Quality Of Care Research Articles

Impact of Racial Bias on Providers' Empathic Communication Behaviors with Women of Color in Postpartum Checkup.

Racial bias in healthcare settings can manifest as biased communication, discriminatory treatment, lower quality of care, and a lack of empathy toward women of color [WoC; Nong et al. in JAMA Netw Open 3:e2029650-e2029650, 1; McLemore et al. in Soc Sci Med 201:127-135, 2; Hagiwara et al. in Patient Educ Couns 102:1738-1743, 3]. Despite a large body of research on racial bias, more research is needed to understand how bias translates into specific communication behaviors to develop interventions that reduce racial mistreatment in communication with WoC (Hagiwara et al. in Patient Educ Couns 102:1738-1743, 3). This study contributes to the existing research by exploring the impact of colorblind racial ideology (i.e., the denial and minimization of racism) and ethnocultural empathy (i.e., the ability to understand and relate to others from different ethnic or cultural groups) on health providers' observed empathic communication behaviors. Providers were recruited through US hospital listservs. Inclusion criteria required that participants work in the field of maternal health. A total of 65 healthcare providers completed a survey, which included measures of colorblindness and ethnocultural empathy, and simulated interaction over HIPAA Zoom with trained actors playing patients. Participants were randomly assigned to administer the Edinburgh Postpartum Depression Scale to a Black, Asian, or White patient in a simulated postpartum 4-week checkup. Path analyses were conducted using Mplus. Findings indicated that colorblind racial ideology and ethnocultural empathy were associated with racially biased reasoning, which in turn was related to a lack of providers' empathic communication behaviors. Study findings suggest racial bias can lead to less empathic patient-provider communication interaction and support changes aimed at both reducing racial bias and increasing empathic interaction.

Diabetic Foot Ulcer Nursing

Introduction and Definition: Diabetic foot ulcers “DFU” are chronic, open sores or wounds that occur on the feet of individuals with diabetes mellitus, typically resulting from a combination of neuropathy, poor circulation, and immune system impairments. These complex ulcers are characterised by their difficulty to heal and high risk of infection, often leading to complications such as amputation and mortality in the event of deterioration. DFU are a debilitating complication of diabetes mellitus, affecting approximately 198 million people globally. The development of these ulcers is typically attributed to a combination of peripheral neuropathy, peripheral arterial disease, and poor glycaemic control. Effective nursing management and prevention of DFU are critical in mitigating these risks. Body: Advances in clinical intervention have progressed from management to prevention, enhancing patient lifespan; however, DFU continue to pose significant challenges to healthcare providers in both primary and secondary settings as a detriment to health-related quality of life. Nurses play an integral role in the comprehensive management of DFU within acute and community healthcare settings. Their responsibilities encompass a wide variety of practices including the identification of risk factors, thorough wound assessments, implementing effective wound care plans and preventing infection, which are all vital for improving patient outcomes. Moreover, nurses are pivotal in educating patients on the importance of blood glucose control, proper foot care, and lifestyle modifications to prevent the onset and recurrence of ulcers. Through interdisciplinary collaboration, nurses work alongside physicians, podiatrists, and other healthcare professionals to develop and execute individualized care plans. This multidisciplinary approach not only enhances the quality of care but also fosters better patient engagement and adherence to treatment protocols. The role of nursing in DFU management is crucial in achieving improved healing rates, reducing complications, and ultimately enhancing the quality of life for affected individuals.

The relationship between positive psychological capital and work engagement in clinical nurses: mediation effect of job crafting

BackgroundNurses’ work engagement is critical for improving quality care, facilitating positive patient outcomes, and solving considering the nursing shortage. This study aimed to identify the mediating effect of job crafting on the relationship between positive psychological capital and work engagement in registered nurses.MethodsA total of 132 hospital nurses with clinical experience of more than one year, excluding nurse administrators, participated. The participants were recruited from three hospitals in South Korea from August to September 2021. The SPSS 27.0 and PROCESS macro were used for data analysis.ResultsPositive psychological capital had a significant association with job crafting (β = 0.74, 95% CI = 0.71 to 0.95), and job crafting had a positive association with work engagement (β = 0.51, 95% CI = 0.29 to 0.56). In the mediating effect analysis, the mediating role of job crafting on the relationships between positive psychological capital and work engagement was statistically significant (β = 0.35, 95% CI = 0.24 to 0.48).ConclusionsBased on our findings that positive psychological capital and job crafting could improve the work engagement of registered nurses, strengths coaching-based programs for increasing positive psychological capital and job crafting exercises for helping nurses make their job more engaging need to be developed.

