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1.  Perception of anesthesia safety and postoperative symptoms of surgery patients in Ho Chi Minh City, Vietnam: a pioneering trial of postoperative care assessment in a developing nation 
Vietnamese patients’ views on healthcare are changing as surgical interventions become more commonplace, but their views on perioperative care have remained largely unstudied during this period of rapid change. This study assesses Vietnamese patients’ impression of anesthesia safety and postoperative pain in relation to clinical outcomes with the aim of improving patient-centered perioperative care.
The study cohort consisted of 180 hospitalized patients who were followed for 24 h following abdominal surgery. The assessments of these patients on the use of anesthesia and postoperative pain were measured by means of a 5-point Likert scale survey. Perioperative events were recorded on standardized forms by medical staff. The relationship between relevant factors affecting the patients’ perceptions of anesthesia safety, postoperative symptoms, and pain was examined using multiple logistic regression analysis.
The perception of a low level of anesthesia safety by 105 patients (59%) was associated with a low satisfaction in terms of preoperative anesthesia education [odds ratio (OR) 15.03], poor interaction with family (OR 21.80), and absence of perioperative adverse effects (OR 6.10). The occurrence of three or more postoperative symptoms (59%) was associated with a surgery ≥3 h (OR 2.00). Severe pain at 2 h (25%) post-surgery was associated with male gender (OR 2.08) and open surgery (OR 3.30), no reduction in pain at 24 h (51%) was associated with female gender (OR 2.08), and experiencing as much or more pain than expected (46%) was associated with blood loss ≥100 ml (OR 1.04) and low satisfaction with staff communication (OR 1.90).
Our results suggest that facilitating patients’ communication with staff and families and paying attention to gender differences in pain management are important factors to take into consideration when the aim is to improve perioperative care in the rapidly developing healthcare environment of Vietnam.
PMCID: PMC2955904  PMID: 21432564
Anesthesia safety; Patient satisfaction; Postoperative pain
2.  Development of a Safety Net Medical Home Scale for Clinics 
Journal of General Internal Medicine  2011;26(12):1418-1425.
Existing tools to measure patient-centered medical home (PCMH) adoption are not designed for research evaluation in safety-net clinics.
Develop a scale to measure PCMH adoption in safety-net clinics.
Research Design
Cross-sectional survey.
Sixty-five clinics in five states.
Main Measures
Fifty-two-item Safety Net Medical Home Scale (SNMHS). The total score ranges from 0 (worst) to 100 (best) and is an average of multiple subscales (0–100): Access and Communication, Patient Tracking and Registry, Care Management, Test and Referral Tracking, Quality Improvement, and External Coordination. The scale was tested for internal consistency reliability and tested for convergent validity using The Assessment of Chronic Illness Care (ACIC) and the Patient-Centered Medical Home Assessment (PCMH-A). The scale was applied to centers in the sample. In addition, linear regression models were used to measure the association between clinic characteristics and medical home adoption.
The SNMHS had high internal consistency reliability (Cronbach’s alpha = 0.84). The SNMHS score correlated moderately with the ACIC score (r = 0.64, p < 0.0001) and the PCMH-A (r = 0.56, p < 0.001). The mean SNMHS score was 61 ± SD 13. Among the subscales, External Coordination (66 ± 16) and Access and Communication (65 ± 14) had the highest mean scores, while Quality Improvement (55 ± 17) and Care Management (55 ± 16) had lower mean scores. Clinic characteristics positively associated with total SNMHS score were having more providers (β 15.8 95% CI 8.1–23.4 >8 provider FTEs compared to <4 FTEs) and participation in financial incentive programs (β 8.4 95% 1.6–15.3).
The SNMHS demonstrated reliability and convergent validity for measuring PCMH adoption in safety-net clinics. Some clinics have significant PCMH adoption. However, room for improvement exists in most domains, especially for clinics with fewer providers.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1767-9) contains supplementary material, which is available to authorized users.
PMCID: PMC3235610  PMID: 21837377
medical home; community health center; access to care; quality of care
3.  Availability of Safety Net Providers and Access to Care of Uninsured Persons 
Health Services Research  2004;39(5):1527-1546.
To understand how proximity to safety net clinics and hospitals affects a variety of measures of access to care and service use by uninsured persons.
Data Sources
The 1998–1999 Community Tracking Study household survey, administered primarily by telephone survey to households in 60 randomly selected communities, linked to data on community health centers, other free clinics, and safety net hospitals.
Study Design
Instrumental variable estimation of multivariate regression models of several measures of access to care (having a usual source of care, unmet or delayed medical care needs, ambulatory service use, and overnight hospital stays) against endogenous measures of distances to the nearest community health center and safety net hospital, controlling for characteristics of uninsured persons and other area characteristics that are related to access to care. The models are estimated with data from a nationally representative sample of uninsured people.
