Improving Patient Mortality Rates: The Impact of Front-line Staff Collaboration on Quality of Care

1. Improving Patient Mortality Rates: The Impact of Front-line Staff Collaboration on Quality of Care Ingrid Nembhard, Yale Anita Tucker, Harvard Richard Bohmer, Harvard Joseph Carpenter, VON Jeffrey Horbar, VON Financial Support from HBS Division of Research, Wharton’s Fishman Davidson Center, Sloan Industry Studies Fellowship

2. Why focus on front-line staff? • Front-line staff: • Staff directly responsible for providing service to customers (physicians, nurses, etc.) • Arguably, organizations’ most valuable asset: • Achieving organizational goals requires their efforts • They are experts in real-time problem-solving • Their first-hand knowledge of successes and failures that can inform performance improvement • Unfortunately, many barriers to leveraging front-line knowledge

3. An IOM call for front-line staff engagement “HCOs [Health Care Organizations] should . . . • employ management structure and processes . . . that . . . engage workers in nonhierarchical decision makingand in the design of work processes and work flow” (IOM, 2004, Rec. 4-3) Collaborate in unit management • take action to support interdisciplinary collaboration by adopting such interdisciplinary practice mechanisms as interdisciplinary rounds”(Rec. 5-6) Collaborate in patient care • directly involve direct-care nurses throughout all phases of the work design and should concentrate on [preventing] errors” (Rec. 6-2) Collaborate in process improvement

4. Collaboration • Definition: Individuals working together to achieve a common goal via • Information-sharing • Joint decision-making • Coordination of activities (Baggs et al, 1999)

5. Research Question What is the impact of different types of collaboration on performance, as measured by patient mortality? Hypothesis 1: Collaboration in unit management is positively related to performance. Hypothesis 2: Collaboration in patient care (routine production) is positively related to performance. Hypothesis 3: Collaboration in process improvement is positively related to performance.

6. Research Context • Vermont Oxford Network (VON) NIC/Q2002 national collaborative to improve neonatal care (44 NICUs) • Improvement teams met 2x/yr (2002-2004) • Worked together to develop list of “best” practices • Implemented its own portfolio of practices in NICU • Entered clinical outcome data into database • Three data sources: • Survey of 1,440 staff at 23 NICUs in 2003 (58% NICUs, 46% individuals, mean N = 63 per NICU) • Follow-up survey of improvement teams • VON patient database

7. Measuring: Collaboration in Unit Management • Shared governance:an organizational model in which nurses control their practices as well as influence administrative areas previously controlled only by managers (Hess 2004) • Did improvement teams report the use of shared governance (including all front-line staff) in their NICU? (Yes = 1; No=0)

8. Measuring: Collaboration in Patient Care • Interdisciplinary rounds • Number of disciplines regularly present on rounds • Collaborative communication • Nurses’ and respiratory therapists’ survey responses to 6 items (a=.88) • Sample survey items: • “Communication between nurses and physicians is open and positive.” • “The input of respiratory therapists and/or other ancillary staff is regularly sought when developing treatment plans.”

9. Measuring: Collaboration in Process Improv. • Shared identification of projects • Did project teams report that staff identified which improvement projects to implement on the unit? • Learn-how • Extent to which the NICU engaged in 7 learning activities when implementing new practice (a=.88) • Pilot runs- use new process on a small subset of patients • Dry runs- practice new process WITHOUT a real patient • Found to be significant in explaining staff’s perception of the impact of performance improvement projects (Tucker et al, 2007)

10. Control Variables • Individual patient-level control variables: • Gestational age, • Small for gestational age, etc. • Unit-level control variables: • 2003 Patient Volume (ELBW) • Type of NICU (Cardiac Care = 0 or 1) • Size of the “improvement team” • Other control variables were found to be insignificant: • teaching status, • hospital ownership, • number of NICU beds, • staff to bed ratio, • average staff tenure on the unit, etc.

11. Outcome: Patient Mortality • Patient: Extremely Low BirthWeight (ELBW) infants (<1000 g); N=1061 infants • Mortality: Binary outcome variable (0, 1) –> logistic regression “XTLOGIT” • Year: 2004 (end of the VON collaborative) • Controlling for prior performance: Included 2001 standardized mortality ratio (SMR) as a control variable to measure improvement in mortality over the course of the collaborative • Interpretation: LOWER ODDS RATIO is BETTER (less likely to die)

12. Results * = p < 0.05, ** = p<.01, *** = p<.001

13. Summary • Effect of collaboration on patient mortality varies by type of collaboration: • Collaboration in unit management as measured by shared governance + Collaboration in patient care as measured by collaborative communication + Collaboration in process improvement as measured by learn-how i.e. staff engagement with new practices

14. Implications • Collaboration in patient care & process improvement are important contributors to performance. • However, the selection of managerial practices intended to achieve each must be carefully considered. • “Active” forms of collaboration – e.g. learn-how and collaborative communication during patient care – can have a beneficial impact on quality. • Shared governance as a uniform approach to unit management can have a negative effect on patient mortality – due to inefficiency and compromised solutions?

15. Thank you

16. Additional slides

17. Summary Statistics: NICU Level

18. Summary Statistics: Patient Level

19. Comparison of participants and non-participants

20. Acknowledgements • Advocate Lutheran General Children’s Hospital • Children’s Hospital of Illinois at OSF Saint Francis Medical Center • Children’s Hospital and Research Center in Oakland, CA • Children’s Hospital of Orange County • Children’s Hospital at Providence, Anchorage, Alaska • Children’s Hospital, St. Paul • Children’s Hospital of Southwest Florida • Children’s Medical Center at Rockford Health System • Janet Weis Children’s Hospital at Geisinger Medical Center • Parkview Hospital • Providence St. Vincent Medical Center • University of Minnesota Children’s Hospital • Woman’s Hospital Baton Rouge, LA • Yakima Valley Memorial Hospital