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Research Abstract Purpose: to explain how there is a direct correlation between nursing staff ratios and patient results regarding mortality, infection, poor patient safety, and other sentinel events. Aims: how is patient care compromised by nursing staff shortage? Methods: observational studies from public information records such as Medicare patient claims, AHA, and surveys from RNs working at acute care hospitals. Results: certain groups are more susceptible to sentinel events. Patients with chronic diseases, elderly, patients needing intensive care, or overall unstable patients are examples of patients who fall under this category. Studies show that patients are at higher risk for receiving detrimental care due to poor nurse to patient ratio. Conclusions: adding to a nurse’s workload increases patient mortality in length of stay in hospitals due to hospital administration only needing to meet the minimum staffing requirements. The minimum staffing required for operations still does not meet the recommendations provided by the Safe Staffing Act. Key Words: nurse shortages, patient safety, patient outcomes, healthcare quality, workload, hospital acquired infections, staffing, CAUTI, VAP, CABI

Esse estudo de caso teve como objetivo analisar a estrutura, o processo de trabalho e os resultados do Programa de Transplante de Fígado de um hospital universitário do interior paulista, em 2017. Foram analisados 325 prontuários de pacientes submetidos ao transplante de fígado no período de abril de 2001 a junho de 2016. Elegeu-se as variáveis sociodemográficas, clínicas, de tratamento, de estrutura, de processo e de resultados. Para a coleta de dados foram utilizados três formulários e um diário de campo. Para a análise dos dados quantitativos e qualitativos utilizou-se a abordagem de Avaliação em Saúde proposta por Donabedian (1980), a Resolução de Diretoria Colegiada º 50/2002 e a Portaria º 356/2014. Para o cálculo da sobrevida do paciente utilizou-se o método de Kaplan-Meyer e o Modelo de Regressão de Cox. Para o cálculo da sobrevida do enxerto utilizou-se o método de Kaplan-Meyer e o modelo de Regressão de Riscos Competitivos. Os resultados mostraram que a maioria dos pacientes era homens, adultos de meia idade, com comorbidades prévia, doença hepática moderada ou grave, complicações imediatas e tardias com baixa probabilidade de sobrevida. Quanto a estrutura o Programa atendeu em parte as recomendações para os componentes da estrutura organizacional-física (58,3%), organizacional de recursos humanos (55,6%), estrutural-física para funcionários e alunos (60,0%) e estrutural-física do ambulatório (50,0%). Em relação ao processo de atendimento identificou-se lacunas de documentos e ou diretrizes que norteiam a equipe de saúde no processo de trabalho. No que se refere aos indicadores de resultados, o número de transplantes sofreu alteração devido a fatores extrínsecos e intrínsecos. A maioria dos pacientes permaneceu em lista de espera por até 12 meses. Os pacientes encontravam-se em gravidade moderada a alta e probabilidade de mortalidade de 76%. O tempo de isquemia fria variou de 240 a 970 minutos, média de 499 (±112,0) minutos. A sobrevida do paciente após um, três e cinco anos de transplante foi de 66,4%, 60,4% e 56,5%, respectivamente, e a incidência acumulada para perda do enxerto foi da ordem de 10%. A maioria dos pacientes foi internada ao menos uma vez no primeiro ano após o transplante e os motivos principais foram relacionados a terapia de imunossupressão e as complicações cirúrgicas. Mais da metade (53,6%) dos pacientes estavam em seguimento ambulatorial no Programa e 43,7% evoluíram à óbito. O óbito foi relacionado, em sua maioria, ao choque séptico ou hipovolêmico. Conclui-se que os indicadores encontrados no presente estudo estão, em parte, de acordo com a legislação vigente sobre um Programa de Transplante de Fígado e que os indicadores de resultados precisam ser repensados para o fortalecimento e a consolidação do Programa no hospital estudado / The objective of this study was analyze structure, work process and outcomes of the Liver Transplantation Programme in a teaching hospital in Sao Paulo state\'s interior in 2017. It was analyzed 325 patients\' records which were submitted to liver transplantation from April 2011 to June 2016. Sociodemographic, clinical, treatment, structure, process and outcomes were the variables chosen in this study. Three forms and a field diary were used how strategy to data collection. Qualitative and quantitative data have analyzed using Healthcare Evaluation approach purposed by Donabedian (1980), the Directors\' Collegiate Resolution n. 50/2002 and Ministerial Order n. 356/2014. Kaplan-Meyer method and Cox Regression Model were used to estimate the patient survival rate. Kaplan-Meyer Method and Competing Risks Regression Model were used to calculate the graft survival. Study results showed that most patients were men, mid-aged adults, with previous comorbidities, moderate