Engineering a Clinical Microsystem to Decrease Workplace Violence for Medically and Psychiatrically Concurrently Decompensated Patients.

Abstract

Hospitalized medical patients with concurrently decompensated psychiatric and medical conditions experience worse clinical outcomes. Health care providers caring for this patient population are at increased risk of workplace violence. The authors sought to understand the effects of a clinical microsystem specifically designed to care for patients too psychiatrically ill for medical units and too medically ill for psychiatry units. The research team performed a quality improvement study in which a medicine-psychiatry co-managed clinical microsystem incorporating high performance teamwork principles was engineered in an urban academic medical center to improve patient and staff safety, as well as operational outcomes. Poisson regression was performed to determine differences between workplace violence events, falls, 30-day emergency department (ED) revisits, and hospital readmissions, comparing the baseline period to the intervention period. There were 321 patients discharged in the baseline period and 310 during the intervention period. Workplace violence events decreased by 65.6% (incidence rate ratio [IRR] 0.34, 95% confidence interval [CI] 0.20-0.57, p < 0.001) after implementation of the clinical microsystem when compared to the baseline period. The rate of ED utilization at 30 days postdischarge also decreased from 30.6% at baseline to 21.0% postintervention (adjusted odds ratio [aOR] 0.60, 95% CI 0.42-0.87, p = 0.006). No differences were detected in falls and 30-day readmissions. For patients with concurrently decompensated medical and psychiatric conditions, the incidence of workplace violence and postdischarge ED utilization can be improved by creating a clinical microsystem that integrates changes to both the physical environment and teamwork processes.