Time Out: The Impact of Physician Burnout on Patient Care Quality and Safety in Perioperative Medicine.

Perioperative care delivery is a patient-centered, multidisciplinary process. It relies heavily on synchronized teamwork from a well-coordinated team. Perioperative physicians-surgeons and anesthesiologists-face enormous challenges in surgical care delivery due to changing work environments, post-COVID consequences, shift work disorder, value conflict, escalating demands, regulatory complexity, and financial uncertainties. Physician burnout in this working environment has become increasingly prevalent. It is not only harmful to physicians' health and well-being, but it also affects the quality and safety of patient care. Additionally, the economic costs associated with physician burnout are untenable due to the high turnover rate, high recruitment expenses, and potential early permanent exit from medical practice. In this deteriorating environment of unbalanced physician supply/demand, recognizing, managing, and preventing physician burnout may help preserve the system's most valuable asset and contribute to higher quality and safety of patient care. Leaders in government agencies, health care systems, and organizations must work together to re-engineer the health care system for better physicians and patient care.

Calling all nurses-Now is the time to take action on improving the quality of care in nursing homes.

For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee's vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented.

The relationship between nurse burnout, missed nursing care, and care quality following COVID-19 pandemic.

OBJECTIVES: To determine the relationship between nurse burnout, missed nursing care, and care quality following the COVID-19 pandemic. BACKGROUND: Quality of care and missed nursing care can be consequences of nurse burnout. Little is known about how these factors related to nurse burnout following the COVID-19 pandemic. DESIGN: This study used a cross-sectional correlational design and was conducted in 12 general hospitals across Thailand from August to October 2022. METHODS: 394 nurses providing direct nursing care to patients during the COVID-19 pandemic completed the survey. The Emotional Exhaustion (EE) subscale of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), MISSCARE survey, and quality of care reported by nurses were used to collect data. Descriptive statistics and logistic regression models were used to analyse the data. RESULTS: Approximately thirty-six percent of nurses had burnout following the COVID-19 pandemic. Missed nursing care was higher among nurses with burnout. Most participants reported illness/symptoms such as anxiety, fatigue, a lack of concentration, and sleeping problems. After adjusting for demographic characteristics, every additional unit of emotional exhaustion was associated with 1.61 times higher odds of missed nursing care, 3.37 times higher odds of poor quality of nurse care, and 2.62 times higher odds of poor quality of care for the overall unit. CONCLUSION: The study findings demonstrate that burnout is associated with missed nursing care and poor quality of care following the COVID-19 pandemic. RELEVANCE TO CLINICAL PRACTICE: Policymakers, hospital administrators, and nurse managers should invest in strategies to reduce nurse burnout, which can increase patient safety and quality of care.

Serious illness care quality during COVID-19: Identifying improvement opportunities in narrative reports from a National Bereaved Family Survey.

BACKGROUND: COVID-19 significantly impacted care delivery to seriously ill patients, especially around including family and caregivers in patient care. AIM: Based on routinely collected bereaved family reports, actionable practices were identified to maintain and improve care in the last month of life, with potential application to all seriously ill patients. DESIGN: The Veterans Health Administration's Bereaved Family Survey is used nationally to gather routine feedback from families and caregivers of recent in-patient decedents; the survey includes multiple structured items as well as space for open narrative responses. The responses were analyzed using qualitative content analysis with dual review. SETTING/PARTICIPANTS: Between February 2020 and March 2021, there were 5372 responses to the free response questions of which 1000 (18.6%) responses were randomly selected. The 445 (44.5%) responses from 377 unique individuals included actionable practices. RESULTS: Bereaved family members and caregivers identified four opportunities with a total of 32 actionable practices. Opportunity 1: Facilitate the use of video communication, included four actionable practices. Opportunity 2: Provide timely and accurate responses to family concerns, included 17 actionable practices. Opportunity 3: Accommodate family/caregiver visitation, included eight actionable practices. Opportunity 4: Offer physical presence to the patient when family/caregivers are unable to visit, included three actionable practices. CONCLUSION: The findings from this quality improvement project are applicable during a pandemic, but also translate to improving the care of seriously ill patients in other circumstances, such as when family members or caregivers are geographically distant from a loved one during the last weeks of life.

