Effects of Description of Options on Parental Perinatal Decision-Making
Objective: To examine whether parents' delivery room management decisions for extremely preterm infants are influenced by (a) the degree of detail with which options-comfort care (CC) or intensive care (IC)-are presented or (b) their order of presentation. Methods: 309 volunteers, 18-55 years old, were each randomized to one of 4 groups: 1. detailed descriptions, CC presented first; 2. detailed descriptions, IC presented first; 3. brief descriptions, CC presented first; and 4. brief descriptions, IC presented first. Each received the description of a hypothetical delivery of a 23-week gestation infant and chose either IC or CC. Open-ended and structured questions elicited reasoning. Data were analyzed by chi-square and logistic regression analysis. Results: Neither degree of detail, comparing groups 1+2 with 3+4 (37% v 41%, OR=0.85, 95%CI=0.54-1.34, p=0.48), nor order, comparing groups 1+3 with 2+4 (40% v 37 %, OR=0.88, 95%CI=0.56-1.39; p=0.59), influenced the likelihood of choosing IC. Participants choosing IC were more likely to invoke sanctity of life and religiosity as personal values. Additional reasons for choosing IC were experiences with infants born at later gestational ages, giving the baby a chance, not watching their baby die, and equating CC with euthanasia. Some choosing CC wanted to avoid infant suffering. Conclusions: The degree of detail and order of presentation had no effect on treatment decisions, suggesting that individuals bring well-articulated preexisting preferences to such decisions. Understanding beliefs and attitudes motivating these preferences can assist physicians in helping parents make informed decisions consistent with their values.
Keywords: Decision Making;
Motivation and Incentives;
Family and Family Relationships;
Health Care and Treatment;
Haward, Marlyse F., Leslie John, John M. Lorenz, and Baruch Fischhoff. "Effects of Description of Options on Parental Perinatal Decision-Making." Pediatrics
129, no. 5 (2012).
A Randomized Field Study of a Leadership WalkRoundsTM -Based Intervention
Background: Leadership WalkRoundsTM have been widely adopted as a technique for improving patient safety and safety climate. WalkRoundsTM involve senior managers directly observing frontline work and soliciting employees' ideas about improvement opportunities. However, the hypothesized link between WalkRoundsTM-based programs and performance has not been rigorously examined in a set of randomly selected hospitals. Objective: To fill this research gap, we conducted a randomized field study of a WalkRoundsTM-based program.
Research Design: Fifty-six work areas from 19 randomly selected hospitals agreed to implement an 18-month long WalkRoundsTM-based program to improve safety. We compared their results to 138 work areas in 48 randomly selected control hospitals. Participants: We conducted the program in four types of clinical work areas: operating rooms/post-anesthesia care units; emergency departments, intensive care units, and medical/surgical units. We collected survey data from nurses in those work areas. Measures: To measure the program's impact, we collected pre and post survey data on perceptions of improvement in performance (PIP)—a proxy for quality and an important organizational climate antecedent for positive, discretionary behaviors of frontline staff. We compare change in PIP in the treatment work areas to the same type of work areas in control hospitals.
Results: On average, compared to control work areas, our WalkRoundsTM-based program was associated with a statistically significant decrease in PIP of .17 on a 5-point scale (4.5%). Conclusions: Our study calls into question the general effectiveness of WalkRoundsTM on employees' perceptions, which had been assumed in prior literature.
Keywords: quality improvement;
Health Care and Treatment;
Outcome or Result;
Key Drivers of Successful Implementation of an Employee Suggestion-Driven Improvement Program
Service organizations frequently implement improvement programs to increase quality. These programs often rely on employees' suggestions about improvement opportunities. Organizations face a trade-off with such suggestion-driven improvement programs. On one hand, the improvement literature recommends that managers focus organizational resources on surfacing a large number of problems, prioritizing these, and selecting a small set of high priority ones for solution efforts. The theory is that soliciting a large number of ideas from employees will surface a set of higher priority problems than would have been identified with a less extensive search. Scarce organizational resources can be allocated to resolving the set of problems that provide the greatest improvement in performance. We call this an "analysis-oriented" approach. On the other hand, managers can allocate improvement resources to addressing problems raised by frontline staff, regardless of priority ranking. This "action-oriented" approach enables more resources to be spent on resolving problems because prioritization receives less attention. To our knowledge, this tradeoff between analysis and action in process improvement programs has not been empirically examined. To fill this gap, we randomly selected 20 hospitals to implement an 18-month long employee suggestion-driven improvement program; 58 work areas participated. Our study finds that an action-oriented approach was associated with higher perceived improvement in performance, while an analysis-oriented approach was not. Our study suggests that the analysis-oriented approach negatively impacted employees' perceptions of improvement because it solicited, but did not act on, employees’ ideas. We discuss the conditions under which this might be the case.