Principal Findings
Shorter distances to the nearest safety net providers increase access to care for uninsured persons. Failure to account for the endogeneity of distance to safety net providers on access to care generally leads to finding little or no safety net effects on access.
Closer proximity to the safety net increases access to care for uninsured persons. However, the improvements in access to care are relatively small compared with similar measures of access to care for insured persons. Modest expansion of the safety net is unlikely to provide a full substitute for insurance coverage expansions.
PMCID: PMC1361082  PMID: 15333121
Safety net; community health centers; access to care; uninsured
4.  Error, stress, and teamwork in medicine and aviation: cross sectional surveys 
BMJ : British Medical Journal  2000;320(7237):745-749.
To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew.
Cross sectional surveys.
Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world.
1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers).
Main outcome measures:
Perceptions of error, stress, and teamwork.
Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes.
Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
PMCID: PMC27316  PMID: 10720356
5.  Holes in the Safety Net: A Case Study of Access to Prescription Drugs and Specialty Care 
The health care safety net in the United States is intended to fill gaps in health care services for uninsured and other vulnerable populations. This paper presents a case study of New Brunswick, NJ, a small city rich in safety net resources, to examine the adequacy of the American model of safety net care. We find substantial gaps in access to care despite the presence of a medical school, an abundance of primary care and specialty physicians, two major teaching hospitals, a large federally qualified health center and other safety net resources in this community of about 50,000 residents. Using a blend of random-digit-dial and area probability sampling, a survey of 595 households was conducted in 2001 generating detailed information about the health, access to care, demographic and other characteristics of 1,572 individuals. Confirming the great depth of the New Brunswick health care safety net, the survey showed that more than one quarter of local residents reported a hospital or community clinic as their usual source of care. Still, barriers to prescription drugs were reported for 11.0% of the area population and more than two in five (42.8%) local residents who perceived a need for specialty care reported difficulty getting those services. Bivariate analyses show significantly elevated risk of access problems among Hispanic and black residents, those in poor health, those relying on hospital and community clinics or with no usual source of care, and those living at or below poverty. In multivariate analysis, lack of health insurance was the greatest risk factor associated with both prescription drug and specialty access problems. Few local areas can claim the depth of safety net resources as New Brunswick, NJ, raising serious concerns about the adequacy of the American safety net model, especially for people with complex and chronic health care needs.
PMCID: PMC2443252  PMID: 18437581
Access to care; Specialty care; Prescription drugs; Health care safety net.
6.  Hospital Safety Culture in Taiwan: A Nationwide Survey Using Chinese Version Safety Attitude Questionnaire 
Safety activities have been initiated at many hospitals in Taiwan, but little is known about the safety culture at these hospitals. The aims of this study were to verify a safety culture survey instrument in Chinese and to assess hospital safety culture in Taiwan.
The Taiwan Patient Safety Culture Survey was conducted in 2008, using the adapted Safety Attitude Questionnaire in Chinese (SAQ-C). Hospitals and their healthcare workers participated in the survey on a voluntary basis. The psychometric properties of the five SAQ-C dimensions were examined, including teamwork climate, safety climate, job satisfaction, perception of management, and working conditions. Additional safety measures were asked to assess healthcare workers' attitudes toward their collaboration with nurses, physicians, and pharmacists, respectively, and perceptions of hospitals' encouragement of safety reporting, safety training, and delivery delays due to communication breakdowns in clinical areas. The associations between the respondents' attitudes to each SAQ-C dimension and safety measures were analyzed by generalized estimating equations, adjusting for the clustering effects at hospital levels.
A total of 45,242 valid questionnaires were returned from 200 hospitals with a mean response rate of 69.4%. The Cronbach's alpha was 0.792 for teamwork climate, 0.816 for safety climate, 0.912 for job satisfaction, 0.874 for perception of management, and 0.785 for working conditions. Confirmatory factor analyses demonstrated a good model fit for each dimension and the entire construct. The percentage of hospital healthcare workers holding positive attitude was 48.9% for teamwork climate, 45.2% for perception of management, 42.1% for job satisfaction, 37.2% for safety climate, and 31.8% for working conditions. There were wide variations in the range of SAQ-C scores in each dimension among hospitals. Compared to those without positive attitudes, healthcare workers with positive attitudes to each SAQ dimension were more likely to perceive good collaboration with coworkers, and their hospitals were more likely to encourage safety reporting and to prioritize safety training programs (Wald chi-square test, p < 0.001 for all).
Analytical results verified the psychometric properties of the SAQ-C at Taiwanese hospitals. The safety culture at most hospitals has not fully developed and there is considerable room for improvement.
PMCID: PMC2924859  PMID: 20698965
7.  The Resilience of the Health Care Safety Net, 1996–2001 
Health Services Research  2003;38(1 Pt 2):489-502.
