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Background: A prevailing blame culture in health care has been suggested as a major source of an unacceptably high number of medical errors. A just culture has emerged as an imperative for improving the quality and safety of patient care. However, health care organizations are finding it hard to move from a culture of blame to a just culture. Purpose: We argue that moving from a blame culture to a just culture requires a comprehensive understanding of organizational attributes or antecedents that cause blame or just cultures. Health care organizations need to build organizational capacity in the form of human resource (HR) management capabilities to achieve a just culture. Methodology: This is a conceptual article. Health care management literature was reviewed with twin objectives: (a) to ascertain if a consistent pattern existed in organizational attributes that lead to either blame or just cultures and (2) to find out ways to reform a blame culture. Conclusions: On the basis of the review of related literature, we conclude that (a) a blame culture is more likely to occur in health care organizations that rely predominantly on hierarchical, compliance-based functional management systems; (b) a just or learning culture is more likely to occur in health organizations that elicit greater employee involvement in decision making; and (c) human resource management capabilities play an important role in moving from a blame culture to a just culture. Practice Implications: Organizational culture or human resource management practices play a critical role in the health care delivery process. Health care organizations need to develop a culture that harnesses the ideas and ingenuity of health care professional by employing a commitment-based management philosophy rather than strangling them by overregulating their behaviors using a control-based philosophy. They cannot simply wish away the deeply entrenched culture of blame nor can they outsource their way out of it. Health care organizations need to build internal human resource management capabilities to bring about the necessary changes in their culture and management systems and to become learning organizations. [ABSTRACT FROM AUTHOR]

The relationship between cost and quality of care in nursing homes was examined using quality indicator measures of resident outcomes. While each individual quality measure makes only small contributions to costs, when considered across the facility, quality could have a substantial financial impact on the operations of the home. [ABSTRACT FROM AUTHOR]

In 1994 12.7% of the population was 65 and over, while 10.6% were 85 and over. Expenditures for nursing homes reached $72.3 billion in 1994 (much of which is tax-supported) accounting for 8.7% of all personal health money spent. Data from the 1993 Missouri Medicaid cost reports for 403 nursing homes were reviewed to determine differences in costs per resident day (PRD) and discover which factors most influenced these differences. Mid-sized facilities with 60-120 beds reported the lowest resident-related PRD costs. PRD expenses for aides and orderlies were higher in tax-exempt facilities, which was thought to be related to their 'more altruistic' mission. Investor-owned facilities showed significantly greater administrative costs PRD, which may relate to higher administrative salaries and fancier offices. The authors suggest further study that would incorporate location, occupancy rate, quality of care, case mix, and payer mix data. [ABSTRACT FROM AUTHOR]

In the name of costing accuracy, nurses are asked to track inventory use on per treatment basis when more significant costs, such as general overhead and nursing salaries, are usually allocated to patients or treatments on an average cost basis. Accurate treatment costing and financial viability require analysis of all resources actually consumed in treatment delivery, including nursing services and inventory. More precise costing information enables more profitable decisions as is demonstrated by comparing the ratio-of-cost-to-treatment method (aggregate costing) with alternative activity-based costing methods (ABC). Nurses must participate in this costing process to assure that capitation bids are based upon accurate costs rather than simple averages. [ABSTRACT FROM AUTHOR]

This article presents a model of the role of work and organizational stress upon the qualitative performance and productivity of nursing employees. [ABSTRACT FROM AUTHOR]

Three pilot studies ( N total  = 832) revealed that people held more positive attitudes toward targets wearing protective face masks. Therefore, we examined whether knowledge of this self-presentational benefit would increase people's intentions to wear face masks. Participants ( N  = 997) were randomly assigned to read a passage about the COVID-19 pandemic, the safety benefit of mask-wearing, the self-presentational benefit of mask-wearing, or a combination of the latter two. Although this manipulation failed, findings revealed that preexisting beliefs about masked targets being more likable were positively associated with mask-wearing intentions, particularly among participants less concerned with disease or more politically conservative.

