Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study.

Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.

Racial/ethnic disparities in wait-list outcomes are only partly explained by socioeconomic deprivation among children awaiting liver transplantation.

BACKGROUND AND AIMS: Racial/ethnic minority children have worse liver transplant (LT) outcomes. We evaluated whether neighborhood socioeconomic deprivation affected associations between race/ethnicity and wait-list mortality. APPROACH AND RESULTS: We included children (age <18) listed 2005-2015 in the Scientific Registry of Transplant Recipients. We categorized patients as non-Hispanic White, Black, Hispanic, and other. We matched patient ZIP codes to a neighborhood socioeconomic deprivation index (range, 0-1; higher values indicate worse deprivation). Primary outcomes were wait-list mortality, defined as death/delisting for too sick, and receipt of living donor liver transplant (LDLT). Competing risk analyses modeled the association between race/ethnicity and wait-list mortality, with deceased donor liver transplant (DDLT) and LDLT as competing risks, and race/ethnicity and LDLT, with wait-list mortality and DDLT as competing risks. Of 7716 children, 17% and 24% identified as Black and Hispanic, respectively. Compared to White children, Black and Hispanic children had increased unadjusted hazard of wait-list mortality (subhazard ratio [sHR], 1.44; 95% CI, 1.18, 1.75 and sHR, 1.48; 95% CI, 1.25, 1.76, respectively). After adjusting for neighborhood deprivation, insurance, and listing laboratory Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease, Black and Hispanic children did not have increased hazard of wait-list mortality (sHR, 1.12; 95% CI, 0.91, 1.39 and sHR, 1.21; 95% CI, 1.00, 1.47, respectively). Similarly, Black and Hispanic children had a decreased likelihood of LDLT (sHR, 0.58; 95% CI, 0.45, 0.75 and sHR, 0.61; 95% CI, 0.49, 0.75, respectively). Adjustment attenuated the effect of Black and Hispanic race/ethnicity on likelihood of LDLT (sHR, 0.79; 95% CI, 0.60, 1.02 and sHR, 0.89; 95% CI, 0.70, 1.11, respectively). CONCLUSIONS: Household and neighborhood socioeconomic factors and disease severity at wait-list entry help explain racial/ethnic disparities for children awaiting transplant. A nuanced understanding of how social adversity contributes to wait-list outcomes may inform strategies to improve outcomes.

Caregiver perspectives on the everyday medical and social needs of long-term pediatric liver transplant patients.

Using in-depth interviews, we sought to characterize the everyday medical and social needs of pediatric liver transplant caregivers to inform the future design of solutions to improve care processes. Participants (parents/caregivers of pediatric liver transplant recipients) completed a survey (assessing socioeconomic status, economic hardship, health literacy, and social isolation). We then asked participants to undergo a 60-min virtual, semistructured qualitative interview to understand the everyday medical and social needs of the caregiver and their household. We intentionally oversampled caregivers who reported a social or economic hardship on the survey. Transcripts were analyzed using thematic analysis and organized around the Capability, Opportunity, Motivation-Behavior model. A total of 18 caregivers participated. Of the participants, 50% reported some form of financial strain, and about half had less than 4 years of college education. Caregivers had high motivation and capability in executing transplant-related tasks but identified several opportunities for improving care. Caregivers perceived the health system to lack capability in identifying and intervening on specific family social needs. Caregiver interviews revealed multiple areas in which family supports could be strengthened, including (1) managing indirect costs of prolonged hospitalizations (e.g., food, parking), (2) communicating with employers to support families' needs, (3) coordinating care across hospital departments, and (4) clarifying care team roles in helping families reduce both medical and social barriers. This study highlights the caregiver perspective on barriers and facilitators to posttransplant care. Future work should identify whether these themes are present across transplant centers. Caregiver perspectives should help inform future interventions aimed at improving long-term outcomes for children after liver transplantation.

Center variation in long-term outcomes for socioeconomically deprived children.

