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The rising population of older Americans with advanced illness challenges current care delivery models. We use the metaphor of advanced illness as a difficult journey and propose a specific role, that of the "OACIS NP [nurse practitioner]," who helps provide a place of refuge during this journey. "OACIS" is an acronym for Optimizing Advanced Complex Illness Support, a program to provide home-based palliative medical care. The 4 pillars of this collaborative model for advanced nursing care include care coordination, medical management, psychosocial support, and education. We make the case for this expanded role for nurse practitioners who specialize in palliative care.

In the context of the current health care payer system, quality of care standards, financial incentives and consumer choice are not well aligned, yet competition for increased admissions has become a matter of survival. Satisfaction and loyalty are two constructs that are the most meaningful measures in the context of sustaining and increasing admissions. Lehigh Valley Hospital and Health Network (LVHHN) launched an ambitious patient satisfaction improvement initiative in 2001. LVHHN augmented existing patient service excellence programs with an ethnographic study of a representative unit. Interview and observational data were analyzed using NVivo software. These results (four distilled domains of patient experience) can then be used to identify key components of the care environment that made meaningful differences in the perceptions of patients and their satisfaction. A designated interdepartmental task force can then develop interventions from those learnings, track outcomes through the Press Ganey scores, and ultimately yield increased admissions through unit-specific process change across the hospital. Admissions for fiscal year 2001 to fiscal year 2003 increased from 5,817 to 7,795 patients. The clear value and return on this initiative for our organization included a 34% increase in patient admissions over a four-year period. Improvements in both patient satisfaction and loyalty were demonstrated by a 24% increase for the question, "Likelihood of your recommending this hospital to others" as measured by the Press Ganey Inpatient survey. This initiative demonstrates the successful application of qualitative methods in a clinical microsystem to better understand patient perceptions that determine their satisfaction with medical care.

Purpose: Recent literature defines certain cognitive errors that emergency physicians will likely encounter. The authors have utilized simulation and debriefing to teach the concepts of metacognition and error avoidance., Method: The authors conducted a qualitative study of an educational intervention at Lehigh Valley Hospital during academic year 2002-03. Fifteen emergency medicine residents--eight from postgraduate year three (PGY3) and seven from postgraduate year two (PGY2)--experienced a difficult simulator lab scenario designed to lead them into a cognitive error trap. The debriefing was a PowerPoint with audio format CD-ROM with a didactic on succinylcholine (15 minutes) and cognitive forcing strategies (30 minutes). After debriefing, residents were interviewed by an ethnographer with an 11-question (15-minute) interview and completed an eight-question written survey., Results: The residents ranked this experience second only to direct patient care for educational effectiveness. Survey results (Likert scale, 1 = disagree completely to 5 = agree completely) included "Improved my ability to use succinylcholine" (mean = 4.73), "Improved my ability to diagnose and treat hyperkalemia" (mean = 4.6), and "Cognitive forcing strategies is a useful educational effort" (mean = 4.33). The major interview themes that evolved were that the simulation lab was a positive experience; succinylcholine knowledge was gained; mistakes caused reflection/motivation; the lab was stressful; attending feedback was desired; the lab was realistic; and cognitive forcing strategies were discussed. When asked what they learned, more of the PGY3s commented on cognitive strategies or heuristic techniques (six out of eight), whereas the PGY2s commented on knowledge gained about succinylcholine (five out of seven) and only one PGY2 mentioned cognitive strategies., Conclusion: Pilot data suggest that metacognitive strategies can be taught to residents, though they may be better understood by upper-level residents.