or severe liver disease, immediate and late complications with survival probability decreased. Regarding structure the Programme reached partially the recommendations of components physical-organizational structure (58.3%), organizational of human resources (55.6%), structural-physical to employers and students (60.0%) and structural-physical of clinic (50.0%). With respect to healthcare process was identified clinicals protocols absences as well as guidelines which should lead the healthcare providers in the working process. Regarding to outcomes indicators, the transplantation numbers suffered changes due intrinsic and extrinsic factors. Most patients remained in waiting list for until 12 months. The patients presented from moderate to high severity and the probability of mortality was 76% for them. The cold ischemic time range was from 240 to 970 minutes, with mean 499 (±112,0) minutes. The patient survival after one, three and five years after transplantation was 66.4%, 60.4%, 56.5%, respectively. The cumulative incidence to loss graft have been 10%. The most patients were hospitalized at least once in the first year after transplantation and the principal causes were related to immunosuppressive therapy and surgical complications. At the end of the study, more than half of patients (53.6%) were in clinical Programme follow-up and 43.7% had died. The most deaths were related with septic or hypovolemic shock. Therefore, is possible conclude that the indicators found in this investigation were, partially, according with Brazilian Current Law recommendations about Liver Transplantation Programs. The outcomes indicators should be rethought to promote strengthening and consolidation of Programme in the Hospital studied

The Centers for Medicare and Medicaid Services have been working with hospital networks across the United States to improve health care through education and training on clinical best practices and leadership frameworks. Some organizations have failed to reach the high-quality standards of care expected and have adverse patient care outcomes. The purpose of the study was to determine the relationship between leadership actions, funding type, and clinical care outcomes in participating Partners for Patients hospital programs in Iowa. The secondary variable data were provided from a Partnership for Patients contractor, through the Centers for Medicare and Medicaid Services Organizational Assessment Tool. Multiple linear regression analyses were used to determine the relationship between the leadership actions, funding type, and the clinical quality outcomes of catheter-associated urinary tract infections, central line associated bloodstream infections, falls with injury, and venous thromboembolism. The findings demonstrated no statistically significant relationships between leadership actions, such as completing a leadership checklist, incident dashboard, and board involvement in decision making, and the specified clinical care outcomes. There was a statistically significant relationship between leadership actions of completing a root cause analysis for incidents, federal funding type, and the clinical quality outcomes of falls with injury and venous thromboembolism. The results of this study will be shared with Partnership for Patients program leadership to positively impact patient care. The results may be useful as organizations continue to implement best practices to reduce medical errors, save cost, and increase patient safety.

In comparison to the European healthcare system, the U.S. healthcare system has lower quality care, higher costs, and covers a smaller percentage of the population. Despite the high costs, the U.S. healthcare system remains dysfunctional. The purpose of this exploratory single case study was to identify the strategies that some healthcare managers in a hospital setting in the midwestern region of the United States use to improve efficiency while decreasing healthcare costs. Complex adaptive systems theory was used to frame this study that included face-to-face interviews with 6 highly experienced healthcare managers. Data were collected from audio recorded interviews and publicly available documents, and the audio recordings were transcribed and analyzed using deductive and open coding techniques to identify themes regarding strategies used by managers to find effective ways for improvement. Three strategies emerged as themes, including improving the accuracy of information and reports, implementing precise and accurate information, and improving quality. The findings of this study may directly benefit healthcare managers and compel positive social change by facilitating successful strategies to improve efficiency and reduce costs. The successful strategies identified in the study might provide a new direction to healthcare managers attempting to adopt new methods. The findings may also contribute to social change by providing solutions that may improve overall organizational performance in a hospital setting.