To determine how the capacity and viability of local health care safety nets changed over the last six years and to draw lessons from these changes.
Data Source
The first three rounds (May 1996 to March 2001) of Community Tracking Study site visits to 12 communities.
Study Design
Researchers visited the study communities every two years to interview leaders of local health care systems about changes in the organization, delivery, and financing of health care and the impact of these changes on people. For this analysis, we collected data on safety net capacity and viability through interviews with public and not-for-profit hospitals, community health centers, health departments, government officials, consumer advocates, academics, and others. We asked about the effects of market and policy changes on the safety net and how the safety net responded, as well as the impact of these changes on care for the low-income uninsured.
Principal Findings
The safety net in three-quarters of the communities was stable or improved by the end of the study period, leading to improved access to primary and preventive care for the low-income uninsured. Policy responses to pressures such as the Balanced Budget Act and Medicaid managed care, along with effective safety net strategies and supportive conditions, helped reinforce the safety net. However, the safety net in three sites deteriorated and access to specialty services remained inadequate across the 12 sites.
Despite pessimistic predictions and some notable exceptions, the health care safety net grew stronger over the past six years. Given considerable community variation, however, this analysis indicates that policymakers can apply a number of lessons from strong and improving safety nets to strengthen those that are weaker, particularly as the current economy poses new challenges.
PMCID: PMC1360896  PMID: 12650377
Safety net; low-income uninsured; charity care; uncompensated care; indigent care
8.  Access, Interest, and Attitudes Toward Electronic Communication for Health Care Among Patients in the Medical Safety Net 
Electronic and internet-based tools for patient–provider communication are becoming the standard of care, but disparities exist in their adoption among patients. The reasons for these disparities are unclear, and few studies have looked at the potential communication technologies have to benefit vulnerable patient populations.
To characterize access to, interest in, and attitudes toward internet-based communication in an ethnically, economically, and linguistically diverse group of patients from a large urban safety net clinic network.
Observational, cross-sectional study
Adult patients (≥ 18 years) in six resource-limited community clinics in the San Francisco Department of Public Health (SFDPH)
Current email use, interest in communicating electronically with health care professionals, barriers to and facilitators of electronic health-related communication, and demographic data—all self-reported via survey.
Sixty percent of patients used email, 71 % were interested in using electronic communication with health care providers, and 19 % reported currently using email informally with these providers for health care. Those already using any email were more likely to express interest in using it for health matters. Most patients agreed electronic communication would improve clinic efficiency and overall communication with clinicians.
A significant majority of safety net patients currently use email, text messaging, and the internet, and they expressed an interest in using these tools for electronic communication with their medical providers. This interest is currently unmet within safety net clinics that do not offer a patient portal or secure messaging. Tools such as email encounters and electronic patient portals should be implemented and supported to a greater extent in resource-poor settings, but this will require tailoring these tools to patients’ language, literacy level, and experience with communication technology.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2329-5) contains supplementary material, which is available to authorized users.
PMCID: PMC3682038  PMID: 23423453
health information technology; disparities; clinical communication; electronic patient portal
9.  The complexity of team training: what we have learned from aviation and its applications to medicine 
Quality & safety in health care  2004;13(Suppl 1):i72-i79.
Errors in health care that compromise patient safety are tied to latent failures in the structure and function of systems. Teams of people perform most care delivered today, yet training often remains focused on individual responsibilities. Training programmes for all healthcare workers need to increase the educational experience of working in interdisciplinary teams. The complexities of team training require a multifunctional (systems) approach, which crosses organisational divisions to allow communication, accountability, and creation and maintenance of interdisciplinary teams. This report identifies challenges for medical education in performing the research, identifying performance measurements, and modifying educational curricula for the advancement of interdisciplinary teams, based on the complexity of team training identified in commercial aviation.
PMCID: PMC1765797  PMID: 15465959
10.  Patient-Centered Medical Home Characteristics and Staff Morale in Safety Net Clinics 
Archives of internal medicine  2012;172(1):23-31.
We sought to determine whether perceived patient-centered medical home (PCMH) characteristics are associated with staff morale, job satisfaction, and burnout in safety net clinics.
Self-administered survey among 391 providers and 382 clinical staff across 65 safety net clinics in 5 states in 2010. The following 5 subscales measured respondents’ perceptions of PCMH characteristics on a scale of 0 to 100 (0 indicates worst and 100 indicates best): access to care and communication with patients, communication with other providers, tracking data, care management, and quality improvement. The PCMH sub-scale scores were averaged to create a total PCMH score.
