Defining and Measuring Safety Climate: A Review of the Construction Industry Literature.

Safety climate measurements can be used to proactively assess an organization's effectiveness in identifying and remediating work-related hazards, thereby reducing or preventing work-related ill health and injury. This review article focuses on construction-specific articles that developed and/or measured safety climate, assessed safety climate's relationship with other safety and health performance indicators, and/or used safety climate measures to evaluate interventions targeting one or more indicators of safety climate. Fifty-six articles met our inclusion criteria, 80% of which were published after 2008. Our findings demonstrate that researchers commonly defined safety climate as perception based, but the object of those perceptions varies widely. Within the wide range of indicators used to measure safety climate, safety policies, procedures, and practices were the most common, followed by general management commitment to safety. The most frequently used indicators should and do reflect that the prevention of work-related ill health and injury depends on both organizational and employee actions. Safety climate scores were commonly compared between groups (e.g. management and workers, different trades), and often correlated with subjective measures of safety behavior rather than measures of ill health or objective safety and health outcomes. Despite the observed limitations of current research, safety climate has been promised as a useful feature of research and practice activities to prevent work-related ill health and injury. Safety climate survey data can reveal gaps between management and employee perceptions, or between espoused and enacted policies, and trigger communication and action to narrow those gaps. The validation of safety climate with safety and health performance data offers the potential for using safety climate measures as a leading indicator of performance. We discuss these findings in relation to the related concept of safety culture and offer suggestions for future research and practice including (i) deriving a common definition of safety climate, (ii) developing and testing construction-specific indicators of safety climate, and (iii) focusing on construction-specific issues such as the transient workforce, subcontracting, work organization, and induction/acculturation processes.

Change in frontline supervisors' safety leadership practices after participating in a leadership training program: Does company size matter?

INTRODUCTION: The majority of construction companies are small businesses and small business often lack the resources needed to ensure that their supervisors have the safety leadership skills to build and maintain a strong jobsite safety climate. The Foundations for Safety Leadership (FSL) training program was designed to provide frontline leaders in all sized companies with safety leadership skills. This paper examines the impact of the FSL training by size of business. METHODS: Leaders, defined as foremen or other frontline supervisors, from small, medium, and large construction companies were recruited to participate in a study to evaluate the degree to which the FSL changed their understanding and use of the leadership skills, safety practices and crew reporting of safety-related conditions. We used linear mixed modeling methods to analyze pre-post training survey data. RESULTS: Prior to the training, leaders from small and medium sized companies reported using safety leadership skills less frequently than those from large ones. After the training, regardless of business size, we observed that the FSL training improved leaders understanding of safety leadership skills from immediately before to immediately after the training. Additionally, leaders reported greater use of safety leadership skills, safety practices, and crew reporting of safety-related conditions from before to two-weeks after the training. However, those from small and medium sized companies reported the greatest improvement in their use of safety leadership skills. CONCLUSIONS: The FSL training improves safety leadership outcomes regardless of the size company for which the leader worked. However, the FSL may be even more effective at improving the safety leadership skills of leaders working for smaller sized construction companies or those with lower baseline levels of safety leadership skills. Practical applications: The majority of construction companies employ a small number of employees and therefore may not have the resources to provide their frontline leaders with the leadership training they need to be effective leaders who can create a strong jobsite safety climate. The Foundations for Safety Leadership (FSL) training can help fill this gap.

Opinions and clinical practices related to diagnosing and managing patients with psychogenic movement disorders: An international survey of movement disorder society members.

