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Competing Interests: Dr. Shankar-Hari received funding from the National Institute for Health Research (NIHR) Clinician Scientist Award (NIHR-CS-2016-16-011). Dr. Wunsch received funding from a Canada Research Chair in Critical Care Organization and Outcomes, an Excellence in Research Award from the Department of Anesthesia at the University of Toronto, the Canadian Institutes of Health Research, and the National Institutes of Health (NIH) (R01 DA042299; HL137816). Dr. Singer’s institution received funding from Deltex, Biotest, Fresenius, Roche Diagnostics, and New B; he received funding from a NIHR Emeritus Senior Investigator Award. Dr. Angus received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on the application of management strategies in health systems. Much of this research appears as a natural extension of the cross-disciplinary field of systems theory. Since writing my 1st article for Managing Organizational Complexity in 2004, much has happened to further our understanding of complexity in healthcare systems. The growth of new computational methods in the fields of data science and data analytics has allowed scientists to identify signals or patterns in large complex data sets (big data) that in the past were seemingly hidden. Rather than relying on historical statistical methods to infer outcomes, these advanced methods combined with increased computer processing power allow machines to learn the structure of data and create artificial intelligence (AI). In our ongoing efforts to find solutions for complex healthcare problems, AI is becoming more and more an accepted method. The purpose of this edition of Managing Organizational Complexity is to define AI and machine learning, discuss the recent resurgence of AI, and then provide examples of how AI can provide value to healthcare with an emphasis on nursing.

MINI: The time trend for the number of minimally invasive spine surgery articles showed a significant increase over time with an average of 93.23 articles per year. Among all related journals, Spine published the largest number of articles in minimally invasive spine surgery research and was the most popular one in the top five countries., Study Design: Bibliometric analysis., Objective: This study aimed to reveal the characteristics of world productivity in the field of minimally invasive spine surgery (MISS) research and to provide a general picture for surgeons and researchers., Summary of Background Data: Significant growth has been observed in the field of MISS research in recent years. However, bibliometric studies concerning the quantity and quality of articles published in MISS journals are scarce., Methods: All the data concerning MISS in this study originate from the Web of Science (Thomson Reuters, New York, NY) without restrictions. All selected literates were evaluated in the following aspects: publication year, publication journals, author, times cited, Web of Science category, countries/territories., Results: A total number of 2051 articles were published worldwide. The articles published during 2000 to 2015 are more than 11.28 times when compared to those published before 2000. The United States published the largest number of articles (855/2051, 41.7%), followed by Germany (245/2051, 11.9%), South Korea (160/2051, 7.8%), China (147/2051, 7.2%), and Japan (108/2051, 5.2%) and had the highest total citations (16,626). Additionally, the United States had the highest average citations per article (12.14), followed by Japan (11.98), Germany (11.19), South Korea (11.04), and China (10.95). High-income countries published 98.73% of articles, upper-middle-income countries published 0.24% of articles, and middle-income countries published 1.03% of articles., Conclusion: The time trend for the number of MISS articles showed a significant increase over time with an average of 93.23 articles per year. The United States was the most productive country and had the highest average citations per article. Among related journals, Spine published the largest number of articles in MISS research and was the most popular one in the top five countries., Level of Evidence: 5.

As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on the application of management strategies in health systems. This article is the 2nd in a series of articles that focuses on why technological complexity is increasing and strategies nurse administrators can use to successfully implement change in the face of it.

The call for care model innovation is clear, spearheaded by rising healthcare costs, changing payer expectations, overall fiscal and workforce shortages, and an increasingly comorbid patient population requiring significant, long-term support. As part of care model innovation, the leveraging of technology is key.

There are conflicting data about the ability of peer review percentile rankings to predict grant productivity, as measured through publications and citations. To understand the nature of these apparent conflicting findings, we analyzed bibliometric outcomes of 6873 de novo cardiovascular R01 grants funded by the National Heart, Lung, and Blood Institute (NHLBI) between 1980 and 2011. Our outcomes focus on top-10% articles, meaning articles that were cited more often than 90% of other articles on the same topic, of the same type (eg, article, editorial), and published in the same year. The 6873 grants yielded 62 468 articles, of which 13 507 (or 22%) were top-10% articles. There was a modest association between better grant percentile ranking and number of top-10% articles. However, discrimination was poor (area under receiver operating characteristic curve [ROC], 0.52; 95% confidence interval, 0.51-0.53). Furthermore, better percentile ranking was also associated with higher annual and total inflation-adjusted grant budgets. There was no association between grant percentile ranking and grant outcome as assessed by number of top-10% articles per $million spent. Hence, the seemingly conflicting findings on peer review percentile ranking of grants and subsequent productivity largely reflect differing questions and outcomes. Taken together, these findings raise questions about how best National Institutes of Health (NIH) should use peer review assessments to make complex funding decisions., (© 2015 American Heart Association, Inc.)

Hospitals nationwide must demonstrate meaningful use by 2015 or face fines. For over 20 years, researchers have attempted to assess the impact of electronic record keeping technologies on the quality, safety, and efficiency of care, but results are inconclusive and hospital managers have little evidence on which to base staffing decisions as we hurtle toward the era of the paperless hospital.

Background and Purpose: The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes., Methods: A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented., Sample: pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66)., Conclusions: Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.