Three Missed Critical Nursing Care Processes on Labor and Delivery Units During the COVID-19 Pandemic.

OBJECTIVE: To examine the relationships of three missed critical nursing care processes on labor and delivery units with reduced nursing time at the bedside and adequacy of unit staffing during the COVID-19 pandemic in the United States. DESIGN: A cross-sectional survey. SETTING: Online distribution from January 14 to February 26, 2021. PARTICIPANTS: A national convenience sample (N = 836) of registered nurses employed on labor and delivery units. METHODS: We conducted descriptive analyses on respondent characteristics and critical missed care items adapted from the Perinatal Missed Care Survey. We conducted robust logistic regression analyses to assess the relationships of three missed critical nursing care processes (surveillance of fetal well-being, excessive uterine activity, and development of new maternal complications) with reduced nursing time at the bedside and adequacy of unit staffing during the COVID-19 pandemic. RESULTS: Less nursing time at the bedside was associated with greater odds of missing any of the critical aspects of care, adjusted odds ratio = 1.77, 95% confidence interval [1.12, 2.80]. Adequate staffing greater than or equal to 75% of the time was associated with lower odds of missing any of the critical aspects of care compared to adequate staffing less than or equal to 50% of the time, adjusted odds ratio = 0.54, 95% confidence interval [0.36, 0.79]. CONCLUSION: Perinatal outcomes are dependent on the timely recognition of and response to abnormal maternal and fetal conditions during childbirth. In times of unexpected complexity in care and resource constraints, a focus on three critical aspects of perinatal nursing care is needed to maintain patient safety. Strategies that enable bedside presence of nurses, including maintaining adequate unit staffing, may help to mitigate missed care.

A qualitative study of organisational resilience in care homes in Scotland.

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.

A Crisis in the Health System and Quality of Healthcare in Economically Developed Countries.

A health crisis caused by a pandemic tested the effectiveness of national healthcare systems by testing both financing and organizational and technical performance of patient care. At that time, the structural flaws in healthcare systems and inequalities in the level of healthcare in its different dimensions and countries due to resource constraints were highlighted. Therefore, the paper concentrates on investigating how the crisis in the health system affects the quality of healthcare services as a result of changes in the availability of financial, material, and human resources belonging to this system. The quantitative data, in terms of healthcare characterizing the OECD countries and selected non-member economies, treated as an example of economically developed regions, were chosen for the analysis. The study included five areas of resources, i.e., demographic, financial, human, technical, and the delivery of basic services in healthcare. T-test method for dependent samples, supplemented with Hedge's g statistics, was applied to test the differences between the mean values of individual indicators. The results indicate the occurrence of changes in some areas of the healthcare system due to a crisis. Identifying areas that are particularly vulnerable to sudden changes in the healthcare system helps to understand which resource areas need to be strategically managed first, as shifts in levels respond to deteriorating healthcare quality outcomes.

Changes in Primary Care Quality Associated With Implementation of the Veterans Health Administration Preventive Health Inventory.