A new goal-systems model is proposed to help explain when individuals will protect themselves against the risks inherent to social connection. This model assumes that people satisfy the goal to feel included in safe social connections-connections where they are valued and protected rather than at risk of being harmed-by devaluing rejecting friends, trusting in expectancy-consistent relationships, and avoiding infectious strangers. In the hypothesized goal system, frustrating the fundamental goal to feel safe in social connection sensitizes regulatory systems that afford safety from the risk of being interpersonally rejected (i.e., the risk-regulation system), existentially uncertain (i.e., the social-safety system), or physically infected (i.e., the behavioral-immune system). Conversely, fulfilling the fundamental goal to feel safe in social connection desensitizes these self-protective systems. A 3-week experimental daily diary study ( N = 555) tested the model hypotheses. We intervened to fulfill the goal to feel safe in social connection by repeatedly conditioning experimental participants to associate their romantic partners with highly positive, approachable words and images. We then tracked how vigilantly experimental versus control participants protected themselves when they encountered social rejection, unexpected behavior, or contagious illness in everyday life. Multilevel analyses revealed that the intervention lessoned self-protective defenses against each of these risks for participants who ordinarily felt most vulnerable to them. The findings provide the first evidence that the fundamental goal to feel safe in social connection can co-opt the risk-regulation, social-safety, and behavioral-immune systems as independent means for its pursuit. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The height of the COVID-19 pandemic was an exceptionally stressful time for families that offered a unique opportunity to understand how stressful experiences occurring outside the relationship shape behavior occurring inside the relationship. Given the social distancing requirements of the pandemic, however, most research addressing this issue has relied on self-reports of behavior, which are susceptible to bias. In the summer of 2020, we asked a sample of married individuals living in the United States, Canada, Ireland, and the United Kingdom to complete online questionnaires assessing neuroticism and attachment insecurity, their levels of chronic stress, and their levels of acute stress due to the COVID-19 pandemic. We then asked participants to submit a 10-min video of themselves and their spouse attempting to solve an important marital problem that they recorded on their smartphone or other device and uploaded to a secure server. Coders were able to reliably code the behavior of both partners using an established coding system, and the distribution of codes was similar to prior research. Consistent with predictions, participants' COVID-19 stress interacted with their neuroticism and attachment avoidance to predict their levels of oppositional behavior, controlling for their levels of chronic stress and their partner's behavior; neuroticism and attachment avoidance were associated with behaving in a more oppositional manner among participants who reported high but not low COVID-19 stress. Attachment anxiety trended toward predicting more oppositional behavior regardless of stress. These results shed light on how stress affects behavior and introduce a novel way to observe family behavior remotely. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prior research provides mixed evidence regarding the direction of the association between sexual and marital satisfaction. Whereas some studies suggest a bidirectional association, other studies fail to document one direction or the other. The current investigation used a 12-day diary study of 287 married individuals to clarify the nature of this association. Results from time-lagged mixed modeling revealed a significant positive bidirectional association. Both higher global sexual satisfaction one day and satisfaction with sex that occurred that day predicted higher marital satisfaction the next day; likewise, higher marital satisfaction one day significantly predicted higher global sexual satisfaction the next day and higher satisfaction with sex that occurred the next day. Both associations remained significant after controlling for participant's gender/sex, neuroticism, attachment insecurity, self-esteem, stress, perceived childhood unpredictability and harshness, age of first intercourse, construal level, age, and length of marriage. We also explored whether these covariates moderated either direction of the association. Daily stress was the most reliable moderator, with three of the four interactions tested remaining significant after Bonferroni corrections. The bidirectional association between global sexual and marital satisfaction and the positive association between satisfaction with sex that occurred that day and marital satisfaction the next day were significantly stronger when individuals experienced high versus low stress. Although the exploratory nature of all moderation analyses suggests they should be replicated before drawing strong conclusions, these findings highlight the importance of sexual satisfaction to marital satisfaction and vice versa and point to the power of stress in strengthening these associations., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Dual-process models of cognition distinguish relatively automatic from relatively controlled processes in terms of their interactive impact on perception, judgment, and behavior. Such models have advanced explanation and prediction in a variety of domains across psychology but have yet to be comprehensively applied to the pressing societal and public health problem of suicide. We propose a model of suicide that integrates dual-process models of social cognition with ideation-to-action conceptualizations of suicide. The model specifies: (a) suicide-relevant automatic associations involving the self, others, the future, death, and bodily harm, (b) suicide-relevant motives involving the self, interpersonal relations, the future, and the desire to die, and (c) hypotheses regarding the conditions under which automatic associations and motives individually and interactively impact suicidal ideation and lethal action at various stages of an ideation-to-action framework. The model recasts a number of suicide-relevant variables in terms of the opportunity factor of dual-process theories of attitudes, which encompasses capacity-relevant variables (e.g., time, cognitive resources) that determine whether suicide-relevant judgments and behavior are the result of relatively automatic associations or more controlled, deliberative cognition. Accordingly, the model articulates a number of novel predictions regarding the sources of suicide-relevant automatic associations, motives, and opportunity factors, as well as their interactive influences on suicidal ideation and action. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The behavioral immune system is an evolved adaptation comprised of automatic behavioral, cognitive, and affective reactions that has allowed humans throughout evolutionary history to avoid situations that risk infection by pathogens (e.g., physical proximity to sick people). Although behavioral immune system activation may be functional by helping people avoid such situations, experiencing these automatic reactions during sexual interactions may undermine people's evaluations of those interactions because sex requires close physical contact. We examined whether two sources of behavioral immune system activation (daily concern over contracting COVID-19 and individual differences in infection concern) undermined satisfaction with sex among 318 partnered adults in the U.S. during the COVID-19 pandemic. Participants reported individual differences in perceived infectability and then, every night for two weeks, reported their (a) daily concern about contracting COVID-19, (b) daily stress, (c) whether they had sex with their partner, and (d) their satisfaction with sex when it occurred. People's perceived infectability moderated the association between their daily concern about contracting COVID-19 and the extent to which they enjoyed sex when it occurred, such that people higher, but not lower, in perceived infectability enjoyed sex less on days that they were more worried about contracting COVID-19 than usual. This effect was not moderated by biological sex and remained significant when controlling for biological sex, age, relationship length, and frequency of sex. Results highlight the importance of the behavioral immune system to sexual functioning and suggest a novel avenue through which the COVID-19 pandemic has disrupted relationships., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Do people realize the evaluative feelings that are spontaneously activated by their partner? If so, do they use those evaluations when judging their romantic relationships? To answer these questions, we investigated the association between automatic partner attitudes and judgments of relationship satisfaction in 7 studies. Study 1 was a meta-analysis of 86 correlations that revealed a very weak association between implicitly and explicitly assessed relationship evaluations, and Studies 2a-2c revealed that people failed to accurately report their automatic partner attitudes even when specifically asked to do so. Consistent with the idea that such inaccuracy emerged in part because motivational factors led people to override their automatic attitudes, Studies 3 and 4 demonstrated that automatic partner attitudes better aligned with relationship judgments when people were incentivized with money (Study 3) and had dissolved their relationship (Study 4). Nevertheless, consistent with the idea that overriding automatic attitudes requires the opportunity to deliberate, Studies 4 and 5 demonstrated that automatic partner attitudes better aligned with relationship judgments when people experienced more stress at the daily level (Study 4) and yearly for two years (Study 5). In Study 5, the interaction between stress and automatic attitudes emerged controlling indicators of negativity and was further moderated by relationship enhancing motivations among wives. These studies (a) help explain why automatic partner attitudes predict self-reported relationship satisfaction over time and (b) provide support for theories of social cognition suggesting that people have access to implicitly assessed attitudes that is obscured by motivations and opportunities to deliberate. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Traditional pathogen surveillance methods for white-nose syndrome (WNS), the most serious threat to hibernating North American bats, focus on fungal presence where large congregations of hibernating bats occur. However, in the western USA, WNS-susceptible bat species rarely assemble in large numbers and known winter roosts are uncommon features. WNS increases arousal frequency and activity of infected bats during hibernation. Our objective was to explore the effectiveness of acoustic monitoring as a surveillance tool for WNS. We propose a non-invasive approach to model pre-WNS baseline activity rates for comparison with future acoustic data after WNS is suspected to occur. We investigated relationships among bat activity, ambient temperatures, and season prior to presence of WNS across forested sites of Montana, USA where WNS was not known to occur. We used acoustic monitors to collect bat activity and ambient temperature data year-round on 41 sites, 2011-2019. We detected a diverse bat community across managed (n = 4) and unmanaged (n = 37) forest sites and recorded over 5.37 million passes from bats, including 13 identified species. Bats were active year-round, but positive associations between average of the nightly temperatures by month and bat activity were strongest in spring and fall. From these data, we developed site-specific prediction models for bat activity to account for seasonal and annual temperature variation prior to known occurrence of WNS. These prediction models can be used to monitor changes in bat activity that may signal potential presence of WNS, such as greater than expected activity in winter, or less than expected activity during summer. We propose this model-based method for future monitoring efforts that could be used to trigger targeted sampling of individual bats or hibernacula for WNS, in areas where traditional disease surveillance approaches are logistically difficult to implement or because of human-wildlife transmission concerns from COVID-19., Competing Interests: Weyerhaeuser provided access and logistical support to collect empirical data and provided support in the form of salary for Lorin Hicks and Jessica Homyack. Plum Creek Timber, Stimson Lumber, F. H. Stoltze Land and Timber also provided funding and support in the form of salary for Lorin Hicks. Weyerhaeuser also contracted with TetraTech for data collection and analysis and Nathan Schwab received support in the form of salary. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Sex presumably facilitates pair bonding, but how do partners remain pair-bonded between sexual acts? Evolutionary perspectives suggest that sexual afterglow serves this purpose. We explored how long sexual satisfaction would remain elevated following sex and predicted that stronger sexual afterglow would characterize more satisfying partnerships. We pooled the data from two independent, longitudinal studies of newlywed couples to examine these issues. Spouses reported their daily sexual activity and sexual satisfaction for 14 days and their marital satisfaction at baseline and 4 or 6 months later. Results demonstrated that sexual satisfaction remained elevated approximately 48 hr after sex, and spouses experiencing a stronger afterglow reported higher levels of marital satisfaction both at baseline and over time. We interpret these findings as evidence that sexual afterglow is a proximal cognitive mechanism through which sex promotes pair bonding.