Submitted by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2013-10-07T19:52:03Z No. of bitstreams: 1 Diss MP. PatriciaFreitas 2013.pdf: 1300546 bytes, checksum: 25ffe46fe68afa3da83ceb7580071b42 (MD5) / Approved for entry into archive by Maria Creuza Silva(mariakreuza@yahoo.com.br) on 2013-10-07T19:52:15Z (GMT) No. of bitstreams: 1 Diss MP. PatriciaFreitas 2013.pdf: 1300546 bytes, checksum: 25ffe46fe68afa3da83ceb7580071b42 (MD5) / Made available in DSpace on 2013-10-07T19:52:15Z (GMT). No. of bitstreams: 1 Diss MP. PatriciaFreitas 2013.pdf: 1300546 bytes, checksum: 25ffe46fe68afa3da83ceb7580071b42 (MD5) Previous issue date: 2013 / A assistência farmacêutica enquanto componente do sistema de saúde é determinante para a efetividade da atenção e dos serviços de saúde, pois tem importante papel na prevenção de doenças e na recuperação de grande parte das enfermidades. Os poucos estudos sobre o assunto têm mostrado, entretanto, que o setor da assistência farmacêutica é ineficiente, com gasto de recurso crescente e pouca qualidade na prestação do serviço. A instituição do monitoramento e avaliação no setor pode auxiliar na melhoria da qualidade dos serviços prestados e na implementação das políticas farmacêuticas, ao assegurar o acompanhamento das ações realizadas e a adoção de medidas para enfrentamento das dificuldades e problemas, porém, ainda hoje, não há nenhum instrumento voltado especificamente para a assistência farmacêutica no país. Visando preencher esta lacuna, este trabalho apresenta uma proposta metodológica para o monitoramento e para avaliação da assistência farmacêutica básica municipal. Para o desenvolvimento da proposta, foi construído um modelo teórico-lógico tendo por componentes as ações estratégicas que compõem o ciclo da assistência farmacêutica, além do componente transversal "institucionalização". Na matriz de dimensões e critérios do modelo, foram definidos vários critérios e padrões para cada componente, organizados nas dimensões "gestão" e "práticas". A construção do modelo baseou-se na análise de documentos relacionados à execução do programa de assistência farmacêutica na atenção básica, manuais e normas técnicas do Ministério da Saúde, legislação sanitária relacionada e legislação que regulamenta o exercício da profissão farmacêutica. A matriz foi submetida à consulta com especialistas, reformulada, sendo, então, elaborado o protocolo de aplicação da proposta. / Salvador

Made available in DSpace on 2010-04-20T20:15:05Z (GMT). No. of bitstreams: 1 106674.pdf: 904594 bytes, checksum: b288b443fcee4a4b63a1ee332274a957 (MD5) Previous issue date: 2007-08-15T00:00:00Z / A segurança do paciente é um dos pilares de uma organização hospitalar. O objetivo deste estudo foi conhecer as opiniões dos profissionais de saúde, que trabalham em organizações hospitalares, quanto às dimensões de segurança do paciente. Foram abordados conceitos de acreditação, qualidade, cultura de segurança e segurança do paciente. A metodologia utilizada foi a aplicação de um questionário da Agency for Healthcare Research and Quality, traduzido para o português, às lideranças administrativas e assistenciais de hospitais acreditados (tanto pela metodologia da Organização Nacional de Acreditação quanto pela metodologia da Joint Commission International), no Estado de São Paulo. Também identificou-se a freqüência com que os erros são reportados e se as respostas aos erros cometidos são punitivas ou não. / Patient safety is one of the pillars of a healthcare organization. The aim of this study was to know the opinions of the hospital staff about the safety culture dimensions. Concepts of accreditation, quality, safety culture and patient safety are approached. The methodology consisted of a questionnaire application prepared for Agency for Healthcare Research and Quality, translated to portuguese, to the medical and nonmedical leaderships of accredited hospitals (by the methodology of the Organização Nacional de Acreditação and by the methodology of the Joint Commission International), in São Paulo state. The frequency of error reporty was also identified, as well as whether the response to error is punitive or not.

