Vol. 00 No. 0 xxxx 2013
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Geographic Localization of Housestaff Inpatients Improves Patient–Provider Communication, Satisfaction, and Culture of Safety Douglas P. Olson, Barry G. Fields, Donna M. Windish
Purpose The present study was designed to evaluate the effects of geographic localization on patient and provider satisfaction and other domains of care in an internal medicine housestaff inpatient service. This is the first study, to our knowledge, to evaluate nurse, physician, and patient perceptions of care and satisfaction as well as changes in the culture of safety in a comprehensive and integrated manner.
Review of the Literature In 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted new regulations for housestaff duty hours, with shorter shifts for both interns and residents (Iglehart, 2010). With this change, patient care by trainees now relies more heavily on a team approach (Horwitz et al., 2009). Improving teamwork and the culture of safety in residency training programs is critical to ensure safe and effective care (Chakraborti et al., 2008). Furthermore, with the Centers for Medicare and Medicaid Services (CMS), including patient satisfaction as part of hospital reimbursement, improving patients’ perceptions of care by housestaff and other medical providers will not simply be encouraged; it will now contribute to financial compensation (Center for Medicare and Medicaid Services, 2011). Effective communication forms the backbone of a trusting patient–provider relationship. Prior studies have shown significant discrepancies in communication between physicians and patients (Olson & Windish, 2010) and physicians and nurses (O’Leary et al., 2010). Recently, many outpatient practices have changed to provide healthcare in a patient-centered medical home model where communication is improved by care that is patient-centered, localized, coordinated, and comprehensive. In such models, morale of providers and staff increases (Lewis et al., 2012). In the hospital setting, caregivers of-
Abstract: This study assesses whether geographic localization of housestaff patients contributes to improved patient knowledge of diagnosis, patient satisfaction, provider satisfaction, and workplace culture of safety. Due to national changes to graduate medical education, housestaff patients were localized to a single general medicine ward. Ninety-three patients prelocalization, 64 patients postlocalization, 26 localized physicians, and 10 localized nurses were surveyed. Validated questionnaires assessed patients’ experiences during hospitalization, and physician and nurse job satisfaction. Fifty-seven percent of patients knew their diagnosis prior to localization, compared to 80% postlocalization (p < .0001). Prior to localization, 39% of patients who reported experiencing anxieties or fears during hospitalization felt physicians frequently discussed these emotions with them compared to 85% after localization (p < .0001). Before localization, 51% of patients stated that doctors spent 4 min or more daily with them discussing care, compared to 91% after localization (p < .0001). Both physician and nurse opinion significantly improved regarding some but not all aspects of collaboration, teamwork, patient safety, appropriate handling of errors, and culture of safety. The average length of stay was unchanged and the change in 30-day readmission rate was not statistically significant. Localization of patients to a single inpatient ward improved patient knowledge and satisfaction, and some aspects of interprofessional communication and workplace culture of safety.
ten see patients on different floors/wards. This dispersion of patients and providers decreases the time providers can interact with patients and nursing staff. Interventions such as multidisciplinary rounds and geographic localization of patients and staff–whereby all patients cared for by a clinician/care team are in the same floor/ward of a hospital-have improved perceptions of teamwork and increased staff perception of communication (O’Leary et al., 2009).
Keywords communication medical education quality redesign satisfaction
Study Design and Methods Study design and sample. This pre–post crosssectional study occurred at Waterbury Hospital, a 367-bed private, not-for-profit community teaching hospital in Waterbury, Connecticut.
