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Quality of Care

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Researchers examine the impact of the health care workplace on quality of care and patient safety

Health care workers are the backbone of the health care system. Yet excessively long workdays, nursing shortages, staff restructuring, financial constraints, and other workplace problems have been linked to low worker morale, poor quality of care, medical errors, and patient deaths. To identify gaps in knowledge about the influence of working conditions on the quality of care provided, the Quality Interagency Coordination Task Force (QuIC) convened two conferences, one in October 1999, and the other in October 2000, which focused on best practices for enhancing patient safety. The QuIC is an interagency initiative that brings together all Federal agencies with health care responsibilities. The conferences were sponsored by the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, the Occupational Safety and Health Administration (OSHA), and the Veterans Health Administration.

Five articles adapted from key conference papers appeared in the September 2001 issue of the Joint Commission Journal on Quality Improvement 27(9) and are summarized here. Nancy Foster, AHRQ Coordinator for Quality Initiatives, Howard Holland of AHRQ's Office of Healthcare Information, and Eileen Hogan of AHRQ's Center for Quality Improvement and Patient Safety, served as guest editors of the issue.

Single copies of the journal may be requested from the AHRQ Publications Clearinghouse (AHRQ Publication No. OM-01-0017), but the supply is limited.

Eisenberg, J.M., Bowman, C.C., and Foster, N.E. (2001, September). "Does a healthy health care workplace produce higher quality care?" Joint Commission Journal on Quality Improvement 27(9), pp. 444-457.

In an overview to the journal, AHRQ Director John M. Eisenberg, M.D., and colleagues note that there has been too little research to evaluate the impact of improvements in the health care workplace on quality of care. They assert that the tradition of evidence-based decisionmaking needs to be applied to health care management, as it has been applied in medicine and nursing, in order to show how staffing, environment, organization, and culture can affect the quality of patient care.

Dr. Eisenberg and colleagues summarize the conclusions of conference participants, who suggest that researchers:

  1. Synthesize strategies known to increase worker satisfaction and initiate interventions that promote recruitment and retention.
  2. Describe and disseminate known best practices that promote workplace health and safety, as well as the safety consequences of certain design features and costs of not providing a safe environment.
  3. Generate a standard nomenclature of appropriate variables that would enable comparisons to be made across data sources and provide an ongoing clearinghouse for these data sources.
  4. Facilitate research partnerships with professional employee organizations.
  5. Test the consequences of esthetic design decisions on workflow efficiencies, especially in terms of worker and patient safety.

Kovner, C. (2001, September). "The impact of staffing and the organization of work on patient outcomes and health care workers in health care organizations." Joint Commission Journal on Quality Improvement 27(9), pp. 458-468.

Christine Kovner, Ph.D., R.N., reviews current studies on the effects of health care staffing and work organization on staff well-being and patient outcomes. Although she and other researchers have demonstrated the possible links between staffing and quality of care, the regulation of staffing levels and staff mix has been controversial. For example, criteria for safe staffing levels have been identified for nursing homes but only in extremely limited cases for hospitals, home care, or other health care settings. In fact, there is little information about the impact of staffing levels and the organization of work on health personnel or on patient outcomes. There is almost no information about staffing and patient outcomes in home health and outpatient care.

In the absence of this information, it is difficult for organizations to define minimum acceptable staffing ratios or their relationship to severity of patient illness and staff mix. Other gaps in knowledge on staffing and organization in care identified at the 1999 conference include: impact of nurse's aides and other personnel who assist nurses on the quality of care; effects of alternative work organization strategies on job longevity; motivations that encourage workers to stay in their jobs and deliver high quality care; and the effects of incentives to promote adoption of new methods to deliver quality care.

Sainfort, F., Karsh, B., Booske, B.C., and Smith, M.J. (2001, September). "Applying quality improvement principles to achieve healthy work organizations." Joint Commission Journal on Quality Improvement 27(9), pp. 469-483.

These authors contend that studies investigating the link between patient outcomes and quality of care have not given sufficient consideration to worker well-being. In addition, few studies have sought this information from the workers themselves. Research on healthy work organizations (HWOs)—organizations that have both financial success and a healthy workforce—is beginning to show that some of the same work organization factors that affect employee outcomes, such as quality of life and safety, also can affect organizational outcomes, such as profits and performance. These authors suggest that, if properly implemented and institutionalized, total quality management (TQM)/quality improvement (QI), currently used in most other sectors of the economy, can serve as the mechanism to transform a health care organization into an HWO.

TQM/QI approaches typically define best practices, include a strong commitment to patient and employee support, a direct line of communication between staff and the hospital CEO, the development of clear protocols, daily staff meetings, and cross-training. Research has shown that TQM/QI can have various effects on work design and quality of work life, depending on the specific approach used by the organization and the way it is implemented over time and institutionalized. The authors recommend that future research target particular organizational features that have the most influence over both quality of work life and quality of patient care.

Meyer, G.S., and Massagli, M.P. (2001, September). "The forgotten component of the quality triad: Can we still learn something from the structure?" Joint Commission Journal on Quality Improvement 27(9), pp. 484-493.

Taking a broader view of how structural features of health care organizations are defined has opened the door for measuring the effects of working conditions on care quality. However, measures have not been developed to sufficiently operationalize and test this linkage. Rigorous development of sound measures requires a substantial investment. Investigators must first begin to understand the complex interaction of structure and care process features and their associated impact on quality outcomes, according to these authors.

They point out that one large group of purchasers has promoted the application of three safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings.

Foley, M.E., Keepnews, D., and Worthington, K. (2001, September). "Identifying and using tools for reducing risks to patients and health care workers: A nursing perspective." Joint Commission Journal on Quality Improvement 27(9), pp. 494-499.

The culture of blame in health care organizations has traditionally held individual health care workers primarily to blame for errors, and workers are often seen as being at fault for their own injuries. However, there is growing recognition that often both of these problems are due to organizational and other systems factors. According to these authors, those who ignore staffing-related issues risk missing a crucial element that lies at the center of both safe patient care and worker health and safety. For example, preliminary research has linked decreases in staffing to higher rates of back and needlestick injuries. OSHA literature contains many systems-oriented strategies, such as lifting devices and needle-less devices, to prevent injury and illness among health care workers.

Other system factors affecting worker and patient safety are the way work processes are structured and managed. Virtually every decision made by health care managers—from designing patient units and selecting medical equipment to scheduling work hours—can affect the safety of patients and health care workers. Therefore, managers should make sure there is an administrative link between those responsible for monitoring patient safety and those monitoring health care worker safety and be alert for common trends or system causes.

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