Showing papers by "Kevin J. O'Leary published in 2015"

Implementation of Unit-Based Interventions to Improve Teamwork and Patient Safety on a Medical Service

Abstract: In a prior study involving 2 medical units, Structured Interdisciplinary Rounds (SIDRs) improved teamwork and reduced adverse events (AEs). SIDR was implemented on 5 additional units, and a pre- versus postintervention comparison was performed. SIDR combined a structured format for communication with daily interprofessional meetings. Teamwork was assessed using the Safety Attitudes Questionnaire (score range = 0-100), and AEs were identified using queries of information systems confirmed by 2 physician researchers. Paired analyses for 82 professionals completing surveys both pre and post implementation revealed improved teamwork (mean 76.8 ± 14.3 vs 80.5 ± 11.6; P = .02), which was driven mainly by nurses (76.4 ± 14.1 vs 80.8 ± 10.4; P = .009). The AE rate was similar across study periods (3.90 vs 4.07 per 100 patient days; adjusted IRR = 1.08; P = .60). SIDR improved teamwork yet did not reduce AEs. Higher baseline teamwork scores and lower AE rates than the prior study may reflect a positive cultural sh...

Assessing Interprofessional Teamwork in Inpatient Medical Oncology Units

Abstract: The authors conclude that in inpatient oncology units, discrepancies exist between nurses' and physicians' ratings of teamwork and collaboration. Oncologists seem to be unaware that teamwork is suboptimal in this setting.

The effect of hospitalist discontinuity on adverse events.

Abstract: BACKGROUND Patient-physician continuity is difficult to achieve in hospital settings because of the need to provide care continuously. The impact of hospital physician discontinuity on patient safety is unknown. OBJECTIVE To determine the association between hospital physician continuity and the incidence of adverse events (AEs). DESIGN Retrospective observational study using multivariable models to adjust for patient characteristics. PARTICIPANTS Patients admitted to a nonteaching hospitalist service in a large academic hospital between March 1, 2009 and December 31, 2011. MAIN MEASURE(S) Two measures of continuity were used. The Number of Physicians Index (NPI) was the total number of unique hospitalists caring for a patient. The Usual Provider of Care (UPC) Index was the proportion of encounters with the most frequently encountered hospitalist. Outcome measures were AEs detected by automated queries of information systems and confirmed by 2 physician researchers. KEY RESULTS Our analysis included data from 474 hospitalizations. In unadjusted models, each 1-unit increase in the NPI (ie, less continuity) was significantly associated with the incidence of 1 or more AEs (odds ratio = 1.75; P < 0.001). However, UPC was not associated with incidence of AEs. Across all adjusted models, neither NPI nor UPC was significantly associated with the incidence of AEs. The direction of the effect of discontinuity on AEs was also inconsistent across models. CONCLUSIONS Hospitalist physician continuity does not appear to be associated with the incidence of AEs. Because hospital care is provided by teams of clinicians, future research should evaluate the impact of team complexity and dynamics on patient outcomes. Journal of Hospital Medicine 2015;10:147–151. © 2014 Society of Hospital Medicine

Medical Inpatients' Use of Information Technology: Characterizing the Potential to Share Information Electronically.

Abstract: Hospitalized patients frequently have an incomplete understanding of important aspects of their care. Patient-facing technologies, increasingly used in outpatient settings to exchange information between patient and provider, may have utility in the hospital setting. We conducted structured interviews of hospitalized medical patients to assess current use of information technology, gauge interest in receiving information electronically, and prioritize potential content options. Overall, 150 of 175 (86%) eligible patients completed interviews. A majority (69%) of patients used the Internet prior to hospital admission. One third (32%) of patients had used the Internet during their hospitalization with half of those reporting use for health information. Overall, nearly half (42%) reported interest in receiving health information electronically during hospitalization and a majority (59%) were interested in receiving health information electronically after hospitalization. Patients expressed high interest in receiving information to help them learn more about diagnoses and treatments, medication lists, lists of planned tests, and summaries of completed tests and procedures. Many general medical patients are interested in receiving health information electronically from hospital providers. Our findings support the development of hospital-based patient-facing health information technologies and prioritize content options patients find most beneficial.

