Health Care Delivery Environment Research Articles

Abstract P300: Evaluation of Organizational Behavior in a Rural Cardiology Clinic

Introduction: In the healthcare industry, organizational behavior plays a pivotal role in patient care and staff well-being. Exploring these dynamics in a rural setting may add the unique factors of community engagement, resource allocation, and staffing limitations. Taking steps to understand how these concepts manifest can improve the effectiveness of healthcare delivery and form positive work environments that benefit both patients and providers. Research Question: How do healthcare staff at a rural cardiology clinic operate in the context of organizational behavior? Goal: The goal is to understand the organizational behavior in a rural clinic to optimize healthcare delivery and tackle operational-related challenges. Methods: Conducted in 2022 during the COVID-19 pandemic, this study employed a mixed-methods approach featuring interviews with staff at the rural Georgia cardiology clinic of Lake Country Medical Group (LCMG) and a five-point Likert scale survey of twenty-three questions developed from qualitative data gathered through the interviews. The survey queried organizational behavior concepts such as job satisfaction, communication, and leadership, with answers being graded on a scale of 1 being “strongly disagree” to 5 being “strongly agree.” Descriptive statistics were used to analyze survey responses. Results: Twenty LCMG staff responded to the survey. Key survey results were analyzed according to organizational behavior categories (Figure 1). Qualitative data from interviews described operational inefficiencies and day-to-day challenges including scheduling issues, billing difficulties, and deficient recordkeeping perpetuated by “siloed” teams at the clinic. Conclusion: LCMG faces some operational challenges that can be ameliorated by organizational behavior approaches. Solutions oriented around enhancing synchronous work, cross-training, and stress-reduction could improve staff well-being and ultimately lead to improved patient care.

Workflow interruptions in an era of instant messaging: A detailed analysis

IntroductionThe complex practice environment and responsibilities incumbent on diagnostic radiologists creates a workflow susceptible to disruption. While interruptions have been shown to contribute to medical errors in the healthcare delivery environment, the exact impact on highly subspecialized services such as diagnostic radiology is less certain. One potential source of workflow disruption is the use of a departmental instant messaging system (Webex), to facilitate communications between radiology faculty, residents, fellows, and technologists. A retrospective review was conducted to quantify the frequency of interruption experienced by our neuroradiology fellows. Materials and methodsData logs were gathered comprising all instant messages sent and received within the designated group chats from July 5–December 31, 2021, during weekday shifts staffed by neuroradiology fellows. Interruptions per shift were calculated based on month, week, and day of the week. Results14,424 messages were sent across 289 total shifts. The 6 fellows assigned to the main neuroradiology reading room sent 3258 messages and received 10,260 messages from technologists and other staff. There was an average of 50 interruptions per shift when examined by month (range 48–53), and 52 interruptions per shift when examined by day of the week (range 40–60). ConclusionNeuroradiology fellows experience frequent interruptions from the departmental instant messaging system. These disruptions, when considered in conjunction with other non-interpretative tasks, may have negative implications for workflow efficiency, requiring iterative process improvements when incorporating new technology into the practice environment of diagnostic radiology.

THE ROLE OF PERSON- AND FAMILY-ORIENTED LONG-TERM SERVICES AND SUPPORTS

Abstract Long-term services and supports (LTSS) in the United States are defined by its patchwork and unequal nature. Data constraints obscure our understanding of inequities in LTSS care experiences and factors that may attenuate them. We advance a conceptual framework of LTSS-relevant environmental domains. We then link measures from public use datasets to person-reported care experiences from the 2015 National Health and Aging Trends Study. We assess relationships between domains of LTSS-relevant environmental characteristics and three LTSS care experiences: 1) adverse consequences due to unmet need, 2) participation restrictions in valued activities, and 3) subjective well-being. We examine 2,411 older adults with disabilities, and key subgroups by race, dementia, and Medicaid enrollment status. We find that for the roughly 10.4 million older adults with disabilities in the community, the LTSS environment is associated with care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, social cohesion) are associated with experiencing adverse consequences due to unmet needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, average direct care worker wage, paid family leave) are inversely associated with experiencing participation restrictions. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and low subjective well-being. Relationships between measures of LTSS-relevant environmental characteristics and care experiences generally held in directionality but were attenuated for key subpopulations. Results reinforce the importance of strengthening environmental policies that support aging in place.