A strong predisposition to engage in sexual intercourse likely evolved in humans because sex is crucial to reproduction. Given that meeting interpersonal preferences tends to promote positive relationship evaluations, sex within a relationship should be positively associated with relationship satisfaction. Nevertheless, prior research has been inconclusive in demonstrating such a link, with longitudinal and experimental studies showing no association between sexual frequency and relationship satisfaction. Crucially, though, all prior research has utilized explicit reports of satisfaction, which reflect deliberative processes that may override the more automatic implications of phylogenetically older evolved preferences. Accordingly, capturing the implications of sexual frequency for relationship evaluations may require implicit measurements that bypass deliberative reasoning. Consistent with this idea, one cross-sectional and one 3-year study of newlywed couples revealed a positive association between sexual frequency and automatic partner evaluations but not explicit satisfaction. These findings highlight the importance of automatic measurements to understanding interpersonal relationships., (© The Author(s) 2016.)

Unlabelled: The US government allocated $30 billion to implement electronic health records (EHRs) in hospitals and provider practices through policy addressing Meaningful Use (MU). Most small, rural hospitals, particularly those designated as Critical Access Hospitals (CAHs), comprising nearly a quarter of US hospitals, had not implemented EHRs before. Little is known about implementation in this setting. Socio-technical factors differ between larger hospitals and CAHs, which continue to lag behind other hospitals in EHR adoption., Objective: The main objective is to provide EHR implementation advice for CAHs from a spectrum of experts with an emphasis on recommendations from their peers at CAHs that have undertaken the process. The secondary objective is to begin to identify implementation process differences at CAHs v. larger hospitals., Methods: We interviewed 41 experts, including 16 CAH staff members from EHR teams at 10 CAHs that recently implemented EHRs. We qualitatively analyzed the interviews to ascertain themes and implementation recommendations., Results: Nineteen themes emerged. Under each theme, comments by experts provide in-depth advice on all implementation stages including ongoing optimization and use. We present comments for three top themes as ranked by number of CAH peer experts commenting - EHR System Selection, EHR Team, and Preparatory Work - and for two others, Outside Partners/Resources and Clinical Decision Support (CDS)/Knowledge Management (KM). Comments for remaining themes are included in tables., Discussion: CAH experts rank the themes differently from all experts, a likely indication of the differences between hospitals. Comments for each theme indicate the specific difficulties CAHs encountered. CAH staffs have little or no EHR experience before implementation. A factor across themes is insufficient system and process knowledge, compounded by compressed implementation schedules. Increased, proactive self-education, via available outside partners and information resources, will mitigate difficulties and aid CAHs in meeting increased CDS requirements in MU Stages 2 and 3.