Esse estudo de caso teve como objetivo analisar a estrutura, o processo de trabalho e os resultados do Programa de Transplante de Fígado de um hospital universitário do interior paulista, em 2017. Foram analisados 325 prontuários de pacientes submetidos ao transplante de fígado no período de abril de 2001 a junho de 2016. Elegeu-se as variáveis sociodemográficas, clínicas, de tratamento, de estrutura, de processo e de resultados. Para a coleta de dados foram utilizados três formulários e um diário de campo. Para a análise dos dados quantitativos e qualitativos utilizou-se a abordagem de Avaliação em Saúde proposta por Donabedian (1980), a Resolução de Diretoria Colegiada º 50/2002 e a Portaria º 356/2014. Para o cálculo da sobrevida do paciente utilizou-se o método de Kaplan-Meyer e o Modelo de Regressão de Cox. Para o cálculo da sobrevida do enxerto utilizou-se o método de Kaplan-Meyer e o modelo de Regressão de Riscos Competitivos. Os resultados mostraram que a maioria dos pacientes era homens, adultos de meia idade, com comorbidades prévia, doença hepática moderada ou grave, complicações imediatas e tardias com baixa probabilidade de sobrevida. Quanto a estrutura o Programa atendeu em parte as recomendações para os componentes da estrutura organizacional-física (58,3%), organizacional de recursos humanos (55,6%), estrutural-física para funcionários e alunos (60,0%) e estrutural-física do ambulatório (50,0%). Em relação ao processo de atendimento identificou-se lacunas de documentos e ou diretrizes que norteiam a equipe de saúde no processo de trabalho. No que se refere aos indicadores de resultados, o número de transplantes sofreu alteração devido a fatores extrínsecos e intrínsecos. A maioria dos pacientes permaneceu em lista de espera por até 12 meses. Os pacientes encontravam-se em gravidade moderada a alta e probabilidade de mortalidade de 76%. O tempo de isquemia fria variou de 240 a 970 minutos, média de 499 (±112,0) minutos. A sobrevida do paciente após um, três e cinco anos de transplante foi de 66,4%, 60,4% e 56,5%, respectivamente, e a incidência acumulada para perda do enxerto foi da ordem de 10%. A maioria dos pacientes foi internada ao menos uma vez no primeiro ano após o transplante e os motivos principais foram relacionados a terapia de imunossupressão e as complicações cirúrgicas. Mais da metade (53,6%) dos pacientes estavam em seguimento ambulatorial no Programa e 43,7% evoluíram à óbito. O óbito foi relacionado, em sua maioria, ao choque séptico ou hipovolêmico. Conclui-se que os indicadores encontrados no presente estudo estão, em parte, de acordo com a legislação vigente sobre um Programa de Transplante de Fígado e que os indicadores de resultados precisam ser repensados para o fortalecimento e a consolidação do Programa no hospital estudado / The objective of this study was analyze structure, work process and outcomes of the Liver Transplantation Programme in a teaching hospital in Sao Paulo state\'s interior in 2017. It was analyzed 325 patients\' records which were submitted to liver transplantation from April 2011 to June 2016. Sociodemographic, clinical, treatment, structure, process and outcomes were the variables chosen in this study. Three forms and a field diary were used how strategy to data collection. Qualitative and quantitative data have analyzed using Healthcare Evaluation approach purposed by Donabedian (1980), the Directors\' Collegiate Resolution n. 50/2002 and Ministerial Order n. 356/2014. Kaplan-Meyer method and Cox Regression Model were used to estimate the patient survival rate. Kaplan-Meyer Method and Competing Risks Regression Model were used to calculate the graft survival. Study results showed that most patients were men, mid-aged adults, with previous comorbidities, moderate or severe liver disease, immediate and late complications with survival probability decreased. Regarding structure the Programme reached partially the recommendations of components physical-organizational structure (58.3%), organizational of human resources (55.6%), structural-physical to employers and students (60.0%) and structural-physical of clinic (50.0%). With respect to healthcare process was identified clinicals protocols absences as well as guidelines which should lead the healthcare providers in the working process. Regarding to outcomes indicators, the transplantation numbers suffered changes due intrinsic and extrinsic factors. Most patients remained in waiting list for until 12 months. The patients presented from moderate to high severity and the probability of mortality was 76% for them. The cold ischemic time range was from 240 to 970 minutes, with mean 499 (±112,0) minutes. The patient survival after one, three and five years after transplantation was 66.4%, 60.4%, 56.5%, respectively. The cumulative incidence to loss graft have been 10%. The most patients were hospitalized at least once in the first year after transplantation and the principal causes were related to immunosuppressive therapy and surgical complications. At the end of the study, more than half of patients (53.6%) were in clinical Programme follow-up and 43.7% had died. The most deaths were related with septic or hypovolemic shock. Therefore, is possible conclude that the indicators found in this investigation were, partially, according with Brazilian Current Law recommendations about Liver Transplantation Programs. The outcomes indicators should be rethought to promote strengthening and consolidation of Programme in the Hospital studied

Submitted by Sandra Denise de Oliveira Clinco (sandraclinco@gvmail.br) on 2013-04-01T17:45:41Z No. of bitstreams: 1 Tese Sandra Clinco versao definitiva abril2013.pdf: 419339 bytes, checksum: 257e9c5fd66cef45c69e044ee8335123 (MD5) / Approved for entry into archive by Suzinei Teles Garcia Garcia (suzinei.garcia@fgv.br) on 2013-04-01T17:54:16Z (GMT) No. of bitstreams: 1 Tese Sandra Clinco versao definitiva abril2013.pdf: 419339 bytes, checksum: 257e9c5fd66cef45c69e044ee8335123 (MD5) / Made available in DSpace on 2013-04-01T17:58:01Z (GMT). No. of bitstreams: 1 Tese Sandra Clinco versao definitiva abril2013.pdf: 419339 bytes, checksum: 257e9c5fd66cef45c69e044ee8335123 (MD5) Previous issue date: 2013-02-28 / A participação do paciente no cuidado é uma importante ferramenta para melhoria dos processos em uma organização hospitalar, pois aumenta a segurança do paciente. Este estudo teve como objetivo analisar se o paciente participa de seu cuidado. Esta análise foi feita por meio de entrevistas estruturadas com 243 pacientes internados em quatro hospitais com certificado de qualidade da Grande São Paulo e com a aplicação de questionário com perguntas abertas a três gestores destas organizações. Os resultados demonstram que os pacientes tem alta participação no cuidado, porém 17,3% dos pacientes referem que participaram do cuidado menos do que queriam e 43,6% não sabiam o nome do médico responsável pelo seu tratamento. Os gestores hospitalares reconhecem que a participação do paciente é importante, mas não há ações proativas efetivas nestas organizações hospitalares para identificar as necessidades dos pacientes. / The patient participation in care is an important tool for improving processes in a hospital organization, it increases patient safety. This study aimed to assess if the patient participates in their care. This analysis was done by structured interviews with 243 patients in four hospitals with quality certificate at the greater São Paulo region and with a questionnaire with open questions to three managers of these organizations. The results demonstrate that patients have high participation in care, but 17,3% of patients report that their participated care was less what they wanted and 43,6% did not know the name of the their attending physician. The hospital managers recognize that the participation of the patient is important, but no effective proactive actions were taken in these hospital organizations to identify the patients’ needs.