Importance: The COVID-19 pandemic caused significant disruptions in primary care delivery. The Veterans Health Administration (VHA) launched the Preventive Health Inventory (PHI) program-a multicomponent care management intervention, including a clinical dashboard and templated electronic health record note-to support primary care in delivering chronic disease care and preventive care that had been delayed by the pandemic. Objectives: To describe patient, clinician, and clinic correlates of PHI use in primary care clinics and to examine associations between PHI adoption and clinical quality measures. Design, Setting, and Participants: This quality improvement study used VHA administrative data from February 1, 2021, through February 28, 2022, from a national cohort of 216 VHA primary care clinics that have implemented the PHI. Participants comprised 829 527 veterans enrolled in primary care in clinics with the highest and lowest decile of PHI use as of February 2021. Exposure: Templated electronic health record note documenting use of the PHI. Main Outcomes and Measures: Diabetes and blood pressure clinical quality measures were the primary outcomes. Interrupted time series models were applied to estimate changes in diabetes and hypertension quality measures associated with PHI implementation. Low vs high PHI use was stratified at the facility level to measure whether systematic differences in uptake were associated with quality. Results: A total of 216 primary clinics caring for 829 527 unique veterans (mean [SD] age, 64.1 [16.9] years; 755 158 of 829 527 [91%] were men) formed the study cohort. Use of the PHI varied considerably across clinics. The clinics in the highest decile of PHI use completed a mean (SD) of 32 997.4 (14 019.3) notes in the electronic health record per 100 000 veterans compared with 56.5 (35.3) notes per 100 000 veterans at the clinics in the lowest decile of use (P < .001). Compared with the clinics with the lowest use of the PHI, clinics with the highest use had a larger mean (SD) clinic size (12 072 [7895] patients vs 5713 [5825] patients; P < .001), were more likely to be urban (91% vs 57%; P < .001), and served more non-Hispanic Black veterans (16% vs 5%; P < .001) and Hispanic veterans (14% vs 4%; P < .001). Staffing did not differ meaningfully between high- and low-use clinics (mean [SD] ratio of full-time equivalent staff to clinician, 3.4 [1.2] vs 3.4 [0.8], respectively; P < .001). After PHI implementation, compared with the clinics with the lowest use, those with the highest use had fewer veterans with a hemoglobin A1c greater than 9% or missing (mean [SD], 6577 [3216] per 100 000 veterans at low-use clinics; 9928 [4236] per 100 000 veterans at high-use clinics), more veterans with an annual hemoglobin A1c measurement (mean [SD], 13 181 [5625] per 100 000 veterans at high-use clinics; 8307 [3539] per 100 000 veterans at low-use clinics), and more veterans with adequate blood pressure control (mean [SD], 20 582 [12 201] per 100 000 veterans at high-use clinics; 12 276 [6850] per 100 000 veterans at low-use clinics). Conclusions and Relevance: This quality improvement study of the implementation of the VHA PHI suggests that higher use of a multicomponent care management intervention was associated with improved quality-of-care metrics. The study also found significant variation in PHI uptake, with higher uptake associated with clinics with more racial and ethnic diversity and larger, urban clinic sites.

Defining measures of emergency care access in low-income and middle-income countries: a scoping review.

BACKGROUND: Over 50% of annual deaths in low-income and middle-income countries (LMICs) could be averted through access to high-quality emergency care. OBJECTIVES: We performed a scoping review of the literature that described at least one measure of emergency care access in LMICs in order to understand relevant barriers to emergency care systems. ELIGIBILITY CRITERIA: English language studies published between 1 January 1990 and 30 December 2020, with one or more discrete measure(s) of access to emergency health services in LMICs described. SOURCE OF EVIDENCE: PubMed, Embase, Web of Science, CINAHL and the grey literature. CHARTING METHODS: A structured data extraction tool was used to identify and classify the number of 'unique' measures, and the number of times each unique measure was studied in the literature ('total' measures). Measures of access were categorised by access type, defined by Thomas and Penchansky, with further categorisation according to the 'Three Delay' model of seeking, reaching and receiving care, and the WHO's Emergency Care Systems Framework (ECSF). RESULTS: A total of 3103 articles were screened. 75 met full study inclusion. Articles were uniformly descriptive (n=75, 100%). 137 discrete measures of access were reported. Unique measures of accommodation (n=42, 30.7%) and availability (n=40, 29.2%) were most common. Measures of seeking, reaching and receiving care were 22 (16.0%), 46 (33.6%) and 69 (50.4%), respectively. According to the ECSF slightly more measures focused on prehospital care-inclusive of care at the scene and through transport to a facility (n=76, 55.4%) as compared with facility-based care (n=57, 41.6%). CONCLUSIONS: Numerous measures of emergency care access are described in the literature, but many measures are overaddressed. Development of a core set of access measures with associated minimum standards are necessary to aid in ensuring universal access to high-quality emergency care in all settings.