Journal for Healthcare Quality Vol. 00, No. 0, pp. 1–10 C 2013 National Association for Healthcare Quality
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Journal for Healthcare Quality
The hospital hosts inpatient rotations for three internal medicine residency programs from the Yale University School of Medicine. Due to ACGME-related changes in residency work hour rules (Iglehart, 2010), the admitting structure of the hospital was changed in January 2011 such that patients admitted to the teaching service were localized to a single general medicine ward. Prior to localization, housestaff patients were dispersed to three different inpatient floors and cared for by many different staff. The new localized ward was strictly composed of teaching team patients, their housestaff providers, and a fixed set of nurses and staff. No other changes were made to the housestaff admitting patterns, team composition, patient mix, or work hour schedules during this time, nor were there any hospital quality improvement initiatives in place. Two months of acclimation to geographic localization were allowed before study recruitment. The study was conducted from March to June 2011, prior to new intern and resident matriculation. This was a similar time-period during which the majority of the prelocalization data were collected. To assess changes to housestaff patients’ knowledge and satisfaction with care, survey results of patients in this study were compared to patient data obtained prior to geographic localization (Olson & Windish, 2010). The prior study was conducted from 2008 to 2009 and assessed 89 patients’ knowledge and perspectives about their inpatient care from the same patient care ward using the same questionnaire. To assess perceptions of patient care and workplace satisfaction due to localization, housestaff physicians and nurses localized to the housestaff ward were surveyed. Finally, patient length of stay and 30-day readmission rates both before and after geographic localization were analyzed. Patients were recruited each morning by asking teaching teams to identify patients who would be discharged that day, as described in prior work (Olson & Windish, 2010). Interview days were chosen at random based on availability of the study authors. Patients were interviewed on the day of discharge, and only those patients who had a length of stay of at least 2 days were eligible to participate. Because teaching teams switch rotations every month, no patients were interviewed within 1 week of team changes. Patient demographics reflected that of the overall adult inpatient population admitted to the hospital, namely adults aged 18–95,
of all races, religions, and nationalities. Patients were excluded if they spoke languages other than English or Spanish, and those with potentially impaired decision-making capacity, that is, those with schizophrenia, mental retardation or dementia, or altered mental status. No member of the research team provided inpatient or outpatient care to those patients being surveyed. Study authors asked patients meeting inclusion criteria to participate in the study and to sign a written consent. Interviewers did not wear white coats or introduce themselves as physicians during interviews. Resident and attending physicians assigned to the localized ward were asked for their participation in the study. Interviews occurred individually after signing a written consent. Housestaff were resident and intern physicians from the same residency programs rotating at the hospital as in prelocalization study. Attending physicians were a mix of generalists, hospitalists, and medicine subspecialists as in the prelocalization study. Only nurses who were assigned to the localized ward both pre- and postlocalization were surveyed as they had sufficient experience prior to and after localization to make comparisons. Nurses from all three shifts (days, evenings, and overnight) were asked to participate in the survey. Physicians were surveyed both and pre- and postlocalization and nurses were surveyed postlocalization. Although all nurses involved on the localized floor were contacted, physician samples were based on a convenience sample.
Survey Instruments Patients Questions from two well-validated Likert-style instruments were used to assess patients’ experiences in a teaching hospital: the Picker Patient Experience Survey (Jenkinson, Coulter, & Bruster, 2002) and the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS; Centers for Medicare and Medicaid Services, 2013; Jha et al., 2008). A three-question, validated survey was used to assess health literacy (Chew, Bradley, & Boyko, 2004). Interviewers read questions and response choices to patients and then recorded answers on the survey instrument. Each researcher obtained demographic and other medical information from a chart review of the patient’s current hospital medical
Vol. 00 No. 0 xxxx 2013
Figure 1. Physician Responses to Work Environment
Note. This figure displays physician responses to work environment before and after localization. The corresponding statement is listed in the tile of each panel. The y-axis denotes percent of physicians agreeing or disagreeing with each statement, as denoted on the x-axis. The corresponding p-value is listed in each panel.
Figure 2. Physician Responses to Culture of Safety
Note. This figure displays physician responses to questions about the culture of safety both before and after localization. The corresponding statement is listed in the tile of each panel. The y-axis denotes percent of physicians agreeing or disagreeing with each statement, as denoted on the x-axis. The corresponding p-value is listed in each panel.
record. Patients were asked to state their diagnosis for admission, allowing for lay terminology and any secondary diagnoses that were listed during each patient’s hospital stay as qualifying answers.
clinical care environment in the workplace. Actual questions are listed in Figures 1 through 4 with their corresponding legends. Patient responses were neither shared with the caregivers nor were caregiver responses shared with patients.
Physicians and Nurses Questions rephrased from the Picker Patient Experience Survey and the HCAHPS were used to survey to assess perceptions of care by physicians and nurses (Olson & Windish, 2010; Windish & Olson, 2011). Questions from a third, well-validated instrument the Safety Attitudes Questionnaire (Sexton et al., 2006) were used to assess provider attitudes about safety and
Measures of Communication and Safety To assess objective measures of communication, the volume of pages to housestaff as measured by analyzing team pager numbers and hospital paging data were analyzed. The number of rapid responses and 30-day readmission rates for housestaff patients were also compared pre- and postlocalization.
