Reducing Boarding in a Post‐Anesthesia Care Unit

When operating room schedules in hospitals are produced, the constraints and preferences of surgeons and hospital workers are a primary consideration. The downstream impact on post‐operative bed availability is often ignored. This can lead to the boarding of patients overnight in the post‐anesthesia care unit (PACU) because intensive care unit beds are unavailable. In this paper, we apply integer programming and simulation to develop improved surgical scheduling assignments. We want to balance new surgeries with hospital discharges in order to reduce the variability of occupied beds from one day to the next and, as a result, to reduce boarding in the PACU.     

Global theory and the nature of risk, Part 2. Towards a choice-based model of managed care

Orthodox managed care depends on top-down, command and control techniques to squeeze efficiency out of the system. But for every unit of economic good this approach produces, two or three bad units come as result. The key to moving to an environment where value and efficiency become self-sustaining is to structurally recognize the medicoeconomic reality of medicine: the episode of care. The episode forms a natural unit of analysis that not only renders costs and outcomes information translucent and accessible, but it also forms the natural conduit through which premium dollars can find their optimal value. By bifurcating probability risk from technical risk and allocating them in the ex ante and ex post markets, respectively, health care insurers and providers return to their rightful economic roles, and to their appropriate fiduciary duties. And patients regain some semblance of reasonable sovereignty in managing their own medical affairs.     

Legal issues in accepting capitation

The effort to reduce the cost of medical, hospital, and ancillary services increasingly focuses on shifting the financial risk for the cost of these services to those who provide them. Shifting arrangements include capitation for physicians classified as "primary care" physicians; capitation arrangements that include primary and specialty services; risk shifting to medical groups, IPAs, and other physician organizations; as well as the packaging of physician and hospital services on a "full risk," "per case," or other basis. Accepting financial risk for the cost of medical and other health care services, as well as the responsibility for managing the provision of services, may very well be the only remaining opportunity for providers to maximize reimbursement and maintain administrative and clinical self-direction. However, physicians must work with managed care organizations (MCOs) through negotiation of contracts and throughout the relationship to make sure: Unnecessary financial and legal risks to the MCO and physicians are eliminated. Risks that cannot be eliminated are apportioned between the MCO and physicians. All risks are managed in a coordinated fashion between the MCO and physicians.     

The Distinction Between Risk and Hazard: Understanding and Use in Stakeholder Communication

A major issue in all risk communication efforts is the distinction between the terms “risk” and “hazard.” The potential to harm a target such as human health or the environment is normally defined as a hazard, whereas risk also encompasses the probability of exposure and the extent of damage. What can be observed again and again in risk communication processes are misunderstandings and communication gaps related to these crucial terms. We asked a sample of 53 experts from public authorities, business and industry, and environmental and consumer organizations in Germany to outline their understanding and use of these terms using both the methods of expert interviews and focus groups. The empirical study made clear that the terms risk and hazard are perceived and used very differently in risk communication depending on the perspective of the stakeholders. Several factors can be identified, such as responsibility for hazard avoidance, economic interest, or a watchdog role. Thus, communication gaps can be reduced to a four‐fold problem matrix comprising a semantic, conceptual, strategic, and control problem. The empirical study made clear that risks and hazards are perceived very differently depending on the stakeholders’ perspective. Their own worldviews played a major role in their specific use of the two terms hazards and risks in communication.     

Institutionalized Ignorance as a Precondition for Rational Risk Expertise

The present case study seeks to explain the conditions for experts’ rational risk perception by analyzing the institutional contexts that constitute a field of food safety expertise in Denmark. The study highlights the role of risk reporting and how contextual factors affect risk reporting from the lowest organizational level, where concrete risks occur, to the highest organizational level, where the body of professional risk expertise is situated. The article emphasizes the role of knowledge, responsibility, loyalty, and trust as risk‐attenuation factors and concludes by suggesting that the preconditions for the expert's rationality may rather be a lack of risk‐specific knowledge due to poor risk reporting than a superior level of risk knowledge.     