The US government has allocated $30 billion dollars to implement Electronic Health Records (EHRs) in hospitals and provider practices through a policy called Meaningful Use. Small, rural hospitals, particularly those designated as Critical Access Hospitals (CAHs), comprising nearly a quarter of US hospitals, had not implemented EHRs before. Little is known on implementation in this setting. We interviewed a spectrum of 31 experts in the domain. The interviews were then analyzed qualitatively to ascertain the expert recommendations. Nineteen themes emerged. The pool of experts included staff from CAHs that had recently implemented EHRs. We were able to compare their answers with those of other experts and make recommendations for stakeholders. CAH peer experts focused less on issues such as physician buy-in, communication, and the EHR team. None of them indicated concern or focus on clinical decision support systems, leadership, or governance. They were especially concerned with system selection, technology, preparatory work and a need to know more about workflow and optimization. These differences were explained by the size and nature of these small hospitals.

A state-sponsored evaluation of aging in place (AIP) as an alternative to assisted living and nursing home has been underway in Missouri. Cost, physical, and mental health assessment data reveal the cost-effectiveness and positive health measures of AIP. Findings of the first four years of the AIP evaluation of two long-term care settings in Missouri with registered nurse care coordination are compared with national data for traditional long-term care. The combined care and housing cost for any resident who received care services beyond base services of AIP and who qualified for nursing home care has never approached or exceeded the cost of nursing home care at either location. Both mental health and physical health measures indicate the health restoration and independence effectiveness of the AIP model for long-term care., (Copyright © 2011. Published by Mosby, Inc.)

The objective of this study was to evaluate the impact of remote monitoring home telehealth on client and provider satisfaction, clinical outcomes, and cost. The project design was a pragmatic evaluation of the technology in a real-world setting at an operational scale rather than a controlled clinical trial. Patients receiving monitoring were selected by the home health agency, and a random sample of other agency clients was selected for comparative purposes. Data were collected on additional costs and benefits associated with home telehealth monitoring. Quantitative and qualitative data suggest that when remote monitoring telehealth technology was utilized in the home-care setting, both clients and providers were very satisfied with services; they felt it was easy to communicate, and that the technology was convenient and user friendly. Clients also felt that home telehealth technology had a very positive impact on the provider-client relationship and improved care. The study also suggests that home care monitoring reduces hospitalizations and decreases personnel expenses. This preliminary study provides evidence as to the value of remote monitoring home telehealth in the delivery of services to home care populations. It also provides evidence as to the positive impact that this form of technology may have on healthcare systems, provider and client satisfaction, and on the relationships that form between providers and clients.

Teledermatology studies have examined diagnostic concordance between live-interactive (LI) and in-person examinations (IP); and between store-and-forward (SF) and IP examinations. However, no studies have looked simultaneously across all three care delivery modalities, and few have measured management concordance and diagnostic confidence of the dermatologist. The purpose of this study was to compare LI and SF modalities with IP with respect to diagnostic and management concordance and to compare physician diagnostic confidence across the three modalities. Four dermatologists, in random rotation among all three care modalities, examined 110 new patients. Confidence was rated on a Likert scale from 1 to 5 (5 = total confidence; 1 = no confidence). Identical diagnoses were given to the patient by examiners from all three examination modalities in 70/110 patients (64%). More identical diagnoses were given for IP and LI examinations than for IP and SF examinations (80% vs. 73%); however, the difference was not statistically significant (p = 0.13). The highest self-reported confidence rating was given for 87% of IP examinations, 59% for LI, and 54% for SF. Diagnostic confidence ratings for SF and LI were not significantly different from each other (p = 0.50); however, diagnostic confidence ratings for LI and SF were both statistically lower than IP (p < 0.0001). Dermatologists were more confident with IP examination than either form of teledermatology. The percent of diagnostic and management agreement among IP, LI, and SF modalities was high.

Background: The viability of trauma care as a surgical subspecialty is continually challenged by economic pressures related to reimbursement and opportunity costs., Methods: The literature was examined for articles focused on economic implications of a trauma focused surgical practice. Economic forecasting techniques were applied using a recalculating spreadsheet to examine charge and revenue generation comparing the effects of numerous variables affecting a trauma or general surgical service., Results: Elective general surgery practices derive the majority of revenues from procedural services, whereas trauma practices derive the majority of revenues from evaluation and management. Only centers with high admission volume can expect trauma surgeons to cover salary and expenses, predictably in association with high opportunity costs., Conclusion: The differences in time, effort, and patient volume required for a trauma surgeon to generate revenues comparable to an elective practice are dramatic. The current system creates disincentives for surgeons to participate in trauma care.