Five hundred and nineteen members of the Movement Disorder Society completed a 22-item questionnaire probing diagnostic and management issues in psychogenic movement disorders (PMD). When patients showed definite evidence of PMD with no other unexplained clinical features, approximately 20% said they informed patients of the diagnosis and requested no further neurological testing. The 51% who reported conducting standard neurological investigations to rule out organic causes before presenting the diagnosis to such patients had fewer years of fellowship training and fewer PMD patients seen per month. A non-PMD diagnosis was correlated with patients' normal social or personal functioning, little or no employment disruption, lack of non-physiologic findings, and lack of psychiatric history. Ongoing litigation was more predictive of the PMD diagnosis for US compared to non-US respondents. Two thirds of respondents, more commonly younger and academic clinician researchers, refer PMD patients to a psychiatrist or mental health specialist while also providing personal follow up. Physician reimbursement, insurability of PMD patients, and ongoing litigation interfered with managing PMD patients to a greater extent in the US compared to non-US countries. Acceptance of the diagnosis by the patient and identification and management of psychological stressors and concurrent psychiatric disorders were considered most important for predicting a favorable prognosis. These findings suggest that expert opinions and practices related to diagnosing and managing PMD patients differ among movement disorders neurologists. Some of the discrepancies may be accounted for by factors such as training, type of practice, volume of patients, and country of practice, but may also reflect absence of practice guidelines.

Leadership skills for strengthening jobsite safety climate.

INTRODUCTION: Construction foremen may lack the leadership skills needed to create a strong jobsite safety climate. Many construction companies address this by sending their lead workers to the OSHA 30-h course; however the course does not include a leadership training module. This article describes the development and pilot testing of such a module and evaluation surveys designed to address this training gap. METHODS: A 17-member curriculum development team, numerous subject matter experts, and an instructional design company helped us develop a comprehensive set of teaching resources and a set of survey instruments for evaluating the materials' effectiveness on improving safety leadership and safety climate. All materials and surveys were pilot tested with representative members of the target population. RESULTS: Pilot surveys showed high reliability and data collected on the resulting Foundations for Safety Leadership (FSL) module indicated that the majority of foremen thought the training was helpful or valuable, particularly the discussion questions. The majority said they intended to use the skills on the jobsite. With the exception of the role-play activities, the trainers rated highly all other components, especially the videos and discussion questions. Modifications were made to the training materials and surveys based on pilot test findings. The most important result of the development and pilot testing efforts is that the OSHA Training Institute (OTI) included the FSL as an elective in the OSHA 30-h course. CONCLUSIONS: The FSL module fills a needed skills gap by providing safety leadership training to all foremen who might otherwise not have access to it through their company or union. The continued success of the FSL training will be ensured by dissemination via the OSHA 30-h course, an established nationwide safety training program. Practical applications: The FSL training module has already been widely accepted by the construction industry as a useful approach for providing construction foremen/See new abstract lead workers with the knowledge and skills they need to become more effective jobsite safety leaders.

The Safety Climate Assessment Tool (S-CAT): A rubric-based approach to measuring construction safety climate.

INTRODUCTION: This paper presents the development and validation of a new rubric-based Safety Climate Assessment Tool (S-CAT). The S-CAT gives companies the opportunity to use rubric descriptors, rather than traditional Likert scale responses, to self-assess their level of safety climate maturity and receive a composite score benchmarked against others in the S-CAT database. METHOD: The S-CAT is composed of 37 separate indicators of 8 safety climate factors identified by construction industry subject matter experts. The eight factors have between three and six indicators each with its own rubric-based response-scale. The scales comprise descriptors for five levels of safety climate maturity ranging from "inattentive" to "exemplary." Nine hundred and eighty-five respondents working in the construction industry completed the S-CAT via our online safety climate website. We used company recordable incident rates (RIR) to assess the S-CAT's criterion-related validity. RESULTS: Cronbach alphas for each factor ranged from 0.77 to 0.90 and a confirmatory factor analysis supported the hypothesized eight factor structure with a higher-order safety climate factor. Seven of the eight factor scores, as well as the overall S-CAT score, were significantly negatively correlated with RIR. Moreover, a relative weights analysis indicated that a weighted combination of the eight safety climate factors explained 27% of the variance in organizational RIR. CONCLUSIONS: These findings provide evidence that the S-CAT is a reliable tool allowing construction companies to self-assess their safety climate along eight different factors. Moreover, the S-CAT was significantly associated with organizational injury rates. Practical applications: We discuss how companies can use the rubric descriptors to strengthen their safety management systems and improve their safety climate maturity.

A training intervention to improve frontline construction leaders' safety leadership practices and overall jobsite safety climate.