From the Inside Out: Environmental Agency Views about Communications with the Public

Relatively few studies have examined risk communication with the public from the viewpoint of the staff of institutions attempting such communications. This paper reports results of interviews with managers and staff of the New Jersey Department of Environmental Protection, on their programs' current and ideal communications with the public. Q analysis revealed two orthogonal perspectives on current program communications, the Enthused and the Constrained views. The primary focus of their divergence was on the matter of commitment and support for such communications. The Enthused group felt that they had attitudinal support from program culture and managers; the Constrained group focused on the lack of concrete operational support in terms of time, money, and expertise. These differences between the two groups did not appear to be associated with gender, managerial status, education, communication training, or organizational unit. When ideal program communications were discussed, the focus was on the need for all kinds of commitment and support (i.e., culture, managers, time, money, building expertise through training), as well as on more proactive and responsive communication. Both perspectives agreed that communication with the public is essential to their programs' success, trying new ways to communicate is worthwhile, scientific bases for decisions are not compromised by communication, and communication is not delegated to specialists. While varying ideas were held of the public's capacity and interest in communication, citizens were largely not held responsible for communication problems.     

Hospital-physician relations: overcoming barriers to cooperation.

In the September-October 1986 issue of Physician Executive, we discussed the application of strategic business units (SBUs) to health care. SBUs are those corporate entities that market similar products to one or more target populations with similar characteristics. Examples of SBUs in health care are obstetrics, cardiology, orthopedics, etc. When the services within each SBU are linked together, they might resemble a vertically integrated health care system. In the case of obstetrics, a woman may have contact with physicians, a hospital, home care nurses, house-cleaning services, birthing teachers, and maternity clothing boutiques. Each of these are products/services within the SBU of obstetrics. Strategy development by SBU implies an external focus on the marketplace in terms of the specific mission of the SBU (clinical specialty). It also implies responding to the needs of consumers for whom the historical and present divisiveness between hospitals and physicians is immaterial and irrelevant. In this article, we will focus on ways to stabilize the relationship between hospitals and physicians within an SBU context in order to compete more successfully as a team in today's health care environment.     

Beyond demand and control: The contribution of organizational risk factors in assessing the psychological well-being of health care employees

Abstract

The job demand–control(–support) model is frequently used as a theoretical framework in studies on determinants of psychological well-being. Consequently, these studies are confined to the impact of job characteristics on worker outcomes. In the present study the relation between work conditions and outcomes (job satisfaction, emotional exhaustion, psychological distress, and somatic complaints) is examined from a broader organizational perspective. This paper reports on an analysis that examines both the unique and the additional contribution of organizational characteristics to well-being indicators, beyond those attributed to job characteristics. A total of 706 care staff from three public residential institutions for people with mental or physical disabilities in the Netherlands took part in this research. To assess organizational risk factors a measurement instrument was developed, the organizational Risk Factors Questionnaire (ORFQ), based on the safety-critical factors of the Tripod accident causation model. Factor analyses and reliability testing resulted in a 52-item scale consisting of six reliable sub-scales: staffing resources, communication, social hindrance, training opportunities, job skills, and material resources. These organizational risk factors explained important parts of the variance in each of the outcome measures, beyond that accounted for by demographic variables and job demand–control–support (JDCS) measures. Communication and training opportunities were of central importance to carers’ job satisfaction. Social hindrance, job skills, and material resources explained a substantial amount of unique variance on the negative outcomes investigated.     