Relationship Between Preoperative Fasting Duration and Anxiety Levels With Postoperative Pain, Nausea-Vomiting, and Sleep Quality in Orthopedic Surgical Patients: A Cross-Sectional Study.

This study is a cross-sectional study aimed to determine the association between preoperative fasting time and anxiety level and early postoperative pain intensity, nausea-vomiting severity, and sleep quality in patients undergoing orthopedic surgery. The study was conducted between March and June 2024 and completed with 188 patients. In the study, patient information form, Amsterdam Preoperative Anxiety and Information Scale, and Richards-Campbell Sleep Questionnaire were used. Correlation analysis indicated a significant negative correlation between postoperative sleep quality and pain intensity. There was a significant positive correlation between preoperative anxiety level and preoperative solid food fasting and fluid fasting times. According to the multiple linear regression model, preoperative anxiety level was found to have a significant effect on pain severity, and pain severity at the postoperative 24th hour significantly affected postoperative sleep quality. Adjusting patients' fasting durations prior to surgical interventions according to evidence-based guideline recommendations and monitoring anxiety closely are simple, practical, and safe measures that could alleviate postoperative pain and nausea-vomiting and improve sleep quality, potentially enhancing outcomes, comfort, and the quality of care.

Personal and Organizational Factors as Predictors of Life Satisfaction Among Older Adults in Long-Term Care Settings

Background and Aims: Resident satisfaction is a critical indicator of the quality of care in long-term care facilities (LTCFs). Yet, the relative importance quality of care factors in predicting resident satisfaction remains unclear for guiding resident support initiatives. This study aims to identify the relative contribution of personal and facility care service factors as predictors of satisfaction LTCF residents. Methods: This cross-sectional study enrolled a convenience sample of 399 older adult residents from LTCFs in Shanghai, Nanjing, and Changsha, China, from June to December 2023. The inclusion criteria were age 65 or older, fluency in speaking and reading simplified Chinese Mandarin, having resided in long-term care facilities for at least one month, and cognitive competence to comprehend the questionnaires. Hierarchical multiple regressions were utilized to examine self-report survey data on ten resident personal variables, and seven care facility service domains were examined for their relative contribution to resident care satisfaction. Moreover, the analysis included the interaction between personal factors and care service attributes. Results: The combined personal and care service factors explained 26.1% of the variance in overall resident satisfaction. Personal factors that predicted resident satisfaction included age, level of independence, and length of stay (ΔR2 = 0.11). Of the care facility factors, the significant predictors of higher resident satisfaction were spending time (β = 0.60, p < 0.01, ΔR2 = 0.09) and environment domains (β = 0.62, p < 0.01, ΔR2 = 0.03). Age moderated the relationship between the spending time domain and overall satisfaction, with a positive effect for residents aged 70–79 compared to those aged 60–69 (β = −1.26, p < 0.05). Conclusions: This study provides evidence to suggest the importance of personal and care facility characteristics to LTFC resident satisfaction. Based on these findings, improved resident satisfaction is likely with LTCF care services that provide tailored care plans using resident characteristics.

Beyond Crisis: Enhancing Behavioral Response Through a Conceptual Framework.