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Figure 3. Nursing Responses to Work Environment
Note. This figure displays nursing responses to work environment before and after localization. The corresponding statement is listed in the tile of each panel. The y-axis denotes percent of nurses agreeing or disagreeing with each statement, as denoted on the x-axis. The corresponding p-value is listed in each panel.
Figure 4. Nursing Responses to Culture of Safety
Note. This figure displays nursing responses to questions about the culture of safety both before and after localization. The corresponding statement is listed in the tile of each panel. The y-axis denotes percent of nurses agreeing or disagreeing with each statement, as denoted on the x-axis. The corresponding p-value is listed in each panel.
Statistical Analyses Stata release 10.1 statistical software (StataCorp, College Station, TX) was used for all statistical analyses. Comparisons between responses before and after localization were done using Wilcoxon rank-sum (Mann–Whitney U) tests and chi-square analyses. Multivariable logistic and linear regression models were used to control for patient characteristics, including age, gender, ethnicity, education, payment source, number of home medications taken, number of medical conditions, and hospital length of stay. Subgroup analyses of patient responses were performed based on patient age, gender, race, substance use, educational level,
payment source, number of medications at admission, health literacy, and overall patient rating of their health using similar methods. An α-value of 0.05 was used to determine statistical significance of all calculations. The study had 80% power to detect a half-day difference in average length of stay for patients pre- and postlocalization. This required a sample size of 64 patients.
Institutional Review Board Approval The Waterbury Hospital institutional review board and the Yale University School of Medicine Human Research Protection Program approved the study protocol.
Vol. 00 No. 0 xxxx 2013
Table 1. Patient and Provider Characteristics Patients Total interviewed Male, n (%) Age, mean (SD) Race, n (%) White Black Latino Other Average length of stay (mean) Thirty-day readmit rate (%) Education level, n (%) Eighth grade or less Some high school High school graduate Some college or associate’s degree College graduate Postgraduate work or degree Admission diagnosis, n (%) Cardiovascular Neurologic Infectious Pulmonary Gastrointestinal Substance use Endocrine/metabolic Hematologic/vascular Renal Other Providers Physicians Total interviewed Male, n (%) Age, mean (SD) Role on teaching team, n (%) Intern Resident Attending Nurses Total interviewed Age, mean (SD)
Prelocalization
Postlocalization
89 47 (52.8) 57.3 years (19.1)
64 30 (46.9) 60.4 years (18.2)
61 (68) 16 (18) 11 (12) 1 (1) 6.8 days 32.1%
28 (44) 19 (30) 16 (25) 1 (2) 6.8 days 34.1%
11 (12.4) 19 (21.3) 29 (32.6) 23 (25.8) 3 (3.4) 4 (4.5)
8 (12.5) 16 (25.0) 22 (34.4) 14 (21.9) 3 (4.7) 1 (1.5)
15 (16.9) 15 (16.9) 14 (15.7) 13 (14.6) 12 (13.5) 6 (6.7) 5 (5.6) 4 (4.5) 2 (2.3) 3 (3.4)
3 (4.7) 2 (3.2) 14 (21.9) 22 (34.4) 11 (17.2) 1 (1.6) 5 (7.8) 2 (3.2) 2 (3.2) 2 (3.2)
N/A N/A
26 14 (54%) 31 years (6.0)
N/A N/A N/A
N/A N/A N/A
12 (46%) 8 (31%) 6 (23%)
N/A N/A N/A
N/A N/A
10 41.6 (11.8)
N/A
p-value .51 .31 .02
.89 .79 .89
.01
Results
Patient Knowledge of Diagnosis
For the prelocalization cohort, 94% (89/95 patients) agreed to participate in the study. Of 67 eligible patients asked to participate in the postlocalization survey, 64 (94%) agreed. All 26 physicians (100%) and 10 of 13 nurses (77%) consented to participate. Table 1 provides demographic information on participating patients, nurses, and physicians with comparison data on patients from prior work. Patients were similar in demographic characteristics pre- and postlocalization except for race and admission diagnoses.