Quality versus variance: a plea for a different focus and terminology

Much has been written about quality assurance in medical practice over the past 15 years. Medicine suddenly found itself trying to design systems that ensured that medicine was being practiced according to standards of quality when it had neither a definition of its product nor defined standards of practice. Consequently, early quality assurance programs focused primarily on documentation of patient care. As the process matured, it evolved to generic screens, with tolerances and outliers. The theory was that the quality of medical care was enhanced by physicians who practiced within often artificially established norms and was diminished by physicians who practiced outside those same norms. It was much like saying that the quality of manufacturing a new car could be improved by reducing all systems down to one of closely standardizing, observing, and documenting how each individual assembly worker put on a lock nut and then holding each worker independently accountable for the final quality of the care. Physicians felt they were being held responsible for conforming to a rigid set of poorly designed and retrospectively applied standards. Moreover, they were held accountable for applying those standards to all practice situations. Understandably, physicians felt at the mercy of nonphysician quality assurance "detectives" in hospitals and became increasingly suspicious of nurses and administrators, who were perceived as abusing the system at the expense of the physicians. Because of these inadequacies of the earlier quality assurance programs, paranoia among physicians about the quality assurance process remains rampant today. The use of blind outcome scores and practice patterns in credentialing and the reporting of these data to databanks have reinforced the paranoia.(ABSTRACT TRUNCATED AT 250 WORDS)     

“Know What to Do If You Encounter a Flash Flood”: Mental Models Analysis for Improving Flash Flood Risk Communication and Public Decision Making

Understanding how people view flash flood risks can help improve risk communication, ultimately improving outcomes. This article analyzes data from 26 mental models interviews about flash floods with members of the public in Boulder, Colorado, to understand their perspectives on flash flood risks and mitigation. The analysis includes a comparison between public and professional perspectives by referencing a companion mental models study of Boulder‐area professionals. A mental models approach can help to diagnose what people already know about flash flood risks and responses, as well as any critical gaps in their knowledge that might be addressed through improved risk communication. A few public interviewees mentioned most of the key concepts discussed by professionals as important for flash flood warning decision making. However, most interviewees exhibited some incomplete understandings and misconceptions about aspects of flash flood development and exposure, effects, or mitigation that may lead to ineffective warning decisions when a flash flood threatens. These include important misunderstandings about the rapid evolution of flash floods, the speed of water in flash floods, the locations and times that pose the greatest flash flood risk in Boulder, the value of situational awareness and environmental cues, and the most appropriate responses when a flash flood threatens. The findings point to recommendations for ways to improve risk communication, over the long term and when an event threatens, to help people quickly recognize and understand threats, obtain needed information, and make informed decisions in complex, rapidly evolving extreme weather events such as flash floods.     

Work satisfaction, health, and stress: A study of Dutch nurses

A study was conducted to compare nurses' work satisfaction and feelings of health and stress in five different nursing departments: a cardiac care unit and a general surgical ward in a general hospital; and an admissions department, a short-stay department, and a long-stay department in a psychiatric hospital. One hundred nurses took part in the study: the instruments used were questionnaires and structured interviews. The main results showed that:

(1) nurses in the cardiac care unit had the most positive satisfaction scores

(2) nurses in the general surgical ward had the most positive scores on the health and stress variables

(3) feelings of dissatisfaction and stress were most prominent in the short-stay department and, to a lesser extent, in the long-stay department.

The findings are interpreted in terms of the different work situations and die implications for hospital management are discussed.

Dr J. A. Landeweerd graduated in industrial and organizational psychology in 1968 (PhD in 1978). He has worked at Eindhoven University of Technology (Department of Industrial Engineering) and now holds a position as senior lecturer at Limburg University (Department of Health Sciences), where he is project-leader for a number of research projects on the relationships between work and health.

Nicolle Boumans, MA, graduated in health sciences in 1985 (specialization: nursing science) and is now a research assistant. She is working on a PhD thesis concerned with the relationship between task characteristics of nurses and their reaction in terms of job satisfaction, health and stress.     

Diagnosis-related group system. Can we still earn a living caring for sick people?

Medicare and Medicaid patients are starting to enroll in managed care organizations, as government tries to lower costs of caring for the elderly, disabled, and poor. Because they are the most likely to be sick, taking care of them imposes serious risks on hospitals and medical groups. The federal government uses the diagnosis-related group (DRG) system to reimburse hospitals. The system depends on physicians documenting diagnoses and complications. Physicians see illness as unpredictable, and so feel that detailed documentation of severity is futile. The government and health plans nevertheless follow case mix index and create hospital and physician profiles, relying on the existing imperfect system. For providers to be recognized for the value they add to the care of the sick, physicians must learn to use the DRG system to best advantage, or risk being driven out of business.     