Neighborhood socioeconomic deprivation is associated with adverse outcomes after pediatric liver transplant. We sought to determine if this relationship varies by transplant center. Using SRTR, we included patients <18 years transplanted 2008-2013 (N = 2804). We matched patient ZIP codes to a deprivation index (range [0,1]; higher values indicate increased socioeconomic deprivation). A center-level patient-mix deprivation index was defined by the distribution of patient-level deprivation. Centers (n = 66) were classified as high or low deprivation if their patient-mix deprivation index was above or below the median across centers. Center quality was classified as low or high graft failure if graft survival rates were better or worse than the overall 10-year graft survival rate. Primary outcome was patient-level graft survival. We used random-effect Cox models to evaluate center-level covariates on graft failure. We modeled center quality using stratified Cox models. In multivariate analysis, each 0.1 increase in the patient-mix deprivation index was associated with increased hazard of graft failure (HR 1.32; 95%CI: 1.05, 1.66). When stratified by center quality, patient-mix deprivation was no longer significant (HR 1.07, 95%CI: 0.89, 1.28). Some transplant centers care for predominantly high deprivation children and maintain excellent outcomes. Revealing and replicating these centers' practice patterns should enable more equitable outcomes.

Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation.

Long-term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index-linked via patient home ZIP code-with a range of 0-1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%-25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%-23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%-23.9%) increased hazard of graft failure and a 9.6% (95% CI: -0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.

Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center.

BACKGROUND: Cincinnati Children's Hospital Medical Center launched the Condition Outcomes Improvement Initiative in 2012 to help disease-based teams use the principles of improvement science to implement components of the Chronic Care Model and improve outpatient care delivery for populations of children with chronic and complex conditions. The goal was to improve outcomes by 20% from baseline. METHODS: Initiative activities included review of the evidence to choose and measure outcomes, development of condition-specific patient registries and tools for data collection, patient stratification, planning and coordinating care before and after visits, and self-management support. RESULTS: Eighteen condition teams, in sequenced cohorts, fully participated in the three-year initiative. As of October 1, 2015, data from 27,221 active patients with chronic conditions were entered into registries within the electronic health record and being used to inform quality improvement and population management. Overall, 13,601 of these children had an improved outcome. Seven of the teams had implemented their evidence-based interventions with ≥ 90% reliability, 83% of teams were regularly using an electronic template to plan care for a child's condition before an encounter, 89% had stratified their population by severity of medical/psychosocial needs, 56% were using registry care gap data for population management, and 72% were doing self-management assessments. Eleven teams achieved the numeric goal of 20% improvement in their chosen outcome. CONCLUSION: The results suggest that, by implementing quality improvement methods with multidisciplinary support, clinical teams can manage chronic condition populations and improve clinical, functional, and patient-reported outcomes. This work continues to be spread across the institution.

Republished: developing capable quality improvement leaders.

BACKGROUND/OBJECTIVE: Cincinnati Children's Hospital Medical Center created the Intermediate Improvement Science Series (I(2)S(2)) training course to develop organisational leaders to do improvement, lead improvement and get results on specific projects. DESIGN METHODS: Each multidisciplinary class consists of 25-30 participants and 12 in-class training days over 6 months. Instructional methods include lectures, case studies, interactive application exercises and dialogue, participant reports and assigned readings. Participants demonstrate competence in improvement science by completing a project with improvement in outcome and/or process measures. They present on their projects and receive feedback during each session and one-on-one coaching between sessions. RESULTS: Since 2006, 279 participants in 11 classes have completed the I(2)S(2) course. Participant evaluations have consistently rated satisfaction, learning, application, impact and value very high. Large and statistically significant changes were observed in pre-course to post-course self-assessment of knowledge of five quality improvement topics. Approximately 85% of the projects demonstrated measurable improvement. At follow-up, 72% of improvement projects were completed and made a part of everyday operations in the participant's unit or were the focus of continuing improvement work. Many changes were spread to other units or programmes. Most (88%) responding graduates continued to participate in formal quality improvement efforts and many led other improvement projects. Nearly half of the respondents presented their results at one or more professional conference. CONCLUSIONS: Through the I(2)S(2) course, the authors are developing improvement leaders, accelerating the shift in the culture from a traditional academic medical centre to an improvement-focused culture, and building cross-silo relationships by developing leaders who understand the organisation as a large system of interdependent subsystems focused on improving health.

