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This study explores the relationships among measures of nurses' perceptions of organizational culture, continuous quality improvement (CQI) implementation, and medication administration error (MAE) reporting. Hospital-based nurses were surveyed using measures of organizational culture and CQI implementation. These data were combined with previously collected data on perceptions of MAE reporting. A group-oriented culture had a significant positive correlation with CQI implementation, whereas hierarchical and rational culture types were negatively correlated with CQI implementation. Higher barriers to reporting MAE were associated with lower perceived reporting rates. A group-oriented culture and a greater extent of CQI implementation were positively (but not significantly) associated with the estimated overall percentage of MAEs reported. We conclude that health care organizations have implemented CQI programs, yet barriers remain relative to MAE reporting. There is a need to assess the reliability, validity, and completeness of key quality assessment and risk management data. [ABSTRACT FROM AUTHOR]

The terrorist acts during the fall of 2001 triggered renewed concern about the capacity of the nation's public health system to deal with crisis. A critical element of the response ability of the public health system is a prepared workforce. Based on a pre-existing concern about emerging infectious disease, the Centers for Disease Control (CDC), working with the Association of Schools of Public Health, had established a network of university-based Centers for Public Health Preparedness. The events of September 11 accelerated, expanded, and focused this effort. This article discusses this national program, details the activities of the based Center for Public Health Preparedness located at the University of Iowa, and suggests preparedness issues deserving future development. [ABSTRACT FROM AUTHOR]

Because the identification and reporting of medication administration errors (MAE) is a nonautomated and voluntary process, it is important to understand potential barriers to MAE reporting. This paper describes and analyzes a survey instrument designed to assist in evaluating the relative importance of 15 different potential MAE-reporting barriers. Based on the responses of over 1300 nurses and a confirmatory LISREL analysis, the 15 potential barriers are combined into 4 subscales: Disagreement Over Error, Reporting Effort, Fear, and Administrative Response. The psychometric properties of this instrument and descriptive profiles are presented. Specific suggestions for enhancing MAE reporting are discussed. [ABSTRACT FROM PUBLISHER]

The prevention of medication administration errors (MAEs) represents a central focus of hospitals' quality improvement and risk management initiatives. Because the identification and reporting of MAEs is a nonautomated and voluntary process, it is essential to understand the extent to which errors may not be reported. This study reports the results of 2 multihospital surveys in which over 1300 staff nurses in each survey estimated the extent to which various types of nonintravenous (non-i.v.) and intravenous (i.v.)-related MAEs are actually being reported on their nursing units. Overall, respondents estimated that about 60% of MAEs are actually being reported. Considerable differences in estimated rates of MAE reporting were found between staff and supervisors working on the same patient care units. A simulation based on actual and perceived rates of MAE reporting is presented to estimate the range of errors not being reported. Implications regarding the reliability, validity, and completeness of MAEs actually being reported are discussed. [ABSTRACT FROM AUTHOR]

The Upper Midwest offers a distinct environment for identifying and addressing threat and preparedness scenarios. The population is often scattered, with residents using urban centers periodically. This has also led to the challenge of providing specific skills and cross-disciplinary awareness and coordination to the public health community. The Upper Midwest Center for Public Health Preparedness was established by a grant from the Centers for Disease Control and Prevention to assist in meeting the challenge of adding capacity to develop the preparedness workforce in the Upper Midwest. Project Public Health Ready (PPHR) provides an example of the role academic preparedness centers can play in partnering with local public health agencies to strengthen the public health workforce. The purpose of this article is to present the Iowa Systems Model for Workforce Development being utilized for workforce training and education, describe how the model has been applied in the example of PPHR, and discuss lessons learned from the PPHR experience. [ABSTRACT FROM AUTHOR]