Six hundred three persons (78.0%) responded. In multivariate generalized estimating equation models, a 10% increase in the quality improvement subscale score was associated with higher morale (provider odds ratio [OR], 2.64; 95% CI, 1.47–4.75; staff OR, 3.62; 95% CI, 1.84–7.09), greater job satisfaction (provider OR, 2.45; 95% CI, 1.42–4.23; staff OR, 2.55; 95% CI 1.42–4.57), and freedom from burnout (staff OR, 2.32; 95% CI, 1.31–4.12). The total PCMH score was associated with higher staff morale (OR, 2.63; 95% CI, 1.47–4.71) and with lower provider freedom from burnout (OR, 0.48; 95% CI, 0.30–0.77). A separate work environment covariate correlated highly with the quality improvement subscale score and the total PCMH score, and PCMH characteristics had attenuated associations with morale and job satisfaction when included in models.
Providers and staff who perceived more PCMH characteristics in their clinics were more likely to have higher morale, but the providers had less freedom from burnout. Among the PCMH subscales, the quality improvement subscale score particularly correlated with higher morale, greater job satisfaction, and freedom from burnout.
PMCID: PMC3752653  PMID: 22232143
11.  Mortality and Readmission at Safety Net and Non-Safety Net Hospitals for Three Common Medical Conditions 
Health affairs (Project Hope)  2012;31(8):1739-1748.
Safety net hospitals remain under financial strain, possibly affecting quality of care, and face uncertain financial consequences under the Patient Protection and Affordable Care Act. We compared risk-standardized mortality and readmission rates among fee-for-service Medicare beneficiaries admitted for acute myocardial infarction, heart failure, or pneumonia to urban hospitals within metropolitan statistical areas containing at least one safety net and non-safety net hospital. There was substantial variation in both mortality and readmission rates among safety-net and non-safety net hospitals for all three conditions, although safety-net hospitals had marginally worse outcomes. Herein we discuss the clinical and policy implications of these findings.
PMCID: PMC3527010  PMID: 22869652
Safety net hospitals; Vulnerable Populations; Quality of Care
12.  Where health and welfare meet: Social deprivation among patients in the emergency department 
As a safety net provider for many disadvantaged Americans, the emergency department (ED) may be an efficient site not only for providing acute medical care, but also for addressing serious social needs.
To characterize the social needs of ED patients, and to evaluate whether the most disadvantaged patients have connections with the health and welfare system outside the ED.
Cross-sectional survey conducted over 24 hours in the fall of 1997.
Three EDs: an urban public teaching hospital, a suburban university hospital, and a semirural community hospital.
Consecutive patients presenting for care, including those transported by ambulance. The survey response rate was 91% (N=300; urban=115, suburban=102, rural=83).
Main Outcome Measure
Index of socioeconomic deprivation described by the US Census Bureau (based on food, housing, and utilities).
Of all ED patients, 31% reported one or more serious social deprivations. For example, 13% of urban patients reported not having enough food to eat, and 9% of rural patients reported disconnection of their gas or electricity (US population averages both less than 3%). While 40% of all patients had no consistent health care outside the ED (≤1 visit/year), those with higher levels of social deprivation had the least contact with the health care system outside the ED (P<.01). Although those with higher levels of deprivation were more likely to receive public assistance, still almost one-quarter of patients with high-level social deprivation were not receiving public aid.
Many ED patients suffer from fundamental social deprivations that threaten basic health. The most disadvantaged of these patients frequently lack contact with other medical care sites or public assistance networks. Community efforts to address serious social deprivation should include partnerships with the local ED.
PMCID: PMC3456193  PMID: 11368190
13.  Adverse events analysis as an educational tool to improve patient safety culture in primary care: A randomized trial 
BMC Family Practice  2011;12:50.
Patient safety is a leading item on the policy agenda of both major international health organizations and advanced countries generally. The quantitative description of the phenomena has given rise to intense concern with the issue in institutions and organizations, leading to a number of initiatives and research projects and the promotion of patient safety culture, with training becoming a priority both in Spain and internationally. To date, most studies have been conducted in a hospital setting, even though primary care is the type most commonly used by the public, in our experience.
Our study aims to achieve the following:
- Assess the registry of adverse events as an education tool to improve patient safety culture in the Family and Community Teaching Units of Galicia.
- Find and analyze educational tools to improve patient safety culture in primary care.
- Evaluate the applicability of the Hospital Survey on Patient Safety Culture by the Agency for Healthcare Research and Quality, Spanish version, in the context of primary health care.
Design and methods
Experimental unifactorial study of two groups, control and intervention.
Study population
Tutors and residents in Family and Community Medicine in last year of studies in Galicia, Spain.
From the population universe through voluntary participation. Twenty-seven tutor-resident units in each group required, randomly assigned.