Health values in adolescents with or without inflammatory bowel disease.

OBJECTIVE: To examine for differences in and predictors of health value/utility scores in adolescents with or without inflammatory bowel disease (IBD). STUDY DESIGN: Adolescents with IBD and healthy control subjects were interviewed in an academic health center. We collected sociodemographic data and measured health status, personal, family, and social characteristics, and spiritual well-being. We assessed time tradeoff (TTO) and standard gamble (SG) utility scores for current health. We performed bivariate and multivariable analyses with utility scores used as outcomes. RESULTS: Sixty-seven patients with IBD and 88 healthy control subjects 11 to 19 years of age participated. Among subjects with IBD, mean (SD) TTO scores were 0.92 (0.17), and mean (SD) SG scores were 0.97 (0.07). Among healthy control subjects, mean (SD) TTO scores were 0.99 (0.03) and mean (SD) SG scores were 0.98 (0.03). TTO scores were significantly lower (P= .001), and SG scores trended lower (P= .065) in patients with IBD when compared with healthy control subjects. In multivariable analyses controlling for IBD status, poorer emotional functioning and spiritual well-being were associated with lower TTO (R(2)=0.17) and lower SG (R(2)=0.22) scores. CONCLUSION: Direct utility assessment in adolescents with or without IBD is feasible and may be used to assess outcomes. Adolescents with IBD value their health state highly, although less so than healthy control subjects. Emotional functioning and spiritual well-being appear to influence utility scores most strongly.

Redesigning intensive care unit flow using variability management to improve access and safety.

BACKGROUND: Poor flow of patients into and out of the ICU can result in gridlock and bottlenecks that disrupt care and have a detrimental effect on patient safety and satisfaction, hospital efficiency, staff stress and morale, and revenue. Beginning in 2006, Cincinnati Children's Hospital Medical Center implemented a series of interventions to "smooth" patient flow through the system. METHODS: Key activities included patient flow models based on surgical providers' predicted need for intensive care and predicted length of stay; scheduling the case and an ICU bed at the same time; capping and simulation models to identify the appropriate number of elective surgical cases to maximize occupancy without cancelling elective cases; and a morning huddle by the chief of staff, manager of patient services, and representatives from the operating room, pediatric ICUS, and anesthesia to confirm that day's plan and anticipate the next day's needs. RESULTS: New elective surgical admissions to the pediatric ICU were restricted to a maximum of five cases per day. Diversion of patients to the cardiac ICU, keeping patients in the postanesthesia care unit longer than expected, and delaying or canceling cases are now rare events. Since implementation of the operations management interventions, there have been no cases when beds in the pediatric ICU were not available when needed for urgent medical or surgical use. DISCUSSION: A system for smoothing flow, based on an advanced predictive model for need, occupancy, and length of stay, coupled with an active daily strategy for demand/capacity matching of resources and needs, allowed much better early planning, predictions, and capacity management, thereby ensuring that all patients are in suitable ICU environments.

Reducing surgical site infections at a pediatric academic medical center.

BACKGROUND: Surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, increased length of stay, and increased hospital costs. Cincinnati Children's Hospital Medical Center (CCHMC) used reliability science to dramatically reduce the rate of surgical site infections. METHODS: Key activities included the development and implementation of strategies to enhance the proportion of patients who receive timely antibiotic administration, a pediatric surgical site infection-prevention bundle, and procedure-specific pediatric surgical site infection-prevention bundles. Measures are presented in monthly reports and annotated control charts that are shared with the improvement team and organizational leadership and that are also posted on the hospital's patient safety intranet site. RESULTS: The Class I and II SSI rate decreased from 1.5 per 100 procedure days at baseline to 0.54 per 100 procedure days, a 64% reduction. The process has remained stable (within control limits) since August 2007. There were 33 fewer surgical site infections in fiscal year (FY) 2006 than in FY 2005, and 21 fewer in FY 2007 than in FY 2006. By December 2007, 91% of eligible same-day surgery patients received antibiotics within 60 minutes before a procedure, and 94% of patients undergoing inpatient surgery received antibiotics within 60 minutes prior to incision. DISCUSSION: Pediatric surgical patients can now expect a safer, more efficient experience with CCHMC's care system and reduced variation in care across CCHMC's surgeons and procedures. Sharing data on individual and collective provider performance was important in recruiting provider support. Examining data on any failures each day allowed assessment and correction, facilitating rapid-cycle improvement. Making the right thing to do the easy thing to do facilitated the behavior changes required.

