Barriers and facilitators to managing multiple chronic conditions: a systematic literature review.

The prevalence of multiple chronic conditions (MCC) is increasing, creating challenges for patients, families, and the health care system. A systematic literature search was conducted to locate studies describing patient's perceptions of facilitators and barriers to management of MCC. Thirteen articles met study inclusion criteria. Patients reported nine categories of barriers including financial constraints, logistical challenges, physical limitations, lifestyle changes, emotional impact, inadequate family and social support, and the complexity of managing multiple conditions, medications, and communicating with health care providers. Four facilitators were found, including health system support, individualized care education and knowledge, informal support from family and social systems, and having personal mental and emotional strength. Existing research on management of MCC from the patient's perspective is limited. Interventions are needed to improve management practices with particular attention to the knowledge and skills required by this unique population.

A regional assessment of information technology sophistication in Missouri nursing homes.

OBJECTIVE: To provide a state profile of information technology (IT) sophistication in Missouri nursing homes. METHOD: Primary survey data were collected from December 2006 to August 2007. A descriptive, exploratory cross-sectional design was used to investigate dimensions of IT sophistication (technological, functional, and integration) related to resident care, clinical support, and administrative processes. Each dimension was used to describe the clinical domains and demographics (ownership, regional location, and bed size). RESULTS: The final sample included 185 nursing homes. A wide range of IT sophistication is being used in administrative and resident care management processes, but very little in clinical support activities. CONCLUSION: Evidence suggests nursing homes in Missouri are expanding use of IT beyond traditional administrative and billing applications to patient care and clinical applications. This trend is important to provide support for capabilities which have been implemented to achieve national initiatives for meaningful use of IT in health care settings.

Creating a shared formulary in 7 critical access hospitals.

PURPOSE: This paper reports a case study of 7 Critical Access Hospitals' (CAH) and 1 rural referral hospital's successful collaboration to develop a shared formulary. METHODS: Study methods included document reviews, interviews with key informants, and use of descriptive statistics. FINDINGS: Through a systematic review and decision process, CAH formularies ranging in size from 667 to 1,351 items were compared, rationalized, and consolidated resulting in an 803-item shared formulary. While the individual CAHs were generally expected to list and stock the same 803 items in the shared formulary's pharmacy information system, they could individually determine the amount to be stocked for each item, as well as stock additional items not included on the shared formulary to reflect local provider preferences and services provided. Final stocked formulary items ranged from 592 to 786 items among the 7 CAHs. Major challenges and lessons learned in the course of developing a shared formulary related to: Meeting Logistics, Facilitator to Manage the Process, Organizing the Review Process, Management Support, Stakeholder Participation, Working Collaboratively, Decision-Making Process, Clarity of Charge, Meeting the Needs of Unique Services, Communicating with Providers, and Adjusting to a Shared Formulary. CONCLUSIONS: Collaborating in the development of a shared formulary allows for a greater range of decision-making expertise, shared workload, and an improved formulary. An organized and well-managed group decision-making process is essential to a successful collaboration.

Nurse burnout and patient safety outcomes: nurse safety perception versus reporting behavior.

This article examines the relationship between nurse burnout and patient safety indicators, including both safety perceptions and reporting behavior. Based on the Conservation of Resources model of stress and burnout, it is predicted that burnout will negatively affect both patient safety perceptions and perceived likelihood of reporting events. Nurses from a Veteran's Administration hospital completed the Maslach Burnout Inventory and safety outcomes subset of measures from the Agency for Healthcare Research and Quality Patient Safety Culture measure. After controlling for work-related demographics, multiple regression analysis supported the prediction that burnout was associated with the perception of lower patient safety. Burnout was not associated with event-reporting behavior but was negatively associated with reporting of mistakes that did not lead to adverse events. The findings extend previous research on the relationship between burnout and patient outcomes and offer avenues for future research on how nurse motivation resources are invested in light of their stressful work environment.

Development of a measure of clinical information systems expectations and experiences.

