A value-based model of job performance.

This agent-based model contributes to a theory of corporate culture in which company performance and employees' behaviour result from the interaction between financial incentives, motivational factors and endogenous social norms. Employees' personal values are the main drivers of behaviour. They shape agents' decisions about how much of their working time to devote to individual tasks, cooperative, and shirking activities. The model incorporates two aspects of the management style, analysed both in isolation and combination: (i) monitoring efforts affecting intrinsic motivation, i.e. the company is either trusting or controlling, and (ii) remuneration schemes affecting extrinsic motivation, i.e. individual or group rewards. The simulations show that financial incentives can (i) lead to inefficient levels of cooperation, and (ii) reinforce value-driven behaviours, amplified by emergent social norms. The company achieves the highest output with a flat wage and a trusting management. Employees that value self-direction highly are pivotal, since they are strongly (de-)motivated by the management style.

Correlation of Colorectal Surgical Skill With Patient Outcomes: A Cautionary Tale.

BACKGROUND: Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement. OBJECTIVE: Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons. DESIGN: Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates. SETTINGS: The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals. PATIENTS: Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons. MAIN OUTCOME MEASURES: Main outcome measures included 30-day risk-adjusted postoperative complications. RESULTS: The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41). LIMITATIONS: Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms. CONCLUSIONS: Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).

Later in Career Surgeon Performance Assessment: Why, When, What, and by Whom.

BACKGROUND: The average age of practicing surgeons is increasing, consistent with the overall population; one third of Americans are over 55 years of age. Aging is clearly associated with varying loss of skills, yet there are no age-based state or federal requirements for professional skill assessment; or age-specific criteria for board certification, recertification, or retirement. Capability based policies are preferred to age based criteria (3) but very few organizations have such policies in place. METHODS: A Delphi method study was utilized to answer: When should a surgeon's performance be assessed? If mandatory, then at what age? If adverse events triggered, then what events? What should be assessed? By whom? And, who determines the result-based actions? A systematic literature review indicated institutional stakeholders. On the basis of this a 20-member expert panel was created drawing from 13 US pediatric institutions: orthopaedic surgical department-division chiefs (14), children's hospital general counsel (3), surgical chief responsible for hospital bylaws-medical peer review (1), OR nursing managers (2). Three rounds of iterative questionnaires were utilized. RESULTS: A 100% response rate was achieved. Consensus supported recommendations included: Mandatory assessments should start at the age of 65 years, after a medical disability, and or at the request of other health care professionals. Assessments should include criteria for behavioral health, mental capacity, physical health, surgical performance, 360 human resource reviews, and surgical adverse events. Assessments should be performed by an external group with validated tools and reviewed by the department and overall surgeon-in-chief. The final decisions for an action plan based on results should be made by departmental and overall surgeon-in-chief. CONCLUSIONS: Our expert panel Delphi method study recognized aging is a risk factor in performance and recommended surgeon assessments should be automatically triggered by the age of 65 years, negative health events, or serious performance concerns. Assessments should be multifaceted, fair, reliable with minimal bias, and performed by an external professional group. Decisions should be managed by departmental and surgical chiefs. LEVEL OF EVIDENCE: Level V.

Automatic and Objective Assessment of Motor Skills Performance in Flexible Bronchoscopy.

BACKGROUND: Motor skills have been identified as a useful measure to evaluate competency in bronchoscopy. However, no automatic assessment system of motor skills with a clear pass/fail criterion in flexible bronchoscopy exists. OBJECTIVES: The objective of the study was to develop an objective and automatic measure of motor skills in bronchoscopy and set a pass/fail criterion. METHODS: Participants conducted 3 bronchoscopies each in a simulated setting. They were equipped with a Myo Armband that measured lower arm movements through an inertial measurement unit, and hand and finger motions through electromyography sensors. These measures were composed into an objective and automatic composite score of motor skills, the motor bronchoscopy skills score (MoBSS). RESULTS: Twelve novices, eleven intermediates, and ten expert bronchoscopy operators participated, resulting in 99 procedures available for assessment. MoBSS was correlated with a higher diagnostic completeness (Pearson's correlation, r = 0.43, p < 0.001) and a lower procedure time (Pearson's correlation, r = -0.90, p < 0.001). MoBSS was able to differentiate operator performance based on the experience level (one-way ANOVA, p < 0.001). Using the contrasting groups' method, a passing score of -0.08 MoBSS was defined that failed 30/36 (83%) novice, 5/33 (15%) intermediate, and 1/30 (3%) expert procedures. CONCLUSIONS: MoBSS can be used as an automatic and unbiased assessment tool for motor skills performance in flexible bronchoscopy. MoBSS has the potential to generate automatic feedback to help guide trainees toward expert performance.