Residents and their respective tutor (tutor-resident pair) in teaching units on Family and Community Medicine from throughout Galicia will be invited to participate. Tutor-resident pair that agrees to participate will be sent the Hospital Survey on Patient Safety Culture. Then, tutor-resident pair will be assigned to each group-either intervention or control-through simple random sampling. The intervention group will receive specific training to record the adverse effects found in patients under their care, with subsequent feedback, after receiving instruction on the process. No action will be taken in the control group. After the intervention has ended, the survey will once again be provided to all participants.
Outcome measures
Change in safety culture as measured by Hospital Survey on Patient Safety Culture
CONSORT Extension for Non-Pharmacologic Treatments 2008 was applied.
The most significant limitations on the project are related to selecting a tool to measure the safety environment, the training calendar of residents in Family and Community Medicine in last year of studies and the no-answer bias inherent to research conducted through self-administered surveys.
The development and application of a safety culture in the health sector, specifically in primary care, is as yet limited. Thus, identifying the strengths and weaknesses in the safety environment may assist in designing strategies for improvement in the primary care health centers of our region.
Trial registration
PMCID: PMC3142500  PMID: 21672197
14.  Evaluation of deficiencies in current discharge summaries for dialysis patients in Canada 
Deficits in the transfer of information between inpatient and outpatient physicians are common and pose a patient safety risk. This is particularly the case for vulnerable populations such as patients with end-stage renal disease requiring dialysis. These patients have unique and complex health care needs that may not be effectively communicated on standard discharge summaries, which may result in potential medical errors and adverse events.
To evaluate Canadian dialysis center directors’ perceptions of deficiencies in the content and quality of hospital discharge summaries for dialysis patients.
A web-based, cross-sectional survey of Canadian dialysis center directors was performed between September and November 2010. The survey consisted of three parts. The first part was designed to assess dialysis center directors’ attitudes on the quality of discharge summaries they receive. The second part was designed to elicit respondents’ preferences for discharge summary content, and the third part consisted of questions regarding demographic and practice information.
Of 79 dialysis center directors, 21 (27%) completed the survey. Sixty-two percent felt that current discharge summaries inadequately communicate dialysis-specific information. Receipt of antibiotics for line sepsis or peritonitis, modifications to vascular access, and changes in target weight/dialysis prescription were rated as essential dialysis-specific information to include in discharge summaries by respondents.
Over three quarters of dialysis center directors find the current practice of transferring discharge information for hospitalized dialysis patients grossly inadequate. The inclusion of dialysis-specific information may improve the quality of discharge summaries for dialysis patients.
PMCID: PMC3333802  PMID: 22536078
information transfer; dialysis patients; discharge information
15.  Improving transitions in inpatient and outpatient care using a paper or web-based journal 
JRSM Short Reports  2011;2(2):6.
To develop a ‘Transitions Journal’ for inter-unit and inter-setting communication for improving quality and safety of care and patient satisfaction with timely, reliable and meaningful information for all stakeholders.
Front-line staff were targeted in a series of four team meetings through which this ‘Journal’ was developed iteratively; initially as a paper-based and subsequently as an IT-based tool. Goals were to: (1) develop a standardized tool based on SBAR format (Situation, Background, Assessment, Recommendation); (2) facilitate improved communication at the points of care; (3) use a bottom-up approach; (4) create situational awareness and facilitate team formation; and (5) create visual workflow models to help inculcate a culture of safety.
A 183-bed community-hospital and its Primary Care Center, in an urban area in western New York State.
Ten nurses and 12 physicians representing both the hospital and primary care center participated voluntarily.
Main outcome measures
(1) Successful development of the ‘Transitions Journal’; and (2) identification of its potential uses.
(1) Development: the journal was successfully developed in both paper and web-based formats; (2) identification of uses: participants recommended using the tool as a checklist to verify appropriate communication at both the sending and receiving ends; as an audit tool for retrospective review of handoffs; and as a teaching tool.
A journal developed by and for front-line staff has the potential to provide opportunities for improvement, instill a systems approach, improve care continuity, improve compliance with safety goals, improve patient and staff satisfaction, reduce duplication and costs, inculcate teamwork, and provide mutual emotional and intellectual support. Further work to evaluate and disseminate this tool is in progress.
PMCID: PMC3046565  PMID: 21369524
16.  A Survey of North Carolina safety-net dental clinics’ methods for communicating with patients of limited English proficiency (LEP) 
Dental providers are increasingly challenged in communicating with limited English proficiency (LEP) patients. Accordingly, the study’s purpose was to examine methods of communicating with LEP patients in North Carolina (NC) safety-net dental clinics as perceived by dental staff.
An anonymous, 36-item, cross-sectional survey was distributed to representatives of 68 NC safety-net dental clinics. Question domains included: 1) perceived need for language services, 2) methods of language services provided, 2) perceptions of dental staff about dental care experiences for LEP patients, and 4) perceived legal and financial roles in providing language services.