INTRODUCTION: The 2.5 h Foundations for Safety Leadership (FSL) training program teaches construction supervisors the leadership skills they need to strengthen jobsite safety climate and reduce adverse safety-related outcomes. METHODS: Using a quasi-experimental prospective switching replications study design, we examined (1) if FSL-trained jobsite safety leaders would report improved understanding and practice of the FSL leadership skills, safety practices and crew reporting of safety related conditions, and (2) if their crew perceived a change in (a) their supervisors' practices, (b) their own safety practices and reporting of safety-related conditions, and (c) overall jobsite safety climate. Twenty construction sub-contracting companies were recruited and randomly assigned to either an early or lagged-control training group. Participating supervisors and workers completed surveys at multiple time points before and after the FSL training. We used linear mixed modeling to test changes over time. RESULTS: Only supervisors in the early group reported a statistically significant improvement in their understanding and practice of the leadership skills as well as safety practices from before to 2- and 4-weeks post-training. Overall, no significant change was detected in crew-reported outcomes from before to after their supervisors' participated in the FSL training. CONCLUSIONS: These results provide evidence that the FSL training can, at least in the short-term, improve construction frontline leaders' jobsite leadership skills. Future research could include an evaluation of FSL refresher activities and a longer-term follow-up. Practical applications: The Foundations for Safety Leadership (FSL) program fills an identified need for construction frontline supervisors to learn and practice critical safety leadership skills on the jobsite. It has already reached over 60,000 leaders and has the potential to reach over 100,000 each year during either an OSHA 30-h or a stand-alone course.

Intervention effectiveness evaluation criteria: promoting competitions and raising the bar.

The Intervention Evaluation Competition at the Work, Stress, and Health conference in Miami (March 2006) highlighted the importance of intervention evaluation studies that promote safety and health at work. A retitled, "Best Practices Evaluation Competition," has been included in the March, 2008, Work, Stress, and Health conference, in Washington, DC. This brief note describes the development of the criteria used to evaluate the manuscripts. The criteria are discussed with respect to (a) improving the science of evaluation methodology, (b) promoting the highest ethical standards in intervention evaluation, and (c) using the current criteria as a starting point for continuing to raise the bar for evaluation methodology. The policy implications of the evaluation criteria are discussed as well.

Construction Safety and Health in the USA: Lessons From a Decade of Turmoil.

The construction industry is one of the largest and also most hazardous industries in the USA. It is affected more severely by the business cycle than most other industries. We examined industry trends during the last decade including the severe recession. During 2008 to 2010, as a result of the recession, 2.7 million workers and 20% of all employers left the industry. By 2010, the number and rate of traumatic fatalities had reached its lowest point ever, only to gradually increase again as the industry recovered from the recession. The risks of a fatality were disproportionate with employer size. The small employers (<20 employees), which account for 37.5% of employment, were responsible for 57% of all fatalities. These small employers are less likely to embrace essential safety culture practices and are slow to adopt new approaches to occupational safety and health. These employers-especially those which hire immigrant workers and self-employed workers-lag far behind in terms of adopting even essential elements of good safety cultures and management practices. Currently, there are no restrictions on going into business as a construction contractor or seeking employment as a construction worker. There is a great need to find ways to establish minimum qualifications for becoming a construction contractor and for becoming a construction worker. Some jurisdictions have established minimum occupational safety and health training. This is a good start, but qualifications must include greater emphasis on minimum skills requirements. State and local jurisdictions have good policy tools which could be deployed for this purpose but which have largely been neglected: licensing of both companies and workers could include skills qualifications; construction permits could include requirements for occupational safety and health; and greater use of criminal prosecution could be pursued where it is obvious that basic requirements for safety and health have been ignored.

Research Methodologies for Total Worker Health®: Proceedings From a Workshop.