Exploring the impact of employee engagement and patient safety.

BACKGROUND: Health service administrators are continually investigating new ways to improve the safety and quality of health services. A positive and powerful relationship between employee engagement and patient safety has been suggested in the research literature, and steps can be taken by employers to enhance engagement to improve the safety of health services, particularly considering the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: The aim of this review was to explore the current literature on the impact of employee engagement on patient safety. METHODS: A review of peer-reviewed literature relating to the impact of employee engagement on patient safety within health services between January 2015 and May 2021 was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline Complete, Scopus, Health Business Elite and Business Source Ultimate databases. A search of grey literature using the Bielefeld Academic Search Engine database was also completed. RESULTS: Of relevant articles, 3693 were identified, of which 15 studies were included in this review. Ten articles measured employee engagement using existing, validated tools, whereas patient safety was most frequently assessed through surveys seeking staff member's perceptions of safety or the quality of care they provide. Overall, there appeared to be a positive correlation between employee engagement and patient safety, but the strength of the relationship varied. CONCLUSION: Anecdotal accounts of improving employee engagement and improving patient safety abound, and the evidence reviewed appears in agreement. However, research into the impact of employee engagement on patient safety is in its early stages. As health service managers consider the best use of funding to support safe and high-quality care, evidence to support the positive impact employee engagement has on patient safety may be useful in managing the fallout from the COVID-19 pandemic.

The Disparity Challenge: How Governance Can Lead the Way on Diversity, Equity, and Inclusion.

Hospitals, health systems, pharmaceutical companies, device makers, and payers have a responsibility to provide high-quality, innovative, cost-effective care and services to their patients and communities. The governing boards of these institutions provide the vision, strategy, and resources and choose the best leaders to achieve those outcomes. Healthcare boards can play a vital role in ensuring that resources are distributed where they are most needed. The need is great in communities of racial and ethnic diversity, which are almost always underserved-a preexisting condition that came into stark relief during the COVID-19 pandemic. Widespread inequities in access to care, housing, nutrition, and other components of good health were documented, and boards promised to pursue change, including becoming more diverse themselves. More than two years later, healthcare boards and senior executives remain mostly white and male. This continuing reality is especially unfortunate because diversity in governance and the C-suite has positive implications for financial, operational, and clinical success, including solving persistent inequities and disparities experienced in disadvantaged communities.

Patient perceptions of care quality and discharge information following same-day cardiac catheterization laboratory procedures: A mixed-methods study.

AIMS: To examine patients' perceptions of care quality following a same-day procedure in the cardiac catheterization laboratory and understand the extent to which they were prepared for discharge. DESIGN: Single-centre, mixed-methods study. METHODS: Postdischarge, online survey of patients who underwent a same-day procedure in the cardiac catheterization laboratory (n = 150) and one-on-one interviews with 13 of these patients. RESULTS: Survey responses were positive with mean scores between 4.39-4.83 out of five and 63.3% of respondents (n = 95) extremely likely to recommend the service to others. Interview data analysis identified three themes: the care experience, information and education for safe discharge, and follow-up needs. Participants spoke highly of their interactions with clinicians and were satisfied with their care experience. Mode and content of information delivered varied, with some participants lacking guidance about postdischarge health management and clarity about follow-up plans. PATIENT OR PUBLIC CONTRIBUTION: Participants were patients.

Healthcare Quality Management and Integrated Care Pathways (ICPs).

