The role of the champion in infection prevention: results from a multisite qualitative study.

BACKGROUND: Although 20% or more of healthcare-associated infections can be prevented, many hospitals have not implemented practices known to reduce infections. We explored the types and numbers of champions who lead efforts to implement best practices to prevent hospital-acquired infection in US hospitals. METHODS: Qualitative analyses were conducted within a multisite, sequential mixed methods study of infection prevention practices in Veteran Affairs and non-Veteran Affairs hospitals in the USA. The first phase included telephone interviews conducted in 2005-2006 with 38 individuals at 14 purposively selected hospitals. The second phase used findings from phase 1 to select six hospitals for site visits and interviews with another 48 individuals in 2006-2007. RESULTS: It was possible for a single well-placed champion to implement a new technology, but more than one champion was needed when an improvement required people to change behaviours. Although the behavioural change itself may appear to be an inexpensive and simple solution, implementation was often more complicated than changing technology because behavioural changes required interprofessional coalitions working together. Champions in hospitals with low-quality working relationships across units or professions had a particularly challenging time implementing behavioural change. Merely appointing champions is ineffective; rather, successful champions tended to be intrinsically motivated and enthusiastic about the practices they promoted. Even when broad implementation is stymied, champions can implement change within their own sphere of influence. CONCLUSIONS: The types and numbers of champions varied with the type of practice implemented and the effectiveness of champions was affected by the quality of organisational networks.

A critical review of recent US market level health care strategy literature.

In this review, we argue that it would be profitable if the neoclassical economic theories that have dominated recent US market level health care strategy research could be complemented by greater use of sociological frameworks. Sociological theory can address three central questions that neoclassical economic theories have tended to slight: (1) how decision-makers' preferences are determined; (2) who the decision-makers are; and (3) how decision-makers' plans are translated into organizational action. We suggest five sociological frameworks that would enable researchers to address these issues better relative to market level strategy in health care. The frameworks are (1) institutional theory, (2) organizational ecology, (3) social movements, (4) social networks, and (5) internal organizational change. A recent global trend toward privatization of health care provision makes US market level strategy research increasingly applicable to non-US readers.

Nursing home-to-nursing home transfers: prevalence, time pattern, and resident correlates.

OBJECTIVES: To characterize the time pattern of nursing home-to-nursing home transfers and assess which resident characteristics are associated with transfers. METHODS: Minimum Data Set assessments of all Maine and New York nursing home residents were obtained for 1994-1996. The hazard rate for nursing home transfers was estimated by nonparametric statistical techniques, censored at loss to follow-up. Comparisons of resident characteristics were made between those who transferred and those who stayed at their initial facility. RESULTS: Residents of Maine nursing homes were considerably more likely to transfer than were New York residents. Transfer rates declined during the first 2 years after admission and remained stable thereafter. Correlates of transfers were similar across states. Residents who transferred were more likely to be male, to be married, to be younger, to have better cognitive and physical health, to have Medicare or private payment sources (vs. Medicaid), and to have pressure ulcers. Rural location did not affect the likelihood of transfer. CONCLUSIONS: This study provides the most detailed information to date on the prevalence, timing, and correlates of nursing home transfers. These transitions occur most frequently early in the stay but continue at a lower rate even among long stayers. This information is useful for understanding lifetime dynamics of long-term-care utilization. Several barriers to mobility appear to be present (eg, less generous payment source, health limitations, and absence of a spouse). The higher transfer rates observed in Maine might imply that institutional or other factors limit the mobility of New York residents.

How other members of the top management team see the nurse executive.

This study compared how top-level organizational groups within Veterans Affairs Medical Center (VAMC) top management teams perceived nurse executives' participation in strategic decision making. Nurse executives' perceptions of their own involvement in strategic decision making generally agreed with the views of both chiefs of staff and directors. However, the associate director's perceptions of the nurse executive's involvement often differed significantly with those of the nurse. Nurse executives will be better prepared to function effectively within the top management team if they are aware of patterns in how they are perceived by other members.

Do market-level hospital and physician resources affect small area variation in hospital use?

This study evaluates the effect of market-level physician and hospital resources on hospital use. It is anticipated that higher hospital discharges are associated with (1) greater hospital and physician resources, (2) more differentiated hospital and physician resources, and (3) higher levels of teaching intensity in the community. Data on 14 modified diagnostically related groups (DRGs) and 58 hospital market communities in Michigan are analyzed during a 7-year period. Findings indicate that physician resources, hospital resources, differentiation of hospital and physician resources, and teaching intensity contribute only modestly to discharges, holding constant the socioeconomic attributes of the community and adjusting for the variation in hospital use over time. With the inclusion of hospital and physician resource variables, socioeconomic factors remain important determinants of the variation across market communities. Findings are discussed in terms of their implications for health care organizations, managed care programs, and cost control efforts in general.

