which type of quality aspects (structure, process, outcome) most strongly determines patients' overall assessment of healthcare, and whether there is a variation between different types of patient groups in this respect.

Methods Secondary analyses were undertaken on survey data from patients who underwent hip or knee surgery, cataract surgery, patients suffering from varicose veins, spinal disc herniation or rheumatoid arthritis. In these analyses, the patient-given global rating served as the dependent variable, and experiences regarding structure (waiting times, continuity of care), process (doctor–patient communication and information) and outcome aspects (improvement or worsening of symptoms) served as independent variables.

Results Experiences regarding process aspects explained most of the variance in the global rating (16.4–23.3%), followed by structure aspects (8.1–21.0%). Experiences regarding outcome did not explain much variance in the global rating in any of the patient groups (5.3–13.5%). The patient groups did not differ with respect to the type of quality aspects that most predicted the overall assessment.

Discussion Improving process and structure aspects of healthcare is most likely to increase patients' overall evaluation of the quality of care as expressed in a global rating. A more sophisticated method of patient reported outcome measurement, with pre- and post-treatment questionnaires and the inclusion of quality-of-life criteria, might lead to higher associations between outcome and the overall evaluation of the received care.

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Structure, process or outcome: which contributes most to patients' overall assessment of healthcare quality?

Implementation of large Health Information Technology (HIT) systems is critical to healthcare organizations and has seen heavy investment. However, research has not fully explored the adaptation of HIT systems, particularly the tensions between individual flexibility and organizational needs in the adaptation process. This study analyzes how Emergency Department (ED) clinicians adapted to a new hospital-wide Electronic Medical Records (EMR) system. We present four adaptation cases revealing two interrelated types of adaptations—technical and organizational—as responses to the new system in use. First, individual clinicians respond to the immediate alteration in workflows caused by the EMR, while the organizational adaptations later mitigate the changes in healthcare quality control resulting from the clinicians’ initial adaptation. Our analysis reflects the critical nature and value of both adaptation types, with an emphasis on the triggers and process of organizational adaptation, for the successful implementation of a socio-technical-political system in a healthcare organization.

Technological and Organizational Adaptation of EMR Implementation in an Emergency Department

Background Although agreement about the need for quality improvement in health care is almost universal, the means of achieving effective improvement in overall care is not well understood. Avedis Donabedian developed the structure–process–outcome framework in which to think about quality-improvement efforts.

Issue There is now a robust evidence-base in the quality-improvement literature on process and outcomes, but structure has received considerably less attention. The health-care field would benefit from expanding the current interpretation of structure to include broader perspectives on organizational attributes as primary determinants of process change and quality improvement.

Solutions We highlight and discuss the following key elements of organizational attributes from a management perspective: (i) executive management, including senior leadership and board responsibilities (ii) culture, (iii) organizational design, (iv) incentive structures and (v) information management and technology. We discuss the relevant contributions from the business and medical literature for each element, and provide this framework as a roadmap for future research in an effort to develop the optimal definition of ‘structure’ for transforming quality-improvement initiatives.

/pdf/promoting-quality-the-health-care-organization-from-a-1qfgznhhmd.pdf

Promoting quality: the health-care organization from a management perspective.

Background. Although agreement about the need for quality improvement in health care is almost universal, the means of achieving effective improvement in overall care is not well understood. Avedis Donabedian developed the structure – process – outcome framework in which to think about quality-improvement efforts. Issue. There is now a robust evidence-base in the quality-improvement literature on process and outcomes, but structure has received considerably less attention. The health-care field would benefit from expanding the current interpretation of structure to include broader perspectives on organizational attributes as primary determinants of process change and quality improvement. Solutions. We highlight and discuss the following key elements of organizational attributes from a management perspective: (i) executive management, including senior leadership and board responsibilities (ii) culture, (iii) organizational design, (iv) incentive structures and (v) information management and technology. We discuss the relevant contributions from the business and medical literature for each element, and provide this framework as a roadmap for future research in an effort to develop the optimal definition of ‘structure’ for transforming quality-improvement initiatives.

Promoting quality: the health-care organization from a management

Objective Central venous catheterization (CVC) is integral to the emergency department (ED) treatment of critically ill patients, such as those receiving early goal-directed therapy for severe sepsis No previous studies have described the overall use of CVC in community EDs The objective of this study was to estimate the overall frequency and temporal trends in CVC use in a sample of patients visiting community EDs Methods This was a retrospective observational study of 297 million patient visits at 28 community EDs (range of annual visits, 10 837-110 136) from January 2004 to February 2008 Data were obtained from a community-based research consortium Central venous catheterization procedures were aggregated at the hospital level for each study year Trends in CVC use were evaluated using linear regression Results Three thousand four hundred eighty-nine patient visits (012% of all ED patient visits) had a CVC procedure performed in the ED The overall rate of CVC procedures per 1000 ED patient visits increased from 087 (95% confidence interval [CI95%], 080-095) in 2004 to 162 (CI95%, 138-191) procedures in 2008 (P value for trend = 003) There was wide variability in the frequency of CVC procedures performed among EDs, ranging from a low of 027 (CI95%, 018-042) to a high of 758 (CI95%, 627-917) procedures per 1000 ED visits The CVC procedure rates were lower in the 8 rural EDs (099 CVCs per 1000 ED patient visits [CI95%, 091-107] compared with the 20 urban EDs (122 CVCs [CI95%, 118-127]; P Conclusion The overall rate of CVC increased from 2004 to 2008 However, there was a wide variation among Eds, and the CVC rate was lower in rural compared with urban EDs The increase in CVC use in urban EDs may reflect more intensive therapy in the management of ED patients with acute illness or injury Future efforts are needed to optimize best practices for the use of CVC in community ED practices and to characterize factors responsible for urban rural differences in the rate of CVC procedures

Increased rate of central venous catheterization procedures in community EDs.

Although the principles of healthcare economics are not usually part of the fundamental education of emergency physicians, an understanding of these elements will enhance our ability to contribute to improved health-care value. This article introduces the practical aspects of microeconomics, insurance, the supply-and-demand relationship, competition, and costs as they affect the practice of medicine on a daily basis. Being cognizant of how these elements create a dynamic interplay in the health-care industry will allow physicians to better understand the expanded role they need to assume in the ongoing cost and quality debate.

Christopher G. Krubert

Papers

Promoting quality: the health-care organization from a management perspective.

Promoting quality: the health-care organization from a management

Increased rate of central venous catheterization procedures in community EDs.

Healthcare economics for the emergency physician.