Impact of surgeon work duration prior to distal pancreatectomy on perioperative outcomes: a propensity score matching analysis.

BACKGROUND: Surgeons are likely to get progressively fatigued during the course of a normal workday. The objective of this study was to evaluate the impact of surgeon work duration prior to performing distal pancreatectomy (DP) on the perioperative outcome, especially frequency of grade II or higher grade postoperative complications. METHODS: Patients undergoing DP for all causes were divided into two groups according to surgeon work hours prior to performing DP: group A (less than 5 h) and group B (5-10 h). Propensity score matching (PSM) analysis (1:1) were performed to balance the baseline characteristics between the two groups. Intraoperative complications were compared between the two groups. Postoperative complications and their severity were followed up for 60 days and mortality for 90 days. The study was powdered to identify a 15% difference in the incidence of grade II or higher grade complications. RESULTS: By using PSM analysis, the patients in group A (N = 202) and group B (N = 202) were well matched regarding demographics, comorbidities, operative technique, pancreatic texture and pathology. There was no significant difference in the incidence of grade II or higher grade complications between the two groups. There was no difference in clinically relevant postoperative pancreatic fistula, percutaneous drainage, readmission, reoperation, or morality. Group B was associated with a higher incidence of intraoperative organ injury, which could be managed successfully during the operation. CONCLUSION: The retrospective study demonstrated that the surgeon work duration did not significantly affect the clinical outcome of DP.

Association of Severity of Dry Eye Disease with Work Productivity and Activity Impairment in the Dry Eye Assessment and Management Study.

PURPOSE: To evaluate the association of dry eye disease (DED) severity with work productivity and activity impairment. DESIGN: Longitudinal, observational study within a randomized clinical trial. PARTICIPANTS: People with moderate to severe DED who enrolled in the multicenter Dry Eye Assessment and Management (DREAM) study. METHODS: Participants completed the Work Productivity and Activity Impairment questionnaire at 0, 6, and 12 months and were assessed in parallel for symptoms and signs (conjunctival and corneal staining, tear film break-up time [TBUT], and Schirmer test) of DED. Associations of work productivity and activity impairment with symptom and signs were evaluated with linear regression models using generalized estimating equations and controlling for demographics and comorbidities. MAIN OUTCOME MEASURES: Work productivity (employment, absenteeism, presenteeism, overall work impairment) and activity impairment. RESULTS: Among 535 participants at baseline, 279 (52%) were employed, and mean activity impairment was 24.5%. Among those employed, the mean score was 2% for absenteeism, 18% for presenteeism, and 19.6% for overall work impairment. Higher Ocular Surface Disease Index (OSDI) symptom scores were associated with greater absenteeism, presenteeism, and activity impairment. Overall work impairment and activity impairment were greater by 4.3% and 4.8%, respectively, per 10-unit difference in OSDI score (P < 0.001). Longitudinal increases (worsening) in OSDI scores were associated with increasing impairment in work and non-work-related activity: 2.0% and 3.1% per 10 units in OSDI, respectively (P < 0.01). Worse corneal staining and TBUT were associated with higher overall work impairment and activity level (P ≤ 0.04). However, longitudinal changes in these two signs were not associated with changes in work productivity or activity impairment. CONCLUSIONS: Worse symptoms of DED are associated with decreased work productivity and activity level, both cross-sectionally (interindividually) and longitudinally within person (intraindividually). Corneal staining and TBUT are associated with interindividual differences but not intraindividual changes in work productivity and activity impairment.

