<p> Within the health care system, patient safety outcomes have been criticized for many years. Medical malpractice, common errors, and nosocomial infections (i.e., hospital-acquired infections) are safety concerns, and represent a public health problem. Since the Institute of Medicine (1999) published To Err is Human: Building a Safer Health System in 1999, changes have been made to improve the use of technology and leverage advancements in research that improve patient safety. Nurse leaders can also help to facilitate process improvements in the patient safety culture. The purpose of this capstone project was to explore the nursing leader role in improving patient safety in a hospital setting. The method utilized for this study was a literature review. Prominent articles identifying the role of nursing leadership were included. Seven drivers of patient safety were identified (Sammer, Lyken, Singh, Mains, &amp; Lackan (2011), and subsequently informed this project. The targeted populations were patients, families, nurses, nurse administrators, and medical personnel. Findings regarding the nurse leader role, patient improvements, and barriers to improvements were reviewed. Nurse leaders were found to be of critical importance to patients, medical personnel, and the health care system. The limitations of this review and implications for policy and practice are discussed. </p>

<p> Accountability in healthcare tends to dominate discussions focused on improving the quality of care, the experience of patients, pay-for-performance, and engaging employees to produce positive performance outcomes. Organizational leaders are held to answer to external regulatory agencies about performance outcomes based on prescribed standards. Frequently, these agencies adopt a punitive approach by imposing rewards and penalties for achieving or failing to meet the performance standards. Furthering the challenges, organizational leaders are expected to model accountability, hold employees accountable, and be a source for inspiration and motivation. The purpose of this qualitative action research study was to examine person-centered accountability (PCA), or the use of positive leadership, positive practices, and positive emotions, as a complementary approach to regulatory-centered accountability (RCA). Six workshops influenced by appreciative inquiry, a practice period, participant journals, interviews and the use of a portable biofeedback device to measure positive emotions were all utilized to develop an understanding of participant&rsquo;s experiences and perceptions about the value of PCA and RCA. Participants were clinical and non-clinical leaders at a Midwest medical center. Results from this study revealed the participants&rsquo; perception about the holistic and interdependent nature of PCA and RCA. Integrating PCA and RCA requires a change in philosophies as well as day-to-day accountability practices. Leaders and employees need to use both PCA and RCA to improve performance outcomes, therefore, it is important to create an organizational reset to change beliefs about accountability, build leadership capacity, and invest in employees. Future research is needed to evaluate the long-term impact of PCA and RCA on performance outcomes in and out of healthcare.</p>

<p> <b>Background:</b> Obesity has recently been classified by the American Medical Association (AMA) as a disease which, if unrecognized and unaddressed in childhood, causes multiple medical and psychological complications that can impact both personal and population health. Unprecedented funding is being invested in electronic health records to improve quality, safety, and delivery of healthcare and reduce healthcare costs. Scant literature has evaluated the use of aids in the electronic health record (EHR) to identify obesity. </p><p> <b>Objectives:</b> The purpose of this study was to determine to what extent the tools available in an EHR for automatic Body Mass Index (BMI) calculation based on height and weight documentation are used by pediatricians to correctly identify obesity in children. Secondary objectives were to evaluate quality of data input (discrete vs. free text) and see if there is any variation in rates of identification among patients of different socio-demographic characteristics and trainees of different levels. </p><p> <b>Methods:</b> We conducted a retrospective chart review for patients aged 2&ndash;18 years seen for a well-child visit at New York Presbyterian Hospital between January 2011 and January 2014, where it is standard practice at these visits to take height and weight measurements. The EHR automatically populates these values onto growth curves, converting them into BMI with percentiles. Standardized definitions from the Centers for Disease Control and Prevention (CDC) 2010 were used to qualify overweight and obese based on BMI. We determined the percentage of patients who were overweight or obese (based on CDC percentiles) that had the diagnosis identified by the pediatrician, and then assessed the quality of data input. We assessed laboratory follow up and referrals for all patients, and assessed for demographic differences among patients properly and not properly documented by providers as obese or overweight. </p><p> <b>Results:</b> We reviewed 700 charts in total. Inclusion criteria were all of the patients who had a BMI between 85&ndash;95% (these were grouped as overweight) and a BMI over 95% (obese). 209 patients were overweight or obese and therefore eligible for inclusion. Of the 209 clinically overweight/obese children, 72.2% had some form of documentation of this diagnosis, although the diagnosis was documented more often in the obese vs. overweight child. The diagnosis was most often captured electronically in the free text progress note. Over half of clinically overweight/obese children aged &ge;8 years did not receive follow-up standard laboratory testing, and only about one-quarter of clinically overweight/obese children had documented in-office nutrition guidance. Diagnosis of overweight was higher in females, but it was almost twice as likely that an obese male would be documented as such. Results showed no identification variation based on age or race/ethnicity. There was no difference in recognition of obesity/overweight based on postgraduate year (PGY) or nurse practitioner (NP) status. </p><p> <b>Conclusion:</b> Despite its importance as a public health priority for children, automatic calculation of BMI by use of an EHR led to documentation by a provider as a child being overweight/obese only three quarters of the time. This study suggests that despite increasing focus on using EHRs to improve individual and population health, including for obesity, clinical decision support remains underutilized.</p>

