Personal Experience Shapes Viewpoint on Transition to Retirement.

Executives transitioning to retirement experience professional and personal challenges. This article provides examples of decision points for timing and potential aspects to consider when transitioning to retirement. Examples are opinion-based as a result of personal experience and observations from an expert vantage point.

The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level.

CONTEXT: Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units. OBJECTIVE: To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA). DESIGN, SETTINGS, AND PATIENTS: A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals. METHODS: We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: : Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality. CONCLUSIONS: Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

Reinventing Veterans Health Administration: focus on primary care.

Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered.

Reinventing Veterans Health Administration: focus on primary care.

Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered. The Veterans Health Administration (VHA) is an integrated healthcare system that has implemented change to improve primary care access to the veterans it serves, while not only maintaining but also actually improving the quality of care. Many healthcare executives are struggling with achieving desirable access to care and continuity of care. To confront this problem, many large and small practices have initiated an approach known as advanced clinic access, open access, or same-day scheduling, introduced by the Institute for Healthcare Improvement (IHI). This approach has increasingly been used to reduce waits and delays in primary care without adding resources. To measure quality of care, specific performance measures were developed to quantify the effectiveness of primary care in VHA. Although it was initially viewed with concern and suspicion and was seen as a symptom of unnecessary micromanagement, healthcare team members were encouraged to use performance feedback as an opportunity for systems improvement as well as self-assessment and performance improvement for the team. All quality data are posted quarterly on VHA's internal web site, providing visible accountability at all levels of the organization. Clinical workflow redesign leads to reduced wait times without compromising quality of care. These large system improvements are applicable to large and small organizations looking to tackle change through the use of a collaborative model.

The reality of virtual learning for nurses in the largest integrated health care system in the nation.

The health care network and hospital system within the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA), provides employment to more than 56,000 nursing personnel and serves as clinical education site to countless other nursing and health professional students. Nurse administrators and educators are posed with the challenge of providing an environment in which each nurse is able to gain needed knowledge, learn new skills, and share and communicate this knowledge with other colleagues. The education of nurses improves the health status of veterans while also realizing individual professional enhancement. Regional and cultural diversity of the system present challenges to education, in both delivery and content. VHA's learning organizations, the Employee Education System and the Office of Special Projects, have maximized new technologies and information systems to provide innovative, virtual education opportunities, capitalizing on the benefits of informal and formal learning, thus moving VHA to the forefront in knowledge sharing and dissemination. The Virtual Learning Center, VA Knowledge Network, Learning Catalog, and VA Learning Online provide VHA's nurses with interactive, desktop virtual learning opportunities.