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J Nurs Care Qual Vol. 29, No. 3, pp. 269–279 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Impact of Provider Coordination on Nurse and Physician Perceptions of Patient Care Quality Nathalie McIntosh, PhD; James F. Burgess, Jr, PhD; Mark Meterko, PhD; Joseph D. Restuccia, DrPH; Anna C. Alt-White, PhD, RN; Peter Kaboli, MD; Martin Charns, DBA The objective of this study was to assess the role of provider coordination on nurse manager and physician perceptions of care quality, while controlling for organizational factors. Findings indicated that nurse-nurse coordination was positively associated with nurse manager perceptions of care quality; neither physician-physician nor physician-nurse coordination was associated with physician perceptions. Organizational factors associated with positive perceptions of care quality included facility support of education for nurses and physicians, and the use of multidisciplinary rounding. Key words: interprofessional coordination, intraprofessional coordination, multidisciplinary rounding, patient care quality, relational coordination
Author Affiliation: Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts (Drs McIntosh, Burgess, Meterko, Restuccia, and Charns); VA Office of Nursing Services, Washington, District of Columbia (Dr Alt-White); Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City VA Healthcare System, Iowa City (Dr Kaboli); Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (Dr Kaboli); Department of Health Policy & Management, Boston University School of Public Health, Boston, Massachusetts (Drs Burgess, Meterko, and Charns); and Boston University School of Management, Boston, Massachusetts (Dr Restuccia).
I
N THE CURRENT CLIMATE of health care reform, hospitals are under increasing pressure to reduce costs while maintaining or improving the quality of care.1 Examining how care is delivered with attention to hospital structures and processes that influence care delivery may identify low- or no-cost factors related to care quality that can then be used to improve care while maintaining or lowering costs.
This study was based on work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Services (HSR&D IIR 08-067). The views and conclusions expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs of the US government.
provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com).
No conflicts of interest are declared for any authors.
Accepted for publication: January 6, 2014 Published ahead of print: February 6, 2014
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are
Correspondence: Nathalie McIntosh, ter for Healthcare Organization and tion Research, VA Boston Healthcare S. Huntington Ave (152-M), Boston, ([email protected]).
PhD, CenImplementaSystem, 150 MA 02130
DOI: 10.1097/NCQ.0000000000000055
269
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014
Providing care to hospitalized patients is an increasingly complex task. Larger numbers of providers are treating individual patients with higher acuity.2 As the number of providers involved in care grows and the interdependencies between them increases, higher levels of intraprofessional (nursenurse and physician-physician) and interprofessional (nurse-physician) coordination are required. As a result, coordination, especially among and between nurses and physicians, is increasingly important for providing care to hospitalized patients.3 This study focused on inpatient medicine units and assessed the effects of intra- and interprofessional coordination on the quality of patient care (QoPC) as perceived by both nurses and physicians. Study results may inform strategies that improve the QoPC. BACKGROUND Coordination is defined as the management of task interdependencies,4 that is, the conscious activity to assemble and synchronize differentiated work efforts so that they function harmoniously in attaining an organizational goal.5 It is a central component of teamwork6 and has verbal and nonverbal communication at its core.7 In medical settings, coordination has been positively associated with patient safety,8,9 patient care quality,10 medication selection and administration,11 patient outcomes,12 and patient satisfaction.13 The Institute of Medicine has recommended that nurses and physicians improve coordination to reduce medical errors and increase patient safety.14 Much of the work examining the association between coordination and patient care quality has been done in intensive care units,13 surgical care units,15,16 and emergency departments.13 Few studies have examined this association in inpatient medicine; the goal of this study is to address this gap. As task interdependencies between providers increases, it becomes more important to better understand the role of coordination in the provision of care to hospitalized patients.
METHODS This was an exploratory, cross-sectional, descriptive study of 36 Veterans Health Administration (VHA) inpatient medicine services selected to provide a sampling of facilities by region and size. Nine medical centers—2 large (>200 medical-surgical beds), 4 medium (100-199 beds), and 3 small ( .05 in an iterative fashion until all variables remaining were significant at P ≤ .05. Sensitivity analyses As hierarchical modeling was not possible, we created variables representing the standard deviations of the facility-level scores for predictors in final models and included them in the final multivariate linear regression models to assess whether between-facility differences were significant.24 If so, this would suggest that a hierarchical nested model rather than the approach taken may have been more appropriate. However, none of the standard deviation variables were significant predictors of perceived quality, suggesting that controlling for facility-specific variables was adequate to address facility differences in the models.