The objective of the study is to present a conceptual model informed by existing literature surrounding behavioral health crises and response teams. The Behavioral Crisis Response Model (BCRM) was developed through a comprehensive literature review, synthesizing existing knowledge to clarify the structure, relationships, and processes between patients and Behavioral Response Teams (BRTs), focusing on published literature from 2018 to 2023. Themes to inform the BCRM were developed through iterative review and discussion with an expert panel. The BCRM framework comprises five key domains: Patient-Centered Care, Preparation, Planning, Execution, and Evaluation. Each domain encompasses specific actions and strategies to ensure comprehensive and effective crisis intervention. The Patient-Centered Care domain ensures the patient remains the focus during a crisis. The Preparation domain focuses on readiness through training and resource verification. The Planning domain involves initial and risk assessments, followed by devising a tailored response plan. The Execution domain emphasizes the implementation of the response plan with adaptable leadership styles. The Evaluation domain involves debriefing, root cause analysis, and performance reviews to promote continuous improvement. The BCRM offers a patient-centered, structured approach to managing behavioral health crises and enhancing team cohesion and effectiveness. Further evaluation of adopting the BCRM is needed within health care institutions to improve patient outcomes, reduce harm, and advance better care quality.

“We don’t just want doulas. We want good doulas.” Examining the role of doula training in promoting perinatal mental health

ABSTRACT While research increasingly explores the role doulas can play in addressing perinatal health disparities, doula training itself remains unexplored. This paper examines the crucial role of doula training in enhancing birthing care accessibility and quality, particularly in addressing mental health disparities and fostering positive birth experiences. Through qualitative analysis, challenges such as cost, time constraints, and training accessibility issues are identified. Key recommendations include removing financial and logistical barriers, incorporating supplemental training for perinatal mood and anxiety disorders (PMADs), and fostering cultural sensitivity to meet diverse community needs, including rural and Indigenous populations.

Quality of care delivery in patients with acute heart failure: insights from the international REPORT-HF registry.

Heart Failure (HF) quality of care (QoC) is associated with clinical outcomes. Therefore, we investigated differences in HF QoC across worldwide regions (with differing national income) and the association of quality indicators with outcomes. We examined the quality of care (QoC) in acute heart failure (HF) patients across different regions using quality indicators (QIs) from the European Society of Cardiology (ESC) and the American Heart Association (AHA) to evaluate QoC. The analysis included 17,632 patients enrolled from 358 medical centres in 44 countries between 23 July 2014 and 24 March 2017, all part of the prospective REPORT-HF cohort study. We investigated how QoC varied by region and its relationship with mortality rates at 30 days and 1 year after hospital discharge. For each QI, percentage attainment of QI among eligible patients was calculated and compared across regions. Among 17,632 patients (median age: 67 years; 61% women) followed up for a median of two years, we assessed 16 QIs. QIs that were least often achieved included measurement of natriuretic peptides, performance of echocardiography, treatment with guideline medical therapy, and a scheduled follow-up consultation after discharge. QI achievement was significantly lower in lower-than higher-income countries. Higher (≥50% vs. <50%) achievement of cumulative QIs was associated with lower 30-day (hazard ratio [HR] 0.58, 95% Confidence Interval [CI] 0.40-0.83; p<0.001), and 1-year mortality (HR 0.58, 95% CI 0.50-0.68; p<0.001). QoC is lower in lower-than higher-income countries and lower QoC is associated with worse outcomes. Improving QoC by addressing structural barriers and quality improvement programs may improve the outcomes of patients with HF. Novartis.

Cross-Country Inequalities in Disease Burden and Quality of Care of Stroke, 1990-2021: A Systematic Analysis of the Global Burden of Disease Study 2021.