OBJECTIVE: There is growing interest in the NIOSH Total Worker Health program, specifically in the process of designing and implementing safer, health-promoting work and workplaces. A Total Worker Health (TWH) Research Methodology Workshop was convened to discuss research methods and future needs. METHODS: Twenty-six experts in occupational safety and health and related fields reviewed and discussed current methodological and measurement issues and those showing promise. RESULTS: TWH intervention studies face the same challenges as other workplace intervention studies and some unique ones. Examples are provided of different approaches and their applications to TWH intervention studies, and desired developments in the TWH literature. CONCLUSIONS: This report discusses and outlines principles important to building the TWH intervention research base. Rigorous, valid methodologic, and measurement approaches are needed for TWH intervention as well as for basic/etiologic, translational, and surveillance research.

Ready or not, here they come: acting interns' experience and perceived competency performing basic medical procedures.

OBJECTIVE: To assess acting interns' (AI's) experience with and perceived level of competency performing 6 basic medical procedures. DESIGN: Fourth-year medical students at the University of Cincinnati (UCCOM) are required to complete 2 AI rotations in Internal Medicine. All AIs in 2003-2004 (n = 150) and 2004-2005 (n = 151) were asked to complete a survey about whether during each of their rotations they had performed and felt competent performing the following procedures: phlebotomy, intravenous (IV) catheter insertion, arterial blood gas (ABG), nasogastric (NG) tube insertion, lumbar puncture (LP), and Foley catheter insertion. RESULTS: Four hundred sixty-seven of 601 possible surveys (across both years and both rotations) were completed (78% response rate). During both rotations, relatively few students performed the procedures, ranging from 9% for Foley catheter insertion (24/208) to 50% for both ABG and NG tube insertion (130/259). The two procedures most often performed were ABG (range 46-50%) and NG tube insertion (range 42-50%). Feelings of competency varied from 12% (LP) to 82% (Foley catheter). Except for LP, if students performed a procedure at least once, they reported feeling more competent (range 85% for ABG to 96% for Foley catheter insertion). Among the students who performed LP during a rotation, many still did not feel competent performing LPs: 23 (74%) in rotation 1 and 20 (40%) in rotation 2. CONCLUSION: Many fourth-year students at UCCOM do not perform basic procedures during their acting internship rotations. Procedural performance correlates with feelings of competency. Lumbar puncture competency may be too ambitious a goal for medical students.

The effect of offering international health training opportunities on family medicine residency recruiting.

BACKGROUND AND OBJECTIVES: While medical students' interest in family medicine declines, and residency programs face recruiting challenges, interest in international health is increasing. We studied the influence of offering an international health track (IHT) on residency recruitment. METHODS: We surveyed all graduates between the years 1994--2003 of a family medicine residency program offering an optional IHT (n=90). Descriptive and bivariate analyses characterized and compared the geographic scope and residency selection criteria of IHT participants and nonparticipants. RESULTS: The response rate was 77%. Compared to nonparticipants in the IHT, residents who participated in the IHT reported coming a significantly greater median distance from their medical school training site (250--499 miles versus 0--99) and from their "home" (500--999 miles versus 100--249) for residency training. Participants reported that the factor most positively influencing their choice of this residency training site over others was the IHT (mean=+2.5, standard deviation [SD]=0.90), outscoring, on average, location, faculty quality, resident quality, and spousal preference. Nonparticipants' choices were influenced most by the traditionally reported selection factors location (mean=+2.37, SD=1.14) and faculty quality (mean=+2.29, SD=0.97). CONCLUSIONS: One program's experience suggests that the presence of international health training opportunities may influence the residency selection choices of family medicine residents. As family medicine moves to reinvent residency education and to recapture student interest, attractive training models that integrate clinical, community, and public health should be evaluated further.

Effectiveness of a geriatric medical student scholars program: a qualitative assessment.

In 2003, the University of Cincinnati College of Medicine initiated a 4-year Geriatric Medical Student Scholars (GMSS) program in which a selected group of 14 medical students participated in a variety of extracurricular geriatrics-related activities such as one-on-one mentoring and discussion groups. These students were also required to compose journal entries describing GMSS program-related activities using a semistructured on-line computer program designed specifically for this purpose. The reflective journals, in combination with the American Geriatrics Society (AGS) competencies, were used to evaluate the degree to which the GMSS program achieved its goal of enhancing students' understanding of the complex health and social challenges facing older adults. Using a confirmatory qualitative analysis strategy, the AGS competencies served as an a priori codebook to evaluate the student journal entries. Of the original 53 AGS competencies identified as being relevant for a first- or second-year medical student, 74% were used at least one time, and only 26% were never used. These findings strongly suggest that the GMSS program successfully moved this group of first- and second-year medical students closer to at least understanding the content of many of the AGS competencies by providing them with geriatrics-related experiences and a geriatrics-related framework they could draw on when participating in curricular and extracurricular activities. The findings also point to the potential value of using reflective journaling as a tool for conducting process evaluation of medical education interventions.