The Significance of Socioeconomic and Ethnic Diversity for the Risk Communication Process

Risk communication is being characterized as one way of facilitating more effective, democratic and participatory risk management strategies. An emphasis on formal communication approaches as a means to improve decisions and decrease conflict will highlight the challenge of managing hazards within a culturally heterogeneous society. Communication and participatory strategies will be considered successful only if diverse communities can be engaged as partners in the policy process. Because responses to risks are embedded and evolve within broader social environments, achieving the promise of risk communication across a diverse society may not be possible absent an understanding of how sociocultural variables and past experiences shape the exchange of ideas or information in any particular situation. This paper considers the implications of ethnic and socioeconomic variability for the risk communication process, summarizing theoretical perspectives and empirical evidence on the link between sociocultural features and risk responses. Specifically, the factors that define the context of communication may influence: the initial framing of a risk issue, particularly, the adoption of an environmental justice vs. scientific/economic perspective; the perceived importance of various aspects of the decision problem; and prior beliefs about environmental hazards and agencies involved in risk management. Two examples of situations requiring communications about risk are presented and illustrate how these principles could operate in minority or lower-income communities. A significant challenge for health and regulatory officials will be to engage in an interactive process of information and opinion exchanges that is reasonable and effective within vastly different socioeconomic and cultural contexts.     

Understanding Gaps Between the Risk Perceptions of Wildland–Urban Interface (WUI) Residents and Wildfire Professionals

Research across a variety of risk domains finds that the risk perceptions of professionals and the public differ. Such risk perception gaps occur if professionals and the public understand individual risk factors differently or if they aggregate risk factors into overall risk differently. The nature of such divergences, whether based on objective inaccuracies or on differing perspectives, is important to understand. However, evidence of risk perception gaps typically pertains to general, overall risk levels; evidence of and details about mismatches between the specific level of risk faced by individuals and their perceptions of that risk is less available. We examine these issues with a paired data set of professional and resident assessments of parcel‐level wildfire risk for private property in a wildland–urban interface community located in western Colorado, United States. We find evidence of a gap between the parcel‐level risk assessments of a wildfire professional and numerous measures of residents’ risk assessments. Overall risk ratings diverge for the majority of properties, as do judgments about many specific property attributes and about the relative contribution of these attributes to a property's overall level of risk. However, overall risk gaps are not well explained by many factors commonly found to relate to risk perceptions. Understanding the nature of these risk perception gaps can facilitate improved communication by wildfire professionals about how risks can be mitigated on private lands. These results also speak to the general nature of individual‐level risk perception.     

Health care trends, Part 2. The new health care team. Panel discussion

In Part 2 of this third annual panel discussion, six experts talk about the growing diversity of health care providers and what it means for consumers and physicians. Americans are getting their wellness and health care services from a wider variety of non-physician practitioners than ever before. The number of allied health and alternative providers with direct patient access is likely to continue growing. This trend is being driven by consumer demand, by the lobbying efforts of non-physician providers, and by federal, state, and private payers who see the potential for reduced health care spending, greater consumer satisfaction, and better outcomes. In practice, this means physicians and non-physician providers, some of whom may not be sanctioned by the medical establishment, are obligated to collaborate as a team. Members of this new provider team will have to communicate effectively (with each other, with consumers, and with payers) and make evidence-based clinical decisions. Physicians may have to share decision-making with other members of this new health care team.     

