Abraham A. Brody

Abstract

Objective: This study aimed to examine the effects of participation in staff nurse-led practice councils on nurse job satisfaction and professional development. Background: Although evidence-based practice (EBP) has become a key component of improving the quality of care, few studies have examined how implementation of staff nurse led councils model affect the involved nurses. Methods: A 3-stage evaluation involving ethnography, semi-structured phenomenological private interviews and a 10-item survey were conducted with nurses, managers and executives participating in or involved with EBP councils tasked with improving patient outcomes at 6 community hospitals in a single non-profit hospital system. Results: Five themes were identified as outcomes: empowerment, meaningfulness, leadership growth, exposure to quality improvement, and vision. Conclusions: Staff-led councils have the potential to improve quality of care, job satisfaction, vision and leadership provided that managers and executives are sufficiently prepared to work with and support the councils.

Abstract

Engaging bedside clinicians, especially nurses, is essential for the success of sustainable process improvement programs and thus for improving the quality of health care. Studies have shown that properly implemented professional councils can be effective in engaging and empowering bedside clinicians to create lasting and meaningful improvements. This case study describes a 5-year program to implement and operate staff-led councils to lead evidence-based practice (EBP) quality improvement initiatives at 6 community hospitals. The outcomes presented in this case study demonstrate that staff-led councils have the potential to improve patient safety and quality of care as evidenced by observed reductions in ventilator-associated pneumonias, central line-associated bloodstream infections, and mortality from acute myocardial infarction and severe sepsis.

Abstract

Overview: Inpatient palliative care teams' (PCT) contribution to improved quality of life and patient satisfaction as well as decreased utilization and costs has been well established. Yet few studies have examined the specific effect of an inpatient PCT on discharge disposition, despite evidence of an association between hospice enrollment, decreased rehospitalization, and improved resource utilization. Methods: Patients admitted to a large nonprofit multisite hospital between June 2004 and December 2007 and seen by the PCT were matched to usual care (UC) patients on age, mortality risk, prior year hospitalized days, and disease severity. Discharge disposition and demographic factors were abstracted from hospital administrative claims; mortality data was collected from the social security death index. Analyses were performed using Wilcoxon's test, χ2 analysis, and multinomial logit regression. Results: Three hundred sixty-one matched pairs were available for analysis. Compared to UC, patients who received a PCT consultation were 3.24 times more likely to be discharged to hospice (p< 0.0001), 1.52 times more likely to be discharged to a nursing facility, and 1.59 times more likely to be discharged home with services (p< 0.001), controlling for patient demographics and disease severity. PCT patients were also referred to hospice earlier in their disease trajectory, rather than in the last few weeks of life. Conclusion: Patients receiving an inpatient PCT consultation are more likely to receive follow-up services upon discharge from the hospital. These services likely contribute to better quality of care and financial benefits, and warrants further study, especially considering the current focus on health care efficiency and quality.

Abstract

Objective. To analyze corporate governance arrangements and quality and financial performance outcomes among large multi-facility nursing home corporations (chains) that pursue stakeholder value (profit maximization) strategies. Study Design. To establish a foundation of knowledge about the focal phenomenon and processes, we conducted an historical (1993-2005) case study of one of the largest chains (Sun Helathcare Inc.) that triangulated qualitative and quantitative data sources. Data Sources. Two main sets of information were compared: (1) corporate sources including Sun's Security Exchange Commission (SEC) Form 10-K annual reports, industry financial reports, and the business press; and (2) external sources including, legal documents, press reports, and publicly available California facility cost reports and quality data. Principal Findings. Shareholder value was pursued at Sun through three inter-linked strategies: (1) rapid growth through debt-financed mergers; (2) labor cost constraint through low nurse staffing levels; and (3) a model of corporate governance that views sanctions for fraud and poor quality as a cost of business. Conclusions. Study findings and evidence from other large nursing home chains underscore calls from the Institute of Medicine and other bodies for extended oversight of the corporate governance and performance of large nursing home chains.

Abstract

Purpose: The aim of this article was to identify major research needs related to quality of life at the end of life and quality of the dying process for vulnerable older people at home, in assisted living facilities, in skilled nursing facilities, and in prisons. Design and Methods: Review and analysis of the literature was used. Results: The science is generally weak in relationship to what is known about quality of life at the end of life and quality of dying for vulnerable older adults in different settings. Few studies address actively dying patients and the reasons for transfers between home and other settings. Existing studies are primarily anecdotal, descriptive, have small samples, and involve a single setting. Participant decisional capacity is a barrier to conducting research in these settings. Implications: Research recommendations for each setting and across settings are provided. The National Institutes of Health should clarify criteria for enrollment of persons with diminished, fluctuating, and absent decisional capacity in research.