Reliable implementation of evidence: a qualitative study of antenatal corticosteroid administration in Ohio hospitals.

BACKGROUND: Antenatal corticosteroids (ANCS) reduce complications of preterm birth; however, not all eligible women receive them. Many hospitals and providers do not have the right processes and conditions to enable ANCS administration with high reliability. The objective of this study was to understand conditions that enable delivery of ANCS with high reliability among hospitals participating in an Ohio Perinatal Quality Collaborative (OPQC) ANCS project. METHODS: We conducted focus groups and semistructured interviews with members of the OPQC project team (n=27) and other care providers (n=70) using a purposeful sample of 6 sites involved in the OPQC ANCS project. Participants including nurses (n=57), attending obstetricians (n=17), physician trainees (n=21) and certified nurse midwives (n=2) were asked to reflect on their experiences and to identify factors contributing to optimal use of ANCS. Focus groups and interviews were transcribed verbatim and were analysed by a multidisciplinary team using an iterative approach that combined inductive and deductive methods to identify and categorise themes. RESULTS: Six major themes supporting reliable implementation of ANCS at these hospitals emerged including: (1) presence of a high reliability culture, (2) processes that emphasise high reliability, (3) timely and efficient administration process, (4) multiple disciplines are involved, (5) evidence of benefit supports ANCS use and (6) benefit is recognised at all levels of the care team. CONCLUSIONS: Our findings identify the key processes and supports needed to ensure delivery of ASCS with high reliability and are reinforced by implementation and reliability science. They are useful for foundation of the successful implementation of other evidence-based practices at high levels of reliability.

If you've seen one construction worksite stretch and flex program you've seen one construction worksite stretch and flex program.

BACKGROUND: Work-related Musculoskeletal Disorders (WMSD) account for approximately one-third of all injuries in the U.S. construction industry. Many companies have implemented stretch and flex (s/f) programs to reduce WMSD despite a lack of evidence showing effectiveness. METHODS: We conducted a mixed-methods study to understand (a) why employers continue devoting resources to s/f programs; (b) how programs vary; and (c) any actual or perceived benefits. RESULTS: Nineteen safety and health professionals were interviewed and 133 more (13.3% response rate) completed an on-line survey. Fifty-six percent had implemented an s/f program with the primary goal of reducing WMSDs; though most did not review data to determine goal achievement. Program structure varied in terms of duration, frequency, and type of stretches. There was strong agreement about mandating attendance but not participation, due primarily to liability issues. Cost was a factor when deciding to implement a program but not for sustaining one. The majority had not implemented other ergonomic prevention activities, but many had started conducting daily safety huddles for task and safety planning. Those reporting a reduction in WMSDs agreed that it was not due to the s/f program alone and that other benefits included increased worker camaraderie, communication, and collaboration. CONCLUSION: Although there is little to no scientific evidence showing that they work as intended, construction companies continue to implement s/f programs with the goal of reducing WMSDs. Bringing work crews together for s/f activities has prompted employers to also begin conducting daily safety huddles. Although employers may not be able to link reduced WMDS to an s/f program, the ancillary benefits may warrant the time and resources. PRACTICAL APPLICATIONS: S/f programs should be only one component of a more comprehensive ergonomics prevention program. Conducting daily safety huddles at the same time also may enhance worker communication, camaraderie, collaboration and improve safety outcomes.

Geriatric medicine fellowship programs: a national study from the Association of Directors of Geriatric Academic Programs' Longitudinal Study of Training and Practice in Geriatric Medicine.