The Effect of Health Evolution Plan on Health System Responsiveness: An Experience of Health System Reform from Iran.

The purpose of this study was to investigate the effect of the Health Evolution Plan (HEP) on Health System Responsiveness (HSR) in hospitals of Hamadan, Iran. Data were collected before and after the implementation of the HEP by interviewing hospital inpatient referrals about factors relating to responsiveness. The difference between the mean responsiveness scores before (2014) and after (2018) implementation of the HEP was not significant. The study findings demonstrate that, even though one of the most important goals of the HEP was the improvement of HSR, the responsiveness of hospitals was unchanged.

US Department of Defense Warfighter Brain Health Initiative: Maximizing performance on and off the battlefield.

The US Department of Defense (DoD) recognizes the importance of warfighter brain health with the establishment of the Warfighter Brain Health Initiative and Strategy. For a warfighter, also known as a service member, to perform at their highest level, cognitive and physical capabilities must be optimized. This initiative addresses brain health, brain exposures, to include blast overpressure exposures from weapons and munitions, traumatic brain injury (TBI), and long-term or late effects of TBI. The DoD's pursuit of maximal strength hinges on the speed of decisions (neurocognitive) and detection of brain injury when it occurs. The strategy creates a framework for deliberate, prioritized, and rapid development of end-to-end solutions for warfighter brain health. Through this strategy, DoD is addressing the needs of our service members, their families, line leaders/commanders, and their communities at large. The implications of this initiative and strategy are noteworthy for practitioners because the DoD Warfighter Brain Health construct lends itself to nurse practitioner engagement in clinical practice, patient education, policy development, and emerging research.

Nurse practitioner productivity measurement: An organizational focus and lessons learned.

Nurse practitioners (NPs) are valued members of the health care team, and their numbers are growing each year. The volume of literature demonstrating the impact on quality, safety, patient satisfaction, and access measures is substantial and growing. There is a significant lack of measurement methods and outcomes related to NP contributions to organizational productivity. The construction of strategy for measurement of NP productivity is a prerequisite for studies focusing on impact. Models that are being used to measure physician productivity are available to be examined in terms of their applicability to the NP work force. In 2005, the Deputy Under Secretary for Health for Operations and Management directed Veterans Healthcare Administration (VHA) to develop a productivity-based model for physicians using the Medicare Resource-Based Relative Value Scale, which was created in 1992 to provide guidance on determining payment for physician services. In 2015, the VHA set out to set standards for productivity measurements for NPs, physician assistants, and clinical nurse specialists, and in doing so, the physician productivity model was adapted for the NP workforce. The work of adapting the model will be presented in this article. The specific steps in the process of measurement, operational definitions for work activities, and calculations are provided. The article concludes with a discussion of lessons learned and next steps.

Maintaining High Professional Standards, morally, ethically and fairly: what doctors need to know right now.

Facing an investigation into performance concerns can be one of the most traumatic events in a doctor's career, and badly handled investigations can lead to severe distress. Yet there is no systematic way for National Health Service (NHS) Trusts to record the frequency of investigations, and extremely little data on the long-term outcomes of such action for the doctors. The document-Maintaining High Professional Standards in the Modern NHS (a framework for the initial investigation of concerns about doctors and dentists in the NHS)-should protect doctors from facing unfair or mismanaged performance management procedures, which include conduct, capability and health. Equally, it provides NHS Trusts with a framework that must be adhered to when managing performance concerns regarding doctors. Yet, very few doctors have even heard of it or know about the provisions it contains for their protection, and the implementation of the framework appears to be very variable across NHS Trusts. By empowering all doctors with the knowledge of what performance management procedures exist and how best practice should be implemented, we aim to ensure that they are informed participants in any investigation should it occur.