Fifty-five (55) of the 68 clinics responded (81%). All clinics reported treating LEP patients, and 93% of clinics reported a need for providing language services. Many clinics used multiple methods to provide language services. Some clinics reported differences in treatment recommendations (13%), treatment provided (19%), and visit length (61%) for LEP patients. All responded that additional costs are incurred to treat LEP patients, and only 69% of responding clinics recognized legal obligations of treating LEP patients.
There is a reported need for language services in NC safety-net dental clinics. These services often resulted in additional cost to the dental clinic. To maintain the quality of care and to comply with legal requirements related to LEP dental patients, additional funding sources may be required to recruit multi-lingual staff, support language services in dental clinics, and provide language skills training for practicing dentists. Additionally, studies are suggested to measure LEP patient perception of the effectiveness of communication methods.
PMCID: PMC2862257  PMID: 19054313
Access-to-care; Language; Translating; Dental Clinics; Limited English Proficiency; Cultural Competency; Communication Barriers; North Carolina; Public Health
17.  An Educational Intervention to Enhance Nurse Leaders' Perceptions of Patient Safety Culture 
Health Services Research  2005;40(4):997-1020.
To design a training intervention and then test its effect on nurse leaders' perceptions of patient safety culture.
Study Setting
Three hundred and fifty-six nurses in clinical leadership roles (nurse managers and educators/CNSs) in two Canadian multi-site teaching hospitals (study and control).
Study Design
A prospective evaluation of a patient safety training intervention using a quasi-experimental untreated control group design with pretest and posttest. Nurses in clinical leadership roles in the study group were invited to participate in two patient safety workshops over a 6-month period. Individuals in the study and control groups completed surveys measuring patient safety culture and leadership for improvement prior to training and 4 months following the second workshop.
Extraction Methods
Individual nurse clinical leaders were the unit of analysis. Exploratory factor analysis of the safety culture items was conducted; repeated-measures analysis of variance and paired t-tests were used to evaluate the effect of the training intervention on perceived safety culture (three factors). Hierarchical regression analyses looked at the influence of demographics, leadership for improvement, and the training intervention on nurse leaders' perceptions of safety culture.
Principal Findings
A statistically significant improvement in one of three safety culture measures was shown for the study group (p<.001) and a significant decline was seen on one of the safety culture measures for the control group (p<.05). Leadership support for improvement was found to explain significant amounts of variance in all three patient safety culture measures; workshop attendance explained significant amounts of variance in one of the three safety culture measures. The total R2 for the three full hierarchical regression models ranged from 0.338 and 0.554.
Sensitively delivered training initiatives for nurse leaders can help to foster a safety culture. Organizational leadership support for improvement is, however, also critical for fostering a culture of safety. Together, training interventions and leadership support may have the most significant impact on patient safety culture.
PMCID: PMC1361187  PMID: 16033489
Patient safety; safety culture; leadership; training intervention
18.  Medicare payments for common inpatient procedures: Implications for episode-based payment bundling 
Health services research  2010;45(6 Pt 1):1783-1795.
Aiming to align provider incentives toward improving quality and efficiency, the Center for Medicare and Medicaid Services is considering broader bundling of hospital and physician payments around episodes of inpatient surgery. Decisions about bundled payments would benefit from better information about how payments are currently distributed among providers of different perioperative services and how payments vary across hospitals.
Study design
Using the national Medicare database, we identified patients undergoing one of 4 inpatient procedures in 2005 (coronary artery bypass, hip fracture repair, back surgery, and colectomy). For each procedure, price-standardized Medicare payments from the date of admission for the index procedure to 30 days post discharge were assessed and categorized by payment type (hospital, physician, and post-acute care) and sub-type.
Average total payments for inpatient surgery episodes varied from $26,515 for back surgery to $45,358 for CABG. Hospital payments accounted for the largest share of total payments (60-80%, depending on procedure), followed by physician payments (13-19%) and post-acute care (7-27%). Overall episode payments for hospitals in the lowest and highest payment quartiles differed by $16,668 for CABG, $18,762 for back surgery, $10,615 for hip fracture repair, and $12,988 for colectomy. Payments to hospitals accounted for the largest share of variation in payments. Among specific types of payments, those associated with 30-day readmissions, and post-acute care varied most substantially across hospitals.
Fully bundled payments for inpatient surgical episodes would need to be dispersed among many different types of providers. Hospital payments—both overall and for specific services—vary considerably and might be reduced by incentives for hospitals and physicians to improve quality and efficiency.
PMCID: PMC3026958  PMID: 20698899
19.  Medicare Payments for Common Inpatient Procedures: Implications for Episode-Based Payment Bundling 
Health Services Research  2010;45(6 Pt 1):1783-1795.