Coordination and organizational factor variable selection (steps 1 and 2)
FINDINGS
To identify the coordination and organizational variables to retain in each of the 2 models, we first computed bivariate correlations between all items and each of the outcome variables. Variables that correlated at P ≤ .10 with an outcome were retained and then included as a block in a linear regres-
Survey respondents Chiefs of medicine at all 36 VHA facilities responded to the survey as did 80% of nurse managers (n = 67) and 57% of attending physicians (n = 474). The response rate of medicine service nurses in the VA RN Satisfaction Survey (N = 1002) could not be
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
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20:37
Provider Coordination and Perceptions of Patient Care Quality computed because the denominator for this nurse subgroup was not known. However, on the basis of that total RN count, the overall response rate was good (51%). Descriptive statistics Descriptive statistics for the outcome variables indicated variation in the perceptions of the QoPC across facilities within respondent types: for the nurse managers (n = 35), mean (SD) = 49.1 (9.4); for the attending physicians (n = 36), mean (SD) = 50.2 (5.5). Table 1 shows the descriptive statistics for the facilitylevel aggregate scores of the macro-level organizational variables that were retained after bivariate analyses and tested in regression models. Table 2 shows the descriptive statistics for the micro-level coordination variables. There was variation in responses within respondent types at the facility level for all items. For example, facility maximum scores were on average 2 times the facility minimum across these variables. In Table 1, larger standard deviations are indicative of more variation across facilities for that item. In Table 2, the larger the difference between the facility maximum and facility minimum scores, the greater is the variation across facilities. On the coordination items, higher scores indicate better perceived coordination. Cronbach α scores of nurse-nurse, nurse-physician, and physician-physician RC evaluations were 0.93, 0.85, and 0.93, respectively. The correlation between nurse manager and attending physician ratings of the QoPC was 0.22. Supplemental Digital Content, Table 3 (available at: http://links.lww.com/JNCQ/ A69) shows correlations between coordination factors and nurse manager and attending physician perceptions of the QoPC. Results indicate that perceptions of the QoPC are more highly correlated with ratings of coordination within respondent groups than across groups. For instance, nurse manager and physician ratings of the coordination factors have higher correlations with nurse manager and physician perceptions of the QoPC, respectively.
275
Multivariate linear regression models Table 3 presents results from the regression analyses. The adjusted R2 for the nurse manager perceived QoPC model was 0.58 and for the attending physician QoPC model was 0.72. Nurse-nurse coordination was associated with nurse manager QoPC, but coordination factors were not significant predictors in the attending physician QoPC model. In addition, facility support for appropriate continuing education and training was a predictor in both the nurse manager and attending physician QoPC models and the use of multidisciplinary rounding was a predictor in the nurse manager QoPC model. Therefore, the main findings were as follows: (1) for nurse managers, facility support of nurses (specifically relating to nursing training and education), nurse-nurse coordination, and the use of multidisciplinary rounding were associated with better perceptions of patient care quality; (2) for attending physicians, facility commitment to the highest patient care and facility support of physicians (specifically related to physician training and education) were associated with better perceptions of patient care quality. DISCUSSION Nurse-nurse RC and strong facility support for nursing continuing education were significant predictors of nurse manager perceptions of the QoPC. These are both nursing-centric factors—that is, factors that support nurses in their efforts to provide quality nursing care. This is supported by literature linking positive nurse working environments, especially ones with strong collegial relationships among nurses, and patient care and outcomes.25-28 These findings reinforce the benefit of facility support (eg, access, time, funding) of nurses, especially related to nursing education, and also suggest that procedures and practices (eg, establishing consistent nursing schedules or creating all 8- or 12-hour shifts29 ) that facilitate coordination among nurses may improve the QoPC.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Table 3. Final Multivariate Linear Regression Models Predictor Variable (Survey)
Organizational Domain or Type of Coordination
Dependent variable: NM rating of QoPCa My facility provides RN-MD work conditions: appropriate continuing Facility support education and training to do my job. (NM) When physicians do their RN-MD interaction: rounds, what % of the Multidisciplinary rounding time did nurses on your unit round with them? (NM) Overall RC score Intraprofessional coordination: between nurses (NM) Nurse-nurse Dependent variable: ATT rating of QoPCb Facility is committed to RN-MD work conditions: highest patient care. Leadership (ATT) My facility provides RN-MD work conditions: appropriate continuing Facility support education and training to do my job. (ATT)
Std β
SE
.4399
0.12
.001
.4362
0.03
.001
.3428
0.15
.01
.6429
0.11
JNCQ-D-13-00136
May 12, 2014
20:37
