Thesis (Ph. D.)--University of Virginia, 2007. / Includes bibliographical references. Also available online through Digital Dissertations.

Background: Long outpatient waiting time is a significant problem in Mainland China’s healthcare system. Long patient waiting time negatively affects actual care quality as well as patients’ perceptions of medical care. Aim: This study aims to understand the causes of long patient wait times in China’s outpatient care departments, and how those waits influence patients’ attitudes towards medical care. The rhythm of hospital patient flow will be explored in order to posit modest suggestions to resolve these issues. Objectives: The objectives of this study are to identify the causes of long waiting times in China’s outpatient care departments, to distinguish the specific bottleneck points in patient flow, and to characterize the relationship between waiting time length and the patients’ perceptions of medical care. Method: Two tertiary care hospitals in Mainland China were included as study sites. Macroergonomic methodologies were adopted to guide the data collection and analysis. The Systems Engineering Initiative for Patient Safety (SEIPS) model was specifically adopted to guide the study design and data analysis procedures. First, audio records were made of interviews with care providers from the two hospitals in order to document and discern the causes of long outpatient care waiting times. Second, a time study was carried out with patients visiting two outpatient departments at the two study sites in order to identify inefficiencies and bottleneck points in the patient flow. Third, a questionnaire survey was provided to the patients in order to understand the impact of lengthy wait times on their overall perceptions of medical care. The interview data was analyzed using content analysis methods, time study data was used to generate a patient flow model, and the questionnaire feedback was analyzed in tandem with the time study data using a linear regression analysis. Results: Sixty-three factors contributing to lengthy patient wait time were discerned from the interview data, concerning each of the five dimensions of the SEIPS model work system. Two patient flow diagrams were designed based on identified patient flow inefficiencies and bottlenecks. A majority (four-fifths and three-quarters, respectively, at the two study sites) of total patient visit time was spent on waiting for physician services and ancillary, non-medical activities. Serious bottlenecks in patient flow occurred while waiting for physician consultation, ultrasound examinations, and medical test result feedback. Patients’ evaluations of medical care quality dropped 0.04 points for each minute of consultation wait time, and 0.02 points for each minute of total visit duration and total waiting time. Conclusions: The causes of long patient wait times concern the physicians’ and patients’ characteristics, the organization and management of the hospital, the tasks, technology, and tools involved, and the hospital environment. Waiting for physician consultation, ultrasound examinations, and medical test result feedback cause the most patient flow problems. Long wait times have an adverse impact upon patients’ perceptions of medical care. The macroergonomic methodologies prove feasible and effective in evaluating health care systems. / published_or_final_version / Industrial and Manufacturing Systems Engineering / Master / Master of Philosophy

The critical care unit (CCU) is a unit where different health care professionals work together to care for the patient efficiently. A lot of studies in the past have shown that good communication and transfer of information from one health care professional to the other is an essential aspect in the transfer of a patients care. Most of these studies are concentrated on the reporter or informant. Lapses in communication and information transfer could result in unnecessary suffering both for the patient and for the health care worker. There are very few studies on how well the recipient of the information or report understands or comprehends the information passed. The aim of this study was to illuminate the critical care nurses (CCN) experiences of receiving report of patients transferred from other units. A qualitative design was chosen and five CCNs in a particular CCU were interviewed. The analysis was done using the content analysis method. The analysis resulted in four main categories which are: The patient’s situation-a determinant factor, the work environment, communication deficit creates uncertainty and structure enhances report and ten subcategories. The findings showed that CCNs' experience a feeling of uncertainty as a result of lapses in communication and their work environment and its attendant distractions has a great influence on the quality of the report they receive. To ensure a good quality of care that promotes patient’s safety and job satisfaction, it would be necessary to address the factors that hinder effective communication during handover in nurses' education programs and clinical practices.