Increasingly, telecommunications and advanced information technologies are being used for a variety of activities: clinical, administrative, and education/research. These activities are undertaken with the expectation that health care delivery will be improved. To validate this expectation, a number of investigations have been undertaken to assess the effectiveness and efficiency of the activities. Unfortunately, many of these investigations have either been incomplete or have applied inappropriate techniques in the evaluation process. This is especially true in the attempts to evaluate the cost effectiveness of various telecommunication technologies and service delivery. The model presented here provides a systematic framework that can be used in evaluating the effectiveness, efficiency, and feasibility of telemedicine. The model delineates the different aspects and characteristics of an evaluation across three dimensions-focus (cost, quality, access), level (individual, community, society), and activities (clinical, administration, education/research). These dimensions are interrelated, making comprehensive evaluation difficult.

We collected data on patient satisfaction with the use of teledermatology services. During a 27-month study, a single dermatologist saw a total of 321 patients via telemedicine. The patients completed 483 surveys, although not all questions were answered on all surveys. There was a high level of satisfaction among patients using teledermatology: 88% of 258 respondents said that they were satisfied with their telemedicine session. In terms of the eight questions on the questionnaire, 84% of the responses were in the top two positive categories on a seven-point Likert scale. In addition, access to dermatology appeared to increase with the availability of the telemedicine service.

Access to emergency treatment in rural areas can often mean the difference between life and death. Telemedicine technologies have the potential of providing earlier diagnosis and intervention, of saving lives and of avoiding unnecessary transfers from rural hospital emergency departments to urban hospitals. This study examined the hypothetical impact of telemedicine services on patients served by the emergency departments of two rural Missouri hospitals and the potential financial impact on the affected hospitals. Of the 246 patients transferred to the hub hospital from the two facilities during 1996, 161 medical records (65.4 percent) were analyzed. Using a conservative approach, only 12 of these cases were identified as potentially avoidable transfers with the use of telemedicine. Of these 12, 5 were admitted to the hub hospital after transfer. In addition to this conservative estimate of avoidable transfers based on current availability of resources in the rural hospitals, two more aggressive scenarios were developed, based on an assumption of increased service availability in the rural hospitals. Economic multipliers were used to estimate the financial impacts on communities in each scenario. This evaluation study demonstrates the potential value of telemedicine use in rural emergency departments to patients, rural hospitals and rural communities.

The "Observable Indicators of Nursing Home Care Quality" instrument was developed as a new measure of nursing home care quality. The instrument is based on a theoretical model of quality nursing home care grounded in data from provider and consumer focus groups. The instrument was piloted in 10 Missouri nursing homes. Subsequent versions were tested in 109 Missouri and 11 Icelandic nursing homes. Content validity was established using experts. Concurrent and known groups validity was evaluated using Minimum Data Set quality indicators, survey citations, and a process of care measure. Interrater and test-retest reliabilities were calculated as well as coefficient alpha. The "Observable Indicators of Nursing Home Care Quality" instrument is a new measure that can be used by researchers, and potentially by regulators, consumers, or providers, to observe and score specific indicators of quality care following a 20- to 30-minute inspection of a nursing home.

Background: Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas in nursing home care is critical for preparing reports for nursing homes to use in their quality improvement programs. This article builds on the work of an earlier panel of experts that set thresholds for quality indicators (QIs) derived from Minimum Data Set (MDS) assessment data. Thresholds were now set for the revised MDS 2.0 two-page quarterly form and Resource Utilization Groups III (RUGS III) quarterly instrument., Setting Thresholds: In a day-long session in October 1998, panel members individually determined lower (good) and upper (poor) threshold scores for each QI, reviewed statewide distributions of MDS QIs, and completed a follow-up Delphi of the final results., Reporting Mds Qis for Quality Improvement: The QI reports compiled longitudinal data for all residents in the nursing home during each quarter and cumulatively displayed data for five quarters for each QI. A resident roster was provided to the nursing home so that the quality improvement team could identify the specific residents who developed the problems defined by each QI during the last quarter. Quality improvement teams found the reports helpful and easy to interpret., Summary and Conclusions: As promised in an earlier report, to ensure that thresholds reflect current practice, research using experts in a panel to set thresholds was repeated as needed. As the MDS instrument or recommended calculations for the MDS QIs change, thresholds will be reestablished to ensure a fit with the instrument and data.

