A Multidisciplinary Initiative to Increase Inpatient Discharges Before Noon.

OBJECTIVE: The aim of this study is to evaluate the effect of 2 hospital-wide interventions on achieving a discharge-before-noon rate of 40%. BACKGROUND: A multidisciplinary team led by administrative and physician leadership developed a plan to diminish capacity constraints by minimizing late afternoon hospital discharges using 2 patient flow management techniques. METHODS: The study was a preintervention/postintervention retrospective analysis observing all inpatients discharged across 19 inpatient units in a 484-bed, academic teaching hospital measuring calendar month discharge-before-noon percentage, patient satisfaction, and readmission rates. Patient satisfaction and readmission rates were used as baseline metrics. RESULTS: The discharge-before-noon percentage increased from 14% in the 11-month preintervention period to an average of 24% over the 11-month postintervention period, whereas patient satisfaction scores and readmission rates remained stable. CONCLUSIONS: Implementation of the 2 interventions successfully increased the percentage of discharges before noon yet did not achieve the goal of 40%. Patient satisfaction and readmission rates were not negatively impacted by the program.

Innovation amidst radical cost containment in health care.

The changing health care environment is requiring nurse executives within a hospital setting to design and implement innovative workforce practices that will both improve patient outcomes and lower costs. Since registered nurses comprise the largest percentage of a hospital's workforce, finding ways to incorporate them in these efforts is essential. The Magnet Recognition Program through the American Nurses Credentialing Center is one successful evidence-based strategy that can be adopted to engage nurses in quality improvement processes. This article describes how two community hospitals used the principles of the Magnet Recognition Program to develop and implement new approaches to meet the health care imperative of providing safer, high-quality, cost-effective care.

Impact of unit practice councils on culture and outcomes.

This article describes positive outcomes in culture, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, employee engagement, and clinical quality as a result of using shared governance, specifically unit practice councils (UPC) or staff councils, to implement Relationship-Based Care (RBC).

Partners advancing clinical excellence: building professional councils for quality improvement at six community hospitals.

Engaging bedside clinicians, especially nurses, is essential for the success of sustainable process improvement programs and thus for improving the quality of health care. Studies have shown that properly implemented professional councils can be effective in engaging and empowering bedside clinicians to create lasting and meaningful improvements. This case study describes a 5-year program to implement and operate staff-led councils to lead evidence-based practice (EBP) quality improvement initiatives at 6 community hospitals. The outcomes presented in this case study demonstrate that staff-led councils have the potential to improve patient safety and quality of care as evidenced by observed reductions in ventilator-associated pneumonias, central line-associated bloodstream infections, and mortality from acute myocardial infarction and severe sepsis.

Tools for developing a quality management program: human factors and systems engineering tools.

During the past 10 years, there has been growing acceptance and encouragement of partnerships between medical teams and engineers. Using human factors and systems engineering descriptions of process flows and operational sequences, the author's research laboratory has helped highlight opportunities for reducing adverse events and improving performance in health care and other high-consequence environments. This research emphasized studying human behavior that enhances system performance and a range of factors affecting adverse events, rather than a sole emphasis on human error causation. Developing a balanced evaluation requires novel approaches to causal analyses of adverse events and, more importantly, methods of recovery from adverse conditions. Recent work by the author's laboratory in collaboration with the Regenstrief Center for Healthcare Engineering has started to address possible improvements in taxonomies describing health care tasks. One major finding includes enhanced understanding of events and how event dynamics influence provider tasks and constraints. Another element of this research examines team coordination tasks that strongly affect patient care and quality management, but may be undervalued as "indirect patient care" activities.

A Unique Institutional Response to the Zika Virus Epidemic.

In 2015, Zika virus rapidly emerged as a concern for obstetric patients and health care providers as the disease spread geographically and it was discovered that Zika virus infection had the potential to cause devastating birth defects. Essentially overnight, obstetric care providers were faced with an influx of rapidly evolving information and an increased workload. New systems, workflows, and personnel were needed to effectively address the new patient care needs fueled by the burgeoning Zika virus epidemic. The University of California, San Francisco responded by filling a Zika Response Nurse Coordinator position to take on tasks necessary to design a systematic approach for Zika virus management. The Zika Response Coordinator at the University of California, San Francisco serves as a subject matter expert who counsels patients and health care providers, arranges testing and follow-up care after potential Zika virus exposure, and helps design the screening tools, protocols, and educational material needed to manage the evolving Zika virus response. The position has enabled a Zika virus response that has been tightly coordinated, consistent, and thorough without overburdening health care providers. The Zika Response Nurse Coordinator Role serves as a template for how institutions can model coordinated Zika virus care and prepare for future threats that will necessitate a focused and rapid response. Timely institutional financial support is critical for an appropriate response to emerging diseases for not only Zika virus but future epidemics as well.

Leadership and management training of pediatric intensivists: how do we gain our skills?