Cooling The Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach To Population Health.

Improving population health requires a focus on neighborhoods with high rates of illness. We aimed to reduce hospital days for children from two high-morbidity, high-poverty neighborhoods in Cincinnati, Ohio, to narrow the gap between their neighborhoods and healthier ones. We also sought to use this population health improvement initiative to develop and refine a theory for how to narrow equity gaps across broader geographic areas. We relied upon quality improvement methods and a learning health system approach. Interventions included the optimization of chronic disease management; transitions in care; mitigation of social risk; and use of actionable, real-time data. The inpatient bed-day rate for the two target neighborhoods decreased by 18 percent from baseline (July 2012-June 2015) to the improvement phase (July 2015-June 2018). Hospitalizations decreased by 20 percent. There was no similar decrease in demographically comparable neighborhoods. We see the neighborhood as a relevant frame for achieving equity and building a multisector culture of health.

Improving access to pediatric subspecialty care: initial failures and lessons learned.

OBJECTIVES: We originally examined the effectiveness of strategies, proven successful in improving appointment availability in primary care, at a large tertiary-care academic medical center. We then sought to describe the reasons for the initial failure of these strategies. METHODS: Clinics participating in an access improvement initiative were matched to control clinics. Intervention clinics used a variety of techniques to improve access. Run charts were used to determine the impact of the interventions on appointment availability. Linear models, control charts, and other graphic displays were used to understand the relationship among supply, demand, and appointment availability. RESULTS: Access did not improve in intervention clinics. Neither a linear models approach nor the use of control charts resulted in a simple tool to help clinics better understand the relationship among supply, demand, and days to third next available appointment. However, the development of a single clinic chart that incorporated supply and demand, plus estimates of future supply and demand, made it clear that current supply would not be able to meet demand. This helped teams focus their efforts on improving supply. CONCLUSIONS: Use of detailed data-based tools to guide choices of interventions, coupled with new and explicit institutional expectations for physician attendance at clinics, appears to be a promising strategy for enhancing access.

Using a network organisational architecture to support the development of Learning Healthcare Systems.

The US National Academy of Sciences has called for the development of a Learning Healthcare System in which patients and clinicians work together to choose care, based on best evidence, and to drive discovery as a natural outgrowth of every clinical encounter to ensure innovation, quality and value at the point of care. However, the vision of a Learning Healthcare System has remained largely aspirational. Over the last 13 years, researchers, clinicians and families, with support from our paediatric medical centre, have designed, developed and implemented a network organisational model to achieve the Learning Healthcare System vision. The network framework aligns participants around a common goal of improving health outcomes, transparency of outcome measures and a flexible and adaptive collaborative learning system. Team collaboration is promoted by using standardised processes, protocols and policies, including communication policies, data sharing, privacy protection and regulatory compliance. Learning methods include collaborative quality improvement using a modified Breakthrough Series approach and statistical process control methods. Participants observe their own results and learn from the experience of others. A common repository (a 'commons') is used to share resources that are created by participants. Standardised technology approaches reduce the burden of data entry, facilitate care and result in data useful for research and learning. We describe how this organisational framework has been replicated in four conditions, resulting in substantial improvements in outcomes, at scale across a variety of conditions.

Pay for performance alone cannot drive quality.