Cancer Survivorship in Gulf Countries: An Updated Systematic Review

Introduction Cancer survivorship addresses attendant challenges beyond treatment, emphasizing outcomes of patient quality of life, costs, emergency services/hospitalization, and mortality. Nekhlyduov L et al., 2019 describe nine domains of cancer survivorship which, although represented distinctly, are interrelated and codependent. Despite the sustained worldwide increase in the burden of cancer in the past decade, there is a paucity of evidence regarding cancer survivorship pertaining to patient needs across the Gulf countries. Methods A systematic review adhering to the PRISMA 2020 guidelines was conducted to assess cancer survivorship across the 6 Gulf countries Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. We utilized search results across Medline, Embase, Cochrane, SciELO, and Web of Science published in English through April 1, 2023. Our search terms were inclusive of the country's names, cancer, survivors, neoplasm, survivorship, and follow-up studies were used. Included articles were then evaluated for nine domains of cancer survivorship outlined by Nekhlyduov L et al., 2019. Results Thirty-one articles were included in the systematic review. Cancer survivorship in the context of hematological malignancy (leukemia, lymphoma, and multiple myeloma) was observed in 48% (n = 15) of studies. Saudi Arabia accounted for most of the published literature, 67.7% (n = 21). Kuwait, Qatar, and Bahrain all reported the least on cancer survivorship, 3.2% (n = 1). Clinical structure, surveillance, and management of physical and psychosocial effects were the most reported domains across the included articles, 87.1% (n = 27), 74.2% (n = 23), and 67.7% (n = 21), respectively. Conversely, the surveillance and management of chronic medical conditions and patient and caregiver experience domains were the least reported,12.9% (n = 4) and 9.7% (n = 3), respectively. The clinical structure domain refers to the type of healthcare delivery environment, cancer survivorship providers' education and training status, availability, and access to needed specialty care, healthcare professionals, health information systems, and opportunities for research participation to patients. The surveillance and management of physical and psychosocial effects domains encompassed assessment of patient symptoms and conditions, referral of recommended evaluation, recommendations of and adherence to appropriate treatment and risk-reducing strategies, and reassessment of symptoms and/or conditions at defined intervals and/or treatment phases. The domain of surveillance and management of chronic medical conditions involves evaluating and treating noncancer comorbidities using disease-specific indications and medical reconciliation. The patient and caregiver experience domain assesses the patient's satisfaction with the healthcare provider, perceived timely access to healthcare and services, and follow-up regarding test results. Conclusion Our findings siren the need for a clear focus on the clinical structure domain. There are significant gaps in both the countries reporting on the topic and the domains of cancer survivorship included in their studies. Importantly, Oman, Kuwait, Qatar, and Bahrain require further cancer survivorship research. Moreover, all the countries need to emphasize domains of surveillance and management of chronic conditions and patient caregiver experience.

The International Initiative to Measure Perceived Risk in Arthroplasty: The Results From a Multinational Survey

BackgroundThere is an inherent moral imperative to avoid complications from arthroplasty. Doing so at ideal cost is also associated with surgeon reputation, and, increasingly in health care delivery systems that measure and competitively score outcomes, reimbursement to the surgeons and their hospitals. As a result, patients who are perceived to be in higher risk comorbidity groups, such as the obese and diabetics, as well as those challenged by socioeconomic factors may face barriers to access elective arthroplasty. MethodsIn this initiative, surveys were sent to surgeons in 8 different countries, each adapted for their own unique payment, remuneration, and punitive models. The questions in the surveys pertained to surgeons’ perception of risk regarding medical and socioeconomic factors in patients indicated for total hip or knee arthroplasty. This paper primarily reports on the results from Canada, Ireland, and the United Kingdom. ResultsThe health care systems varied between a universal/state funded health care system (Canada) to those that were almost exclusively private (India). Some health care systems have “bundled” payment with retention of fees for postoperative complications requiring readmission/reoperation and including some with public publication of outcome data (United States and the United Kingdom), whereas others had none (Canada). There were some major discrepancies across different countries regarding the perceived risk of diabetic patients, who have variable Hemoglobin A1c cut-offs, if any used. However, overall the perception of risk for age, body mass index, age, sex, socioeconomic, and social situations remained surprisingly consistent throughout the health care systems. Any limitations set were primarily driven by surgeon decision making and not external demands. ConclusionSurgeons will understandably try and optimize the health status of patients who have reversible risks as shown by best available evidence. The evidence is of variable quality, and, especially for irreversible social risk factors, limited due to concerns over cost and quality outcomes that can be influenced by experience-driven perceptions of risk. The results show that perceptions of risk do have such influence on access across many health care delivery environments. The authors recommend better risk-adjustment models for medical and socioeconomic risk factors with possible stratification/exclusions regarding reimbursement adjustments and reporting to help reverse disparities of access to arthroplasty.