Context: The public health system faces unprecedented challenges due to the pandemic, racism, health inequity, and the politicization of public health. At all levels of the system, the workforce is experiencing distress, burnout, safety issues, and attrition. Public health is being challenged to demonstrate and justify its impact and value, while also leveraging opportunities for learning and system strengthening., Program: To explore the current state and identify opportunities to strengthen the public health system, the Region 7 Midwestern Public Health Training Center (MPHTC), with support from Engaging Inquiry, embarked on a distinctive type of systems analysis, called "dynamic systems mapping.", Implementation: This approach brought together diverse sectors of public health partners in the region to develop a rich contextual narrative and system-level understanding to highlight and align existing and emergent strengths, areas for growth, and tangible goals for the immediate- and long-term sustainability of local and regional health., Evaluation: Focus groups and workshops were conducted with diverse practitioners to identify upstream causes and downstream effects of 11 key forces driving system behavior. These focus groups resulted in the development of a visual map that MPHTC is utilizing to identify opportunities for leverage, develop strategies to maximize the potential impact of these leverage points, as well as facilitate continuous learning., Discussion: Public health utilization of systems mapping is a valuable approach to strengthening local and national system responses to current and future public health needs. Outcomes and lessons learned from the systems mapping process are discussed., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: With the current economic climate, money for training is scarce. In addition, time is a major barrier to participation in trainings. To meet the public health workforce's rising demand for training, while struggling with less time and fewer resources, the Upper Midwest Preparedness and Emergency Response Learning Center has developed a model of online training that provides the public health workforce with individually customized, needs-based training experiences., Background/rationale: Adaptive scenarios are rooted in case-based reasoning, a learning approach that focuses on the specific knowledge needed to solve a problem. Proponents of case-based reasoning argue that learners benefit from being able to remember previous similar situations and reusing information and knowledge from that situation. Adaptive scenarios based on true-to-life job performance provide an opportunity to assess skills by presenting the user with choices to make in a problem-solving context., Methods/activities: A team approach was used to develop the adaptive scenarios. Storylines were developed that incorporated situations aligning with the knowledge, skills, and attitudes outlined in the Public Health Preparedness and Response Core Competency Model. This article examines 2 adaptive scenarios: "Ready or Not? A Family Preparedness Scenario" and "Responding to a Crisis: Managing Emotions and Stress Scenario.", Results/outcomes: The scenarios are available on Upper Midwest Preparedness and Emergency Response Learning Center's Learning Management System, the Training Source (http://training-source.org). Evaluation data indicate that users' experiences have been positive., Discussion: Integrating the assessment and training elements of the scenarios so that the training experience is uniquely adaptive to each user is one of the most efficient ways to provide training. The opportunity to provide individualized, needs-based training without having to administer separate assessments has the potential to save time and resources., Lessons Learned/next Steps: These adaptive scenarios continue to be marketed to target audiences through partner organizations, various Web sites, electronic newsletters, and social media. Next steps include the implementation of a 6-month follow-up evaluation, using Kirkpatrick level III. Kirkpatrick level III evaluation measures whether there was actual transfer of learning to the work setting.

Background: The Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline outlines a set of recommendations for physicians to follow in daily practice. However, the effectiveness of this guideline has not been reported. The goal of this project was to evaluate the effect of the AHCPR smoking cessation guideline on provider practices with smokers and on patient smoking rates., Methods: Patient survey and chart review data from 138 Veterans Administration (VA) acute care medical centers with outpatient facilities were examined. Data were available from both sources in 1996, 1997, and 1998. At the midpoint of this period (1997), the VA recommended the AHCPR smoking cessation clinical practice guideline for implementation throughout the VA healthcare system., Results: From 1996 to 1998, both the chart audit and the patient survey showed a significant increase in the percentage of patients in the VA who were counseled about smoking and a significant decrease in the percentage of patients who smoke., Conclusions: Because the VA tied the guideline implementation to report cards and other performance-enhancing measures, guideline adherence may have been maximized in this setting. These findings suggest that healthcare systems should take an integrated approach to guideline implementation.