Improving patient satisfaction: Timely feedback to specific physicians is essential for success

Abstract: Patient satisfaction has received increased attention in recent years, which we believe is well deserved and long overdue. Anyone who has been hospitalized, or has had a loved one hospitalized, can appreciate that there is room to improve the patient experience. Dedicating time and effort to improving the patient experience is consistent with our professional commitment to comfort, empathize, and partner with our patients. Though patient satisfaction itself is an outcome worthy of our attention, it is also positively associated with measures related to patient safety and clinical effectiveness. Moreover, patient satisfaction is the only publicly reported measure that represents the patient’s voice, and accounts for a substantial portion of the Centers for Medicare and Medicaid Services payment adjustments under the Hospital Value Based Purchasing Program. However, all healthcare professionals should understand some key fundamental issues related to the measurement of patient satisfaction. The survey from which data are publicly reported and used for hospital payment adjustment is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed by the Agency for Healthcare Research and Quality. HCAHPS is sent to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey uses ordinal response scales (eg, never, sometimes, usually, always) that generate highly skewed results toward favorable responses. Therefore, results are reported as the percent “top box” (ie, the percentage of responses in the most favorable category) rather than as a median score. The skewed distribution of results indicates that most patients are generally satisfied with care (ie, most respondents do not have an axe to grind), but also makes meaningful improvement difficult to achieve. Prior to public reporting and determination of effect on hospital payment, results are adjusted for mode of survey administration and patient mix. The same is not true when patient satisfaction data are used for internal purposes. Hospital leaders typically do not perform statistical adjustment and therefore need to be careful not to make “apples-to-oranges”–type comparisons. For example, obstetric patient satisfaction scores should not be compared to general medical patient satisfaction scores, as these populations tend to rate satisfaction differently. The HCAHPS survey questions are organized into domains of care, including satisfaction with nurses and satisfaction with doctors. Importantly, other healthcare team members may influence patients’ perception in these domains. For example, a patient responding to nurse communication questions may also reflect on experiences with patient care technicians, social workers, and therapists. A patient responding to physician communication questions might also reflect on experiences with advanced practice providers. A common mistake is the practice of attributing satisfaction with doctors to the individual who served as the discharge physician. Many readers have likely seen patient satisfaction reports broken out by discharge physician with the expectation that giving this information to individual physicians will serve as useful formative feedback. The reality is that patients see many doctors during a hospitalization. To illustrate this point, we analyzed data from 420 patients admitted to our nonteaching hospitalist service who had completed an HCAHPS survey in 2014. We found that the discharge hospitalist accounted for only 34% of all physician encounters. Furthermore, research has shown that patients’ experiences with specialist physicians also have a strong influence on their overall satisfaction with physicians. Having reliable patient satisfaction data on specific individuals would be a truly powerful formative assessment tool. In this issue of the Journal of Hospital Medicine, Banka and colleagues report on an impressive approach incorporating such a tool to give constructive feedback to physicians. Since 2006, the study site had administered surveys to hospitalized patients that assess their satisfaction with specific resident physicians. However, residency programs only reviewed the survey results with resident physicians about twice a year. The multifaceted intervention developed by Banka and colleagues included directly emailing the survey results to internal medicine resident physicians in real time while they were in service, a 1-hour conference on best communication practices, and a reward program in which 3 residents were *Address for correspondence and reprint requests: Kevin J. O’Leary, MD, Associate Professor of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 E. Ontario St., Chicago, IL 60611; Telephone: 312-926-5984; Fax: 312-926-4588; E-mail: keoleary@nmh.org

Compliance in guideline-based management of febrile neutropenia.

Abstract: e17667 Background: Neutropenic Fever (NF) is a prevalent complication of myelosuppressive chemotherapy with significant morbidity, mortality, and cost Despite clear treatment guidelines by the Inf

Rapid response teams in teaching hospitals: Aligning efforts to improve medical education and quality

Abstract: The use of RRTs in teaching hospitals raises impor-tant concerns. The ability of nurses and other profes-sionals to activate the RRT without need for priorapproval from a physician could potentially under-mine resident physician autonomy. Residents may feelthat their clinical judgment has been usurped or sec-ond guessed. Whether nurse led or physician led,RRTs always introduce new members to the careteam.

