<p> The objective of this dissertation was to examine the association between patients' race and receipt of National Comprehensive Cancer Network guideline-adherent and timely colorectal cancer (CRC) and non-small cell lung cancer (NSCLC) care in the Veterans Affairs (VA) healthcare system. Data were from the External Peer Review Program (EPRP) Special Study on CRC and NSCLC, originally purposed for performance monitoring, examined in an observational, retrospective study design. The sample consisted of African American (AA) and Caucasian patients diagnosed with CRC between 2003 and 2006 or NSCLC between 2006 and 2007 at VA hospitals nationwide. Statistical analysis approaches included multivariate logistic regression and survival analysis methods. </p><p> Our first analysis used multivariable logistic regression to examine associations between race and receipt of guideline-concordant care (computed tomography scan, preoperative carcinoembryonic antigen, clear surgical margins, medical oncology referral for Stages II-III; fluorouracil-based adjuvant chemotherapy for Stage III; surveillance colonoscopy for Stages I-III). There were no significant racial differences in receipt of guideline-concordant CRC care. Our second analysis examined associations between race and CRC care timeliness. There were no racial differences in time to chemotherapy initiation (HR 0.82, p=0.61) or surgery to death (HR 0.94, p=0.0.49). Caucasian race was protective for shorter time to first surveillance colonoscopy (HR 0.63, p=0.02). On average, the difference in time to colonoscopy was sixteen days. Our third analysis examined associations between race and NSCLC care timeliness. There were no racial differences in time to initiation of treatment (72 days for AA versus 65 days for Caucasian patients, HR 1.03, p=0.80) or palliative care or hospice referral (129 versus 116 days, HR 1.10, p=0.34). However, the adjusted model found longer survival for African American compared to Caucasian patients (133 versus 117 days, HR 1.31, p=0.00). </p><p> In these data there were minimal statistically significant racial differences. We identified no clinically meaningful racial differences in cancer care quality, timeliness, or patient outcomes. This suggests that VA may be a leader in providing equitable cancer care. Future studies could examine causal pathways for the VA's equal, quality care and ways to translate the VA's success into other hospital systems.</p>

<p>The general problem is Native American tribes have high prevalence rates of diabetes. The specific problem is the failure of IHS sites to adopt EHR may cause health care providers to miss critical opportunities to improve screening and triage processes that result in quality improvement. The purpose of the quantitative correlational study was to explore a possible correlation between electronic health record use and reductions in diabetes co-morbidities. The study involved examining over 10 years of ex post facto data, with over one million patient encounters, from the Resource and Patient Management System database. Electronic health records containing key components such as clinical decision support with clinical reminders, evidence-based guidelines, template-driven protocols, and algorithmic modeling changes clinical provider behavior resulting in quality improvement. The study identifies the theoretical constructs from over 50 years of literature that converge to support quality improvement using electronic health records. Quality improvement theory and the unified theory of acceptance and use of technology were examined to explore relationships between process changes and behavioral modification. Results revealed a significant positive correlation between total blood pressure control screenings and the diagnosis of hypertension for fiscal years 2005 &ndash; 2009 <i>r</i>(4) = .947, <i>p</i> = .007. A significant positive correlation also existed between blood pressure control screenings with values >130/80 and diagnosis of hypertension for fiscal years 2005 &ndash; 2009 <i>r</i>(4) = .909, <i>p</i> = .016. The study concludes with a rejection of the posited null hypotheses, revealing a statistically significant correlation between use of a comprehensive electronic health record and health care quality improvement. </p>

<p>Healthcare as an industry included over 14 million workers in the United States and accounted for more than 15 percent of total Gross Domestic Product in 2008. Healthcare, particularly hospitals, played a significant role in shaping the culture, economy and quality of life throughout the United States beginning in the late nineteenth century and continuing to the present. For this reason, it was important to understand the nature of hospitals as healthcare organizations and the nature of leadership within these organizations. Metaphors were identified as a viable way to capture the structure and functioning of hospitals through their evolution as organizations over the past century and were used to evaluate the effectiveness of hospital leadership in responding to environmental, financial and societal changes. Based on this assessment, the role of metaphors as a leadership tool was examined and as well as the potential role of metaphors in promoting organizations development. </p><p> A survey of Certified Professionals in Healthcare Quality (CPHQ) in the Northeastern United States was used to assess the prevalence of the two most common metaphors cited in the literature for healthcare organizations, mechanistic and complex adaptive system. A unique aspect of this survey was the use of paired statements reflecting characteristics of the two most common metaphors to evaluate their use in healthcare organizations. Surprisingly, the metaphors frequently cited in the literature were identified infrequently and no metaphors were identified consistently across hospitals in the region. </p>