The Role of Place in Person- and Family-Oriented Long-Term Services and Supports.

Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them. We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations. We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.

Disruptions in Sexual and Reproductive Health Care Service Delivery for Immigrants During COVID-19.

To provide perspectives from heterogenous cisgender immigrant women and service providers for immigrants in New York City (NYC) on how restrictive sexual and reproductive health (SRH) care delivery environments during COVID-19 shape immigrant's access to health care and health outcomes to generate insights for clinical practices and policies for immigrant women's health care needs. A qualitative study was conducted in 2020 and 2021, including in-depth interviews with 44 immigrant women from different national origins and 19 direct service providers for immigrant communities in NYC to explore how immigrants adapted to and were impacted by pandemic-related SRH care service delivery barriers. Interviews were coded and analyzed using a constant comparative approach. Pandemic-related delays and interrupted health care, restrictive accompaniment policies, and the transition from in-person to virtual care compounded barriers to care for immigrant communities. Care delays and interruptions forced some participants to live with untreated health conditions, resulting in physical pain and emotional distress. Participants also experienced challenges within the health care system because of changes to visitor policies that restricted the accompaniment of family members or support persons. Some participants experienced difficulties accessing telehealth and technology, while others welcomed the flexibility given the demands of frontline work and childcare. To mitigate the health and social implications of increasingly restrictive immigration, reproductive, and social policies, clinical practices like expanding access to care for all immigrants, engaging immigrant communities in health care institutions policies and practices, and integrating immigrant's support networks into care play an important role.

Mothers’ Satisfaction with Midiwifery Care During Second Stage of Labour at University of Medical Sciences Teaching Hospital Complex, Akure

The midwife's care of the woman during the second stage of labour entails guiding the labour process, offering physical comfort, emotional support, and keeping a positive relationship while ministering to the woman. Gaining the patient's trust during the labour process requires a strong nurse-patient connection. Midwives play a crucial role in ensuring the best possible pregnancy outcome by establishing rapport with expectant mothers and their families prior to, during, and after labour. At the University of Medical Sciences Teaching Hospital Complex in Akure, the study evaluated mothers' satisfaction with midwifery care during the second stage of labour. The study employed a descriptive research design. The respondents were chosen using a purposive sampling technique. Respondents included only 199 mothers who gave birth vaginally and gave their assent to the study. The majority of respondents (130(65.3%) had a positive experience with their care throughout the second stage of labour, whereas (69(34.7%, had a negative experience. The majority of respondents (127(63.8%) expressed positive satisfaction with midwifery treatment, while 72 (36.2%), expressed negative satisfaction. Finally, it was noted that a p-value of 0.05 (0.000, 2=24.705) exists between maternal satisfaction and the type of midwifery care received by the mother during the second stage of labour. It was recommended among others that Government should provide adequate facilities, staffing and conducive environment for quality health care delivery.

Introduction: The Journal of Clinical Ethics, the MacLean Center, and the Future of Clinical Ethics.

Introduction: The Journal of Clinical Ethics, the MacLean Center, and the Future of Clinical Ethics.

Lessons learned about policymaking: Moving an emergency department-initiated screening protocol to systemwide input in the development and implementation process.

Lessons learned about policymaking: Moving an emergency department-initiated screening protocol to systemwide input in the development and implementation process.

