Modifiable Organizational Factors Research Articles

Role of modifiable organisational factors in decreasing barriers to mental healthcare: a longitudinal study of mission meaningfulness, team relatedness and leadership trust among Canadian military personnel deployed on Operation LASER

ObjectivesThe literature presents complex inter-relationships among individual-factors and organisational-factors and barriers to seeking mental health support after deployment. This study aims to quantify longitudinal associations between such factors and barriers...

Measuring Critical Care Unit Performance Using a Postoperative Mechanical Ventilation Quality Metric

BackgroundSafely minimizing postoperative mechanical ventilation duration after congenital heart surgery could be a cardiac intensive care unit (CICU) quality measure. We aimed to measure CICU performance using duration of postoperative mechanical ventilation and identify organizational factors associated with this metric. MethodsObservational analysis of 16,848 surgical hospitalizations of patients invasively ventilated on admission from the operating room from 26 Pediatric Cardiac Critical Care Consortium CICUs. We fitted a multivariable model to predict duration of postoperative mechanical ventilation adjusting for pre- and postoperative factors to measure CICU performance accounting for postoperative illness severity. We used our model to calculate observed-to-expected (adjusted) ventilation duration ratios for each CICU, describe variation across CICUs, and characterize outliers based on bias-corrected bootstrap 95% CIs. We explored associations between organizational characteristics and patient-level adjusted ventilation duration by adding these as independent variables to the model. ResultsWe observed wide variation across CICUs in adjusted ventilation duration ratios, ranging from 0.7 to 1.7. Nine of 26 CICUs had statistically better than expected ventilation duration, while 10 were significantly worse than expected. Organizational characteristics associated with shorter adjusted ventilation duration included mixed (60%-90%) staffing by critical care or anesthesia-trained attendings, lower average attending-to-patient ratio, average CICU daily occupancy 80% to 90%, and greater nurse staffing ratios and experience. ConclusionsCICU performance in postoperative duration of mechanical ventilation varies widely across Pediatric Cardiac Critical Care Consortium centers. Several potentially modifiable organizational factors are associated with this metric. Taken together, these findings could spur efforts to improve ventilation duration at outlier hospitals.

Burnout of the US midwifery workforce and the role of practice environment.

ObjectivesTo determine the prevalence of burnout among the midwifery workforce and the association between fixed personal and practice characteristics and modifiable organizational factors, specifically practice environment, to burnout among midwives in the United States.Data SourcePrimary data collection was conducted via an online survey of the complete national roster of certified nurse‐midwives and certified midwives over 3 weeks in April 2017.Study DesignThe study was a cross‐sectional observational survey consisting of 95 items about personal and practice characteristics, respondents' practice environments, and professional burnout.Data Collection MethodsThe inclusion criterion was actively practicing midwifery in the United States. Data were analyzed with bivariate analyses to determine the association between personal and practice characteristics and burnout. A hierarchal multilinear regression evaluated the interrelationship between personal and practice characteristics, practice environment, and burnout.Principal FindingsOf the almost one third (30.9%) of certified nurse‐midwives and certified midwives who responded to the survey, 40.6% met criteria for burnout. Weak negative correlations existed between burnout and indicators of career longevity: age (r(2256) = −0.09, p < 0.01), years as a midwife (r(2267) = −0.07, p = 0.01), and years with employer (r(2271) = −0.05, p = 0.02). There were significant relationships between burnout score and patient workload indicators: patients per day in outpatient setting (F(5,2292) = 13.995, p < 0.01), birth volume (F(3,1864) = 8.35, p < 0.01), and patient acuity (F(2,2295) = 20.21, p < 0.01). When the practice environment was entered into the model with personal and practice characteristics, the explained variance increased from 6.4% to 26.5% (F(20,1478) = 27.98, p < 0.01).ConclusionsOur findings suggested that a key driver of burnout among US midwives was the practice environment, specifically practice leadership and participation and support for the midwifery model of care. Structural and personal characteristics contributed less to burnout score than the practice environment, implying that prevention of burnout may be achieved through organizational support and does not require structural changes to the provision of perinatal health.

Midwifery students’ perceptions of the modifiable organisational factors that foster bullying behaviours whilst on clinical placement. A qualitative descriptive study

ProblemAn increasing body of research suggests midwifery students experience bullying and harassment whilst on clinical placement. Little is known, however, about factors that foster bullying within this context and how they may be addressed. AimTo explore and describe midwifery students’ perceptions of what modifiable organisational factors foster bullying behaviours and to map the identified factors against the students’ perceptions of a solution. MethodsA qualitative descriptive design was used. A total of 120 midwifery students from the United Kingdom and Australia participated in this study. Participants completed an online qualitative survey and data was thematically analysed. FindingsThe midwifery students in this study perceive that several organisational factors exist that help foster bullying behaviours towards them whilst undertaking clinical placement. Three overarching themes were identified relating to ineffective midwifery mentorship, the high stress environment of the maternity unit, and challenges faced with transparency and whistleblowing. Students identified a range of potential structural responses to bullying. ConclusionsRecommendations are made that midwifery managers and academics acknowledge how students perceive several potentially modifiable organisational factors which either lead to or exacerbate the likelihood of them being the target of bullying whilst on clinical placement. Consideration should be given to solutions that from the student’s perspective may help tackle bullying and subsequently lead to fewer students leaving midwifery education and further depleting the future workforce.