Prior to localization, 57% of patients could correctly state their diagnosis, with 43% either not knowing or incorrectly stating their reason for admission (Olson & Windish, 2010). After localization, 80% of patients correctly stated their diagnosis (p < .0001). Admission diagnoses were those typical of admitting problems seen on a general medicine ward (Windish & Olson, 2011). There was no statistically significant association between knowledge of diagnosis and patients’ health literacy. In multivariable analysis, the likelihood of patients knowing their
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diagnosis after localization was significantly greater than prior to localization, OR 2.57 (95% CI: 1.52, 3.62), p < .0001.
Communication between Physicians and Patients Patients’ perception of the time physicians spent with them at the bedside differed preand postlocalization. Fifty-one percent of patients felt that physicians spent more than 4 min a day with them prior to localization, compared to 91% postlocalization (p < .0001). This significance remained after multivariable analysis (Table 2). Prior to localization, 50% of patients stated they had anxiety or fears about their condition or treatment, and of those, only 39% stated that physicians discussed these fears with them “usually” or “always.” After localization, 42% of patients reported that they had anxiety or fears, and 85% stated that physicians discussed these with them either “usually” or “always” (p < .0001). These results remained significant in the multivariable analysis which showed a three times greater odds of having fears addressed after localization, OR 3.33 (1.47, 5.19), p < .0001. No differences occurred in patient perceptions of being treated with respect by physicians or nurses, being listened to carefully by physicians or nurses, overall rating of hospital, or the percentage of patients that would recommend the hospital to family and friends (all p > .05).
way after localization (p < .0001; Figure 1A). In assessing teamwork, 42% of physicians agreed that physicians and nurses worked as part of a team before localization compared with 88% after localization (p < .0001; Figure 1B). The perception of workplace culture also changed in that 35% of physicians felt that they “worked as part of a large family” prior to localization compared to 84% after localization (p < .0001; Figure 1C). Overall morale about working in the hospital and with patient care increased such that 66% of physicians reported that they agreed with the statement, “I am proud to work here” prior to localization, with that percentage increasing to 93% after localization (p = .001). Nurses also reported improved collaboration with physicians: 10% agreed that they experienced good collaboration with physicians prior to localization compared to 40% after localization (p = .01; Figure 3A). The percentage of nurses who felt that physicians and nurses worked as a well-coordinated team increased from 50% prelocalization to 90% postlocalization (p = .02; Figure 3B). Unlike physicians, nurses’ opinions regarding working as part of a large family (Figure 3C) did not change preand postlocalization. Despite the change in perceived communication, the actual number of pages to housestaff did not change before or after localization (data not shown).
Patient Safety and Culture of Safety Patient Subgroup Analyses The results of our study did not differ based on patient characteristics such that no statistically significant differences existed when patient responses to any question were analyzed by gender, age, race and ethnicity, payment source, or health literacy. Due to a large variation in patient diagnoses (Table 1), we were unable to make comparisons based on medical complexity except for the readmission rates that revealed no statistically significant differences.
Communication between Physicians and Nurses Physicians reported that their work experience after localization improved in several areas. Prior to localization, 4% of physicians strongly agreed that they experienced good collaboration with nursing compared to 58% who felt this
The average length of stay for patients on the localized general medical floor remained identical to prelocalization at 6.8 days. Readmission rates for patients were not statistically different pre- and postlocalization: such that 32.1% of patients were readmitted before localization compared to 34.1% after localization (p > .05). The numbers of rapid responses on housestaff patients also did not differ. Despite the lack of change to objective data regarding patient safety, the physician opinion of the culture of safety did improve, with 35% of physicians agreeing that the working culture allowed them to learn easily from the mistakes of others prior to localization compared to 62% after localization (p = 0.001; Figure 2A). When errors did occur, physicians felt that they were handled appropriately 35% of the time prior to localization compared to 53% after localization (p = 0.0028; Figure 2B). Finally,
∗
80%
91% 85%
81% 75%
81% 69%
2.72 8.42
51% 39%
79% 75%
81% 80%
2.79 8.56
Postlocalization (N = 64)
57%
Prelocalization (N = 89)
Analysis done using multivariable logistic regression. † Analysis done using multivariable linear regression.