Purpose: There is a pressing need to enhance patient safety in the hospital environment. While there are many initiatives that focus on improving patient safety, few have studied engaging patients themselves to participate in patient safety efforts. This work was motived by the belief that patients can contribute valuable information to their care and when equipped with the right tools, can play a role in improving medication safety in the hospital. Methods: This research had three aims and used a mixed-methods approach to better understand the concept of engaging patients to improve medication safety. In order to gain insight into whether patients could beneficially contribute to the safety of their hospital care, my first aim was to understand current perspectives on the sharing of clinical information with patients while they were in the hospital. To accomplish this aim, I conducted surveys with clinicians and enrolled patients in a short field study in which they received full access to their clinical chart. In Aim 2, I conducted a study to establish that the Patient Activation Measure (PAM), a common measure of patient engagement in the outpatient setting, showed reliability and validity in the inpatient setting. Building on the knowledge from Aim 1 and using the PAM instrument from Aim 2, my third aim evaluated the impact of providing patients with access to a medication review tool while they were preparing to be admitted to the hospital. Aim 3 was achieved through a randomized controlled trial (RCT) involving 65 patients I recruited from the emergency department at Columbia University Medical Center. I also conducted a survey of admitting clinicians who had patients participate in the trial to identify the impact on clinician practices and to elicit feedback on their perceptions of the intervention. Results: My research findings suggest that increased patient information sharing in the inpatient setting is beneficial and desirable to patients, and generally acceptable to clinicians. The clinician survey from Aim 1 showed that most respondents were comfortable with the idea of providing patients with their clinical information. Some expressed reservations that patients might misunderstand information and become unnecessarily alarmed or offended. In the patient field study from Aim 1, patients reported perceiving the information they received as highly useful, even if they did not fully understand complex medical terms. My primary contribution in Aim 2 was to provide sound evidence that the Patient Activation Measure is a valid and reliable tool for use in the inpatient setting. Establishing the validity and reliability of the PAM instrument in inpatient setting was essential for conducting the RCT in Aim 3, and it will provide a foundation for future clinicians and research investigators to measure and understand hospital patients’ levels of engagement. The results from the RCT in Aim 3 did not support my primary hypothesis that clinicians who had patients participate in their medication review process using an informatics tool would make more changes to the home medication list than clinicians who had patients in the control group. However, the results did suggest that most hospital patients are knowledgeable, willing, and able to contribute useful and important information to the medication reconciliation process. Interestingly, the clinicians I surveyed seemed far less convinced that their patients would be able to beneficially participate in the medication reconciliation process due to low health literacy and other barriers. Nevertheless, the clinicians did seem to believe that in theory, at least, patient involvement in the medication reconciliation process could have positive impacts on their workflow and potentially save them time. Conclusion: The overall theme resulting from my research is that patients can be a valuable resource to improve patient safety in the hospital. Patients are generally knowledgeable and willing to more actively participate in their hospital care. By developing the structures and processes to facilitate greater patient engagement, hospitals can provide an extra layer of safety and error prevention, particularly with respect to the medications patients take at home. As with any medical treatment, active participation in patient safety efforts may not be possible for all patients. However, I believe that if the culture of a hospital encourages openness and transparency, and if patients are given the proper tools and information, the quality and safety of hospital care will improve.

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no / Introduction Patients represent an important and as yet untapped source of information about the factors that contribute to the safety of their care. The aim of the current study is to test the reliability and validity of the Patient Measure of Safety (PMOS), a brief patient-completed questionnaire that allows hospitals to proactively identify areas of safety concern and vulnerability, and to intervene before incidents occur. Methods 297 patients from 11 hospital wards completed the PMOS questionnaire during their stay; 25 completed a second 1 week later. The Agency for Healthcare Research and Quality (AHRQ) safety culture survey was completed by 190 staff on 10 of these wards. Factor structure, internal reliability, test-retest reliability, discriminant validity and convergent validity were assessed. Results Factor analyses revealed 8 key domains of safety (eg, communication and team work, access to resources, staff roles and responsibilities) explaining 58% variance of the original questionnaire. Cronbach’s α (range 0.66–0.89) and test-retest reliability (r=0.75) were good. The PMOS positive index significantly correlated with staff reported ‘perceptions of patient safety’ (r=0.79) and ‘patient safety grade’ (r=−0.81) outcomes from the AHRQ (demonstrating convergent validity). A multivariate analysis of variance (MAMOVA) revealed that three PMOS factors and one retained single item discriminated significantly across the 11 wards. Discussion The PMOS is the first patient questionnaire used to assess factors contributing to safety in hospital settings from a patient perspective. It has demonstrated acceptable reliability and validity. Such information is useful to help hospitals/units proactively improve the safety of their care.