Rationale, Aims and Objectives: Although clinical practice guidelines have been promoted widely, there is considerable concern that physicians have not incorporated them into their practice. Models suggest that a 'knowledge-attitude-behaviour' sequence is important in modifying physician practice patterns. To address this, we examined physicians' knowledge of, attitudes towards and compliance with a widely implemented guideline - the Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline., Methods: A survey was mailed to a random sample of physicians at 128 veterans health administration facilities, which had implemented the guideline 2 years previously., Results: Completed surveys were received from 879 physicians (50.3 response rate). Only 26 of physicians reported receiving a copy or summary of the guideline, 44 reported little or no familiarity with it, 42 did not know if they agreed with it, 40 did not know if they complied with it and 46 did not know if it was effective. However, a high percentage of physicians reported that they always or usually explain the health risks of smoking (86) and that they always or usually suggest that their smoking patients stop (94)., Conclusions: In spite of little familiarity with the guideline, the responding physicians reported practice patterns consistent with adherence to it. Knowledge is only one of a spectrum of barriers that affects physician adherence to guidelines. There are numerous opportunities for health care organizations to overcome the barriers to physician adoption of clinical practice guidelines in their day-to-day practice.

We examined the relationship between physician adherence with a smoking cessation guideline and organizational structures, policies, leadership support, and physician knowledge and attitudes. A random sample of 844 physicians practicing in 127 VHA hospitals was surveyed. Survey results were aggregated to the hospital level and linked with data on organizational characteristics from the 1998 annual survey of hospitals by the American Hospital Association. Significant predictors of adherence included organizational policies related to nicotine replacement prescriptions, the timing and effectiveness of guideline implementation, physicians' knowledge of VHA clinical guidelines generally, and physicians' beliefs about the receptiveness of patients to smoking cessation.

Monitoring medication administration errors (MAE) is often included as part of the hospital's risk management program. While observation of actual medication administration is the most accurate way to identify errors, hospitals typically rely on voluntary incident reporting processes. Although incident reporting systems are more economical than other methods of error detection, incident reporting can also be a time-consuming process depending on the complexity or "user-friendliness" of the reporting system. Accurate incident reporting systems are also dependent on the ability of the practitioner to: 1) recognize an error has actually occurred; 2) believe the error is significant enough to warrant reporting; and 3) overcome the embarrassment of having committed a MAE and the fear of punishment for reporting a mistake (either one's own or another's mistake).

Nurses play a key role in medication administration in hospital settings. Five categories of reasons for medication errors were identified in a survey of 1,384 nurses. These categories include physician, systems, pharmacy, individual, and knowledge-related factors. In this article, issues surrounding the occurrence and prevention of medication errors are discussed.

Objective: To assess the level of consensus among the administrative and health care leaders at rural Iowa hospitals regarding service gaps and priorities for developing telemedicine services., Methods: In the summer of 1994, a survey was conducted of all rural hospital chief executive officers, chiefs of medical staffs, and directors of nursing in Iowa concerning their perceptions of telemedicine services., Results: With the exception of teleradiology, few clinical specialties received high ratings as areas of need or priorities for the development of telemedicine. There was a general lack of agreement among respondents from the same hospital on such priorities. In contrast, respondents expressed higher priorities for the development of telemedicine-based educational services., Conclusions: The interest in teleradiology is consistent with the fact that teleradiology has been more thoroughly tested for medical efficacy than other telemedicine applications. Continuing medical education may represent another potential for widespread successful telemedicine application. Financial issues were reported as the greatest barriers to the development of telemedicine systems.

This article examines the applicability of a "report card" strategy as a means of differentiating among providers on the basis of performance. The specific focus is on the potential effect of differences in data collection processes on the meaningfulness of subsequent comparisons among similar types of providers. Variations in reported nosocomial infection rates are analyzed in light of differences in reported surveillance practices; data for similar nursing units are analyzed as well. Thirty-one rural, rural referral, and urban acute care hospitals in the midwest participated in the study. The reported nosocomial infection rates for different types of nursing units and different hospital groups varied substantially. Likewise, there were marked variations in the nosocomial infection surveillance practices at the hospitals, which were found to explain some of the variation in the reported nosocomial infection rates for specific types of nursing units and nosocomial infections. The study conclude that differences in data collection processes may result in incorrect conclusions about differences in the quality of care provided by various providers.