Short Version of Self-Assessment Scale of Job Performance / Versión reducida de la Escala de Autoevaluación del Desempeño en el Trabajo

This paper aims to reduce the job performance self-assessment scale as well as control the response Bias and acquiescence bias using vignettes anchors and inverted items. The original scale database was composed of 20 items divided into two factors: task and context. For the reduction, the ten items with higher factor loads and thresholds were chosen. The reduced scale was estimated by a general factor and two specific dimensions: task and context, representing a bifactor model, with adequate adjustment indicators (RMSEA = .05; TLI = .98). To control response bias and acquiescence, a second study was carried out, in which the responses were recoded and factor analyses were performed in order to make a comparison of the results with and without the use of the vignettes and inverted items. The results indicated that the vignettes improved the factorial loads; however, the reversed items did not perform better than the vignettes

Este artículo tiene como objetivo reducir la Escala de autoevaluación de Desempeño en el trabajo, como también controlar el direccionamiento de respuesta y aprobación, utilizando la técnica de viñetas y elementos invertidos. Para la reducción de la escala, se utilizó el banco de datos de la escala original, compuesta por 20 elementos divididos en dos factores: tarea y contexto. Para la reducción, fueron elegidos los 10 elementos con mayores cargas factoriales y thresholds. La escala reducida fue estimada por un factor general y dos dimensiones específicas: Tarea y contexto, representando un modelo bifactor, con indicadores de ajustes adecuados (RMSEA = 0,05; TLI = 0,98). Para controlar el direccionamiento de respuesta y aprobación, fue realizada una colecta de datos, en la cual las respuestas fueron recodificadas y realizados análisis factoriales con la finalidad de realizar una comparación de los resultados con y sin la utilización de viñetas y elementos invertidos. Los resultados apuntaron a que las viñetas mejoraron las cargas factoriales de los análisis, y que los elementos invertidos no tuvieron mejores resultados además de las viñetas

Impact of organizational silence and favoritism on nurse's work outcomes and psychological well-being.

OBJECTIVES: The study aimed to assess the impacts of organizational silence and favoritism on work outcomes and psychological wellbeing among nurses working in hospitals. BACKGROUND: Literature on the organizational climate among nurses in hospital settings is limited, particularly on favoritism and organizational silence and their effect on nurses. METHODS: Purposive sampling was used to gather 549 registered nurses who participated in this cross-sectional study. Standardized self-report questionnaires were used to gather the necessary data. RESULTS: Years in the nursing profession (ß = .028, P < .001), location of work (ß = 0.481, P < .001), and facility size (ß = 0.451, P < .001) strongly predicted organizational silence, while years in the present unit (ß = 0.020, P = .022) and last shift length (ß = 0.200, P = .012) predicted favoritism. Favoritism (ß = 0.226, P = .028) significantly influenced turnover intention in nurses. CONCLUSION: Higher levels of favoritism within the organization are strongly linked with nurses' turnover intention. Few individual and organizational variables predicted organizational silence and favoritism. IMPLICATIONS TO NURSING MANAGEMENT: The results of this study provide an insight to the effects of organizational silence and favoritism towards nurses' work outcomes and psychological wellbeing. Improving the channels of communication among the healthcare team is vital to promote inclusivity among healthcare workers and enhance organizational viability.

Reconstructing family doctors' psychological well-being and motivation for effective performance in China: the intervening role of psychological capital.

BACKGROUND: Family practice and family doctors are critical part of China's primary healthcare delivery in a constantly evolving society. As the first point of contact with the medical system, family practices require physically and psychologically sound and a well-motivated family doctors at all times. This is because an error can lead to loss of lives as gatekeepers of the medical system. Our study explored the extent to which positive psychological capital promotes higher performance among family doctors. METHODS: A questionnaire was used to collect data from family doctors in Shanghai, Nanjing, and Beijing. We applied a structural equation analysis to analyze the causal relationship among the variables. RESULTS: We found out that psychological well-being and job involvement significantly influences the performance of family doctors in China. The study also noted that psychological capital moderates the relationship between psychological well-being attainment, job involvement, and performance. CONCLUSIONS: Studies have shown that these pressures affect their well-being considerably. For this reason, a healthcare professional who experiences positive emotions affects the total behavior which culminates into performance.

A quantitative assessment of the parameters of the role of receptionists in modern primary care using the work design framework.