Dollars and Sense: The Business of Pediatric Surgery

IntroductionThis study evaluated North American pediatric surgeons’ opinions and knowledge of business and economics in medicine and their perceptions of trends in their healthcare delivery environment. MethodsWe conducted an elective online survey of 1119 American Pediatric Surgical Association members. Over 8 mo, we iteratively developed the survey focused on four areas: opinion, knowledge, current practice environment, and trends in practice environment over the past 5 y. ResultsWe received 227 (20.3%) complete surveys from pediatric surgeons. One hundred ninety four (85.5%) perceive healthcare as a business and most (85.9%) believe healthcare decisions may affect patients’ out-of-pocket expenses. More than half (51.1%) of surgeons believe it has become more challenging to perform emergent cases and most believe staff quality has decreased for elective (56.4%) and emergent (63.0%) cases over the past 5 y. ConclusionsPediatric surgeons recognize that medicine is a business and have concerns regarding the decreasing quality of operating room staff and the increasing difficulty providing surgical care over the last 5 y.

GERONTOLOGICAL BIOSTATISTICS AS THE FOUNDATION OF INTERDISCIPLINARY DATA SCIENCE IN AGING

Abstract Explosive growth in computing power has increased by orders of magnitude the complexity of data structures and the number of analyses that may be performed per unit time. Contemporary gerontology utilizes diverse data ranging from continuous longitudinal assessments (e.g. motion capture) to complex single-timepoint assessments (e.g. bioimages) to systems-level administrative descriptions of the healthcare delivery environment. Paradoxically, this abundance of resources presents a considerable challenge, as the availability of information threatens to overwhelm mechanistic models of aging supportive of intervention development. To inform precision medicine, gerontological biostatistics therefore embraces the opportunity of collaborating with allied quantitative disciplines to bolster the coherence, reproducibility, and generalizability of findings. This presentation will demonstrate the salient advantages of such interdisciplinary collaborations using the example of design and analysis of an intensely longitudinal study of wearable and environmental sensors, conducted with teams in exercise science and architectural design.

Identifying oral disease variables associated with pneumonia emergence by application of machine learning to integrated medical and dental big data to inform eHealth approaches.

The objective of this study was to build models that define variables contributing to pneumonia risk by applying supervised Machine Learning-(ML) to medical and oral disease data to define key risk variables contributing to pneumonia emergence for any pneumonia/pneumonia subtypes. Retrospective medical and dental data were retrieved from Marshfield Clinic Health System's data warehouse and integrated electronic medical-dental health records (iEHR). Retrieved data were pre-processed prior to conducting analyses and included matching of cases to controls by (a) race/ethnicity and (b) 1:1 Case: Control ratio. Variables with >30% missing data were excluded from analysis. Datasets were divided into four subsets: (1) All Pneumonia (all cases and controls); (2) community (CAP)/healthcare associated (HCAP) pneumonias; (3) ventilator-associated (VAP)/hospital-acquired (HAP) pneumonias and (4) aspiration pneumonia (AP). Performance of five algorithms were compared across the four subsets: Naïve Bayes, Logistic Regression, Support Vector Machine (SVM), Multi-Layer Perceptron (MLP) and Random Forests. Feature (input variables) selection and ten-fold cross validation was performed on all the datasets. An evaluation set (10%) was extracted from the subsets for further validation. Model performance was evaluated in terms of total accuracy, sensitivity, specificity, F-measure, Mathews-correlation-coefficient and area under receiver operating characteristic curve (AUC). In total, 6,034 records (cases and controls) met eligibility for inclusion in the main dataset. After feature selection, the variables retained in the subsets were: All Pneumonia (n = 29 variables), CAP-HCAP (n = 26 variables); VAP-HAP (n = 40 variables) and AP (n = 37 variables), respectively. Variables retained (n = 22) were common across all four pneumonia subsets. Of these, the number of missing teeth, periodontal status, periodontal pocket depth more than 5 mm and number of restored teeth contributed to all the subsets and were retained in the model. MLP outperformed other predictive models for All Pneumonia, CAP-HCAP and AP subsets, while SVM outperformed other models in VAP-HAP subset. This study validates previously described associations between poor oral health and pneumonia. Benefits of an integrated medical-dental record and care delivery environment for modeling pneumonia risk are highlighted. Based on findings, risk score development could inform referrals and follow-up in integrated healthcare delivery environment and coordinated patient management.

Computer clinical decision support that automates personalized clinical care: a challenging but needed healthcare delivery strategy.

How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems.