This report documents the development and growth of geriatric medicine fellowship training in the United States through 2002. A cross-sectional survey of geriatric medicine fellowship programs was conducted in the fall 2001. All allopathic (119) and osteopathic (7) accredited geriatric medicine fellowship-training programs in the United States were involved. Data were collected using self-administered mailed and Web-based survey instruments. Longitudinal data from the American Medical Association (AMA) and the Association of American Medical Colleges' (AAMC) National Graduate Medical Education (GME) Census, the Accreditation Council for Graduate Medical Education (ACGME), and the American Osteopathic Association (AOA) were also analyzed. The survey instrument was designed to gather data about faculty, fellows, program curricula, and program directors (PDs). In addition, annual AMA/AAMC data from 1991 to the present was compiled to examine trends in the number of fellowship programs and the number of fellows. The overall survey response rate was 76% (96 of 126 PDs). Most (54%) of the PDs had been in their current position 4 or more years (range: <1-20 years), and 59% of PDs reported that they had completed formal geriatric medicine fellowship training. The number of fellowship programs and the number of fellows entering programs has slowly increased over the past decade. During 2001-02, 338 fellows were training in allopathic programs and seven in osteopathic programs (all years of training). Forty-six percent (n = 44) of responding programs offered only 1-year fellowship-training experiences. PDs reported that application rates for fellowship positions were stable during the academic years (AYs) 1999-2002, with the median number of applications per first year position available in AY 2000-01 being 10 (range: 1-77). In 2001-02, data from the AMA/AAMC National GME Census indicated a fill rate for first-year geriatric medicine fellowship positions of 69% (259 first-year fellows for 373 positions). During 2001-02, more than half of programs (53%) reported having two or fewer first-year fellows, whereas 31% had three or four first-year fellows. Thirty-three programs (36%) reported having no U.S. medical school graduate first-year fellows, and another 25 (28%) reported having only one. Of the 51 programs offering second-year fellowship training, PDs reported 61 post-first-year fellows (median 1, range: 0-7). During the past 10 years, 27 new allopathic geriatric medicine fellowship programs opened; there are now 119 programs. There are also seven osteopathic programs. The recruitment of high-quality U.S. medical school graduates into these programs remains a challenge for the discipline. Furthermore, the retention of first-year fellows for additional years of academic training has been difficult. Incentives will be needed to attract the best graduates of U.S. family practice and internal medicine training programs into academic careers in geriatric medicine.

The "Goldilocks model" of overtime in construction: not too much, not too little, but just right.

PROBLEM: Little research exists on the relationship between working overtime and possible adverse health and safety outcomes for construction workers. METHOD: Five focus-group discussions were conducted with construction workers from around the United States. From the analyzed transcripts, a model of overtime was developed. RESULTS: The model includes three dominant themes: (1) work organization issues [(a) definitions of overtime, (b) scheduling, and (c) economic conditions], (2) why workers choose to work overtime [(a) management expectations, (b) career, and (c) money], and (3) the effects of working overtime [(a) health and safety, including sleep deprivation, injury, fatigue, and stress, and (b) productivity]. DISCUSSION: Health and safety is only one of the adverse outcomes related to working too much overtime. A list of worker-inspired recommendations for addressing overtime issues is provided. IMPACT ON THE INDUSTRY: Both employers and workers need to better understand the potential adverse effects of working too much overtime.

A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk.

BACKGROUND: Situation awareness (SA)-the perception of data elements, comprehension of their meaning and projection of their status in the near future-has been associated with human performance in high-risk environments, including aviation and the operating room. The influences on SA in inpatient medicine are unknown. METHODS: We conducted seven focus groups with nurses, respiratory therapists and resident physicians using a standardised semistructured focus group guide to promote discussion. Recordings of the focus groups were transcribed verbatim, and transcripts were qualitatively analysed by two independent reviewers to identify convergent and divergent themes. RESULTS: Three themes emerged: (1) team-based care, (2) availability of standardised data and (3) standardised processes and procedures. We categorised these into social, technological and organisational influences on SA. Subthemes that emerged from each focus group were shared language to describe at-risk patients, provider experience in critical care/deterioration and interdisciplinary huddles to identify and plan for at-risk patients. An objective early warning score, proactive assessment and planning, adequate clinician staffing and tools for entering, displaying and monitoring data trends were identified by six of seven groups. Our data better reflected the concepts of team SA and shared SA than individual SA. CONCLUSIONS: Team-based care and standardisation support SA and the identification and treatment of patient risk in the complex environment of inpatient care. These findings can be used to guide the development and implementation of targeted interventions such as huddles to proactively scan for risk and electronic health record displays of data trends.