<p> This research investigated a queuing theory known as Erlang-C and its applicability in its use in central sterile supply. Erlang-C was used to calculate human resource needs in real time to encourage effectiveness in preparing trays for surgery. No consistent way of organizing tray preparation for surgery in a hospital currently exists. Efficiency in preparing trays is the goal of this study. Once surgical instruments are used, they need to be organized in sterilizable trays by a sterile processing technician before being sterilized. This study examines the actual versus the predicted output. The current situation can be described in three parts. First, there is no existing system to mathematically define the process of quality when preparing a surgical tray. There is no currently existing system to describe what theoretical productivity (benchmark) in tray preparation consists of. There is no currently existing system to describe how many technicians are needed to complete the surgical trays necessary for one day of surgery. There are several different types of sterilizable trays and the number and complexity of instruments in each of these types of containers (small, medium or large) varies. The current process is facilitated by a program called ABACUS with VIA Embedded software&trade; which provides information to the technician about which instrument to inspect and in what order. The proposed process could easily be integrated into the ABACUS system. This dissertation should improve both quality and productivity to address the three following points: 1) To improve quality, for which new parameters are added called instrument inspection specifications or instrument characteristics (lumen, traction surface, box lock, recess and handling time) introduced to describe what should be inspected during tray preparation (these instrument inspection specifications were assigned an ancillary number of seconds of inspection time for each specific feature of the instrument), 2) A new definition for trays is proposed based on the number of instruments and characteristics per tray (small trays are defined as having between 0 and 18 box locks, medium trays 18 to 75 box locks per tray and large trays 75 to 161 box locks) 3) To optimize manpower, Erlang-C queuing system was used as a simulation tool to describe the needs measured in number of technicians per type of tray per half hour. Further improvement to the Erlang program would be required to generate data for a full day of surgery. </p>

<p>This capstone project evaluated the Idaho Plate Method (IPM) as an effective nutrition self-management program for adults with type 2 diabetes mellitus (T2DM) with limited health literacy (LHL) in one rural clinic in West Virginia. A one-way pretest-posttest design was used to evaluate the effects of the program on food choices, confidence, and HbA1c. A convenience sample of 30 volunteers participated in the program with 3-month follow-up data collected on 22 volunteers. A Wilcoxon test was conducted to evaluate choices of fruits, vegetables, and fatty foods and participant confidence in making healthful food choices. Data analysis found significant differences in fruit intake (<i>z</i> = -1.98, <i>p</i> 0.05); vegetables intake (<i>z</i> = -2.58, <i>p</i> .01); and skim milk intake (<i>z</i> = -2.094, <i>p</i> .04). There was a decrease intake of French-fries and fried potatoes (<i>z</i> = -2.26, <i> p</i> .02); butter or margarine on bread or pancakes (<i>z</i> = -2.494, <i>p</i> .01); regular fat hot dogs (<i>z</i> = -2.693, <i>p</i>&lt;0.01); and total fat consumption (<i> z</i> = -2.50, <i>p</i> .01). A significant increase in confidence was found in participants ability to prepare or share food with non-diabetics (<i>z</i> = -3.10, <i>p</i> .002); to choose appropriate foods when hungry (<i>z</i> = -2.72, <i>p</i> = .006); to eat smaller portions at dinner (<i>z</i> = -2.46, <i>p</i> .014); and to add less fat than a recipe calls for (<i>z</i> = -2.10, <i> p</i> .035). Paired t-test analysis compared pretest-posttest HbA1c results with a very nearly significant difference between the HbA1c pretest (<i> M</i> = 7.96, <i>SD</i> = 1.83) and posttest (<i>M</i> = 7.34, <i>SD</i> = 1.60), <i>t</i> (24) = 2.02, <i> p</i> .055). Limitations of the study included the study design, lack of participants with LHL, high attrition rate, and study time restraints. Conclusions found, despite limitations, adults in rural WV with T2DM increased confidence in making healthy food choices, choosing healthy foods, and improving their glycemic control using the IPM. </p>