Cancer survivorship in gulf countries: A systematic review.

e24046 Background: Cancer survivors have been increasing worldwide due to advancements in early cancer detection, chemo-hormonal therapy, and improved supportive care with an estimated four-to-five-fold increase in cancer burden in Gulf countries by the year 2040. Cancer survivorship deals with the host of challenges that cancer leaves in its wake. We seek to explore the experience of Gulf countries' cancer survivors and identify the gaps that need to be addressed. Methods: A systematic review of current evidence regarding cancer survivorship in the 6 Gulf countries (inclusive of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) was conducted according to the PRISMA 2020 checklist, without restricting to a starting date. We searched five major online databases: Embase, Cochrane, PubMed, SciELO, and Web of Science. Twenty-two articles were reviewed for the inclusion of predefined domains of cancer survivorship (Nekhlyudov et al, JNCI 2019). Results: Most of the studies included were published in Saudi Arabia (63.6%), followed by UAE (13.6%), Oman (9.1%), Bahrain (4.5%), Kuwait (4.5%), and Qatar (4.5%). Data within the included studies encompassed 9 domains of survivorship, of which clinical structure was reported most consistently (95.5%), followed by surveillance and management of physical and psychosocial effects (77.3% and 68.2% respectively). The most frequently reported domain, clinical structure, refers to the type of healthcare delivery environment offered, patient education, availability of necessary specialty care and subsequent healthcare professionals, access to care, the functionality of available healthcare information systems (e.g., electronic medical records and telehealth) and whether opportunities for research participation was offered to patients. Comparatively, the three domains health promotion (27%), patient experience (27%), and surveillance and management of chronic medical conditions (13%) were reported least frequently. Conclusions: Cancer survivorship in Gulf countries is currently in its infancy, evidenced by a paucity of literature on the topic. This systematic review assesses domains explored by available studies, finding a significant focus on clinical structure. Gaps in literature particularly within the surveillance and management of chronic medical conditions in cancer survivor patients need to be addressed in future research.[Table: see text]

Rebuilding a foundation of trust: A call to action in creating a safe environment for everyone

Well before the COVID-19 pandemic, incivility and physical threats directed toward healthcare employees and often registered nurses was a growing concern by Chief Nurse Executive (CNE) leaders. In 2019, conversations initiated by The Beryl Institute’s Nurse Executive Council (NEC) to consider how best to achieve a much-needed balance between patient/family and staff safety have now become a critical priority to ensure the safety of everyone receiving and providing health care services. The heart of this work was organized around a set of newly developed ethical precepts designed to guide the exploration of key concepts. A call to action grounded in rebuilding a foundation of trust is proposed. In pursuing future steps to deepen this foundation, and to reaffirm the vital role for nurse leaders and of all in healthcare, we must be willing to engage in dialogue, to ask openly, and question respectfully. We believe healthcare systems and nurse leaders both play a vital role in elevating the humanity on which we will find brighter days ahead. Through a sustained commitment to this aim, we seek to strengthen health care delivery environments that shape physically and psychologically safe environments for everyone.

Quality and Safety Challenges in Inpatient Pediatric Care during the COVID‐19 Pandemic: A National Qualitative Study