Background: As a specialty, anesthesiology has relatively low research productivity. Prior studies indicate that junior faculty development programs favorably affect academic performance. We therefore initiated a junior faculty development program and hypothesized that most (>50%) new junior faculty would take <50 nonclinical days to achieve a primary program goal (e.g., investigation or publication), and <5 nonclinical days to achieve a secondary program goal (e.g., teaching or nonclinical service)., Methods: Twenty new junior faculty participated in the 2-year program which had a goal-oriented structure and was supported by nonclinical time, formally assigned mentors, and a didactic curriculum. Goal productivity equaled the number of program goals accomplished divided by the amount of nonclinical time received. Primary goal productivity was expressed as primary goals accomplished per 50 nonclinical days. Secondary goal productivity was expressed as secondary goals accomplished per 5 nonclinical days., Results: Median primary goal productivity was 0.45 primary goals per 50 nonclinical days (25th-75th interquartile range = 0.00-0.73). Contrary to our hypothesis, most new junior faculty needed >50 nonclinical days to achieve a primary goal (17/20, P = 0.0026). Median secondary goal productivity was 0.57 secondary goals per 5 nonclinical days (25th-75th interquartile range = 0.38-0.77). Contrary to our hypothesis, most new junior faculty needed >5 nonclinical days to accomplish a secondary goal (18/20, P = 0.0004). It was not clear that the faculty development program increased program goal productivity., Conclusions: Even with structured developmental support, most new junior anesthesia faculty needed >50 nonclinical days to achieve a primary (traditional academic) goal and >5 nonclinical days to achieve a secondary goal. Currently, most new anesthesia faculty are not productive in traditional academic activities (research). They are more productive in activities related to clinical care, education, and patient care systems management.

Purpose of Review: To review the current state of anesthesiology for operative and invasive procedures, with an eye toward possible future states., Recent Findings: Anesthesiology is at once a mature specialty and in a crisis--requiring breakthrough to move forward. The cost of care now approaches reimbursement, and outcomes as commonly measured approach perfection. Thus, the cost of further improvements seems ready to topple the field, just as the specialty is realizing that seemingly innocuous anesthetic choices have long-term consequences, and better practice is required., Summary: Anesthesiologists must create more headroom between costs and revenues in order to sustain the academic vigor and creativity required to create better clinical practice. We outline three areas in which technological and organizational innovation in anesthesiology can improve competitiveness and become a driving force in collaborative efforts to develop the operating rooms and perioperative systems of the future: increasing the profitability of operating rooms; increasing the efficiency of anesthesia; and technological and organizational innovation to foster improved patient flow, communication, coordination, and organizational learning.

This article is part 2 of the series "Pulling the Plug on 12-Hour Shifts." In part 1 (March 2010), the authors provided an update on recent evidence that challenges the current scheduling paradigm that supports the lack of safety of long work hours. Part 2 describes the barriers to change and challenges for the nurse executive in moving away from the practice of 12-hour shifts. This is an executive-level analysis of barriers and recommends strategies for change. Translation of evidence into administrative practice requires examination of external environmental factors, internal system consequences, organizational culture, and measures of executive performance.

Objective: To assess the prevalence of "best practice" program components across a select sample of organizations, and to explore differences in engagement rates and health risk reduction between organizations using "best-practice" and "common-practice" health management approaches., Methods: Using a retrospective approach, researchers assigned organizations to a "best practice" or "common-practice" group based on well-defined criteria. The study examined group differences in employee health assessment participation rates, health coaching program participation and completion rates, and organizational-level health risk reduction., Results: Best-practice organizations achieved higher levels of engagement than common-practice organizations in both health assessment and health coaching programs. Population-level and intervention-level health risk reduction was 2.35 and 1.08 times higher, respectively, among best-practice organizations compared with common-practice organizations., Conclusions: This study demonstrates the contribution of quality program components to superior program engagement rates and health outcomes.

A Montreal-area hospital implemented organizational changes to improve the psychosocial environment for patients and health care workers and enhance organizational efficiency. This article describes a participatory approach to improving the organization of care and work, an approach focused on productivity gains in an organization. Productivity gains were analyzed in 13 units of the Department of Nursing, which had introduced a series of organizational changes. Changes introduced in care and work organization led to productivity gains in all units overseen by the Nursing Directorate. A reorganization of care and work based on the psychosocial work environment and staff participation can have positive outcomes, both for employees and for the wider organization.

This study examines characteristics associated with high- and low-performing hospitals, where performance is defined in terms of both mortality outcomes and efficiency. In particular, we use data for Florida hospitals in 1999-2001 to classify hospitals into performance groups based on both risk-adjusted excess mortality and cost efficiency. The results indicate that hospitals in the high-performing group were more likely to be for-profit, had higher occupancy rates, had proportionately more Medicare and proportionately fewer Medicaid and self-pay patients, used fewer patient-care personnel per admission, and had higher operating margins than all other hospitals. Hospitals in the low-performing group, on the other hand, were less likely to be for-profit, had more beds, used more patient-care personnel per admission, had lower pay per patient-care personnel, had higher average costs, and had lower operating margins than all other hospitals. Interestingly, managed care presence, measured by proportion of HMO-PPO admissions, was not a significant factor in differentiating hospital performance groups.