A survey was conducted among non-doctor health-care professionals in six rural counties in Missouri. The purpose of the survey was to establish baseline data to evaluate the effect of changes in the health-care sector, especially technology changes, on the job satisfaction, career satisfaction, relationships and communication activities of health professionals. The survey included three rural counties in which integrated telecommunication and interactive video telemedicine services were being installed, but before significant activities had begun, and three comparator counties without substantial integrated telecommunications infrastructure and telemedicine services. During a one-month study period, 1108 questionnaires were distributed. The total response rate was 50.1% (n = 555). Of the respondents, 30.3% indicated that technology in health-care was having a large effect on their work, although only 18.2% indicated that telemedicine and telecommunications were having a large effect. No systematic differences were found among the health professionals in the two communities at the time telemedicine equipment was being installed.

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality from the viewpoint of consumers of nursing home care. Eleven focus groups were conducted in five Missouri communities. The seven dimensions of the consumer multidimensional model of nursing home care quality are: staff, care, family involvement, communication, environment, home, and cost. The views of consumers and families are compared with the results of a previous study of providers of nursing home services. An integrated, multidimensional theoretical model is presented for testing and evaluation. An instrument based on the model is being tested to observe and score the dimensions of nursing home care quality.

The evaluation of telemedicine activity in rural communities is complicated by the fact that most telemedicine sites are chosen because of their existing telecommunications infrastructure and institutional relationships, not by a random selection process. In addition, it is difficult to draw conclusions about the effects of telemedicine without a careful analysis of parallel changes in communities which do not have access to telemedicine services. We have developed a method of identifying comparable counties based on an aggregate measure of health status. A set of 66 variables was collected in a previous project to develop a model to evaluate the relative health status of the population in Missouri. A stepwise regression was used to identify a subset of 15 variables that had the highest predictive value for the health status of a county. Distance measures were then used to identify six counties which were most similar to three telemedicine counties. The method can be used with any study set chosen non-randomly, to identify similar objects that can be used for comparative purposes.

Objectives: The purpose of this study was to evaluate the effect of clinical direct reports (practice data with pertinent evidence from the literature) on dialysis modality selection for patients with end-stage renal disease., Methods: A randomized controlled clinical trial was conducted at five dialysis centers. Five of the 10 physician participants were assigned through centralized computerized randomization to the intervention group (who received 12 center-specific clinical direct reports encouraging the consideration of peritoneal dialysis), and five were assigned to the control group, who received usual information but no similar report. One hundred fifty-two patients were eligible for monitoring., Results: The number of patients allocated to peritoneal dialysis was significantly higher in the intervention group than in the control group (15.3% versus 2.4%; P = 0.044). Due to a need for transient initial hemodialysis by some patients, the percentage of patients receiving peritoneal dialysis further increased through the end of the 3-month follow-up (18.0% versus 4.9%, P = 0.041)., Conclusions: There were no significant differences between the intervention and control groups in meeting patient preferences, metabolic status, and complication rates. The results of this study show that linking pertinent published evidence to actual practice data can support the implementation of practice recommendations and influence the selection of dialysis treatment for new patients.

Background: Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas is critical for quality improvement reports. Without thresholds, an organization may interpret its performance as superior to others because it is "better than average" and falsely assume it does not have care problems in certain areas., Setting Thresholds: The Minimum Data Set (MDS) assessment instrument is mandated for use nationwide in all nursing homes participating in Medicaid or Medicare programs. Since 1993 a research team at the University of Missouri-Columbia has been developing and testing quality indicators (QIs) derived from MDS data as a foundation for quality improvement activities. In July 1996, a cross-section of 13 clinical care personnel from nursing homes participated on an expert panel for threshold setting for QIs derived from MDS assessment data. Panel members individually determined good and poor threshold scores for each QI, reviewed statewide distributions of MDS QIs, and, two weeks later, completed a follow-up Delphi round. Three members of the research team reviewed the results of the expert panel and set the final thresholds. With thresholds established for good and poor scores, MDS QI scores are reported to a sample of Missouri nursing homes using the thresholds., Conclusions: To ensure that thresholds reflect current practice, threshold setting with another panel of experts will be repeated as needed, but at least biannually. The report format will be revised on the basis of user input, and a statewide study testing different educational support methods for quality improvement using MDS QIs is now underway.