Aiming to align provider incentives toward improving quality and efficiency, the Center for Medicare and Medicaid Services is considering broader bundling of hospital and physician payments around episodes of inpatient surgery. Decisions about bundled payments would benefit from better information about how payments are currently distributed among providers of different perioperative services and how payments vary across hospitals.
Study Design
Using the national Medicare database, we identified patients undergoing one of four inpatient procedures in 2005 (coronary artery bypass [CABG], hip fracture repair, back surgery, and colectomy). For each procedure, price-standardized Medicare payments from the date of admission for the index procedure to 30 days postdischarge were assessed and categorized by payment type (hospital, physician, and postacute care) and subtype.
Average total payments for inpatient surgery episodes varied from U.S.$26,515 for back surgery to U.S.$45,358 for CABG. Hospital payments accounted for the largest share of total payments (60–80 percent, depending on procedure), followed by physician payments (13–19 percent) and postacute care (7–27 percent). Overall episode payments for hospitals in the lowest and highest payment quartiles differed by U.S.$16,668 for CABG, U.S.$18,762 for back surgery, U.S.$10,615 for hip fracture repair, and U.S.$12,988 for colectomy. Payments to hospitals accounted for the largest share of variation in payments. Among specific types of payments, those associated with 30-day readmissions and postacute care varied most substantially across hospitals.
Fully bundled payments for inpatient surgical episodes would need to be dispersed among many different types of providers. Hospital payments—both overall and for specific services—vary considerably and might be reduced by incentives for hospitals and physicians to improve quality and efficiency.
PMCID: PMC3026958  PMID: 20698899
Surgery; Medicare; bundled payments
20.  US Cancer Center Implementation of ASCO/Oncology Nursing Society Chemotherapy Administration Safety Standards 
Given wide variation in the implementation of ASCO/Oncology Nursing Society chemotherapy administration safety standards at US cancer centers, there are significant opportunities for improvement.
Because cancer chemotherapy is a high-risk intervention, ASCO and the Oncology Nursing Society (ONS) established in 2009 consensus- and evidence-based national standards for the safe administration of chemotherapy. We sought to assess the implementation status of the ASCO/ONS chemotherapy administration safety standards.
A written survey of chemotherapy practices was sent to National Cancer Institute–designated cancer centers. Implementation status of each of 31 chemotherapy administration safety standards was self-reported.
Forty-four (80%) of 55 eligible centers responded. Although the majority of centers have fully implemented at least half of the standards, only four centers reported full implementation of all 31. Implementation varied by standard, with the poorest implementation of standards that addressed documentation of chemotherapy planning, agreed-on intervals for laboratory testing, and patient education and consent before initiation of oral or infusional chemotherapy.
Given wide variation in the implementation of ASCO/ONS chemotherapy administration safety standards at US cancer centers, there are significant opportunities for improvement.
PMCID: PMC3266320  PMID: 22548004
21.  Asan Medical Information System for Healthcare Quality Improvement 
Healthcare Informatics Research  2010;16(3):191-197.
This purpose of this paper is to introduce the status of the Asan Medical Center (AMC) medical information system with respect to healthcare quality improvement.
Asan Medical Information System (AMIS) is projected to become a completely electronic and digital information hospital. AMIS has played a role in improving the health care quality based on the following measures: safety, effectiveness, patient-centeredness, timeliness, efficiency, privacy, and security.
AMIS consisted of several distinctive systems: order communication system, electronic medical record, picture archiving communication system, clinical research information system, data warehouse, enterprise resource planning, IT service management system, and disaster recovery system. The most distinctive features of AMIS were the high alert-medication recognition & management system, the integrated and severity stratified alert system, the integrated patient monitoring system, the perioperative diabetic care monitoring and support system, and the clinical indicator management system.
AMIS provides IT services for AMC, 7 affiliated hospitals and over 5,000 partners clinics, and was developed to improve healthcare services. The current challenge of AMIS is standard and interoperability. A global health IT strategy is needed to get through the current challenges and to provide new services as needed.
PMCID: PMC3089858  PMID: 21818439
Hospital Information Systems; Quality of Health Care; Clinical Decision Support Systems; Electronic Medical Record
22.  Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center 
Quality & safety in health care  2003;12(6):405-410.
Background: Despite the emphasis on patient safety in health care, few organizations have evaluated the extent to which safety is a strategic priority or their culture supports patient safety. In response to the Institute of Medicine's report and to an organizational commitment to patient safety, we conducted a systematic assessment of safety at the Johns Hopkins Hospital (JHH) and, from this, developed a strategic plan to improve safety. The specific aims of this study were to evaluate the extent to which the culture supports patient safety at JHH and the extent to which safety is a strategic priority.