<p> <b>Purpose:</b> It is imperative to assure that health care organizations provide excellent care and create value by improving quality while eliminating unnecessary costs. Lean management is a continuous improvement management plan that uses work flow design to produce improvements in quality, safety, cost and productivity; it has been used in manufacturing, service and, more recently, healthcare industries. This study developed and tested an instrument to measure frontline nurse caregivers' perception of the penetration of lean management in hospitals that report using lean strategies. </p><p> <b>Methods:</b> The study consisted of three phases. In Phase 1, using the Delphi technique, an on-line survey of experts (<i>n</i>=10) and a review of the literature identified the domains and subdomains of lean management. Ideas from each domain were formed into items on the Frontline Improvement Thinking (FIT) instrument. The experts also assessed content validity. In Phase 2, nurses assessed the instrument's format, on-line usability of the instrument and content validity. In Phase 3, the instrument was administered to frontline nurses working on units in hospitals that reported using lean methods. Their responses (<i>n</i>= 212) provided the data for assessing the instrument's psychometric properties. </p><p> <b>Results:</b> Exploratory factor analysis yielded a scale with 75 items in 12 factors. Three domains were identified: organizational, unit and individual areas of improvement. The 4-factor, 29-item,<i> FIT Unit </i>had the highest reliability (&amp;alpha;=.86-0.94; inter-item correlation range=.26-0.63). The 2-factor, 10-item <i>FIT Organization</i> was also acceptable (&amp;alpha;=.87 and 0.79, inter-item correlation range=.30-0.72. The <i>FIT Individual</i> had less than desired reliability on one factor (&amp;alpha;=.66) but had acceptable reliability on the other six factors (0.75-0.94; inter-item correlation range =.25-0.89). Test-retest reliability estimates were acceptable for the organization and unit based on Pearson's R correlations (0.53-0.77). </p><p> <b>Conclusion:</b> In the early stage of development, the FIT instrument proved helpful in describing diffusion of lean management. Sample size and quality proved to be problems, however. Nurses from hospitals with a history of lean quality improvement did not participate in the study and some of the hospitals studied were in the very early phases of lean management. Recommendations include continuing work on measure development by increasing the sample of lean-thinking nurses.</p>

<p> Discrimination against immigrants based on country of origin, gender, or race is known to contribute to wage inequality, lower morale, and decrease worker satisfaction. Healthcare leaders are just beginning to study the impact of gender and race on the wages of internationally educated nurses (IENs). Grounded in Becker's theory of discrimination, this cross-sectional study examined nursing wages for evidence of wage inequality among IENs working in the United States using secondary data collected in the 2008 quadrennial National Sample Survey of Registered Nurses. Ordinary least square regression coupled with the Blinder-Oaxaca wage decomposition was used to analyze the wages of 757 IENs working in the U.S. healthcare system. <i>T</i> tests with effect size were calculated to find the impact of gender, race, and country of education on wage. The study found that white male IENs earned higher wages than all other immigrant groups, followed by nonwhite males and nonwhite females (R² = .143; <i>F</i>(8,748) = 15.60; <i> p</i> =.000;). White female IENs earned the least, at 80%, 88%, and 91% of wages earned by white male, nonwhite male, and nonwhite female IENs, respectively (<i>p</i> &lt; <i>.005</i>). The relationship between hourly wage and being a white female was negative and statistically significant (<i>p</i> = .006) and white females earned 19.6% less per hour than white male IENs. Working in tertiary care contributed 21.60% of wages for white IENs and 10.30% of wages for nonwhite IENs. Inequality in nursing wages was related to an interaction between race and gender for wages of white female IENs but not in wages for nonwhite female IENs. Results of this study promote positive social change by motivating nursing departments to equalize wages and policymakers to strengthen equal pay statutes.</p>

<p> This study is an examination of the prevalence of asthma in adolescents, and it seeks to identify associations that may exist among individuals from different racial and socioeconomic backgrounds. The primary areas of focus were defined by the two research questions posed; these explored the differences among individuals in the study population who had a primary diagnosis of asthma and those who did not. The population consisted of children from birth to 17 years old treated in an emergency department during 2009. The National Hospital Ambulatory Medical Care Survey dataset from 2009 was used as the secondary data source for this retrospective study. After conducting a statistical analysis using a Chi-Squared test, it was determined that race has a statistically significant relationship to pediatric asthma. The factors for this correlation can be attributed to a number of theories that are discussed in detail throughout this research.</p>

<p> The purpose of this study is to establish a relationship between responsiveness of hospital staff to a patient's call for help and the hospital fall rate. Patient falls are a very serious matter so data that furthers understanding in this area may be of help for hospitals trying to raise patient satisfaction scores, improve patient outcomes, and improve financial impact. The data utilized in this project are datasets downloaded from the Centers for Medicare and Medicaid Services (CMS) website.</p><p> Two hypotheses were tested from each extreme end of the responsiveness spectrum. The final conclusion is that the hospital fall rate is strongly associated with the high ("Always") but not the lower end ("Sometimes or Never"). </p><p> Further research in this area is recommended to account for casual factors. The limitations of the study may be the collection and manipulation of the data by CMS.</p>

<p> Emergency Department (ED) overcrowding is both a financial and patient care/satisfaction issue throughout the United States. Current literature includes examination of frequent ED users as well as low-acuity ED users, but seldom combines the two. The purpose of this study was to increase the knowledge surrounding ED overcrowding, which may be used to inform ED cost reduction strategies. This was done by utilizing National Hospital Ambulatory Medical Care Survey (NHAMCS) data and Chi-Square tests in order to investigate possible associations between frequent, lowacuity ED users and-independently-the following items: payment type, age, sex, and race/ethnicity. Findings show that there is a subset of ED users frequently present for low-acuity ED visits and that significant association exists between these ED users and payment type, age, and race/ethnicity. Through these findings additional information about a subset of frequent ED user is found and an additional context for discussing previous data is provided.</p>