OBJECTIVE: To determine whether aligning design characteristics of a pay-for-performance program with objectives of an asthma improvement collaborative builds improvement capability and accelerates improvement. DESIGN: Interrupted time series analysis of the impact of pay for performance on results of an asthma improvement collaborative. SETTING: Forty-four pediatric practices within greater Cincinnati. PARTICIPANTS: Forty-four pediatric practices with 13 380 children with asthma. INTERVENTIONS: The pay-for-performance program rewarded practices for participating in the collaborative, achieving network- and practice-level performance thresholds, and building improvement capability. Pay for performance was coupled with additional improvement interventions related to the collaborative. OUTCOME MEASURES: Flu shot percentage, controller medication percentage for children with persistent asthma, and written self-management plan percentage. RESULTS: The pay-for-performance program provided each practice with the potential to earn a 7% fee schedule increase. Three practices earned a 2% increase, 13 earned a 4% increase, 2 earned a 5% increase, 14 earned a 6% increase, and 11 earned a 7% increase. Between October 1, 2003, and November 30, 2006, the percentage of the network asthma population receiving "perfect care" increased from 4% to 88%. The percentage of the network asthma population receiving the influenza vaccine increased from 22% to 41%, and then to 62% during the prior 3 flu seasons. CONCLUSION: Linking design characteristics of a pay-for-performance program to a collaborative focused on improving care for a defined population, building improvement capability, and driving system changes at the provider level resulted in substantive and sustainable improvement.

Putting evidence-based clinical practice guidelines into practice: an academic pediatric center's experience.

BACKGROUND: Clinical practice guidelines can provide a much-needed interface between research and practice, pointing the way to higher quality, evidence-based, and more cost-effective care. Cincinnati Children's Hospital Medical Center developed a formal process for the production of 29 evidence-based guidelines and companion tools. COMPONENTS OF DEVELOPMENT AND IMPLEMENTATION: Clinical practice guidelines and their companion documents are developed by interprofessional teams that are led by community physicians and that include hospital-based physicians, nurses, other allied health professionals, and patients or parents. An education coordinator develops an education plan that outlines specific clinical practice changes and expected outcomes to be monitored. Guideline evidence is embedded into companion documents and processes available at the point of care. Electronic order sets for treatments and medications have been developed using available guidelines as sources of evidence. All guideline-based order sets include an automatic order for use of the associated clinical pathway. It is important to create and maintain an evidence-based environment in an academic medical center. CONCLUSIONS: Keys to success include a rigorous methodology, tools that place the evidence in the hands of providers at the site of care, feedback on outcomes, and an environment that encourages evidence-based care.

Financial impact of failing to prevent surgical site infections.

BACKGROUND: Despite advances in infection-control practices, surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, and increased costs among hospitalized patients. METHODS: We used a matched cohort design to compare costs and length of stay for 16 pediatric patients with an SSI with those of 16 matched control patients who had a similar operative procedure during the same time period but in whom an SSI did not develop. RESULTS: On average, length of stay was increased by 10.6 days (P = .02) and costs were increased by $27,288 (P = .01) for each patient with a potentially preventable SSI. On the day of the surgical procedure, costs between study patients and matched controls differed by only 1.4%. By day 3, however, costs were 36% higher for patients with an SSI. CONCLUSIONS: While matching study patients and control patients requires significant time from financial and clinical staff, this approach and the resulting data analysis strengthened and focused our efforts to prevent future SSIs and aligned initiatives to reduce SSIs with the business case for quality.

Significant and Sustained Reduction in Chemotherapy Errors Through Improvement Science.