BACKGROUND: Amidst increased pressures on General Practice across England, the receptionist continues to fulfil key administrative and clinically related tasks. The need for more robust support for these key personnel to ensure they stay focussed and motivated is apparent, however, to be effective a more systematic understanding of the parameters of their work is required. Here we present a valuable insight into the tasks they fulfil, their relationship with colleagues and their organisation and their attitudes and behaviour at work collectively defined as their 'work design'. METHODS: Our aim was to quantitatively assess the various characteristics of receptionists in primary care in England using the validated Work Design Questionnaire (WDQ) a 21 point validated questionnaire, divided into four categories: task, knowledge and social characteristics and work context with a series of sub-categories within each, disseminated online and as a postal questionnaire to 100 practices nationally. RESULTS: Seventy participants completed the WDQ, 54 online and 16 using the postal questionnaire with the response rate for the latter being 3.1%. The WDQ suggested receptionists experience high levels of task variety, task significance and of information processing and knowledge demands, confirming the high cognitive load placed on receptionists by performing numerous yet significant tasks. Perhaps in relation to these substantial responsibilities a reliance on colleagues for support and feedback to help negotiate this workload was reported. CONCLUSION: The evidence of our survey suggests that the role of modern GP receptionists requires an array of skills to accommodate various administrative, communicative, problem solving, and decision-making duties. There are ways in which the role might be better supported for example devising ways to separate complex tasks to avoid the errors involved with high cognitive load, providing informal feedback, and perhaps most importantly developing training programmes.

Quality of work among part-time nurses and its relationship to job satisfaction and work values: A cross-sectional study.

This study compared the quality of work between part-time and full-time nurses and investigated the relationship between quality of work and satisfaction with the work itself among part-time nurses. Quality of work was measured by specific work content and job characteristics. It was hypothesized that work content would affect satisfaction mediated by job characteristics. Furthermore, the moderating effects of intrinsic work values on the relationship between job characteristics and satisfaction were examined. A cross-sectional survey was conducted with 444 part-time and 795 full-time nurses working in Japanese hospital wards in 2017. The Mann-Whitney U test, χ2 test, and hierarchical multiple regressions were used. Work content differed between part-time and full-time nurses; however, job characteristics and satisfaction showed little difference. Work content was not associated with satisfaction mediated by job characteristics. Within the job characteristics, autonomy and feedback had positive effects on the satisfaction of part-time nurses, whereas interaction with work values was insignificant. When assigning work, it is important to allow part-time nurses to experience higher levels of autonomy and feedback regardless of their intrinsic work values.

Disentangling the Relationship between Physician and Organizational Performance: A Signal Detection Approach.

Background. In previous research, we employed a signal detection approach to measure the performance of general practitioners (GPs) when deciding about urgent referral for suspected lung cancer. We also explored associations between provider and organizational performance. We found that GPs from practices with higher referral positive predictive value (PPV; chance of referrals identifying cancer) were more reluctant to refer than those from practices with lower PPV. Here, we test the generalizability of our findings to a different cancer. Methods. A total of 252 GPs responded to 48 vignettes describing patients with possible colorectal cancer. For each vignette, respondents decided whether urgent referral to a specialist was needed. They then completed the 8-item Stress from Uncertainty scale. We measured GPs' discrimination (d') and response bias (criterion; c) and their associations with organizational performance and GP demographics. We also measured correlations of d' and c between the 2 studies for the 165 GPs who participated in both. Results. As in the lung study, organizational PPV was associated with response bias: in practices with higher PPV, GPs had higher criterion (b = 0.05 [0.03 to 0.07]; P < 0.001), that is, they were less inclined to refer. As in the lung study, female GPs were more inclined to refer than males (b = -0.17 [-0.30 to -0.105]; P = 0.005). In a mediation model, stress from uncertainty did not explain the gender difference. Only response bias correlated between the 2 studies (r = 0.39, P < 0.001). Conclusions. This study confirms our previous findings regarding the relationship between provider and organizational performance and strengthens the finding of gender differences in referral decision making. It also provides evidence that response bias is a relatively stable feature of GP referral decision making.