Percutaneous kidney biopsies have been performed since 1944 to establish diagnoses and treatment. Risk factors based on a limited amount of data have shown age, blood pressure, kidney function and needle size as some risk factors for biopsy complications. Although the techniques of biopsy have improved over the years, it is still an invasive procedure and serious complications can occur. The overall aim of this thesis was to obtain a large series of data from biopsy procedures and to use these to bring further light on risk factors to help minimize the risk for patients and to optimize diagnostics. Specific aims were to clarify if different factors, such as gender, diagnoses, localization of biopsies, needle types and sizes, could be useful to help minimize complication risks in native kidney biopsies (Nkb) and transplant kidney biopsies (Txb). Another point to investigate was the value of the Resistive Index (RI) obtained at ultrasound before performing Txb. Materials and methods: A protocol for prospective multicentre registration of various factors and complications associated with Nkb and Txb was designed. Consecutive data were obtained from seven hospitals. All biopsies, except one computer tomography-guided Nkb, were performed using real-time ultrasound guidance and an automated spring-loaded biopsy device. For the biopsies 14- to 20- Gauge (G) needles were used. The kidney function level, i.e. estimated glomerular filtration rate (eGFR), was calculated using the Modification of Diet in Renal Disease (MDRD) formula (GFR in mL/min per 1.73m2). For statistical analyses the IBM SPSS Statistic 22 (Armonk, NY, USA) and OpenEpi (Open Source Epidemiologic Statistics for Public Health, www.OpenEpi.com) were used. Data were presented as Odds Ratio (OR), Risk Ratio (RR) and Confidence Intervals (CI). A two sided p-value of <0.05 was considered significant. In total 1299 consecutive biopsies (1039 native and 260 transplant kidneys) in 1178 patients (456 women and 722 men) were used for investigation. The median age of patients was 55 years (range 16 to 90 years). Major (require an intervention) and minor biopsy complications (no need of intervention) were registered. Results: The overall frequency of biopsy complications for Nkb was 8.8% (major 6.7%, minor 2.1%) and for Txb was 6.5% (major 3.8%, minor 2.7%); no death. Women had a higher risk for development of major (10.7% versus 4.7%, OR 2.4, CI 1.4-4.2) and overall biopsy complications (13.2% versus 6.5%, OR 2.2, CI 1.4-3.5) compared to men in Nkb. In Nkb, major complications were more common after biopsies from the right kidney in women versus men (10.8% vs 3.1%, OR 3.7, CI 1.5–9.5), in patients with lower versus higher BMI (25.5 vs 27.3, p=0.016) and for younger versus older age (44.8 vs 52.3 years, p=0.002). Lower (90 mmHg) compared to higher (98 mmHg) mean arterial pressure in Txb indicated a risk of major complications (p=0.039). Factors such as number of passes and kidney function did not influence complication rates. Biopsy needles of 16 G compared to 18 G showed more glomeruli per pass in Nkb (11 vs 8, p<0.001) and in Txb (12 vs 8, p<0.001). Sub-analysis revealed that 18 G 19 mm side-notch needles in Nkb resulted in more major (11.3% vs 3%, OR 4.1, CI 1.4-12.3) and overall complications (12.4% vs 4.8%, OR 2.8, CI 1.1-7.1) in women than in men. If the physician had performed less compared to more than four Nkb per year, minor (3.5% vs 1.4%, OR 2.6, CI 1.1-6.2) and overall complications (11.5% vs 7.4%, OR 1.6, CI 1.1-2.5) were more common. The localization of biopsy within the kidney (Nkb and Txb) was not a risk factor for complications. Patients with IgA-nephritis compared to patients with other diseases had a higher risk of major complications (11.7% vs 6.4 %, OR 1.8, CI 1.1–3.2). More major complications were found in Nkb if they had higher versus lower degree of glomerulosclerosis (31% vs 20 %, p=0.008) and in Txb if there was a higher versus lower degree of interstitial fibrosis (82% vs 33%, p<0.001). Re-biopsies (Nkb) were more common in patients with IgA-nephritis than those with other diseases (4.7% vs 1.3 %, OR 4, CI 1.5–11), in younger versus older age (42.6 vs 52.3 years, p=0.031), and in those with a higher versus lower degree of interstitial fibrosis (63% vs 34 %, p=0.046). In Txb, a RI≥0.8 compared to RI<0.8 predicted major (13.3% vs 3.2%, RR 4.2, CI 1.3-14.1) and overall biopsy complications (16.7% vs 5.3%, RR 3.2, CI 1.2-8.6). In the group <0.8, RI correlated with age (rs=0.28, p<0.001) and systolic blood pressure (rs=0.18, p=0.02). In the group ≥0.8, RI correlated with degree of interstitial fibrosis (rs=0.65, p=0.006) and systolic blood pressure (rs=0.40, p=0.03). The multiple regression analysis