Decision-making activity and influence of nurse executives in top management teams.

This study assesses the impact on decision-making when introducing the nurse executive into the top management team (TMT) in Veterans Affairs Medical Centers. Results indicate that nurse executives formally elevated to the TMT were no more likely to perceive greater involvement in decision-making than non-TMT nurse executives or nurses informally appointed to the TMT. However, nurse executives in all categories perceived themselves as more involved in strategic decisions than other TMT members.

Organizational characteristics associated with agency position in community care networks.

This study examines how organizational characteristics affect agency participation and centrality in community service networks. We find that the network structure of agency relations varies for administrative and client-related activities among the 69 agencies studied, which include all but the most isolated agencies serving people with physical disabilities in a single community. In identifying structurally equivalent groups using network analysis, we find that all types of agencies except HMOs are found throughout community service networks. Analyses show that among the five types of relations, minimal intergroup activity occurs within funding and planning networks and that organizational size and ownership are the best organizational predictors of network location and centrality. Non-profits are the most central for planning and client referrals, and large agencies are the most central for funding. We explore the implications of these findings, particularly for sustaining cooperation within the service networks and for the role of non-profits and medical providers in the community.

Top management team characteristics and innovation in nursing homes.

This study examines how the demographic characteristics of the top management team in 236 nursing homes can affect the adoption of innovations. The computerization of the Minimum Data Set (MDS) is the innovation we examine, and tenure, education, and involvement in a professional society are the demographic characteristics investigated. Controlling for 10 organizational and environmental factors, the results are generally significant for each of these demographic factors. However, the results for top managers of nonchain nursing homes show a greater association between these demographic factors and innovation than the results for top managers of nursing homes belonging to a chain. We discuss these results in terms of their significance for innovation research, nursing homes, and top management.

Specialization and diversification in the nursing home industry.

Recent increases in the types of services offered by nursing facilities and in the formation of specialized care units have resulted in the emergence of two distinct but broadly defined types of services: subacute and long-term care. The authors examine the market, regulatory, and structural incentives behind diversification and specialization and speculate how these trends will affect the future of the nursing home industry.

Special care hospice units in nursing homes.

The emergence of hospice care in the nursing home is a trend about which we have virtually no information. As a first step to a more comprehensive examination of this phenomenon, we provide a descriptive analysis of nursing homes that contain special care hospice units and a preliminary analysis of the determinants of nursing homes with special care hospice units. We found that being small, being a proprietary facility, being part of a chain, and being located in a more competitive environment are significantly related to having a hospice special care unit.

Factors associated with nursing home staff turnover.

This study examines whether, while controlling for local economic conditions, job design and other organizational factors affect facility aide turnover rates in a sample of 250 nursing homes from 10 states. Facility characteristics were largely based on administrator and director of nursing interviews conducted in 1993 as part of the Health Care Financing Administration's evaluation of the Resident Assessment Instrument (RAI) implementation. Aide turnover was significantly reduced by involvement in interdisciplinary care plan meetings. Turnover rates were higher in for-profit homes. Aide involvement in assessments, aide training and workload, case mix severity, payor source mix, and facility size were not significantly related to aide turnover.

The impact of market and organizational characteristics on nursing care facility service innovation: a resource dependency perspective.

OBJECTIVE: Using resource dependency theory as a conceptual framework, this study investigates both the organizational and environmental factors associated with an emerging health care service delivery innovation, the provision of specialty care in designated units in nursing care facilities. We consider two types of specialty units, Alzheimer's Disease and subacute care. DATA SOURCES: The Medicare/Medicaid Automated Certification Survey (MMACS) data file was merged with local market area data obtained from the 1992 Area Resource File and with state level regulatory data. STUDY DESIGN: The likelihood of providing Alzheimer's Disease or subacute care in dedicated units was estimated by separate logistic regressions. PRINCIPAL FINDINGS: Results indicate that facilities with fewer Medicare patients are more likely to operate a dedicated Alzheimer's care unit, while facilities located in markets with a large HMO population and greater hospital supply are more likely to operate a subacute care unit. While competition among nursing homes, for the most part, is an incentive to innovate, greater regulatory stringency appears to constrain the development of specialty care units of both types. Finally, organizational characteristics (e.g., size and proprietary status) appear to be important enabling factors influencing the propensity to provide specialty care in dedicated units. CONCLUSIONS: Nursing care facilities are moving toward providing specialty care units partly as a response to a growing demand by resource providers and to maintain a competitive edge in tighter markets. Loosening regulation directed at cost containment would further encourage the development of specialty care but should be preceded by some evaluation of population needs for specialty care and the effectiveness of specialty care units.