The authors reply "The effect of hospitalist continuity on adverse events".

Abstract: We greatly appreciate the thoughtful points made by Dr. Kerman regarding our recently published study evaluating the association of hospitalist continuity on adverse events (AEs). We agree that a 7-on/7-off staffing model may limit discontinuity relative to models using shorter rotations lengths. Many hospital medicine programs use a 7-on/7-off model to optimize continuity. Longer rotation lengths are uncommon, as they may lead to fatigue and negatively affect physician work-life balance. Shorter rotation lengths do exist, and we acknowledge that a study in a setting with greater fragmentation may have detected an effect. We respectfully disagree with Dr. Kerman’s concern that our methods for AE detection and confirmation may have been insensitive. We did not rely on incident reports, as these systems suffer from under-reporting and often represent only a fraction of true AEs. We used a modified version of the classic 2-stage method to identify and confirm AEs. In the first stage, we used computerized screens, based on criteria from the Harvard Medical Practice Study and Institute for Healthcare Improvement global trigger tool, to identify potential AEs. A research nurse created narrative summaries of potential AEs. A physician researcher then reviewed the narrative summaries to confirm whether an AE was truly present. This timeconsuming method is much more sensitive and specific than other options for patient safety measurement, including administrative data analyses and incident reporting systems. With respect to other outcomes that may be affected by hospitalist continuity, we recently published a separate study showing that lower inpatient physician continuity was significantly associated with modest increases in hospital costs. We found no association between continuity and patient satisfaction, but were likely underpowered to detect one. Interestingly, some of the models in our study suggested a slightly reduced risk of readmission with lower continuity. We were surprised by this finding and hypothesized that countervailing forces may be at play during handoffs of care from 1 hospitalist to another. Transitions of care introduce the opportunity for critical information to be lost, but they also introduce the potential for patient reassessment. A hospitalist newly taking over care from another may not be anchored to the initial diagnostic impressions and management plan established by the first. Of course, the potential benefit of a reassessment could only occur if the new hospitalist has time to perform one. At extremely high patient volumes, this theoretical benefit is unlikely to exist. We did not include length of stay (LOS) as an outcome because hospitalist continuity and LOS are interdependent. Although discontinuity may lead to longer LOS, longer LOS definitely increases the probability of discontinuity. Thus, we controlled for LOS in our statistical models to isolate the effect of continuity. The study by Epstein and colleagues did not take into account the interdependence between LOS and hospitalist continuity. Observational studies are not ideal for determining the effect of continuity on LOS. The Combing Incentives and Continuity Leading to Efficiency (CICLE) study by Chandra and colleagues was a pre-post evaluation of a hospitalist staffing model specifically designed to improve continuity. In the CICLE model, physicians work in a 4-day rotation. On day 1, physicians exclusively admit patients. On day 2, physicians care for patients admitted on day 1 and accept patients admitted overnight. On days 3 and 4, physicians continue to care for patients received on days 1 and 2, but receive no additional patients. The remaining patients are transitioned to the next physician entering the cycle at the end of day 4. Chandra and colleagues found a 7.5% reduction in LOS and an 8.5% reduction in charges. Interestingly, they also found a 13.5% increase in readmissions that did not achieve statistical significance (P 5 0.08). The CICLE study suggests continuity does affect LOS, but is limited in that it did not account for a potential preexisting trend toward lower LOS. Dr. Kerman presents data showing that it takes longer for a physician to care for a patient who is new to him or her than for a patient who is previously known. This finding has face validity. However, as we have suggested, the extra time spent by the oncoming physician may have both advantages and Received: April 20, 2015; Accepted: April 22, 2015 2015 Society of Hospital Medicine DOI 10.1002/jhm.2405 Published online in Wiley Online Library (Wileyonlinelibrary.com).