Research ObjectiveThe COVID‐19 pandemic has necessitated rapid changes in healthcare delivery, including surge planning and modifying healthcare delivery environments and practices. Our objective was to identify the major resulting challenges for quality and safety of pediatric inpatient care.Study DesignWe conducted semi‐structured video interviews. Using constant comparative methods, we iteratively coded data to identify themes related to pediatric inpatient quality and safety challenges during the pandemic.Population StudiedWe purposefully sampled from community and children's hospitals serving pediatric patients in the 6 U.S. states with the highest COVID‐19 hospitalization rates at the onset of the pandemic (NY, NJ, DC, MA, CT, LA). We recruited 2 front‐line clinicians per site (mix of administrators, nurses, physicians).Principal FindingsTwenty‐four participants from 12 hospitals were interviewed. The most commonly encountered themes are detailed in Table 1. Changes in healthcare delivery practices potentially impacting quality and safety of inpatient pediatric care included: 1) limits on family and caregiver visitation, which may have hindered gathering important details for diagnosis and engaging in shared‐decision making about management; 2) personal protective equipment and isolation practices, which may have compromised effective communication with caregivers and interpreters; 3) changes in quality improvement (QI) infrastructure and activities, with potential decreases in monitoring and safety efforts; 4) difficulties defining and providing high‐quality care for children with COVID‐19 and multi‐system inflammatory syndrome in children, both novel diagnoses; and 5) potential increases in safety events due to decreased direct contact with patients and monitoring (e.g., wound infections, central line‐associated bloodstream infections and catheter‐associated urinary tract infections).TABLE 1 ThemeExemplary QuoteLimiting family or caregiver visitation“In challenging diagnoses, even if it wasn't COVID‐related, you couldn't have both parents there at the same time.”Experiencing personal protective equipment or isolation status as a barrier to communication“With non‐English speaking parents, we were trying to use an interpreter phone with an N9, an extra mask, the negative pressure circulator running in the background. Trying to get a good history and to provide quality care was really brutal.”Difficulty maintaining high‐quality care“These people would not have any care. They would be sitting in the ED in the hallway, one ED doc taking care of 50 patients. No, you were not qualified to take care of this patient, but this is a pandemic.”Changes in QI operations (staffing, data monitoring, QI activities)“Everything non‐essential stopped. Meetings canceled, research on hold, IRB halted, labs shut down. We have mandatory reporting on things like sepsis. There was too much else going on, we stopped measuring certain things.”Increasing healthcare‐associated safety events or harms“We had an uptake in our CLABSI, in every healthcare‐associated condition we were capable of tracking. After the fact, because that was not the priority.”ConclusionsThis national qualitative study of early COVID‐19 epicenters described changes in several domains of healthcare delivery affecting quality and safety of pediatric inpatient care.Implications for Policy or PracticeThe several potential areas of focus identified can help clinicians and hospital leaders plan for safe and high‐quality care for hospitalized children, during this ongoing crisis and for future pandemics.Primary Funding SourceAgency for Healthcare Research and Quality.

Transitional challenges in a two-plus-two nursing program: Phenomenology of student experiences

Aim/ObjectiveWith the concept of self-efficacy as a theoretical framework, this qualitative research study explored the academic, social and psychological challenges faced by students transferring from a community college into a baccalaureate nursing program. BackgroundAs the demand for baccalaureate-prepared nurses rises to meet the needs of more complex health care delivery environments, the two-plus-two educational model to earn the Bachelor of Science in Nursing (BSN) degree is gaining popularity across the country. DesignInterpretative phenomenology was used to explore the lived experiences of students enrolled in a two-plus-two nursing program. MethodsA purposeful sample of 16 junior and senior students in a two-plus-two nursing program completed a questionnaire describing positive and negative factors related to the transition process and the impact of these factors on the students’ perceived levels of self-efficacy academically and psychosocially. ResultsLack of academic preparedness for baccalaureate-level work, high levels of anxiety during the transition period, reliance on internal and external social support systems and the need for guidance from faculty, staff and peer mentors were the primary themes reported by the participants. Several subthemes were also identified. ConclusionsMany themes and subthemes identified in data analysis were found to be interrelated, suggesting the value of a holistic, multifaceted set of supportive resources to address the challenges experienced by students transitioning into two-plus-two nursing programs.

A lean approach to healthcare management using multi criteria decision making

Recent challenges induced by the global pandemic COVID-19 have highlighted the critical importance of coping with a sudden surge in demand for front line healthcare services. Motivated by the success of lean implementation in manufacturing systems, this study attempts to apply the lean principles in healthcare delivery environments. The lean approach begins with the identification of seven types of wastes in any production or service system. This study attempts to identify and prioritize the present in hospitals. The study contributes to the existing body of knowledge in two ways. First, we identify the various sources contributing to the seven basic wastes in healthcare delivery. Second, we prioritize the seven types of wastes and the dimensions contributing to these wastes using a Multi-Criteria Decision Making (MCDM). This paper used the fuzzy analytical hierarchy process approach, which is a well-accepted tool in MCDM. The study was conducted at select hospitals located in and around Pune city in India. We find that waiting, transportation, motion, and defects are dominant in adopting lean practices among the seven wastes. The findings of this study may guide hospital management in strategic planning in adopting a lean healthcare process. To our knowledge, this is one of the first studies to extract, and prioritise lean wastes within the context of the healthcare sector.

Oregon Health & Science University School of Medicine.

Oregon Health & Science University School of Medicine.