Differences in patient demographics and expenditures among Medicare hospice providers.

This study compares differences in demographics and Medicare expenditures for beneficiaries in 4 different types of hospice programs: hospital based, skilled nursing facility (SNF) based, home health agency based, and freestanding across the years 1987-1990. Enrollment and expenditures in hospital based hospices is increasing faster than for other types of hospices; at the same time, both hospital and SNF based programs are attracting greater proportions of non-white and female beneficiaries but fewer beneficiaries with non-cancer diagnoses. These results indicate that expansion of the hospice benefit has increased institutionalized use of hospice and that this institutionalized form of hospice may benefit demographic groups that previously underutilized the hospice benefit.

Changing career patterns of deans of medicine, 1940-1992.

This study examined the occupational experiences of deans of medicine during five decades, 1940-1992, to explore whether changes in their prior career paths could explain the increasing turnover of deans that occurred during this period. The results indicate that deans are now more likely to have had previous administrative experience, as either chairs or lower-level administrators, than they were in earlier decades; in most cases, this administrative experience has occurred in the same institutions in which they were appointed to the deanship ("inside hires"). However, the greater number of deans with prior administrative experience cannot explain the increasing turnover of deans because administrative experience was associated with longer tenures. The kinds of positions the deans took upon leaving office did not change during the study period, particularly among those who had short tenures of four years or less. During the five decades, inside hires leaving during their first five years in office most often moved into faculty, chair, or lower-level administrative positions. Outside hires leaving during their first five years most often went on to higher-level administrative positions. The study results do not support the hypothesis that the shorter tenures of deans in recent decades are related to their previous professional experiences or to increasing opportunities for deans to move to better positions. In conclusion, the authors emphasize that organizational and environmental factors rather than deans' individual characteristics must have played the dominant role in the increasing turnover of deans of medicine in recent years.

Turnover of deans of medicine during the last five decades.

This report uses published information on the tenures of the 862 U.S. medical school deans who served from 1940-41 through 1990-91 to ascertain whether the turnover of deans has increased historically. The data confirm the wide-spread impression that there has been increasing instability of medical school leadership in recent decades. The proportion of deans who survive to a specific tenure in office has diminished, and the proportion of schools with new deans has increased, although with marked yearly fluctuations. Furthermore, the frequency of deans' turnover has not been evenly distributed among medical schools. Some schools have had large numbers of short-tenured deans, while other schools have had only a few deans over the five decades studied. The authors speculate that the rise in the turnover of deans may be related to the criteria used for their selection and/or because American academic medical centers have grown in size and are increasing in organizational complexity. The authors urge that future research that explores the causes of recent deans' turnover should incorporate modern management and statistical techniques and consider organizational variables as well as the personal and professional characteristics of deans.

HIV-1 seroprevalence and risk behaviors in an urban African-American community cohort.

OBJECTIVES: Previous attempts at obtaining population estimates of human immunodeficiency virus type 1 (HIV-1) seroprevalence have been beset by problems of cooperation bias. As part of the fourth round of study with an urban African-American community cohort, the following investigation was aimed at assessing HIV-1 prevalence and the relative importance of sex and drug injection as risk factors in infection. METHODS: Personal interviews were conducted in the home with 364 respondents, followed by voluntary blood sample collection from 287 of these individuals. RESULTS: Blood assays showed a point prevalence of 8.4% HIV-1 seropositivity in this community cross section, with a higher female-to-male ratio than appears among acquired immunodeficiency syndrome (AIDS) case reports. Most infected persons were unaware and unsuspecting of their infection. CONCLUSIONS: First, findings underscore the need to focus on risk behaviors rather than on risk groups. Second, the smaller than 2:1 ratio of infected men to women suggests that current AIDS case reports seriously underestimate HIV-1 infection among certain cohorts of African-American women. Finally, widespread ignorance of own infected status and inaccurate risk assessment signal the substantial task for community health educators in reaching inner-city African-American men and women at risk.