BACKGROUND: Intensivists manage a diverse team of health care professionals. For decades, business literature has recognized the value of leadership and management skills, yet this is relatively unexplored in critical care. OBJECTIVE: Investigate the status of intensivists' preparation for the clinical leadership and management roles that they will assume after medical training. DESIGN: Authoritative business leadership literature was reviewed to identify attributes of successful leadership and management relevant to critical care. A survey was designed to assess the process by which intensivists learn these attributes and to assess their perceived level of preparedness (20 items). Each survey item received a preparedness score structured as a Likert scale (1=not prepared, 5=very prepared), representing the averaged response to each item. In addition, an inadequate preparedness percentage was created representing the percentage of respondents answering "not at all prepared" and "hardly prepared" on the Likert-scaled items. SETTING: Pediatric Critical Care Medicine Board Review Course, Washington, DC, 2004. SUBJECTS: Physician course participants (n=259). INTERVENTION: Survey administration. MEASUREMENTS AND MAIN RESULTS: The response rate was 61% (n = 159). The majority of respondents (69%) had completed fellowship training (median, 1 yr posttraining). Modeling the behavior of other physicians was the dominant technique for leadership and management skill acquisition (86%). The respondents were taught these skills by a variety of sources (attendings, 92%; other fellows, 42%; nurses, 37%; teachers, 20%; residents, 14%). Most (82%) thought that leadership and management training was important or very important, yet only 47% had received any formal training (40% fellowship, 36% residency, 21% medical school, 16% masters, 30% other). Overall, respondents felt only "somewhat prepared" for the 20 leadership and management items surveyed (mean+/- sd of preparedness score, 2.8+/- 0.2). Respondents were least prepared to manage conflict within a team, manage conflict with other groups, and manage stress effectively (preparedness scores of 2.5, 2.4, and 2.6 and inadequate preparedness percentages of 19.5%, 15.7%, and 18.9%, respectively). Respondents were most prepared to "set high standards" (preparedness score=3.3). Of the respondents feeling at least somewhat prepared, only 33% credited medical training as preparing them. CONCLUSIONS: Although leadership and management training was perceived as important to this sample of pediatric generally young intensivists, most feel inadequately prepared for critical aspects of these responsibilities, most notably, stress and conflict management. These findings provide an opportunity for specific curriculum development in leadership and management for those believing these skills should be further refined.

Understanding "people" people.

Nearly all areas of business--not just sales and human resources--call for interpersonal savvy. Relational know-how comprises a greater variety of aptitudes than many executives think. Some people can "talk a dog off a meat truck," as the saying goes. Others are great at resolving interpersonal conflicts. Some have a knack for translating high-level concepts for the masses. And others thrive when they're managing a team. Since people do their best work when it most closely matches their interests, the authors contend, managers can increase productivity by taking into account employees' relational interests and skills when making personnel choices and project assignments. After analyzing psychological tests of more than 7,000 business professionals, the authors have identified four dimensions of relational work: influence, interpersonal facilitation, relational creativity, and team leadership. This article explains each one and offers practical advice to managers--how to build a well-balanced team, for instance, and how to gauge the relational skills of potential employees during interviews. To determine whether a job candidate excels in, say, relational creativity, ask her to describe her favorite advertising campaign, slogan, or image and tell you why she finds it to be so effective. Understanding these four dimensions will help you get optimal performance from your employees, appropriately reward their work, and assist them in setting career goals. It will also help you make better choices when it comes to your own career development. To get started, try the authors' free online assessment tool, which will measure both your orientation toward relational work in general and your interest level in each of its four dimensions.

System review: a method for investigating medical errors in healthcare settings.

System analysis is a process of evaluating objectives, resources, structure, and design of businesses. System analysis can be used by leaders to collaboratively identify breakthrough opportunities to improve system processes. In healthcare systems, system analysis can be used to review medical errors (system occurrences) that may place patients at risk for injury, disability, and/or death. This study utilizes a case management approach to identify medical errors. Utilizing an interdisciplinary approach, a System Review Team was developed to identify trends in system occurrences, facilitate communication, and enhance the quality of patient care by reducing medical errors.

Using financial metrics to prove and communicate value to management. Occupational health nurses as key players on the management team.

Successfully communicating value to management starts by gaining visibility and by knowing what management wants to hear. Communicating budget information, including cost savings and time value of money, is an essential skill for the occupational health nurse. The occupational health nurse must be able to speak the language of business to make a meaningful impact in the 21st century work environment.

Delegation can make (or break) your career.

Delegation is not a soft skill. Physician executives who do not delegate well and strategically cannot expect to achieve the top jobs now or in the future. It's not enough to have great communications skills to convey your vision. You won't achieve that vision alone; you must have a great team to bring that vision to fruition. However, you can't delegate your first and most important step--self-assessment. To maximize your strengths and minimize your weaknesses, you'll need a clear view of what makes you tick. Then start thinking about your executive role in these terms: Conceptualize work mandates as projects; choose people who are better than you for your team; and try to work yourself out of a job. By learning to delegate, physician executives can make their own careers (as well as those on their team) richer and more fulfilled.

Why executive teams fail and what to do.

Strife-torn management teams in hospitals and other health care organizations are hindering progress toward real change in the field. What can be done? CEOs and other senior executives often shy away from the "human" issues, but successfully dealing with those concerns will help management teams conquer the business issues.

Ten years after the IOM report: Engaging residents in quality and patient safety by creating a House Staff Quality Council.

Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.

The value analysis team: a shared mental model.

Value analysis teams, which standardize procurement and use of products across hospitals and health systems, have experienced great success in saving money for health care organizations. One example is the work of the Medical/Surgical Value Analysis Team at a larger New York metropolitan multihospital system, which has saved the system $1.2 million. This article examines what managers need to consider before forming such teams and how to guide the work. It will also look at the qualities and qualifications of the people who must be involved to make the process effective.