showed that the <0.8 RI group correlated only with age (p<0.001), whereas the ≥0.8 RI group correlated only with the degree of interstitial fibrosis (p=0.003). Conclusions: The present results motivate greater attention to be paid to the possibility of major side-effects after Nkb in women and biopsies from their right side, but as well in younger patients, and in those with lower BMI. This also applies for patients with presumptive IgA-nephritis and higher degree of glomerulosclerosis. In Txb, patients with higher degree of interstitial fibrosis had a greater risk of major complications. Moreover, the present data indicate that Nkb and Txb should be preferably taken with 16 G needles with 20 mm sample size. This results in better histological quality and there is a lower risk for major complications as compared to 18 G needles. The localization of biopsy within the kidney (Nkb and Txb) does not alter complication rates. For Nkb there were fewer complications if the physician had performed at least four biopsies per year. A RI≥0.8 in Txb indicates a greater risk for major and overall complications.

Transparency in healthcare relates to formally reporting medical errors and disclosing bad outcomes to patients and families. Unfortunately, most physicians are not in the habit of communicating transparently, as many studies have shown the existence of a large medical error information gap. Research also shows that creating a culture of transparency would mutually support patient safety and risk management goals by concomitantly reducing medical errors and alleviating the malpractice crisis. Three predictor variables are used to represent the various dimensions of the context just described. Perfectionism represents the intrapersonal domain, socio-organizational climate represents the interpersonal and institutional domains, and medico-legal environment represents the societal domain. Chin and Benne’s normative re-educative strategy provides theoretical support for the notion that successful organizational change hinges upon addressing the structural and cultural barriers displayed by individuals and groups. The Physician Transparency Questionnaire was completed by 270 physicians who were drawn from a multi-site healthcare organization in Central Florida. Structural equation modeling was used to determine whether perfectionism, socio-organizational climate, and medico-legal environment significantly predict two transparency outcomes, namely, error reporting transparency and provider-patient transparency. Perfectionism and socio-organizational climate were found to be statistically significant predictors. Collectively, these variables accounted for nearly half of the variance in each transparency outcome. Within socio-organizational climate, policies had the greatest influence iv on transparency, followed by immunity and professional norms. Multiple group analysis showed that the covariance model developed in this study generalizes across gender, medical specialty, and occupation. In addition, group means comparisons tests revealed a number of interesting trends in error reporting and disclosure practices that provide insights about the behavioral and cognitive psychology behind transparent communication: 1) Physicians are more inclined to engage in provider-patient transparency compared to error reporting transparency, 2) physicians are more inclined to report serious errors compared to less serious errors, and 3) physicians are more inclined to express sympathy for bad outcomes than they are to apologize for a preventable error or be honest about the details surrounding bad outcomes. These results suggest that change efforts would need to be directed at medical education curricula and health provider organizations to ensure that current and future generations of physicians replace the pursuit for perfectionism with the pursuit for excellence. Also, a number of institutional changes are recommended, such as clearly communicating transparency policies and guidelines, promoting professional norms that encourage learning from mistakes rather than an aversion to error, and reassuring physicians that reporting and disclosure activities will not compromise their reputation. From the perspective of patient safety advocates and risk managers, the results are heartening because they emphasize a key principle in quality improvement - i.e., small changes can yield big results. From an ethical standpoint, this research suggests that healthcare organizations can inhibit (or facilitate) the emergence of professional virtues. Thus, although organizations cannot make a physician become virtuous, it is within their power to create conditions that encourage the physician to practice certain virtues. With respect to leadership styles, this research finds that v bottom-up, grassroots change efforts can elicit professional virtues, and that culture change in healthcare lies beyond the scope of the medico-legal system