Keywords: Health Care and Treatment;
Randomized Government Safety Inspections Reduce Worker Injuries with No Detectable Job Loss
Controversy surrounds occupational health and safety regulators, with some observers claiming that workplace regulations damage firms' competitiveness and destroy jobs and others arguing that they make workplaces safer at little cost to employers and employees. We analyzed a natural field experiment to examine how workplace safety inspections affected injury rates and other outcomes. We compared 409 randomly inspected establishments in California with 409 matched-control establishments that were eligible, but not chosen, for inspection. Compared with controls, randomly inspected employers experienced a 9.4% decline in injury rates (95% confidence interval = -0.177 to -0.021) and a 26% reduction in injury cost (95% confidence interval = -0.513 to -0.083). We find no evidence that these improvements came at the expense of employment, sales, credit ratings, or firm survival.
difference in differences;
Governing Rules, Regulations, and Reforms;
Addressing the Leadership Gap in Medicine: Residents' Need for Systematic Leadership Development Training
All clinicians take on leadership responsibilities when delivering care. Evidence suggests that effective clinical leadership yields superior clinical outcomes. However, few residency programs systematically teach all residents how to lead, and many clinicians are inadequately prepared to meet their day-to-day clinical leadership responsibilities. The purpose of this article is twofold: first, to make the case for the need to refocus residency education around the development of outstanding "frontline" clinical leaders and, second, to provide an evidence-based framework for designing formal leadership development programs for residents. The authors first present a definition of clinical leadership and highlight evidence that effective frontline clinical leadership improves both clinical outcomes and satisfaction for patients and providers. The authors then discuss the health care "leadership gap" and describe barriers to implementing leadership development training in health care. Next, they present evidence that leaders are not just "born" but, rather, can be "made" and offer a set of best practices to facilitate the design of leadership development programs. Finally, the authors suggest approaches to mitigating barriers to implementing leadership development programs and highlight the major reasons why health care delivery organizations, residency programs, and national accreditation bodies must make comprehensive leadership education an explicit goal of residency training.
Keywords: Health Care and Treatment;
Blumenthal, Daniel Mark, Kenneth Richard Lee Bernard, Jordan David Bohnen, and Richard Bohmer. "Addressing the Leadership Gap in Medicine: Residents' Need for Systematic Leadership Development Training." Academic Medicine
87, no. 4 (April 2012).
A 2-phase Labeling and Choice Architecture Intervention to Improve Healthy Food and Beverage Choices
Objectives: We assessed whether a 2-phase labeling and choice architecture intervention increased sales of healthy food and beverages in a large hospital cafeteria. Methods: Phase 1 was a 3-month color-coded labeling intervention (red="unhealthy" yellow="less healthy" green="healthy"). Phase 2 added a 3-month choice architecture intervention which increased visibility and convenience of some green items. We compared relative changes in 3-month sales from baseline to Phase 1 and from Phase 1 to Phase 2. Results: At baseline (N=977,793 items, including 199,513 beverages), 24.9% of sales were red and 42.2% green. Sales of red items decreased in both phases (p<0.001), and green items increased in Phase 1 (p<0.001). Largest changes occurred among beverages. Red beverages decreased 16.5% during Phase 1 (p<0.001) and further decreased 11.4% in Phase 2 (p<0.001). Green beverages increased 9.6% in Phase 1 (p<0.001) and further increased 4.0% in Phase 2 (p<0.001). Bottled water increased 25.8% during Phase 2 (p<0.001) but did not increase at two on-site comparison cafeterias (p<0.001). Conclusions: A color-coded labeling intervention improved sales of healthy items and was enhanced by a choice architecture intervention.
Food and Beverage Industry;
Mental Health in the Aftermath of Conflict
We survey the recent literature on the mental health effects of conflict. We highlight the methodological challenges faced in this literature, which include the lack of validated mental health scales in a survey context, the difficulties in measuring individual exposure to conflict, and the issues related to making causal inferences from observed correlations. We illustrate how some of these issues can be overcome in a study of mental health in post-conflict Bosnia and Herzegovina. Mental health is measured using a clinically validated scale; conflict exposure is proxied by administrative data on war casualties instead of being self-reported. We find that there are no significant differences in overall mental health across areas that are affected by ethnic conflict to a greater or lesser degree.
Keywords: Ethnicity Characteristics;
Body of Literature;
Data and Data Sets;
Measurement and Metrics;
Problems and Challenges;
Conflict of Interests;
Bosnia and Hercegovina;
Team Scaffolds: How Minimal Team Structures Enable Role-Based Coordination
In this paper, we integrate research on role-based coordination with concepts adapted from the team effectiveness literature to theorize how team scaffolds enable effective coordination among people who do not work together regularly. We argue that role-based coordination among relative strangers can be interpersonally challenging and propose that team scaffolds (minimal team structures that bound groups of roles) may provide occupants with a temporary shared in-group that facilitates interaction. We develop and test these ideas in a multi-method field study of a hospital emergency department that introduced minimal team structures that we refer to as team scaffolds. We adapt network methods to compare coordination patterns before and after team scaffolds were implemented. Our results show that the team scaffolds improved performance, in part by reducing the number of partners with whom each role occupant coordinated. We then analyze qualitative interview data to theorize the social experience of working in team scaffolds. We find that the minimal team structures provided a kind of social scaffolding that facilitated group-level coordination between roles. The temporary shared in-group that emerged in the team scaffolds supported a sense of belonging, reduced interpersonal risk, and led individuals to expect account-giving behavior from other roles. Our study contributes to research on role-based coordination, team and organizational boundaries, and team size.
Keywords: Team Scaffolds;
Health Care and Treatment;
Data and Data Sets;
Knowledge Use and Leverage;
Outcome or Result;
Groups and Teams;
Balance and Stability;
What Business Schools Can Learn from the Medical Profession
Keywords: Business Education;
The Four Habits of High-Value Health Care Organizations