This study aims to assess the disease burden and care quality along with cross-country inequalities for stroke at global, regional, and national levels from 1990 to 2021. Data on stroke were extracted from the Global Burden of Disease (GBD) study 2021 for the globe, five sociodemographic index (SDI) regions, 21 GBD regions, and 204 countries/territories. The disease burden was quantified using the age-standardized disability-adjusted life years rate (ASDR). Quality of care (QoC) was evaluated through the age-standardized QoC index (QCI). To assess cross-country disparities in both disease burden and age-standardized QCI, the slope index of inequality (SII) and the concentration index were utilized. From 1990 to 2021, the global ASDR of stroke decreased from 3078.95 (95% uncertainty interval [UI]: 2893.58, 3237.34) to 1886.20 (95% UI: 1738.99, 2017.90) per 100,000 population, while the age-standardized QCI improved from 50.79 to 64.61. However, the results of inequalities showed worsening inequalities in both ASDR and QCI, with lower SDI countries shouldering a disproportionate burden and higher SDI countries maintaining higher QoC. The SII and concentration index for ASDR indicated a worsening inequality among lower SDI countries, with SII increasing to -2616.44 and the concentration index increasing to -0.1119 in 2021. Meanwhile, the SII and concentration index for age-standardized QCI showed a worsening inequality among higher SDI countries, with SII of 27.48 and concentration index of 0.0922 in 2021. Despite notable global advancements, significant disparities in stroke still exist, particularly in lower SDI regions facing high disease burdens and substandard care.

Positive reinforcement: Balancing negative and positive feedback for comprehensive improvement.

Patient feedback plays a vital role in healthcare, offering insights into the quality of care and promoting professional development. Despite the emphasis on feedback collection from regulatory bodies, institutional policies appear to focus on processing complaints and negative feedback over positive feedback. The aim of this study is to investigate the processes relevant to the systematic logging of patient feedback in the dental hospitals across the UK and the Republic of Ireland. A cross-sectional survey study was conducted with a prior local survey serving as a pilot. Of the 22 hospitals of the ADH, 13 responded to the questionnaire (59 %). Descriptive statistics including frequencies and percentages were produced to summarise the sample and data. Qualitative data were analysed using Braun and Clark's thematic analysis [1] following an inductive approach. We found that the institutions of the ADH perceive that most negative feedback is logged, whereas most positive feedback is missed. It is evident that positive patient feedback is collected and logged less systematically than negative feedback, and most institutions acknowledge the need for improvement in this area. This discrepancy likely stems from a lack of structured procedures for encouraging and recording positive feedback. Promoting positive feedback is crucial, as both positive and negative feedback offer valuable insights. To enhance feedback collection and utilisation, research should expand to include the perspectives of patients and individual clinicians. Furthermore, exploring the development of a universal feedback system could simplify and improve the collection and use of patient feedback across institutions. CLINICAL SIGNIFICANCE: A discrepancy is apparent in the perceived effectiveness of feedback collected for staff and students, with students receiving more comprehensive feedback. An online platform for capturing patient expressions of gratitude can be beneficial, facilitating the recording of feedback as it is received and encouraging more patients to provide their input.

Exploring the Scholarly Value and Impact of DNP-Prepared Nurses Through the Lens of Nursing Leaders.

To explore organizational nursing leaders' perceptions of impact, value, and support for doctor of nursing practice (DNP)-prepared nurses engaging in practice scholarship. DNP nurses are educated to lead change at the system level and direct practice-based initiatives to enhance health outcomes. Organizational support and the value of DNP scholarship need to be better understood. An exploratory cross-sectional survey of organizational nursing leaders (N = 87) who participated in hiring or interacting with DNP-prepared nurses was implemented. More than half of the organizational nursing leaders reported that scholarship competencies were integrated into DNP-prepared nurses' job descriptions, yet almost half reported no time allotment for scholarship activities. Respondents reported that the highest impact of the DNP-prepared nurse was on the quality of care, and the greatest value reported was the implementation of evidence-based practice and quality improvement initiatives, the development of innovative roles, and as change agents. Consistent organizational support for DNP-prepared nurses to engage in practice scholarship could maximize the value and impact of these highly educated nurses on healthcare systems and health outcomes.

The Association Between the Quality of Care Provided by Family Members and the Quality of Their Relationship With the Care Receiver in Dementia: A Mixed-methods Observational Study.