Patient correctly stated hospital diagnosis Patient opinion about communication with doctors Doctors spent 4 min or more daily with them discussing their care Doctors usually or always discussed any anxieties or fears about patient condition or treatment Doctors always treated patient with courtesy and respect Doctors always listened carefully to patient Patient opinion about communication with nurses Nurses always treated patient with courtesy and respect Nurses always listened carefully to patient Hospital ratings Recommend hospital to others Overall hospital rating
Question content
Univariate Analysis
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Geographic Localization of Housestaff Inpatients Improves Patient–Provider Communication, Satisfaction, and Culture of Safety Douglas P. Olson, Barry G. Fields, Donna M. Windish
Purpose The present study was designed to evaluate the effects of geographic localization on patient and provider satisfaction and other domains of care in an internal medicine housestaff inpatient service. This is the first study, to our knowledge, to evaluate nurse, physician, and patient perceptions of care and satisfaction as well as changes in the culture of safety in a comprehensive and integrated manner.
Review of the Literature In 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted new regulations for housestaff duty hours, with shorter shifts for both interns and residents (Iglehart, 2010). With this change, patient care by trainees now relies more heavily on a team approach (Horwitz et al., 2009). Improving teamwork and the culture of safety in residency training programs is critical to ensure safe and effective care (Chakraborti et al., 2008). Furthermore, with the Centers for Medicare and Medicaid Services (CMS), including patient satisfaction as part of hospital reimbursement, improving patients’ perceptions of care by housestaff and other medical providers will not simply be encouraged; it will now contribute to financial compensation (Center for Medicare and Medicaid Services, 2011). Effective communication forms the backbone of a trusting patient–provider relationship. Prior studies have shown significant discrepancies in communication between physicians and patients (Olson & Windish, 2010) and physicians and nurses (O’Leary et al., 2010). Recently, many outpatient practices have changed to provide healthcare in a patient-centered medical home model where communication is improved by care that is patient-centered, localized, coordinated, and comprehensive. In such models, morale of providers and staff increases (Lewis et al., 2012). In the hospital setting, caregivers of-
Abstract: This study assesses whether geographic localization of housestaff patients contributes to improved patient knowledge of diagnosis, patient satisfaction, provider satisfaction, and workplace culture of safety. Due to national changes to graduate medical education, housestaff patients were localized to a single general medicine ward. Ninety-three patients prelocalization, 64 patients postlocalization, 26 localized physicians, and 10 localized nurses were surveyed. Validated questionnaires assessed patients’ experiences during hospitalization, and physician and nurse job satisfaction. Fifty-seven percent of patients knew their diagnosis prior to localization, compared to 80% postlocalization (p < .0001). Prior to localization, 39% of patients who reported experiencing anxieties or fears during hospitalization felt physicians frequently discussed these emotions with them compared to 85% after localization (p < .0001). Before localization, 51% of patients stated that doctors spent 4 min or more daily with them discussing care, compared to 91% after localization (p < .0001). Both physician and nurse opinion significantly improved regarding some but not all aspects of collaboration, teamwork, patient safety, appropriate handling of errors, and culture of safety. The average length of stay was unchanged and the change in 30-day readmission rate was not statistically significant. Localization of patients to a single inpatient ward improved patient knowledge and satisfaction, and some aspects of interprofessional communication and workplace culture of safety.
ten see patients on different floors/wards. This dispersion of patients and providers decreases the time providers can interact with patients and nursing staff. Interventions such as multidisciplinary rounds and geographic localization of patients and staff–whereby all patients cared for by a clinician/care team are in the same floor/ward of a hospital-have improved perceptions of teamwork and increased staff perception of communication (O’Leary et al., 2009).
Keywords communication medical education quality redesign satisfaction
Study Design and Methods Study design and sample. This pre–post crosssectional study occurred at Waterbury Hospital, a 367-bed private, not-for-profit community teaching hospital in Waterbury, Connecticut.