Improving Risk Communication in Government: Research Priorities

Despite the increased interest in risk communication among government agencies, there is evidence that agencies'risk communication practices lag. We conducted a study to explore which risk communication research would be most important to improve government agencies'risk communication practices. Qualitative interviews and a survey of 145 risk communication experts based in academic institutions and government agencies explored how important research on each of 48 topics would be to improving agencies'risk communication efforts. Respondents identified topics within three areas as priorities for further research: 1) involving communities in agency decisionmaking; 2) communicating with communities of different races, ethnic backgrounds, and incomes; and 3) evaluating risk communication. Both practitioners and researchers responded to additional statements about agencies'risk communication practices with reservations about staff and managers'commitment to effective communication about environmental issues. We discuss the implications of these findings.     

Work satisfaction,health, and stress: A study of Dutch nurses

Abstract

A study was conducted to compare nurses' work satisfaction and feelings of health and stress in five different nursing departments: a cardiac care unit and a general surgical ward in a general hospital; and an admissions department, a short-stay department, and a long-stay department in a psychiatric hospital. One hundred nurses took part in the study: the instruments used were questionnaires and structured interviews. The main results showed that:

(1) nurses in the cardiac care unit had the most positive satisfaction scores

(2) nurses in the general surgical ward had the most positive scores on the health and stress variables

(3) feelings of dissatisfaction and stress were most prominent in the short-stay department and, to a lesser extent, in the long-stay department.

The findings are interpreted in terms of the different work situations and die implications for hospital management are discussed.

Dr J. A. Landeweerd graduated in industrial and organizational psychology in 1968 (PhD in 1978). He has worked at Eindhoven University of Technology (Department of Industrial Engineering) and now holds a position as senior lecturer at Limburg University (Department of Health Sciences), where he is project-leader for a number of research projects on the relationships between work and health.

Nicolle Boumans, MA, graduated in health sciences in 1985 (specialization: nursing science) and is now a research assistant. She is working on a PhD thesis concerned with the relationship between task characteristics of nurses and their reaction in terms of job satisfaction, health and stress.     

Credentialing, the most important function for success

After years of attempting to control costs by changing providers' behavior and practice patterns, it has become apparent that the solution lies in the study and cooperation of practitioners. Computers, reports, analysis, and payment reforms have discovered the truth: Many physicians and hospitals have always provided high-quality care efficiently. Costs will be controlled when these providers dominate the health care delivery system.     

A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health‐Care Settings

In spite of increased attention to quality and efforts to provide safe medical care, adverse events (AEs) are still frequent in clinical practice. Reports from various sources indicate that a substantial number of hospitalized patients suffer treatment‐caused injuries while in the hospital. While risk cannot be entirely eliminated from health‐care activities, an important goal is to develop effective and durable mitigation strategies to render the system “safer.” In order to do this, though, we must develop models that comprehensively and realistically characterize the risk. In the health‐care domain, this can be extremely challenging due to the wide variability in the way that health‐care processes and interventions are executed and also due to the dynamic nature of risk in this particular domain. In this study, we have developed a generic methodology for evaluating dynamic changes in AE risk in acute care hospitals as a function of organizational and nonorganizational factors, using a combination of modeling formalisms. First, a system dynamics (SD) framework is used to demonstrate how organizational‐level and policy‐level contributions to risk evolve over time, and how policies and decisions may affect the general system‐level contribution to AE risk. It also captures the feedback of organizational factors and decisions over time and the nonlinearities in these feedback effects. SD is a popular approach to understanding the behavior of complex social and economic systems. It is a simulation‐based, differential equation modeling tool that is widely used in situations where the formal model is complex and an analytical solution is very difficult to obtain. Second, a Bayesian belief network (BBN) framework is used to represent patient‐level factors and also physician‐level decisions and factors in the management of an individual patient, which contribute to the risk of hospital‐acquired AE. BBNs are networks of probabilities that can capture probabilistic relations between variables and contain historical information about their relationship, and are powerful tools for modeling causes and effects in many domains. The model is intended to support hospital decisions with regard to staffing, length of stay, and investments in safety, which evolve dynamically over time. The methodology has been applied in modeling the two types of common AEs: pressure ulcers and vascular‐catheter‐associated infection, and the models have been validated with eight years of clinical data and use of expert opinion.