Autism and Employment: Implications for Employers and Adults with ASD.

A small but growing body of research has been conducted on vocational outcomes for adults with Autism Spectrum Disorder (ASD); however, limited resources have been directed towards understanding outcomes for competitive employers. While ASD does present with a range of social communication and adaptive behavior deficits, adults on the spectrum may be extremely efficient, trustworthy, reliable, and cost-effective employees. Nevertheless, fewer than half of young adults with ASD maintain a job. Many businesses are unwilling to hire these capable candidates, concerned among other things about an increase in supervision costs and a decrease in productivity. This is a bias based on misperceptions; the financial and social benefits of hiring adults with ASD, for businesses and the individual, often outweigh the costs.

S-MEDUTA: Combining Balanced Scorecard with Simulation and MCDA Techniques for the Evaluation of the Strategic Performance of an Emergency Department.

The scope of this paper is to propose a new integrated methodology for the evaluation of the strategic performance of a healthcare organization. In order to find the optimal strategy for an emergency department, we propose the combination of BSC, simulation, and UTASTAR algorithm. Through the simulation model, the stakeholders have the ability to evaluate the effect of their decisions on a number of KPIs that are important for the successful implementation of strategy on the ED. This method is able to provide a set of completed results (e.g., scores, weights, value functions, etc.), which may help the organization to evaluate and revise its strategy.

Risk Adjustment of the Modified Low Back Pain Disability Questionnaire and Neck Disability Index to Benchmark Physical Therapist Performance: Analysis From an Outcomes Registry.

BACKGROUND: Patient-reported outcomes (PROs) have been touted as the ultimate assessment of quality medical care and have been proposed as performance measures after appropriate risk adjustment. Although spine conditions represent the most common orthopedic disorders, the most used PROs for disabilities related to the back and neck-the Modified Low Back Pain Disability Questionnaire (MDQ) and the Neck Disability Index (NDI)-have not been evaluated as performance measures. OBJECTIVE: The objective of this study was to benchmark physical therapists' performance in the management of spine conditions not involving surgery through the use of risk-adjusted MDQ and NDI outcomes. DESIGN: This was a retrospective observational study. METHODS: Data were accessed for patients seeking physical therapy with no history of related surgery for back or neck pain (315,274 treatment episodes) between January 2015 and June 2018. Patients with complete data, including initial and matched final MDQ or NDI, were considered for analysis (182,276 patients; 2799 physical therapists). Linear models controlling for baseline PRO and patient characteristics predicted PRO change for each patient. An aggregated performance ratio of actual PRO change to predicted PRO change was calculated for each physical therapist, and then empirical bootstrapping was used to develop the median performance ratio and its confidence intervals. Physical therapists who met a 40-patient threshold for either cohort (MDQ or NDI) were classified as "outperforming," "meeting expectations," or "underperforming" relative to predicted values using these 95% confidence intervals. RESULTS: Performance ratios indicated that 10% and 11% of physical therapists outperformed, 79% and 78% met expectations, and 11% and 11% underperformed relative to the risk-adjusted predicted change in the MDQ (1240 therapists; 97,908 patients) and NDI (461 therapists; 26,123 patients), respectively. To demonstrate the clinical importance of risk adjustment, clinical performance was evaluated in the seemingly homogeneous subset of 208 physical therapists within 0.5 SD of the median baseline MDQ and the median actual change in the MDQ. Following risk adjustment, 2 physical therapists were classified in each of the outperforming and underperforming cohorts. LIMITATIONS: The secondarily obtained observational data used were not collected for research purposes. Additionally, the analyses were limited by missing baseline information and follow-up PROs. CONCLUSIONS: The risk-adjusted performance ratios for the MDQ and NDI resulted in disparate conclusions regarding the quality of care compared with the raw, unadjusted change scores. According to the baseline and unadjusted change in the MDQ, even physical therapists in the most homogeneous sample were differentiated following appropriate risk adjustment. Clinically important improvements in actual PROs were observed in the outperforming but not in the underperforming physical therapists. Clinically meaningful differences in the performance ratio are unknown and are a limitation to clinical application and an opportunity for future research.