PURPOSE: A majority of children with cancer are now cured with highly complex chemotherapy regimens incorporating multiple drugs and demanding monitoring schedules. The risk for error is high, and errors can occur at any stage in the process, from order generation to pharmacy formulation to bedside drug administration. Our objective was to describe a program to eliminate errors in chemotherapy use among children. METHODS: To increase reporting of chemotherapy errors, we supplemented the hospital reporting system with a new chemotherapy near-miss reporting system. After the model for improvement, we then implemented several interventions, including a daily chemotherapy huddle, improvements to the preparation and delivery of intravenous therapy, headphones for clinicians ordering chemotherapy, and standards for chemotherapy administration throughout the hospital. RESULTS: Twenty-two months into the project, we saw a centerline shift in our U chart of chemotherapy errors that reached the patient from a baseline rate of 3.8 to 1.9 per 1,000 doses. This shift has been sustained for > 4 years. In Poisson regression analyses, we found an initial increase in error rates, followed by a significant decline in errors after 16 months of improvement work ( P < .001). CONCLUSION: After the model for improvement, our improvement efforts were associated with significant reductions in chemotherapy errors that reached the patient. Key drivers for our success included error vigilance through a huddle, standardization, and minimization of interruptions during ordering.

Coughing, sneezing, and aching online: Twitter and the volume of influenza-like illness in a pediatric hospital.

This study investigates the relation of the incidence of georeferenced tweets related to respiratory illness to the incidence of influenza-like illness (ILI) in the emergency department (ED) and urgent care clinics (UCCs) of a large pediatric hospital. We collected (1) tweets in English originating in our hospital's primary service area between 11/1/2014 and 5/1/2015 and containing one or more specific terms related to respiratory illness and (2) the daily number of patients presenting to our hospital's EDs and UCCs with ILI, as captured by ICD-9 codes. A Support Vector Machine classifier was applied to the set of tweets to remove those unlikely to be related to ILI. Time series of the pooled set of remaining tweets involving any term, of tweets involving individual terms, and of the ICD-9 data were constructed, and temporal cross-correlation between the social media and clinical data was computed. A statistically significant correlation (Spearman ρ = 0.23) between tweets involving the term flu and ED and UCC volume related to ILI 11 days in the future was observed. Tweets involving the terms coughing (Spearman ρ = 0.24) and headache (Spearman ρ = 0.19) individually were also significantly correlated to ILI-related clinical volume four and two days in the future, respectively. In the 2014-2015 cold and flu season, the incidence of local tweets containing the terms flu, coughing, and headache were early indicators of the incidence of ILI-related cases presenting to EDs and UCCs at our children's hospital.

Reliability science and patient safety.

Reliability is failure-free operation over time--the measurable capability of a process, procedure, or service to perform its intended function. Reliability science has the potential to help health care organizations reduce defects in care, increase the consistency with which care is delivered, and improve patient outcomes. Based on its principles, the Institute for Health care Improvement has developed a three-step model to prevent failures, mitigate the failures that occur, and redesign systems to reduce failures. Lessons may also be learned from complex organizations that have already adopted the principles of reliability science and operate with high rates of reliability. They share a preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and underspecification of structures.

At-home recovery following hospitalization for bronchiolitis.

OBJECTIVES: To characterize the at-home recovery of infants after hospitalization for bronchiolitis, the impact of recovery from this illness on the family, and the association between delayed infant recovery and parental satisfaction with hospital care. METHODS: Otherwise healthy infants less than 1 year of age admitted to 6 children's hospitals were eligible. Telephone interviews with 486 parents (85% of sampled), 1-2 weeks following discharge, addressed functional recovery, lingering symptoms, family disruption, returns to the emergency department, and parental recall of satisfaction with care. RESULTS: Two thirds of infants experienced difficulties with normal routines (feeding, sleeping, contentedness, liveliness) on the day of discharge. By 5 days at home, 22% continued to experience disruption in sleeping, and 16% in feeding routines. Coughing (56%) and wheezing (27%) were common 4 to 6 days after discharge. Parents who reported longer delays in return to normal family routines took additional time off work, kept their infants out of day care twice as many days, and were more likely to take their infants to the doctor or hospital for repeat medical care. Parents from families slower to return to a normal routine recalled the hospital stay less favorably. CONCLUSIONS: A small but important proportion of infants have a protracted recovery period following hospitalization for bronchiolitis. Delayed recovery is associated with parental work time loss and less favorable parental impressions of care in the hospital. Anticipatory guidance about home recovery could allow parents to plan for extended home care and improve satisfaction with hospital care.