<p> Organizational work climates in healthcare organizations were described in the literature using a social framework of structured interactions, defined roles, and behavioral responses between team members of physicians and nurses. It was hypothesized that the characteristics of physician-nurse collaboration, physician dominance, and nurse autonomy in socially complex work settings have relationships to turnover intent in nurses who work in operating room settings. In an era of nursing shortages the challenge of nurse retention and the evidence of challenging work climate become even more critical for healthcare organizations. This research study examined a gap in knowledge regarding the extent to which aspects of organizational work climate predict nurse turnover in operating room work settings. A quantitative correlational study using three work climate characteristics of physician-nurse collaboration, physician dominance, and nurse autonomy was conducted using the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (Hojat &amp; Herman, 1985, <i>Developing an Instrument to Measure Attitudes toward Nurses: Preliminary Psychometric Findings</i>) and the Anticipated Turnover Scale (Hinshaw &amp; Atwood, 1983, <i>Nursing Staff Turnover, Stress, and Satisfaction: Models, Measures, and Management</i>). Responses from 322 Operating Room staff nurses who were members of a national professional nursing organization were examined in the analyses. The study concluded that the independent variables of collaboration, dominance, and autonomy were not significant in predicting turnover among nurses in the operating room setting.</p>

<p> In today's modern world of medicine, most, if not all, physician employment contracts contain non-compete clauses. Non-competes, also known as restrictive covenants, essentially function as restraints on trade. Non-competes act as a restraint in the medical arena by preventing physicians from taking patients with them when physicians begin new employment or, alternatively, depart on a self-employment basis. They also restrain physicians from competitively practicing medicine in a predetermined geographic area for a specified period of time. </p><p> Restraints on trade have a long noteworthy history. One case that emphasized the importance of having checks and balances on such restraints is Lochner v. New York. While not relating to the practice of medicine and non-compete provisions, Lochner is nonetheless an important case to the analysis of non-compete provisions in physician employment contracts. Lochner is necessary to the discussion of non-competes because it emphasizes how the history of restrictions on restraints on trade have changed so that now private parties, and not just the government, are allowed to implement restrictions. Additionally, these restrictions vary depending on the profession and where professionals practice. </p><p> Non-compete provisions are found in contracts created by both small private medical practices, as well as bigger entities, such as hospitals and managed care organizations. Therefore, this is not an issue limited to the size of the practice. The physician-patient relationship has gradually become more and more of an impersonal one due to managed care organizations and legislation such as the Affordable Care Act (ACA). This does not, however, mean that physicians and patients approve of this interference and push towards an impersonal relationship. Thus, if patients are unhappy with the resulting impersonal relationship from managed care plans and legislation, patients may suffer further from these non-compete clauses interfering with the patients' utilization of physician services. </p><p> These clauses hurt not only the physicians trying to practice, but also have the capacity to conflict with patient choice in regard to selecting the physician they want for treatment purposes. More importantly, such non-competes negatively interfere with the continuity of patient care. It is for these aforementioned reasons that it would behoove the American Medical Association (AMA) to model its non-compete guidelines after those found in the American Bar Association (ABA), which strictly limit the use of such non-compete provisions in attorney employment contracts.</p>