Research suggests that the quality of care provided by family members may be influenced by the quality of relationship they have with the person living with dementia. The study investigated this in the context of assisting with daily activities. The quality of the relationship was assessed using the conceptual framework of relationship continuity/discontinuity which focuses on whether the carer experiences their relationship as continuous or discontinuous with the pre-dementia relationship. Thirty spousal carers completed the Birmingham Relationship Continuity Measure. Participants were also interviewed about how they provide care for their partner's daily activities. Passages consistent with a more person-centered approach were identified, and the total number of these in each transcript was used as the measure of care quality. There was a significant correlation between questionnaire scores and the number of person-centered passages: Those reporting greater continuity more frequently described using a person-centered approach. Findings were consistent with earlier research suggesting associations between the quality of the relationship and the quality of care. The concept of relationship continuity suggests ways in which relationship and care quality are connected, and these suggestions could be used to develop interventions to help family carers provide better care.

Organizational factors impacting the implementation of a digital mental health tool in Alberta's mental health care of youth and young adults.

With mental health concerns on the rise among youth and young adults (age 12-24), increased mental health options include virtual care, apps and online tools, self-management and tracking tools, and digitally-enabled coordination of care. These tools may function as alternatives or adjuncts to face-to-face models of care. Innovative solutions in the form of digital mental health (dMH) services not only provide support, resources and care, but also decrease wait times and waitlists, increase access, and empower youth. However, organizational factors may impact the extent of dMH interventions are that accepted, used, and sustained in clinical settings. This qualitative study explores organizational barriers and facilitators surrounding the implementation of a digital platform (Innowell), which uses measurement-based care (MBC) to track youth progress and outcomes. Data was collected from 154 mental health care providers participating in 23 focus groups across Alberta, drawing on school and community settings, specialized mental health services, and primary care networks. A thematic analysis revealed the following: barriers included incompatibility with current systems and workflows, lack of inter-organizational collaboration, time commitment, perceived sustainability and lack of digital literacy. Facilitators included positive attitudes towards using dMH to optimize clinical practices by empowering youth and improving continuity of care, transitions in care, and quality of care, as well as workplace culture and leadership. The study highlights a critical need for decision makers and clinical leaders to address organizational factors by integrating training and support, establishing interoperability between digitized and in-person healthcare systems, and leveraging support for MBC and youth-centred care.

How do patients define a good ophthalmologist? A survey from an academic medical center in France

To identify the skills and personality profiles that are most expected by ophthalmology patients and to help ophthalmologists and ophthalmology residents improve their communication with patients and thus their quality of care. This prospective, single-center study was carried out from November 2nd, 2020, to April 30th, 2021 in the ophthalmology department of Strasbourg University Hospital (Strasbourg, France). One thousand one hundred and eighty-three volunteer ophthalmology outpatients participated in the study. We created a French-language questionnaire including 16 physician qualities identified in the literature and 18 qualities drawn from Process-Communication© Model profiles. For the 784 patients meeting inclusion criteria and successfully completing the questionnaire, 60% (n=470) were female and 40% (n=314) male, with a mean and median age of 47 years. The most frequently chosen criteria are those relating to communication (mean score 4.45±0.90 out of 5). Organizational qualities were also frequently chosen (3.83±1.23). Respondents somewhat frequently selected both human qualities (3.72±1.55) and theoretical and practical skills (3.71±1.42). Patients preferred a conscientious (n=611, 13%), responsible (n=519, 11.05%), and reflective (n=491, 10.50%) ophthalmologist. The most chosen Process-Communication Model profiles were persister (n=737, 94%), thinker (n=729, 93%) and imaginer (n=680, 87%). According to patients, the ideal profile of an ophthalmologist is primarily a good communicator, as well as competent and humble. This study will help physicians to better meet patient demands and might also improve the training of ophthalmologists.

A qualitative exploration of the early adoption of an electronic medical record system for type 1 diabetes management in Rwanda.