Journal for Healthcare Quality Vol. 00, No. 0, pp. 1–10 C 2013 National Association for Healthcare Quality
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Journal for Healthcare Quality
The hospital hosts inpatient rotations for three internal medicine residency programs from the Yale University School of Medicine. Due to ACGME-related changes in residency work hour rules (Iglehart, 2010), the admitting structure of the hospital was changed in January 2011 such that patients admitted to the teaching service were localized to a single general medicine ward. Prior to localization, housestaff patients were dispersed to three different inpatient floors and cared for by many different staff. The new localized ward was strictly composed of teaching team patients, their housestaff providers, and a fixed set of nurses and staff. No other changes were made to the housestaff admitting patterns, team composition, patient mix, or work hour schedules during this time, nor were there any hospital quality improvement initiatives in place. Two months of acclimation to geographic localization were allowed before study recruitment. The study was conducted from March to June 2011, prior to new intern and resident matriculation. This was a similar time-period during which the majority of the prelocalization data were collected. To assess changes to housestaff patients’ knowledge and satisfaction with care, survey results of patients in this study were compared to patient data obtained prior to geographic localization (Olson & Windish, 2010). The prior study was conducted from 2008 to 2009 and assessed 89 patients’ knowledge and perspectives about their inpatient care from the same patient care ward using the same questionnaire. To assess perceptions of patient care and workplace satisfaction due to localization, housestaff physicians and nurses localized to the housestaff ward were surveyed. Finally, patient length of stay and 30-day readmission rates both before and after geographic localization were analyzed. Patients were recruited each morning by asking teaching teams to identify patients who would be discharged that day, as described in prior work (Olson & Windish, 2010). Interview days were chosen at random based on availability of the study authors. Patients were interviewed on the day of discharge, and only those patients who had a length of stay of at least 2 days were eligible to participate. Because teaching teams switch rotations every month, no patients were interviewed within 1 week of team changes. Patient demographics reflected that of the overall adult inpatient population admitted to the hospital, namely adults aged 18–95,
of all races, religions, and nationalities. Patients were excluded if they spoke languages other than English or Spanish, and those with potentially impaired decision-making capacity, that is, those with schizophrenia, mental retardation or dementia, or altered mental status. No member of the research team provided inpatient or outpatient care to those patients being surveyed. Study authors asked patients meeting inclusion criteria to participate in the study and to sign a written consent. Interviewers did not wear white coats or introduce themselves as physicians during interviews. Resident and attending physicians assigned to the localized ward were asked for their participation in the study. Interviews occurred individually after signing a written consent. Housestaff were resident and intern physicians from the same residency programs rotating at the hospital as in prelocalization study. Attending physicians were a mix of generalists, hospitalists, and medicine subspecialists as in the prelocalization study. Only nurses who were assigned to the localized ward both pre- and postlocalization were surveyed as they had sufficient experience prior to and after localization to make comparisons. Nurses from all three shifts (days, evenings, and overnight) were asked to participate in the survey. Physicians were surveyed both and pre- and postlocalization and nurses were surveyed postlocalization. Although all nurses involved on the localized floor were contacted, physician samples were based on a convenience sample.
Survey Instruments Patients Questions from two well-validated Likert-style instruments were used to assess patients’ experiences in a teaching hospital: the Picker Patient Experience Survey (Jenkinson, Coulter, & Bruster, 2002) and the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS; Centers for Medicare and Medicaid Services, 2013; Jha et al., 2008). A three-question, validated survey was used to assess health literacy (Chew, Bradley, & Boyko, 2004). Interviewers read questions and response choices to patients and then recorded answers on the survey instrument. Each researcher obtained demographic and other medical information from a chart review of the patient’s current hospital medical
Vol. 00 No. 0 xxxx 2013
Figure 1. Physician Responses to Work Environment
Note. This figure displays physician responses to work environment before and after localization. The corresponding statement is listed in the tile of each panel. The y-axis denotes percent of physicians agreeing or disagreeing with each statement, as denoted on the x-axis. The corresponding p-value is listed in each panel.
Figure 2. Physician Responses to Culture of Safety
Note. This figure displays physician responses to questions about the culture of safety both before and after localization. The corresponding statement is listed in the tile of each panel. The y-axis denotes percent of physicians agreeing or disagreeing with each statement, as denoted on the x-axis. The corresponding p-value is listed in each panel.
record. Patients were asked to state their diagnosis for admission, allowing for lay terminology and any secondary diagnoses that were listed during each patient’s hospital stay as qualifying answers.
clinical care environment in the workplace. Actual questions are listed in Figures 1 through 4 with their corresponding legends. Patient responses were neither shared with the caregivers nor were caregiver responses shared with patients.
Physicians and Nurses Questions rephrased from the Picker Patient Experience Survey and the HCAHPS were used to survey to assess perceptions of care by physicians and nurses (Olson & Windish, 2010; Windish & Olson, 2011). Questions from a third, well-validated instrument the Safety Attitudes Questionnaire (Sexton et al., 2006) were used to assess provider attitudes about safety and
Measures of Communication and Safety To assess objective measures of communication, the volume of pages to housestaff as measured by analyzing team pager numbers and hospital paging data were analyzed. The number of rapid responses and 30-day readmission rates for housestaff patients were also compared pre- and postlocalization.