Factors influencing the amount of therapy received during inpatient stroke care: an analysis of data from the UK Sentinel Stroke National Audit Programme

Objectives: To understand why most stroke patients receive little therapy. We investigated the factors associated with the amount of stroke therapy delivered. Methods: Data regarding adults admitted to hospital with stroke for at least 72 hours (July 2013–July 2015) were extracted from the UK’s Sentinel Stroke National Audit Programme. Descriptive statistics and multilevel mixed effects regression models explored the factors that influenced the amount of therapy received while adjusting for confounding. Results: Of the 94,905 patients in the study cohort (mean age: 76 (SD: 13.2) years, 78% had a mild or moderate severity stroke. In all, 92% required physiotherapy, 87% required occupational therapy, 57% required speech therapy but only 5% were considered to need psychology. The average amount of therapy ranged from 2 minutes (psychology) to 14 minutes (physiotherapy) per day of inpatient stay. Unmodifiable characteristics (such as stroke severity) dominated the variation in the amount of therapy. However important, modifiable organizational factors were the day and time of admission, type of stroke team, timely therapy assessments, therapy and nursing staffing levels (qualified and support staff), and presence of weekend or early supported discharge services. Conclusion: The amount of stroke therapy is associated with unmodifiable patient-related characteristics and modifiable organizational factors in that more therapy was associated with higher therapy and nurse staffing levels, specialist stroke rehabilitation services, timely therapy assessments, and the presence of weekend and early discharge services.

Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study

Background Therapy is key to effective stroke care, but many patients receive little. Objectives To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use. Design Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders. Setting Stroke services in England, Wales and Northern Ireland. Participants A total of 94,905 adults admitted with stroke, who remained an inpatient for &gt; 72 hours. Results Routes through stroke services were highly varied (&gt; 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation. Limitations Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed. Conclusions Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.

Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance.

To examine whether an empirically derived taxonomy of Accountable Care Organizations (ACOs) is associated with quality and spending performance among patients of ACOs in the Medicare Shared Savings Program (MSSP). Three waves of the National Survey of ACOs and corresponding publicly available Centers for Medicare & Medicaid Services performance data for NSACO respondents participating in the MSSP (N=204); SK&A Office Based Physicians Database from QuintilesIMS. We compare the performance of three ACO types (physician-led, integrated, and hybrid) for three domains: quality, spending, and likelihood of achieving savings. Sources of performance variation within and between ACO types are compared for each performance measure. There is greater heterogeneity within ACO types than between ACO types. There were no consistent differences in quality by ACO type, nor were there differences in likelihood of achieving savings or overall spending per-person-year. There was evidence for higher spending on physician services for physician-led ACOs. ACOs of diverse structures perform comparably on core MSSP quality and spending measures. CMS should maintain its flexibility and continue to support participation of diverse ACOs. Future research to identify modifiable organizational factors that account for performance variation within ACO types may provide insight as to how best to improve ACO performance based on organizational structure and ownership.

Hospital characteristics and 30-day all-cause readmission rates.

The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital-wide all-cause readmission rates, which are key indicators of quality and waste. Understanding hospital characteristics that are associated with lower readmission rates is important. The main objective of this article is to identify hospital characteristics associated with lower readmission rates. Specifically, we focus on the relationship between hospitalist staffing levels, the level of physician integration, and physician ownership with hospital-wide all-cause readmissions. We rely on data from CMS, American Hospital Association Annual Survey Database, and Area Health Resource File. We use ordinary least square regression to assess the association between readmission rates and hospitalist staffing levels, physician integration, physician ownership, and the presence of a medical home model, while controlling for key organizational and market factors such as registered nurse (RN) staffing levels and competition. Higher hospitalist staffing levels, the fully integrated physician model, and physician ownership were associated with lower readmission rates. The addition of 1 hospitalist per general and surgical bed was associated with a 0.77 percentage-points decrease in adjusted 30-day all-cause readmission rates. Fully integrated hospitals had adjusted 30-day all-cause readmission rates 0.09 percentage points lower than non-fully integrated hospitals, and hospitals partially or fully owned by physicians had adjusted readmission rates 0.36 percentage points lower than non-physician-owned hospitals. Hospitals should focus on modifiable organizational factors that influence patient outcomes such as hospitalist and RN staffing levels and explore hospital-physician arrangements that result in the greatest alignment between hospital and physician incentives. Journal of Hospital Medicine 2016;11:682-687. © 2016 Society of Hospital Medicine.

Impact of multidisciplinary hip fracture program on timing of surgery in elderly patients.