The objective of this dissertation is to estimate the health and economic outcomes associated with two prominent child health conditions: autism spectrum disorder and influenza illness. Chapter 1 derives utility values associated with the health of children with autism spectrum disorder (ASD) and their parents. Our findings suggest that ASD has a large impact on the health-related quality of life of children and their caregivers, and that this impact is influenced by both the child’s specific diagnosis and the severity of their core social communication and repetitive behavior symptoms. Chapter 2 estimates the annual incremental costs associated with caring for a child with ASD from the societal perspective. Our findings suggest that there is a large economic burden both in terms of formal costs (healthcare, school and other direct costs of care) as well as the informal time costs of caregiving. Specifically, the societal costs of caring for this population amounted to $9.1 billion in 2011 alone, highlighting the tremendous financial challenges our society faces in meeting the needs of children with ASD. Chapter 3 uses a decision analytic model to evaluate 1-year clinical and economic outcomes associated with oseltamivir treatment for seasonal influenza in children, and considers the impact of oseltamivir resistance on these findings. Our results indicate that for unvaccinated children who present to their physician’s office with influenza-like symptoms, empiric antiviral treatment with oseltamivir appears to be a cost-effective treatment option. This is particularly true for ill children aged 1 to 12 years, but results are dependent on the prevalence of circulating seasonal influenza viruses that are resistant to oseltamivir.

<p> The Kingdom of Swaziland is a small African nation with an HIV prevalence rate of 27.4% in adults and up to 39% in pregnant women (Global Health Observatory, 2014). In 2012, life expectancy for a woman in Swaziland was 55-years (World Health Organization, 2014). Health entails more than the absence of disease. Although considered a lower middle-income country, 69% of Swazi citizens live in poverty and nearly one-third live in extremely poor circumstances. The degree to which upstream factors such as social conditions and the cultural environment impact individuals tends to be minimized in Westernized models of health behavior. The purpose of this study was to examine the sociocultural factors that impact self-care and health maintenance of women in Swaziland. The goals related to this were to uncover the salient cultural values, beliefs and attitudes that affect the health of Swazi women, and to develop a deeper understanding of how strongly embedded cultural values are a determinant of health outcomes. Using Carspecken&rsquo;s methodology of critical ethnography, which incorporates both observational and narrative methods, this study focused intensively on the life stories of four rural African women. The findings richly illustrate how social issues such as poverty and food insecurity impact the health of women and their children; and how traditional customs and practices both support and threaten the health of women and families. Women in this study experienced a loss of husband or extended family due to death or abandonment that resulted in losses in supports and resources. Additionally, they worried about the health and education of their children before personal health needs. They also reported chronic employment problems and mistrust in existing governmental agencies including the healthcare system. Application of the culturally sensitive Person-Environment-Neighborhood (PEN-3) model highlights areas of resilience, strengths, and resource targets and identifies the community as an appropriate entry level for health interventions.</p>