J Nurs Care Qual Vol. 29, No. 3, pp. 269–279 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Impact of Provider Coordination on Nurse and Physician Perceptions of Patient Care Quality Nathalie McIntosh, PhD; James F. Burgess, Jr, PhD; Mark Meterko, PhD; Joseph D. Restuccia, DrPH; Anna C. Alt-White, PhD, RN; Peter Kaboli, MD; Martin Charns, DBA The objective of this study was to assess the role of provider coordination on nurse manager and physician perceptions of care quality, while controlling for organizational factors. Findings indicated that nurse-nurse coordination was positively associated with nurse manager perceptions of care quality; neither physician-physician nor physician-nurse coordination was associated with physician perceptions. Organizational factors associated with positive perceptions of care quality included facility support of education for nurses and physicians, and the use of multidisciplinary rounding. Key words: interprofessional coordination, intraprofessional coordination, multidisciplinary rounding, patient care quality, relational coordination
Author Affiliation: Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts (Drs McIntosh, Burgess, Meterko, Restuccia, and Charns); VA Office of Nursing Services, Washington, District of Columbia (Dr Alt-White); Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City VA Healthcare System, Iowa City (Dr Kaboli); Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (Dr Kaboli); Department of Health Policy & Management, Boston University School of Public Health, Boston, Massachusetts (Drs Burgess, Meterko, and Charns); and Boston University School of Management, Boston, Massachusetts (Dr Restuccia).
I
N THE CURRENT CLIMATE of health care reform, hospitals are under increasing pressure to reduce costs while maintaining or improving the quality of care.1 Examining how care is delivered with attention to hospital structures and processes that influence care delivery may identify low- or no-cost factors related to care quality that can then be used to improve care while maintaining or lowering costs.
This study was based on work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Services (HSR&D IIR 08-067). The views and conclusions expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs of the US government.
provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com).
No conflicts of interest are declared for any authors.
Accepted for publication: January 6, 2014 Published ahead of print: February 6, 2014
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are
Correspondence: Nathalie McIntosh, ter for Healthcare Organization and tion Research, VA Boston Healthcare S. Huntington Ave (152-M), Boston, ([email protected]).
PhD, CenImplementaSystem, 150 MA 02130
DOI: 10.1097/NCQ.0000000000000055
269
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
270
JNCQ-D-13-00136
May 12, 2014
20:37
JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014
Providing care to hospitalized patients is an increasingly complex task. Larger numbers of providers are treating individual patients with higher acuity.2 As the number of providers involved in care grows and the interdependencies between them increases, higher levels of intraprofessional (nursenurse and physician-physician) and interprofessional (nurse-physician) coordination are required. As a result, coordination, especially among and between nurses and physicians, is increasingly important for providing care to hospitalized patients.3 This study focused on inpatient medicine units and assessed the effects of intra- and interprofessional coordination on the quality of patient care (QoPC) as perceived by both nurses and physicians. Study results may inform strategies that improve the QoPC. BACKGROUND Coordination is defined as the management of task interdependencies,4 that is, the conscious activity to assemble and synchronize differentiated work efforts so that they function harmoniously in attaining an organizational goal.5 It is a central component of teamwork6 and has verbal and nonverbal communication at its core.7 In medical settings, coordination has been positively associated with patient safety,8,9 patient care quality,10 medication selection and administration,11 patient outcomes,12 and patient satisfaction.13 The Institute of Medicine has recommended that nurses and physicians improve coordination to reduce medical errors and increase patient safety.14 Much of the work examining the association between coordination and patient care quality has been done in intensive care units,13 surgical care units,15,16 and emergency departments.13 Few studies have examined this association in inpatient medicine; the goal of this study is to address this gap. As task interdependencies between providers increases, it becomes more important to better understand the role of coordination in the provision of care to hospitalized patients.
METHODS This was an exploratory, cross-sectional, descriptive study of 36 Veterans Health Administration (VHA) inpatient medicine services selected to provide a sampling of facilities by region and size. Nine medical centers—2 large (>200 medical-surgical beds), 4 medium (100-199 beds), and 3 small ( .05 in an iterative fashion until all variables remaining were significant at P ≤ .05. Sensitivity analyses As hierarchical modeling was not possible, we created variables representing the standard deviations of the facility-level scores for predictors in final models and included them in the final multivariate linear regression models to assess whether between-facility differences were significant.24 If so, this would suggest that a hierarchical nested model rather than the approach taken may have been more appropriate. However, none of the standard deviation variables were significant predictors of perceived quality, suggesting that controlling for facility-specific variables was adequate to address facility differences in the models.