Submitted by Jos? Henrique Henrique (jose.neves@ufvjm.edu.br) on 2018-06-26T23:09:15Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) laura_roberta_sa_ferreira.pdf: 1184127 bytes, checksum: 423bdfb7f8d380519ba2c16211b2795b (MD5) / Approved for entry into archive by Rodrigo Martins Cruz (rodrigo.cruz@ufvjm.edu.br) on 2018-07-18T12:50:54Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) laura_roberta_sa_ferreira.pdf: 1184127 bytes, checksum: 423bdfb7f8d380519ba2c16211b2795b (MD5) / Made available in DSpace on 2018-07-18T12:50:54Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) laura_roberta_sa_ferreira.pdf: 1184127 bytes, checksum: 423bdfb7f8d380519ba2c16211b2795b (MD5) Previous issue date: 2017 / Os erros envolvendo medicamentos podem ocorrer em qualquer fase do processo hospitalar, ou seja, na prescri??o, dispensa??o ou na administra??o. O in?cio do ciclo da medica??o ? a prescri??o, o m?dico deve especificar a terapia e condutas mais adequadas por escrito, levando em considera??o principalmente o uso racional de medicamentos. Quando a prescri??o n?o ? executada de maneira adequada pode contribuir de forma direta com os problemas relacionados a erros de medica??o. O presente trabalho foi realizado em uma Institui??o de sa?de em Diamantina com objetivo de avaliar a efetividade do servi?o realizado pela farm?cia cl?nica; identificar o perfil dos pacientes atendidos pelas cl?nicas m?dica e neurol?gica; os tipos e as frequ?ncias de erros que ocorrem na etapa da prescri??o e identificar os tipos de intera??es medicamentosas e suas frequ?ncias. Ap?s a implanta??o do servi?o de farm?cia cl?nica, em um ano o servi?o de an?lise de prescri??o proporcionou uma queda de +/- 40% das inadequa??es nas prescri??es. O perfil dos pacientes internados nas cl?nicas m?dica e neurol?gica da Institui??o em Diamantina foi de homens idosos que fazem uso de polifarm?cia. E devido ao grande n?mero de medicamentos nas prescri??es, as mesmas apresentaram 66,46% de intera??es medicamentosas, e as intera??es medicamentosas mais frequentes foram do tipo moderada (presentes em 59,76% das prescri??es) e menor (presentes em 20.12% das prescri??es). A inadequa??o mais frequente foi relacionada ao hor?rio de administra??o dos medicamentos. Tamb?m foi verificado que as prescri??es dos pacientes idosos, em sua maioria, apresentaram medicamentos da lista de Beers. Portanto, a realiza??o deste trabalho foi importante para promo??o do uso racional de medicamentos na Institui??o, al?m disso, mostrou a efetividade do servi?o que foi implantado na Institui??o. / Disserta??o (Mestrado) ? Programa de P?s-gradua??o em Ci?ncias Farmac?uticas, Universidade Federal dos Vales do Jequitinhonha e Mucuri, 2017. / Mistakes involving medications can occur at any stage of the hospital process, that is, during prescription, dispensing, or administration. The beginning of the medication cycle is the prescription, when physicians must specify the most appropriate therapy and conduct in writing, taking into account the rational use of medications. When prescription is not performed properly, it may contribute directly to problems related to medication errors. The present study was carried out in a health institution in Diamantina, with the objective of: identifying the profile of patients attended by the medical and neurological clinics; The types and frequencies of medication errors that occur in the prescription step; To identify the types of drug interactions and their frequencies; Evaluate the impact of polypharmacy on patient?s health and use the results of the research to analyze the effectiveness of the institution's clinical pharmacy service. The profile of the patients hospitalized in the medical and neurological clinics of the institution in Diamantina was of elderly men who use the polypharmacy, and also, due to the large number of medications in the prescriptions, the most frequent inadequacies were moderate and minor drug interactions. It was also verified that the prescriptions of these patients had, in their majority, medicines found in the list of Beers. After the implementation of the clinical pharmacy service, in one year of the prescription analysis service, a fall of +/- 40% of the inadequacies in the prescriptions of the medical and neurological clinics was observed. Therefore, the accomplishment of this work was important to promote the rational use of drugs in the institution, and in addition, it showed the effectiveness of the service implanted in the institution.