<p> Contemporary commercial music (CCM) singers may be at a high risk for voice damage due to their increased vocal demands and the chronic exposure to chemical irritants associated with unhealthy lifestyle choices. Continuous mechanical damage, confounded with chemical trauma, has detrimental effects on the biomechanical properties of the vocal folds. Prior research on CCM singers has been limited, with efforts focused on physiologic aspects of voice production. The objective of the study was to report on the lifestyle choices of CCM singers and evaluate their vocal abilities according to healthy vs. unhealthy profile status via acoustic analyses as well as auditory perceptual assessments. The second objective was to evaluate if there were differences in lung volume associated with healthy vs. unhealthy lifestyle profiles. </p><p> Thirteen CCM singers participated in the study where they were assigned to either a healthy or unhealthy lifestyle vocal profile. Acoustic analyses of sound pressure level (SPL), signal-to-noise ratio (SNR), fundamental frequency (F0), and jitter/shimmer were collected during a prolonged singing /i/ in isolation as well as a singing /i/ in context of the &ldquo;Star Spangled Banner&rdquo; at three different vocal intensities <i>(low, comfortable, high)</i>. Lung volume was recorded via a vital capacity maneuver. Voice recordings were then rated via an auditory perceptual assessment (CAPE-V). Results were compared with a Wilcoxon rank-sum test. </p><p> Differences with regard to group trends were observed across all dependent measures. SNR median values for unhealthy singers were significantly lower in both singing tasks during <i>low</i> vocal intensity (p&lt;0.05), with differences approaching significance found during prolonged singing /i/ in isolation at <i>comfortable</i> vocal intensity (p&lt;0.10). F0 analysis noted significantly lower median values for unhealthy singers during isolated /i/ productions at <i>low</i> vocal intensity (p&lt;0.05). Jitter analysis among unhealthy singers showed significantly higher median values during isolated /i/ productions at <i>comfortable</i> vocal intensity (p&lt;0.05), with differences approaching significance found during singing /i/ in context at <i>low</i> vocal intensity (p&lt;0.10). Shimmer analysis among unhealthy singers showed significantly higher median values during isolated /i/ productions at low and comfortable vocal intensity (p&lt;0.05), with differences approaching significance found during singing /i/ in context at low vocal intensity (p&lt;0.10). Unhealthy singers showed lower vital capacity as compared to healthy singers, however results were nonsignificant (p>0.05). Auditory perceptual assessment of voice was perceived to be essentially normal for all participants regardless of healthy versus unhealthy profile status. </p><p> The findings provide a descriptive profile of contemporary commercial music singers and contribute to the existing literature on the harmful effects of exposure to cigarette smoke on voice production. Unhealthy singers displayed significant acoustic differences most often observed in <i>low</i> vocal intensity conditions, which suggest a decreased vocal ability. This may be explained by their repeated exposure to chemical irritants (i.e. cigarette smoke) and possible phonotrauma, causing changes in the biomechanical properties of the vocal folds. Given the disparity between acoustic measures and auditory perceptual assessment, it was concluded that the biomechanical changes might be in the early onset and suggest future voice difficulties.</p>

In this thesis we discuss three models that are used to estimate vehicle busy probabilities when call service time depends on call location and the serving vehicle. The first model requires an assumption that each vehicle operates independently of the other vehicles. The second model approximately corrects for the independence assumption. The third model also approximately corrects for the independence assumption, however it assumes that all vehicles have an equal busy probability. We evaluate model bias by comparing the estimates from each model with estimates from a simulation model. We use extremely long runs to ensure that the simulation is both accurate and precise. Our results suggest that the model using the independence assumption performs poorly as the system utilization increases. The correction models, however, perform well over a wide range of system sizes and utilizations. (Abstract shortened with permission of author.)

<p>An important factor in the rise of health care costs is the structure and performance of health care markets. This is an area in which policy can be particularly effective. Health care markets are characterized by complex interactions between consumers, physicians, insurers, facilities, and government agencies. Physicians, insurers, and facilities operate under a mix of objectives and governance structures. The many varieties of objectives, and governance structures can be broadly categorized as for-profit, not-for-profit, and governmental. </p><p> In the three chapters that follow I construct a theoretical framework to analyze hospital behavior and use a 30 year panel of data on Californian hospitals to assess the validity of the models and to identify the impact of governance structure on behavior. Chapter II addresses firm objectives. I find that firms have a continuum of weighting allocations, with for-profit firms placing greater weight on profit, government firms placing greater weight on social objectives, and not-for-profit firms locating in a middle ground. All three types of governance structures display overlap in their objectives. </p><p> In Chapter III, I identify patterns in hospital entry and exit. Like most manufacturing industries, entering hospitals are significantly smaller than incumbent hospitals and exiting hospitals are significantly smaller than surviving hospitals. The patterns of entry and exit for hospitals vary systematically with both governance structure and geographic diversification. </p><p> In Chapter IV, I develop a model of hospital entry that explains heterogeneous entry size and firm survival. I find entry size to be a relatively important factor in firm survival. In general entering on a larger scale increases the probability of survival. Despite this fact many firms enter relatively small. The model that I develop resolves small entry as a rational choice for uncertain firms. </p>