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Figure 3. Nursing Responses to Work Environment
Note. This figure displays nursing responses to work environment before and after localization. The corresponding statement is listed in the tile of each panel. The y-axis denotes percent of nurses agreeing or disagreeing with each statement, as denoted on the x-axis. The corresponding p-value is listed in each panel.
Figure 4. Nursing Responses to Culture of Safety
Note. This figure displays nursing responses to questions about the culture of safety both before and after localization. The corresponding statement is listed in the tile of each panel. The y-axis denotes percent of nurses agreeing or disagreeing with each statement, as denoted on the x-axis. The corresponding p-value is listed in each panel.
Statistical Analyses Stata release 10.1 statistical software (StataCorp, College Station, TX) was used for all statistical analyses. Comparisons between responses before and after localization were done using Wilcoxon rank-sum (Mann–Whitney U) tests and chi-square analyses. Multivariable logistic and linear regression models were used to control for patient characteristics, including age, gender, ethnicity, education, payment source, number of home medications taken, number of medical conditions, and hospital length of stay. Subgroup analyses of patient responses were performed based on patient age, gender, race, substance use, educational level,
payment source, number of medications at admission, health literacy, and overall patient rating of their health using similar methods. An α-value of 0.05 was used to determine statistical significance of all calculations. The study had 80% power to detect a half-day difference in average length of stay for patients pre- and postlocalization. This required a sample size of 64 patients.
Institutional Review Board Approval The Waterbury Hospital institutional review board and the Yale University School of Medicine Human Research Protection Program approved the study protocol.
Vol. 00 No. 0 xxxx 2013
Table 1. Patient and Provider Characteristics Patients Total interviewed Male, n (%) Age, mean (SD) Race, n (%) White Black Latino Other Average length of stay (mean) Thirty-day readmit rate (%) Education level, n (%) Eighth grade or less Some high school High school graduate Some college or associate’s degree College graduate Postgraduate work or degree Admission diagnosis, n (%) Cardiovascular Neurologic Infectious Pulmonary Gastrointestinal Substance use Endocrine/metabolic Hematologic/vascular Renal Other Providers Physicians Total interviewed Male, n (%) Age, mean (SD) Role on teaching team, n (%) Intern Resident Attending Nurses Total interviewed Age, mean (SD)
Prelocalization
Postlocalization
89 47 (52.8) 57.3 years (19.1)
64 30 (46.9) 60.4 years (18.2)
61 (68) 16 (18) 11 (12) 1 (1) 6.8 days 32.1%
28 (44) 19 (30) 16 (25) 1 (2) 6.8 days 34.1%
11 (12.4) 19 (21.3) 29 (32.6) 23 (25.8) 3 (3.4) 4 (4.5)
8 (12.5) 16 (25.0) 22 (34.4) 14 (21.9) 3 (4.7) 1 (1.5)
15 (16.9) 15 (16.9) 14 (15.7) 13 (14.6) 12 (13.5) 6 (6.7) 5 (5.6) 4 (4.5) 2 (2.3) 3 (3.4)
3 (4.7) 2 (3.2) 14 (21.9) 22 (34.4) 11 (17.2) 1 (1.6) 5 (7.8) 2 (3.2) 2 (3.2) 2 (3.2)
N/A N/A
26 14 (54%) 31 years (6.0)
N/A N/A N/A
N/A N/A N/A
12 (46%) 8 (31%) 6 (23%)
N/A N/A N/A
N/A N/A
10 41.6 (11.8)
N/A
p-value .51 .31 .02
.89 .79 .89
.01
Results
Patient Knowledge of Diagnosis
For the prelocalization cohort, 94% (89/95 patients) agreed to participate in the study. Of 67 eligible patients asked to participate in the postlocalization survey, 64 (94%) agreed. All 26 physicians (100%) and 10 of 13 nurses (77%) consented to participate. Table 1 provides demographic information on participating patients, nurses, and physicians with comparison data on patients from prior work. Patients were similar in demographic characteristics pre- and postlocalization except for race and admission diagnoses.
Prior to localization, 57% of patients could correctly state their diagnosis, with 43% either not knowing or incorrectly stating their reason for admission (Olson & Windish, 2010). After localization, 80% of patients correctly stated their diagnosis (p < .0001). Admission diagnoses were those typical of admitting problems seen on a general medicine ward (Windish & Olson, 2011). There was no statistically significant association between knowledge of diagnosis and patients’ health literacy. In multivariable analysis, the likelihood of patients knowing their
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diagnosis after localization was significantly greater than prior to localization, OR 2.57 (95% CI: 1.52, 3.62), p < .0001.