Methods: During July and August 2001 we implemented two surveys in disparate populations to assess patient safety. The Safety Climate Scale (SCS) was administered to a sample of physicians, nurses, pharmacists, and other ICU staff. SCS assesses perceptions of a strong and proactive organizational commitment to patient safety. The second survey instrument, called Strategies for Leadership (SLS), evaluated the extent to which safety was a strategic priority for the organization. This survey was administered to clinical and administrative leaders.
Results: We received 395 completed SCS surveys from 82% of the departments and 86% of the nursing units. Staff perceived that supervisors had a greater commitment to safety than senior leaders. Nurses had higher scores than physicians for perceptions of safety. Twenty three completed SLS surveys were received from 77% of the JHH Patient Safety Committee members and 50% of the JHH Management Committee members. Management Committee responses were more positive than Patient Safety Committee, indicating that management perceived safety efforts to be further developed. Strategic planning received the lowest scores from both committees.
Conclusions: We believe this is one of the first large scale efforts to measure institutional culture of safety and then design improvements in health care. The survey results suggest that strategic planning of patient safety needs enhancement. Several efforts to improve our culture of safety were initiated based on these results, which should lead to measurable improvements in patient safety.
PMCID: PMC1758025  PMID: 14645754
23.  Understanding diagnostic errors in medicine: a lesson from aviation 
Quality & Safety in Health Care  2006;15(3):159-164.
The impact of diagnostic errors on patient safety in medicine is increasingly being recognized. Despite the current progress in patient safety research, the understanding of such errors and how to prevent them is inadequate. Preliminary research suggests that diagnostic errors have both cognitive and systems origins. Situational awareness is a model that is primarily used in aviation human factors research that can encompass both the cognitive and the systems roots of such errors. This conceptual model offers a unique perspective in the study of diagnostic errors. The applicability of this model is illustrated by the analysis of a patient whose diagnosis of spinal cord compression was substantially delayed. We suggest how the application of this framework could lead to potential areas of intervention and outline some areas of future research. It is possible that the use of such a model in medicine could help reduce errors in diagnosis and lead to significant improvements in patient care. Further research is needed, including the measurement of situational awareness and correlation with health outcomes.
PMCID: PMC2464840  PMID: 16751463
diagnostic errors; situational awareness; aviation; human factors; decision making
24.  The actual development of European Aviation Safety Requirements in Aviation Medicine: Prospects of Future EASA Requirements 
Hippokratia  2009;13(2):106-109.
Common Rules for Aviation Safety had been developed under the aegis of the Joint Aviation Authorities in the 1990ies. In 2002 the Basic Regulation 1592/2002 was the founding document of a new entity, the European Aviation Safety Agency. Areas of activity were Certification and Maintenance of aircraft. On 18 March the new Basic Regulation 216/2008, repealing the original Basic Regulation was published and applicable from 08 April on. The included Essential Requirements extended the competencies of EASA inter alia to Pilot Licensing and Flight Operations. The future aeromedical requirements will be included as Annex II in another Implementing Regulation on Personnel Licensing. The detailed provisions will be published as guidance material. The proposals for these provisions have been published on 05 June 2008 as NPA 2008- 17c. After public consultation, processing of comments and final adoption the new proposals may be applicable form the second half of 2009 on. A transition period of four year will apply. Whereas the provisions are based on Joint Awiation Requirement - Flight Crew Licensing (JAR-FCL) 3, a new Light Aircraft Pilot Licence (LAPL) project and the details of the associated medical certification regarding general practitioners will be something new in aviation medicine.
This paper consists of 6 sections. The introduction outlines the idea of international aviation safety. The second section describes the development of the Joint Aviation Authorities (JAA), the first step to common rules for aviation safety in Europe. The third section encompasses a major change as next step: the foundation of the European Aviation Safety Agency (EASA) and the development of its rules. In the following section provides an outline of the new medical requirements. Section five emphasizes the new concept of a Leisure Pilot Licence. The last section gives an outlook on ongoing rulemaking activities and the opportunities of the public to participate in them.
PMCID: PMC2683453  PMID: 19561781
Aviation Safety Medical Requirements; JAA EASA; Basic Regulation Leisure Pilot Licence
25.  Patient experience of care in the safety net: Current efforts and challenges 
Measuring the patient’s experience of care (PEC) fosters the delivery of patient-centered services and increases health care quality. Most pay-for-performance and public reporting programs focus on care provided to insured populations, excluding the uninsured. Using qualitative research methods, we interviewed leaders of California safety-net practices to assess how they measure PEC and the measurement barriers they encounter. Most had unmet needs for assistance with data collection and quality improvement strategies for their patient population. Tailored measurement and quality improvement resources, coupled with policy mandates to give all patients a voice, would improve the quality of patient-centered care in safety-net organizations.
PMCID: PMC3670776  PMID: 22415288
Safety-net; primary care; patient experience of care; quality of care; quality improvement

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