Coordination and organizational factor variable selection (steps 1 and 2)
FINDINGS
To identify the coordination and organizational variables to retain in each of the 2 models, we first computed bivariate correlations between all items and each of the outcome variables. Variables that correlated at P ≤ .10 with an outcome were retained and then included as a block in a linear regres-
Survey respondents Chiefs of medicine at all 36 VHA facilities responded to the survey as did 80% of nurse managers (n = 67) and 57% of attending physicians (n = 474). The response rate of medicine service nurses in the VA RN Satisfaction Survey (N = 1002) could not be
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-13-00136
May 12, 2014
20:37
Provider Coordination and Perceptions of Patient Care Quality computed because the denominator for this nurse subgroup was not known. However, on the basis of that total RN count, the overall response rate was good (51%). Descriptive statistics Descriptive statistics for the outcome variables indicated variation in the perceptions of the QoPC across facilities within respondent types: for the nurse managers (n = 35), mean (SD) = 49.1 (9.4); for the attending physicians (n = 36), mean (SD) = 50.2 (5.5). Table 1 shows the descriptive statistics for the facilitylevel aggregate scores of the macro-level organizational variables that were retained after bivariate analyses and tested in regression models. Table 2 shows the descriptive statistics for the micro-level coordination variables. There was variation in responses within respondent types at the facility level for all items. For example, facility maximum scores were on average 2 times the facility minimum across these variables. In Table 1, larger standard deviations are indicative of more variation across facilities for that item. In Table 2, the larger the difference between the facility maximum and facility minimum scores, the greater is the variation across facilities. On the coordination items, higher scores indicate better perceived coordination. Cronbach α scores of nurse-nurse, nurse-physician, and physician-physician RC evaluations were 0.93, 0.85, and 0.93, respectively. The correlation between nurse manager and attending physician ratings of the QoPC was 0.22. Supplemental Digital Content, Table 3 (available at: http://links.lww.com/JNCQ/ A69) shows correlations between coordination factors and nurse manager and attending physician perceptions of the QoPC. Results indicate that perceptions of the QoPC are more highly correlated with ratings of coordination within respondent groups than across groups. For instance, nurse manager and physician ratings of the coordination factors have higher correlations with nurse manager and physician perceptions of the QoPC, respectively.
275
Multivariate linear regression models Table 3 presents results from the regression analyses. The adjusted R2 for the nurse manager perceived QoPC model was 0.58 and for the attending physician QoPC model was 0.72. Nurse-nurse coordination was associated with nurse manager QoPC, but coordination factors were not significant predictors in the attending physician QoPC model. In addition, facility support for appropriate continuing education and training was a predictor in both the nurse manager and attending physician QoPC models and the use of multidisciplinary rounding was a predictor in the nurse manager QoPC model. Therefore, the main findings were as follows: (1) for nurse managers, facility support of nurses (specifically relating to nursing training and education), nurse-nurse coordination, and the use of multidisciplinary rounding were associated with better perceptions of patient care quality; (2) for attending physicians, facility commitment to the highest patient care and facility support of physicians (specifically related to physician training and education) were associated with better perceptions of patient care quality. DISCUSSION Nurse-nurse RC and strong facility support for nursing continuing education were significant predictors of nurse manager perceptions of the QoPC. These are both nursing-centric factors—that is, factors that support nurses in their efforts to provide quality nursing care. This is supported by literature linking positive nurse working environments, especially ones with strong collegial relationships among nurses, and patient care and outcomes.25-28 These findings reinforce the benefit of facility support (eg, access, time, funding) of nurses, especially related to nursing education, and also suggest that procedures and practices (eg, establishing consistent nursing schedules or creating all 8- or 12-hour shifts29 ) that facilitate coordination among nurses may improve the QoPC.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014
Table 3. Final Multivariate Linear Regression Models Predictor Variable (Survey)
Organizational Domain or Type of Coordination
Dependent variable: NM rating of QoPCa My facility provides RN-MD work conditions: appropriate continuing Facility support education and training to do my job. (NM) When physicians do their RN-MD interaction: rounds, what % of the Multidisciplinary rounding time did nurses on your unit round with them? (NM) Overall RC score Intraprofessional coordination: between nurses (NM) Nurse-nurse Dependent variable: ATT rating of QoPCb Facility is committed to RN-MD work conditions: highest patient care. Leadership (ATT) My facility provides RN-MD work conditions: appropriate continuing Facility support education and training to do my job. (ATT)
Std β
SE
.4399
0.12
.001
.4362
0.03
.001
.3428
0.15
.01
.6429
0.11