BACKGROUND/OBJECTIVES: The purpose of this study is to describe the development and initial psychometric properties of a measure of expectations and experiences regarding the impact of clinical information systems on work process and outcomes. RESEARCH DESIGN: Basic item analysis, confirmatory factor analysis, cross-validation factor analyses, and reliability analysis were used to assess the psychometric properties of the scale. SUBJECTS: The initial validation sample included registered nurses from a large Midwestern rural referral hospital that implemented electronic medical records and computerized provider order entry systems. Nurses from 3 other hospitals were used to cross-validate the factor structure of the scale. MEASURES: The scale assesses respondents' perceptions related to communication changes, changes in selected work behaviors, perceptions of the implementation strategy, and the impact on quality of patient care. The instrument can be used to assess perceptions before and after implementation. RESULTS: Confirmatory factor analysis generally supported the a priori factor structure for both expectations and experiences regarding the clinical information system. The consistency of the fit to the factor models was also high across the cross-validation samples. The scales demonstrated acceptable internal consistency in all the samples. CONCLUSIONS: Our findings suggest that the measure of clinical information systems expectations and experiences offers a valid and reliable tool for assessing the perceived impact of new clinical technology on work process and outcomes. This instrument can be useful before and after technology implementation by assisting in the identification of staff perceptions and concerns, thus allowing for targeted interventions to address these issues.

A 10-Rights framework for patient care quality and safety.

Recent reports in the lay and professional press document the failings of our patient care systems and have led to a multitude of suggestions for patient care quality and safety improvement initiatives. Given the complexity and range of services being offered, hospitals are launching numerous improvement initiatives in nearly all clinical care and support areas. This article describes a quality improvement framework, the "10 Rights," designed to help leaders better understand, organize, and prioritize patient care quality and safety issues and approaches. In addition to describing the framework, each Right is linked to 3 current national efforts at enhancing patient care quality and safety: the Joint Commission on Accreditation of Healthcare Organizations' National Patient Safety Goals, the National Quality Forum 30 Safe Practices, and the Centers for Medicare and Medicaid Services Hospital Quality Measures.

Clinical information technology in hospitals: a comparison between the state of Iowa and two provinces in Canada.

Despite the growing interest in adopting information technology (IT) in healthcare, the degree of technology sophistication varies among healthcare organizations. Changes in the health care sector and continuous pressure to improve the quality of care have driven the evolution of IT in hospitals. This paper provides an overview of clinical IT sophistication in a sample of U.S. hospitals, and compares clinical IT capacities in this sample with a sample of Canadian hospitals. The instrument used for the comparison measures three clinical dimensions of IT sophistication: functional sophistication, technological sophistication and integration level. Clinical areas that were considered include patient management, patient care activities and clinical support activities. The comparison between hospitals in Iowa and Canada shows differences in clinical IT sophistication between the two settings. Hospitals in Iowa appear to have more technologies but fewer computerized processes and integration of patient management activities. Technological sophistication however, was low in both samples. Our findings confirm the construct validity of the measurement instrument and show initial evidence of its generalizability. More initiatives using the instrument would lead to enhancement in IT assessment tools that can be used for evaluation of IT in relation to patient management and quality outcomes.

Implementation of hospital computerized physician order entry systems in a rural state: feasibility and financial impact.

OBJECTIVE: The aim of this study was to estimate the costs of implementing computerized physician order entry (CPOE) systems in hospitals in a rural state and to evaluate the financial implications of statewide CPOE implementation. METHODS: A simulation model was constructed using estimates of initial and ongoing CPOE costs mapped onto all general hospitals in Iowa by bed quantity and current clinical information system (CIS) status. CPOE cost estimates were obtained from a leading CPOE vendor. Current CIS status was determined through mail survey of Iowa hospitals. Patient care revenue and operating cost data published by the Iowa Hospital Association were used to simulate the financial impact of CPOE adoption on hospitals. RESULTS: CPOE implementation would dramatically increase operating costs for rural and critical access hospitals in the absence of substantial costs savings associated with improved efficiency or improved patient safety. For urban and rural referral hospitals, the cost impact is less dramatic but still substantial. However, relatively modest benefits in the form of patient care cost savings or revenue enhancement would be sufficient to offset CPOE costs for these larger hospitals. CONCLUSION: Implementation of CPOE in rural or critical access hospitals may depend on net increase in operating costs. Adoption of CPOE may be financially infeasible for these small hospitals in the absence of increases in hospital payments or ongoing subsidies from third parties.