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is one of the largest causes of morbidity and chronic mortality and a public health problem of high importance. In Italy, COPD afflicts 5.6% of adult (3.5 million people) and is responsible for 55% of all deaths related to respiratory diseases. Smokers have a higher risk, in fact up to 40% develop the disease. From the Covid-19 pandemic, the most affected population is the elderly (mean age 80 years old), with previous chronic diseases, in 18% with chronic respiratory. The aim of the present work was to validate and measure the outcomes produced by the recruitment and care of COPD patients enrolled by an Healthcare Local Authority in the corresponding Integrated Care Pathways (ICPs) in order to measure how a multidisciplinary, systemic and e-health monitored care impacts upon mortality and morbidity. MATERIALS AND METHODS: Enrolled patients were stratified through the GOLD guidelines classification, a unified method to discriminate the various degrees of severity of COPD, using specific spirometric cut-points and providing homogeneous classes of patients. Monitoring examinations include simple spirometry, global spirometry, diffusing capacity measurement, pulse oximetry, EGA, 6-minute walk test. Chest Rx, chest CT, ECG may also be required. The severity of COPD identifies the timing of monitoring, which involves a fixed annual re-assessment for mild offset clinical forms, biannually in case of exacerbation, a quarterly cadence in moderate forms that becomes bimonthly in severe forms. RESULTS: In 2344 enrolled patients (46% women and 54% men, mean age 78 yo) 18% had GOLD severity 1, 35% GOLD 2, 27% GOLD 3 and 20% GOLD 4. In addition, 73% of patients had at least one other chronic comorbidity, mainly diabetes or hypertension, and in 48% both. The data analysis showed that the population followed in e-health presented a 49% reduction in improper hospital admissions and a 68% reduction in clinical exacerbations compared to the population enrolled in the ICPs but not followed also in e-health. Smoking habits present at the time of patient enrollment in the ICPs remained in 49% of the total population enrolled and in 37% of the population enrolled in e-health. The patients enrolled in GOLD 1 and 2 obtained the same benefits both if treated in e- health and if treated in the clinic. However, GOLD 3 and 4 patients instead presented better compliance if treated in e-health and continuous monitoring allowed punctual and early interventions such as to reduce complications and hospitalization. CONCLUSION: The e-health approach made possible to ensure proximity medicine and personalization of care. Indeed, the implemented diagnostic treatment protocols, if properly followed and monitored, are able to control complications and impact the mortality and disability of chronic disease. The advent of e-health and ICT tools are demonstrating a great support capacity for care taking that also allows greater adherence to patient care pathways, even more than the protocols up to now identified, characterized by a monitoring programmed over time, enhancing a patients and their families quality of life improvement.

Expanding Telehealth in Adolescent Care: Moving Beyond the COVID-19 Pandemic.

Telehealth use has expanded dramatically through the coronavirus disease 2019 pandemic, allowing improved access and convenience for many patients. Before coronavirus disease 2019, there was limited research on the use of telehealth to reach adolescents. During the pandemic, research revealed that adolescents and their parents felt telehealth was convenient and provided confidential, high-quality care. As the use of telehealth to reach adolescents evolves in the postpandemic period, medical providers have the opportunity to transform how care is delivered to adolescents but must strive to ensure that the care is designed to decrease digital health inequities and provide coordinated care.

Differences in Perception of Healthcare Management between Patients and Professionals.

Patient perception and the organizational and safety culture of health professionals are an indirect indicator of the quality of care. Both patient and health professional perceptions were evaluated, and their degree of coincidence was measured in the context of a mutual insurance company (MC Mutual). This study was based on the secondary analysis of routine data available in databases of patients' perceptions and professionals' evaluations of the quality of care provided by MC Mutual during the period 2017-2019, prior to the COVID-19 pandemic. Eight dimensions were considered: the results of care, coordination of professionals, trust-based care, clinical and administrative information, facilities and technical means, confidence in diagnosis, and confidence in treatment. The patients and professionals agreed on the dimension of confidence in treatment (good), and the dimensions of coordination and confidence in diagnosis (poor). They diverged on confidence in treatment, which was rated worse by patients than by professionals, and on results, information and infrastructure, which were rated worse by professionals only. This implies that care managers have to reinforce the training and supervision activities of the positive coincident aspects (therapy) for their maintenance, as well as the negative coincident ones (coordination and diagnostic) for the improvement of both perceptions. Reviewing patient and professional surveys is very useful for the supervision of health quality in the context of an occupational mutual insurance company.