Introduction : Le cadre de la gouvernance clinique a été développé afin d’atteindre de hauts standards de qualité de soins et de services, en conjuguant les notions d’amélioration continue de la qualité, d’excellence clinique et d’imputabilité corporative. La présente démarche doctorale avait pour objectif de comprendre le processus d’institutionnalisation de la gouvernance clinique dans un centre de réadaptation. Méthodologie : Une synthèse méta-narrative de 65 documents répertoriés dans 4 bases de données bibliographiques sur la conceptualisation et la mise en œuvre de la gouvernance clinique a été menée. Une étude qualitative de cas unique a été menée dans un centre de réadaptation en déficience intellectuelle et en troubles du spectre de l’autisme, au Québec (Canada). En mobilisant les cinq construits du cadre conceptuel basé sur théorie du processus de normalisation (cohérence, participation cognitive, action collective, suivi réflexif et contexte organisationnel), une analyse thématique des entrevues individuelles auprès de 22 participants (5 administrateurs, 11 gestionnaires et 6 cliniciens) et de 3 groupes de discussion auprès de 8 cliniciens et de 4 proches d’usagers a été menée. Enfin, une analyse d’une centaine de documents administratifs du Centre a été effectuée. Résultats : L’analyse de la littérature a permis de constater que le cadre de la gouvernance clinique est un concept en évolution et encore perçu comme une avenue intéressante pour l’amélioration de la qualité des soins. Toutefois, la confusion autour de sa définition et de sa conceptualisation ainsi que les difficultés de sa mise en œuvre demeurent des enjeux pour les organisations. Par la mobilisation du cadre de gouvernance clinique, la haute direction du centre de réadaptation à l’étude a souhaité systématiser le processus d’amélioration continue de la qualité des services offerts aux usagers et à leurs proches par l’adoption des bonnes pratiques de gouvernance. Ce virage a été bien reçu par les administrateurs et les gestionnaires, résultant sur une participation active et un fort engagement aux activités de leur part. La complexité du cadre et l’absence d’implication des cliniciens dans le processus de mise en œuvre ont créé chez ces derniers une appréhension quant à l’apport de la gouvernance clinique pour la pratique clinique et le bien-être des usagers. Les cliniciens ont dénoncé l’absence d’arrimage entre la théorie et les réalités de la pratique clinique ; la grande vitesse d’implantation et une approche décisionnelle de type top-down comme des enjeux de l’institutionnalisation de la gouvernance clinique. Pour les gestionnaires, les défis ont été la mise en place des moyens de communication efficaces ; l’arrimage des mécanismes de gestion et la disponibilité des ressources humaines. Pour les administrateurs, l’enjeu principal a été l’instabilité des contextes organisationnels interne et externe qui a ralenti la mise en œuvre et freiné l’élaboration d’un processus évaluatif. Conclusion : L’institutionnalisation de la gouvernance clinique dans les établissements non hospitaliers offrant des services sociaux passe par la valorisation de ce concept comme un projet commun au bénéfice de l’usager en vue de renforcer la participation et l’engagement de tous et l’adoption d’une approche de partenariat entre les usagers, leurs proches et les autres acteurs de l’organisation. / Introduction: Clinical governance framework was developed in order to achieve high standards of quality of care and services, by combining the concepts of continuous quality improvement, clinical excellence and corporate accountability. The aim of this doctoral thesis was to understand the implementation process of clinical governance in a rehabilitation center. Methods: A meta-narrative synthesis on the conceptualization and implementation of clinical governance was conducted. 65 tittles screened in 4 international databases were analysing. A qualitative single case study was conducted in a rehabilitation center for intellectual disabilities and autism spectrum disorders, in Quebec (Canada). By mobilizing the five constructs of the conceptual framework based on normalization process theory (coherence, cognitive participation, collective action, reflexive monitoring and organizational context), a thematic analysis of individual interviews with 22 participants (5 administrators, 11 managers and 6 clinicians) and tree focus groups with 8 clinicians and 4 relatives of users were conducted. Finally, an analysis of around hundred administrative documents from the Center was conducted. Results: The literature revealed that the clinical governance framework is an evolving concept and still seen as an interesting avenue for improving the quality of care. However, confusion over its definition and conceptualization, and the difficulties of its implementation remain challenges for organizations. By mobilizing the clinical governance framework, the senior management of the rehabilitation center under study wished to systematize the process of continuous improvement of quality of services offered to users and their families, by adopting good governance practices. This shift was well received by administrators and managers, resulting in active participation and a strong commitment to activities. The complexity of the framework and the absence of involvement of clinicians in the implementation process have created in them an apprehension regarding the contribution of clinical governance to clinical practice and the well-being of users. Clinicians have criticized the lack of alignment between theory and the realities of clinical practice; the high speed of implementation and a top-down decision-making approach as issues of the implementation of clinical governance. For managers, the challenges have been the establishment of effective communications; the alignment of management mechanisms and the availability of human resources. For administrators, the main issue was the instability of the internal and external organizational contexts which slowed down the implementation and the development of an evaluation plan. Conclusion: The implementation of clinical governance in non-hospital facility requires the promotion of this concept as a joint project for the benefit of the user with a view to strengthening the participation and commitment of all and the adoption of a partnership approach between users, caregivers and other actors in the organization.