Communication between Physicians and Patients Patients’ perception of the time physicians spent with them at the bedside differed preand postlocalization. Fifty-one percent of patients felt that physicians spent more than 4 min a day with them prior to localization, compared to 91% postlocalization (p < .0001). This significance remained after multivariable analysis (Table 2). Prior to localization, 50% of patients stated they had anxiety or fears about their condition or treatment, and of those, only 39% stated that physicians discussed these fears with them “usually” or “always.” After localization, 42% of patients reported that they had anxiety or fears, and 85% stated that physicians discussed these with them either “usually” or “always” (p < .0001). These results remained significant in the multivariable analysis which showed a three times greater odds of having fears addressed after localization, OR 3.33 (1.47, 5.19), p < .0001. No differences occurred in patient perceptions of being treated with respect by physicians or nurses, being listened to carefully by physicians or nurses, overall rating of hospital, or the percentage of patients that would recommend the hospital to family and friends (all p > .05).
way after localization (p < .0001; Figure 1A). In assessing teamwork, 42% of physicians agreed that physicians and nurses worked as part of a team before localization compared with 88% after localization (p < .0001; Figure 1B). The perception of workplace culture also changed in that 35% of physicians felt that they “worked as part of a large family” prior to localization compared to 84% after localization (p < .0001; Figure 1C). Overall morale about working in the hospital and with patient care increased such that 66% of physicians reported that they agreed with the statement, “I am proud to work here” prior to localization, with that percentage increasing to 93% after localization (p = .001). Nurses also reported improved collaboration with physicians: 10% agreed that they experienced good collaboration with physicians prior to localization compared to 40% after localization (p = .01; Figure 3A). The percentage of nurses who felt that physicians and nurses worked as a well-coordinated team increased from 50% prelocalization to 90% postlocalization (p = .02; Figure 3B). Unlike physicians, nurses’ opinions regarding working as part of a large family (Figure 3C) did not change preand postlocalization. Despite the change in perceived communication, the actual number of pages to housestaff did not change before or after localization (data not shown).
Patient Safety and Culture of Safety Patient Subgroup Analyses The results of our study did not differ based on patient characteristics such that no statistically significant differences existed when patient responses to any question were analyzed by gender, age, race and ethnicity, payment source, or health literacy. Due to a large variation in patient diagnoses (Table 1), we were unable to make comparisons based on medical complexity except for the readmission rates that revealed no statistically significant differences.
Communication between Physicians and Nurses Physicians reported that their work experience after localization improved in several areas. Prior to localization, 4% of physicians strongly agreed that they experienced good collaboration with nursing compared to 58% who felt this
The average length of stay for patients on the localized general medical floor remained identical to prelocalization at 6.8 days. Readmission rates for patients were not statistically different pre- and postlocalization: such that 32.1% of patients were readmitted before localization compared to 34.1% after localization (p > .05). The numbers of rapid responses on housestaff patients also did not differ. Despite the lack of change to objective data regarding patient safety, the physician opinion of the culture of safety did improve, with 35% of physicians agreeing that the working culture allowed them to learn easily from the mistakes of others prior to localization compared to 62% after localization (p = 0.001; Figure 2A). When errors did occur, physicians felt that they were handled appropriately 35% of the time prior to localization compared to 53% after localization (p = 0.0028; Figure 2B). Finally,
∗
80%
91% 85%
81% 75%
81% 69%
2.72 8.42
51% 39%
79% 75%
81% 80%
2.79 8.56
Postlocalization (N = 64)
57%
Prelocalization (N = 89)
Analysis done using multivariable logistic regression. † Analysis done using multivariable linear regression.
Patient correctly stated hospital diagnosis Patient opinion about communication with doctors Doctors spent 4 min or more daily with them discussing their care Doctors usually or always discussed any anxieties or fears about patient condition or treatment Doctors always treated patient with courtesy and respect Doctors always listened carefully to patient Patient opinion about communication with nurses Nurses always treated patient with courtesy and respect Nurses always listened carefully to patient Hospital ratings Recommend hospital to others Overall hospital rating
Question content
Univariate Analysis