Delivering adequate quality care remains a challenge in many low-and middle-income countries (LMICs), especially for people living with type 1 diabetes (T1D), requiring a complex treatment regimen. Digital health solutions, including electronic medical record (EMR) systems, have shown potential to improve delivery and quality of care but still require a successful implementation. To analyze the adoption of a newly implemented EMR system in Rwanda from the perspectives of individuals with T1D, health care providers, and experts. A qualitative study was conducted using the Diffusion of Innovation (DoI) theory to guide the focus of the analysis. A data triangulation strategy was used to gain multi-dimensional insights, involving in-depth interviews and participant observations with T1D individuals, EMR system users, and experts (with varying levels of acquaintance with the EMR system). Experiences of early adoption of the EMR system were explored through thematic analysis guided by the DoI theory. In general, all the participant groups had a positive attitude towards the EMR system, believed to increase the likelihood of a successful implementation. The system was described as user-friendly and improved workflows, data quality, and patient care. The main concerns to successful adoption were related to the maintenance and long-term sustainability of the system. The EMR system showed great potential, was valued by users, and was positively believed to have potential to improve care and outcomes for patients. However, sustainability aspects must not be overlooked when assessing the adoption and use of an EMR system.

A blueprint for large language model-augmented telehealth for HIV mitigation in Indonesia: A scoping review of a novel therapeutic modality.

Background: The HIV epidemic in Indonesia is one of the fastest growing in Southeast Asia and is characterised by a number of geographic and sociocultural challenges. Can large language models (LLMs) be integrated with telehealth (TH) to address cost and quality of care? Methods: A literature review was performed using the PRISMA-ScR (2018) guidelines between Jan 2017 and June 2024 using the PubMed, ArXiv and semantic scholar databases. Results: Of the 694 records identified, 12 studies met the inclusion criteria. Although the role of eHealth interventions as well as telehealth in HIV management appears well established, there is a significant literature gap on the integration of telehealth and LLM technology. To address this, we provide a blueprint for the safe and ethical integration of LLM-TH into triage, history taking, patient education highlighting opportunities for reduced consultation time and improved quality of care. Conclusions: Variable access to mobile technology and the need for empirical validation stand out as limitations for LLM-TH. However, we argue that the current evidence base suggests the benefits far outweigh the challenges in applying LLM-TH for HIV care in Indonesia. We also argue this novel therapeutic modality is broadly applicable to the subacute general practice setting.

Association of race and ethnicity with quality of care among head and neck cancer patients in California.

There are significant racial disparities in head and neck cancer (HNC) outcomes. Racial differences in survival may be explained by differential access to high-quality care. The goal of this study was to evaluate the association of race and ethnicity with the quality of the treating hospital, and receipt of guideline-compliant care among HNC patients. Retrospective cohort study of data from the California Cancer Registry dataset linked with discharge records and hospital characteristics. The study cohort included adult patients with HNC diagnosed between January 1, 2010, and December 31, 2019. Outcome measures included the quality of treating hospital, and NCCN guideline-compliant care. Black (OR 0.76, 95% CI 0.67 to 0.85) and Hispanic (OR 0.68, 95% CI 0.63 to 0.74) patients were less likely to be treated in top-quality hospitals compared with non-Hispanic White patients, after adjusting for demographic, and clinical factors. This association disappeared for Black patients, but persisted for Hispanic patients, after additionally adjusting for socioeconomic status and insurance status. Black patients with advanced-stage disease were less likely to be treated with dual-modality therapy (OR 0.82, 95% CI 0.70 to 0.96), however, this association disappeared after adjusting for demographic, and clinical factors, and hospital quality. There are significant racial and ethnic disparities in quality of care for patients with HNC. Our findings suggest that differential access to high-quality care may account for some of the racial disparities in HNC survival, and highlight the need for continued investigation into the drivers of racial disparities in HNC outcomes.

"On the OB Side of Things, It's Completely Disconnected": Early Implementation of Medicaid Accountable Care Organizations and Health Care in the Perinatal Period.