Background: Assuring that medication administration error (MAE) reports are reliable and valid is of great significance for the patient, the hospital, and the nurse. In most hospitals, MAE reporting relies on the nurse who discovers an error to initiate an error report, whether the error was committed by that nurse or someone else. Because of the potential for negative consequences, there may be significant disincentives for the nurse to report the error. This, the first of two articles, describes the results of a large-scale survey designed to assess nurses' perceptions of the reasons why MAE may not be reported. The companion article compares nurses' estimates of the extent to which MAEs are reported with the actual reported medication error rates., Methods: Nurses in 24 acute-care hospitals were surveyed to determine perceptions of reasons why medication errors may not be reported., Results: The factor analysis reveals four factors explaining why staff nurses may not report medication errors: fear, disagreement over whether an error occurred, administrative responses to medication errors, and effort required to report MAEs., Conclusions: There are potential changes in both systems and management responses to MAEs that could improve current practice. These changes need to take into account the influences of organizational, professional, and work group culture.

This paper presents strategies and empirical examples of comparative physician profiling under conditions of limited patient sample sizes and varying patient severity. A method by which clinical and cost outcomes may be evaluated simultaneously is also presented. Physician economic and clinical performance are compared using data abstracted from nine hospitals into the MedisGroups clinical information management system for inpatients treated from July, 1990 through June, 1992. The main outcome measures are comparative total and ancillary adjusted charges, and morbidity status. Results suggest that objective comparative outcome data provide useful information to assist in evaluating physician performance. A simultaneous comparison of clinical outcomes and adjusted charges identifies physicians who experience favorable outcomes at lower charges, as well as those who have higher charges and/or poorer outcomes. Strategies outlined in this paper may be of value to clinicians, governing boards, and third party payors. These strategies may be used to assist with privileging and other peer review activities when pursued proactively within a Continuous Quality Improvement framework to improve care.

Background: Implementing patient-centered care (PCC) requires a fundamental shift in thinking-from how to best provide a wide variety of independent services to how to effectively combine individual service components into an integrated health care experience that meets patient needs and preferences., Discussion: PCC attempts to improve patient care by organizationally and physically moving selected service functions such as basic laboratory, pharmacy, admitting/discharge, medical records, housekeeping, and material support services to patient care areas, thus effecting an organizational restructuring. PCC creates teams composed of multiskilled or cross-trained individuals capable of providing more of the services directly on the patient care unit. Extensive redesign of the basic work processes as proposed by PCC advocates may result in significant changes in employee job scope, task responsibilities, professional autonomy, and reporting relationships. From the employee's perspective such changes may be neither warranted nor welcomed. Therefore, critical PCC implementation issues include obtaining employee buy-in and establishing appropriate incentive structures to facilitate the desired changes. How does PCC fit in with the popular improvement philosophies of total quality management (TQM) and continuous quality improvement (CQI)? Inherent within TQM and CQI is the belief that it is wiser to maximize efforts to design a product or process to be right the first time and to minimize resources devoted to inspection and repair caused by poor processes. PCC builds upon previous TQM/CQI health care efforts by focusing on ways to reduce the white space handoff problem by examining what, if any, changes in underlying structures and processes may be required. In the PCC hospital, TQM/CQI can function as intended, as a methodology for examining and improving the process of care and patient-care outcomes, regardless of internal departmental or profession-based organizational boundaries., Conclusion: For hospitals to remain competitive in today's rapidly changing environment, it is becoming necessary to reevaluate both how they are organized and how their work processes have been designed and controlled. The groundwork already laid by TQM/CQI initiatives will facilitate the more fundamental and long-lasting improvements derived from the redesign of the patient-care unit as prescribed by the goals of PCC.