This research examined the prevalence of second offices and hospital consulting practices of physicians in Missouri, the characteristics of physicians participating in such practices, the change in availability of services through these practices, the characteristics of counties and hospitals involved, and the practice organization of participating physicians. The assessment of the factors was conducted within the conceptual framework of community and physician characteristics, practice form and organization, and health system resources. In 1993, 64 of the 93 nonmetropolitan counties in Missouri gained, on average, 1.3 full-time equivalent physicians through second office and hospital consulting practices. Eighteen nonmetropolitan counties lost, on average, 0.4 full-time equivalent physicians through these practices; 11 nonmetropolitan counties were not affected. The majority of physicians engaged in these two types of practices are nonprimary care specialists. Consequently, in addition to the net contribution to total physician service availability, many nonmetropolitan counties gained access locally to a wider variety of specialty services. This change in availability of physician services, not generally incorporated in decisions, needs to be considered when policy efforts are undertaken to change the spatial and specialty distribution of physicians.

Rural providers must redefine their role in the changing health care system to include a more integrated approach to health care delivery. The rural provider must develop integrated pathways to coordinate all medical, behavior, and social services to ensure that appropriate services are available, locally or through linkages with other providers, for the population. The integrated pathway must manage care across the continuum of services and coordinate decisions occurring at the point of service.

The health care crisis and efforts for reform have taken a variety of forms. Apparently a majority of states have decided that the federal government will develop solutions to this problem slowly, if at all, and have undertaken a variety of activities on their own to address the problem. One state response has been to mandate the collection of data related to health services in an effort to assist purchasers of health care to make more prudent buying decisions. This article contains the results of a survey conducted among the states that have legislatively mandated the collection of health-related data and presents a compilation and discussion of their activities.

The purpose of this study was to specify the financial effect of clinical decisions in a dialysis center. A consecutive sample of 14,343 outpatient hemodialysis treatments (OHD), 16,111 continuous ambulatory peritoneal dialysis (CAPD), and 4,513 chronic cycler-assisted peritoneal dialysis (CCPD) days of treatment was analyzed. An activity-based cost calculation method was applied to the analysis of alternative treatments (service bundles). The weekly cost of OHD was higher ($338 versus $241/$242), and the contribution margin (reimbursement minus total cost) of CAPD/CCPD was much greater ($.48 versus $148/$147 per patient week). Clinical decision-making had an influence on less than 6.8% of OHD and 45.4%/46.6% of CAPD/CCPD related expenses. In comparison to activity-based cost calculation, conventional methods overestimated the overhead expense of CAPD by 3-48%. This study documented that most cost control opportunities reside in the usual process of care and less can be influenced by a direct interference with the patient-physician contacts. Paying for 1 week of renal replacement (capitation) could simplify the process of reimbursement and cost tracking.

This article examines the implications resulting from the closure of 25 rural hospitals during 1990. The implications are evaluated by estimating travel distance and time to the nearest open hospitals. In addition, the types of services offered in the hospitals studied were measured to provide a view of potential change in access to services. The average travel distance and time to the nearest hospital after closure was 25.7 miles and 30.2 minutes, respectively. In most cases, the remaining hospitals offered a broader scope of services than did the hospitals that closed. A possible interpretation is that the hospital closures resulted in a tradeoff between breadth of services and rapid access for emergency conditions.

In this article, the methodology used by the Health Care Financing Administration in the 1992 release of 1990 mortality statistics is described, and the performance of one outlier hospital is evaluated as a case study. The study hospital is compared to all other hospitals, and to a smaller cohort of 200-to-299-bed minor teaching hospitals, in terms of predicted and observed mortality rates and mortality model determinants. Proportionately more patients treated in the study hospital were women and had cerebrovascular degeneration or chronic renal disease; fewer patients had cardiovascular disease. Substantially more patients from this hospital were transfers from a skilled nursing facility. Fewer patients were admitted through the emergency department. Although patients tended to be more seriously ill overall compared with other hospitals in the country, observed mortality rates were still higher than predicted. Possible explanations for the discrepancy were coding inconsistencies, inability to control adequately for the severity of illness of transfers from skilled nursing facilities, or quality of care problems.

The erosion of the traditional market is forcing hospitals and physicians to reevaluate their historical relationships. One method for addressing the potential conflicts created by current pressures is the formation of physician-hospital networks. These entities are formed and function on the basis of mutual interests and responsiveness to change.