More than 40% of U.S. birthing people are covered by Medicaid. Accountable Care Organizations (ACOs) are increasingly common in state Medicaid programs and may influence maternal health, quality of care, and outcomes. However, there has been limited examination of how Medicaid ACOs operate in the context of perinatal care. Our objective was to explore how individuals in ACO leadership have approached program design to address maternal health and how these programs have shaped health care utilization and maternal health from the perspective of postpartum ACO beneficiaries and clinicians. We conducted virtual semi-structured interviews with three key stakeholder groups in Massachusetts (ACO leaders, maternity care clinicians, and Medicaid ACO members who had given birth within the past 6-24months) between November 2021 and May 2023. Purposive sampling aimed to achieve variation in geographic location (members and clinicians) and race/ethnicity (members). Interviews were recorded, professionally transcribed, and analyzed iteratively using thematic analysis. Thirty-three interviews were conducted: four with ACO leaders, 15 with maternity care clinicians, and 14 with ACO members. Maternity care clinicians did not perceive that ACO implementation had substantially impacted perinatal health care. Interviews with ACO leadership suggested that the lack of perceived impact may be partially explained by competing priorities; the Massachusetts Medicaid ACOs generally did not focus on maternal health during the initial implementation period. Postpartum ACO members were largely unaware of ACOs. Lack of explicit attention to the perinatal population in Medicaid financing and delivery system reforms may reduce the potential impact in improving outcomes.

The Effect of Lean Hospital Practices on Nurses' Direct Care Activities: Time and Motion Study.

This study investigates the effects of lean management practices on nurses' direct patient care activities and the interruptions they encounter in healthcare settings. The literature indicates that lean management enhances efficiency and improves patient care. Increased nursing time per patient correlates with better outcomes; however, rising patient loads and frequent interruptions hinder nurses' ability to deliver effective care, jeopardising patient safety. Addressing these inefficiencies is essential, given nurses' critical role in ensuring quality care. Using a single-centre, observational, pre-post time and motion design alongside participatory action research from August 2019 to July 2022, the study included three phases: a survey assessing nurses' views on problem-solving and lean management; observations identifying nurses' activities and interruptions; and focus group discussions. The results presented here are from the observation phase, with 34 nurses from surgical, internal medicine, and mixed services participating. Quantitative variables were expressed as means, standard deviations, and significance was assessed at a 95% confidence interval (p < 0.05). Observations in 2019 (324 h) and 2022 (314 h) revealed that nurses dedicated a significant portion of their time to direct patient care, which increased post-lean implementation (surgical: 50.67%, internal: 50.09%, mixed: 44.38%). Waste rates decreased by 35.81%, and documentation time decreased by 23.55%. Overall interruptions also decreased significantly (p < 0.05). Lean management effectively reduces waste and improves direct patient care time, enhancing patient safety and care quality. Continuous improvement initiatives in nursing practices are essential for success.

Impact of Locum Tenens Providers on Delivery of Pediatric Surgical Care.

We sought to understand the impact of locum tenens surgeons on pediatric surgical care delivery. We conducted a cross-sectional survey of Children's Hospital Association pediatric surgical practices. Anonymous electronic surveys were used to investigate locum tenens utilization, primary reason for use, limitations on clinical activities, and variations in practice standards or quality. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between practice characteristics and locum tenens use. Of 172 practices, 71% (n=122) completed the survey. Median hospital size was 203 beds (interquartile range=130-350). Median number of surgeons per practice was 5 (interquartile range=3-8). Thirty-seven practices (30%) employed locum tenens at primary (n=27) or satellite (n=12) sites. Locum tenens utilization was higher in suburban (odds ratio [OR]=3.78, P=0.006) and rural (OR=4.96, P=0.041) locations and lower at sites with a level 4 neonatal intensive care unit (OR=0.35, P=0.035). Most (51%) used locum tenens ≥ 1 time monthly but < 1 time weekly and for ongoing or interim coverage (87%). In total, 14% of practices reported clinical restrictions for locum tenens surgeons, including limitations on extracorporeal membrane oxygenation, neonatal index cases, and operative trauma. Most (76%) practices using locum tenens reported variations in practice standards or quality; all were perceived as negative (57%) or neutral (43%). Locum tenens providers are utilized most commonly in suburban and rural sites and hospitals without the highest level of neonatal intensive care. While locum tenens surgeons may help maintain access to pediatric surgical care where gaps exist, there may be a need to improve the quality and reliability of care rendered.