Using goal-directed design to create a novel system for improving chronic illness care.

BACKGROUND: A learning health system enables patients, clinicians, and researchers to work together to choose care based on the best evidence, drive discovery as a natural outgrowth of patient care, and ensure innovation, quality, safety, and value in health care; all in a more real-time fashion. OBJECTIVE: Our paper describes how goal-directed design (GDD) methods were employed to understand the context and goals of potential participants in such a system as part of a design process to translate the concept of a learning health system into a prototype collaborative chronic care network (C3N), specifically for pediatric inflammatory bowel disease. METHODS: Thirty-six one-on-one in-depth interviews and observations were conducted with patients (10/36, 28%), caregivers (10/36, 28%), physicians/researchers (10/36, 28%), and nurses (6/36, 17%) from a pediatric gastroenterology center participating in the ImproveCareNow network. GDD methods were used to determine the context and goals of participants. These same methods were used in conjunction with idealized design process techniques to help determine characteristics of a learning health system for this pediatric health care ecology. Research was conducted in a clinic and, in the case of some patients and caregivers, at home. RESULTS: Thematic analysis revealed 3 parent-child dyad personas (ie, representations of interviewees' behavior patterns, goals, skills, attitudes, and contextual information) that represented adaptation to a chronic illness over time. These were used as part of a design process to generate scenarios (potential interactions between personas and the learning health system under design) from which system requirements were derived. These scenarios in turn helped guide generation, prioritization, design, measurement, and implementation of approximately 100 prototype interventions consistent with the aim of C3N becoming a learning health network. CONCLUSIONS: GDD methods help ensure human goals and contexts inform the design of a network of health care interventions which reflect the shape and purpose of a C3N in pediatric chronic illness care. Developing online and in-person interventions according to well-documented context and motivations of participants increases the likelihood that a C3N will enable all participants to act in ways that achieve their goals with grace and dignity. GDD methods complemented quality-improvement methods to generate prototypes consistent with clinical and research aims, as well as the goals of patient disease management.

Huddling for high reliability and situation awareness.

BACKGROUND: Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm. METHODS: Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques. RESULTS: Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff's quality of collective awareness and enhanced capacity for eliminating patient harm. CONCLUSIONS: While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.

Transitioning from a computerized provider order entry and paper documentation system to an electronic health record: expectations and experiences of hospital staff.

OBJECTIVES: To examine healthcare worker's perceptions, expectations, and experiences regarding how work processes, patient-related safety, and care were affected when a quaternary care center transitioned from one computerized provider order entry (CPOE) system to a full electronic health record (EHR). METHODS: The I-SEE survey was administered prior to and 1-year after transition in systems. The construct validity and reliability of the survey was assessed within the current population and also compared to previously published results. Pre- and 1-year post-implementation scale means were compared within and across time periods. RESULTS: The majority of respondents were nurses and personnel working in the acute care setting. Because a confirmatory factor analysis indicated a lack of fit of our data to the I-SEE survey's 5-factor structure, we conducted an exploratory factor analysis that resulted in a 7-factor structure which showed better reliability and validity. Mean scores for each factor indicated that attitudes and expectations were mostly positive and score trends over time were positive or neutral. Nurses generally had less positive attitudes about the transition than non-nursing respondents, although the difference diminished after implementation. CONCLUSIONS: Findings demonstrate that the majority of responding staff were generally positive about transitioning from CPOE system to a full electronic health record (EHR) and understood the goals of doing so, with overall improved ratings over time. In addition, the I-SEE survey, when modified based on our population, was useful for assessing patient care and safety related expectations and experiences during the transition from one CPOE system to an EHR.