The effect of patient characteristics and organizational and system factors on time to surgery were studied using Emilia Romagna Region database and hospital survey. The results showed that the implementation of a Hip Fracture Program significantly increased the probability of early surgery while single intervention had only slight effect The purpose of this study is to evaluate the effect of formal Hip Fracture Program (HFP) on timing of surgery in hip fracture older patients. This is a retrospective cohort study based on Emilia Romagna administrative databases. Data on organizational and system factor were also obtained through a hospital survey. A multilevel logistic regression analysis was carried out to assess the effect of covariates on early surgery, taking into account patient level, hospital level, and trust level variability. From 1 January to 31 December 2011, 5,520 subjects over 65 years old underwent surgical repair for hip fracture in Emilia Romagna. The mean waiting time to surgery was 3.4 ± 12.3 days, and the overall percentage of patients operated within 2 days was 52.2%. In the adjusted multilevel logistic model, significant risk factors affecting the timing of surgical intervention at patient level were age, comorbidity, day of admission, and antiplatelet or warfarin therapy while no significant single variables were found at hospital level including dedicated operation theater, hospital volume, dedicated orthogeriatric beds, and geriatrician involvement. The most significant variable was the implementation of HFP at trust level that increased three times the probability of early surgery after adjusting for confounding variables (OR 3.216, 95% CI 0.582-6.539). Several modifiable organizational factors may affect the proportion of patients with hip fracture undergoing early surgery. This study suggests that the development and the implementation of an evidence-based HFP at trust level are a key point of the strategy of quality of care.

Cardiac Rehabilitation Enrollment Among Referred Patients

Cardiac rehabilitation (CR) is underutilized despite well-documented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment. Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.32-5.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.37-0.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll. Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment.

Cardiac Rehabilitation Patient and Organizational Factors: What Keeps Patients in Programs?

BackgroundDespite documented benefits of cardiac rehabilitation, adherence to programs is suboptimal with an average dropout rate of between 24% and 50%. The goal of this study was to identify organizational and patient factors associated with cardiac rehabilitation adherence.Methods and ResultsFacilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry Project (N=38) were surveyed and records of 4412 enrolled patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. The results show that organizational factors associated with significantly increased adherence were relaxation training and diet classes (group and individual formats) and group‐based psychological counseling, medication counseling, and lifestyle modification, the medical director's presence in the cardiac rehabilitation activity area for ≥15 min/week, assessment of patient satisfaction, adequate space, and adequate equipment. Patient factors associated with significantly increased adherence were aged ≥65 years, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) high‐risk category, having received coronary artery bypass grafting, and diabetes disease. Non‐white race was negatively associated with adherence. There was no significant gender difference in adherence. None of the baseline patient clinical profiles were associated with adherence including body mass index, total cholesterol, low‐density lipoprotein, high‐density lipoprotein, triglycerides, and blood pressure.ConclusionsFactors associated with adherence to cardiac rehabilitation included both organizational and patient factors. Modifiable organizational factors may help directors of cardiac rehabilitation programs improve patient adherence to this beneficial program.

Staff, space, and time as dimensions of organizational slack

: In the theoretical and research literature, organizational slack has been largely described in terms of financial resources and its impact on organizational outcomes. However, empirical research is limited by unclear definitions and lack of standardized measures. : The aim of this study was to assess the psychometric properties of a new organizational slack measure in health care settings. : A total of 752 nurses and 197 allied health care professionals (AHCPs) employed in seven pediatric Canadian hospitals completed the Alberta Context Tool, an instrument measuring organizational context, which includes the newly developed organizational slack measure. The nine-item, 5-point Likert organizational slack measure includes items assessing staff perceptions of available human resources (staffing), time, and space. We report psychometric assessments, bivariate analyses, and data aggregation indices for the measure. : The findings indicate that the measure has three subscales (staff, space, and time) with acceptable internal consistency reliability (alphas for staff, space, and time, respectively:.83,.63, and.74 for nurses;.81,.52, and.76 for AHCPs), links theory and hypotheses (construct validity), and is related to other relevant variables. Within-group reliability measures indicate stronger agreement among nurses than AHCPs, more reliable aggregation results in all three subscales at the unit versus facility level, and higher explained variance and validity of aggregated scores at the unit level. : The proposed organizational slack measure assesses modifiable organizational factors in hospitals and has the potential to explain variance in important health care system outcomes. Further assessments of the psychometric properties of the organizational slack measure in acute and long-term care facilities are underway.

Validation of an Organizational Communication Climate Assessment Toolkit

Effective communication is critical to providing quality health care and can be affected by a number of modifiable organizational factors. The authors performed a prospective multisite validation study of an organizational communication climate assessment tool in 13 geographically and ethnically diverse health care organizations. Communication climate was measured across 9 discrete domains. Patient and staff surveys with matched items in each domain were developed using a national consensus process, which then underwent psychometric field testing and assessment of domain coherence. The authors found meaningful within-site and between-site performance score variability in all domains. In multivariable models, most communication domains were significant predictors of patient-reported quality of care and trust. The authors conclude that these assessment tools provide a valid empirical assessment of organizational communication climate in 9 domains. Assessment results may be useful to track organizational performance, to benchmark, and to inform tailored quality improvement interventions.