Creating Open Access to Exercise for Low-income Patients Through a Community Collaboration for Quality Improvement: If You Build It, They Will Come.

Community health centers face the need for safe, accessible, and affordable exercise for low-income patients to implement self-management strategies. This study reports on one federally qualified health center\’s experience developing a partnership with a local YWCA to offer open access to patients for physical activity. Over a 24-month period, 1060 adult patients made at least 1 visit to the YWCA, logging a total of 14,276 visits. Among the exercisers, 112 had diabetes and made 3225 visits. Frequent users (>/=24 visits), had an HbAlc reduction of 1% (P = .02). Community health centers can collaborate with local exercise facilities to ensure that patients have opportunities to pursue healthier lifestyles.

Candib LM, Silva M, Cashman SB, Ellstrom D, Mallett K.

From the Family Health Center of Worcester (Dr Candib and Ms Ellstrom), Massachusetts College of Pharmacy and Health Sciences (Dr Silva), and Department of Family Medicine and Community Health, University of Massachusetts Medical School (Dr Cashman and Ms Mallett), Worcester, Mass.

The ecology of the patient visit: physical attractiveness, waiting times, and perceived quality of care.

This study examined the relationship between the attractiveness of the physical environment of healthcare facilities and patient perceptions of quality, service, and waiting time through systematic observations and patient satisfaction surveys at 7 outpatient practices at Weill Cornell Medical Center. Findings indicate positive correlations between more attractive environments and higher levels of perceived quality, satisfaction, staff interaction, and reduction of patient anxiety. The comparison of actual observed time and patients\’ perception of time showed that patients tend to overestimate shorter waiting times and underestimate longer waiting times in both the waiting area and the examination room. Further examinations of the way outpatient-practice environments impact patient and staff perceptions and how those perceptions impact behavior and medical outcomes are suggested.

Becker F, Douglass S.

From the Department Design & Environmental Analysis, College of Human Ecology, Cornell University, Ithaca, NY.

The Impact of Primary Care patients\’ Pain and Emotional Problems on Their Confidence With Self-Management.

There is a paucity of information about confidence with self-management in primary care practice. This study examines changes over time in patient-reported confidence with self-management on the basis of 1047 patients aged 50-69 who had common chronic diseases, bothersome pain, or emotional problems. We examined the relationship between patients\’ self-reported confidence, their experiences of medical care, and health outcomes after adjustment for baseline characteristics. We observed that, over a 2-year period, about a third of the patients remained confident and a third remained not confident. Change in pain or emotional problems was strongly associated with whether a patient was confident or not at the end of the follow-up period (P < .001). Persistently good confidence or improved confidence was strongly associated with measures of high-quality medical care. For patients with diabetes, persistent confidence was more often associated with control of blood glucose (P = .004) compared with the control in patients who were not as confident. Confident patients were likely to be fully engaged in everyday work and activities (P < .001). The results suggest that for the majority of patients in primary care practices, the status of their self-reported confidence with self-management persists over time. Their confidence is impacted by their pain or emotional state and strongly associated with their medical care experiences and some outcomes of care.

Wasson JH, Johnson DJ, Mackenzie T.

From the Dartmouth Medical School, Hanover, NH.

The Perceived Financial Impact of Quality Improvement Efforts in Community Health Centers.

We administered surveys to 100 chief executive officers (CEOs) of community health centers to determine their perceptions of the financial impact of the Health Disparities Collaboratives, a national quality improvement initiative. One third of the CEOs believed that the HDC had a negative financial impact on their health center, and this perception was significantly correlated with centers having a higher proportion of uninsured patients. Performance-based payment incentives may improve care but may also add new financial burdens to facilities that treat the uninsured population. As such, a provider\’s payer mix may need to be considered in the design of QI programs if they are to be sustainable.

Cheung K, Moiduddin A, Chin MH, Drum ML, Brown SE, Graber JE, Heuer L, Quinn MT, Schaefer CT, Schlotthauer AE, Huang ES.

From the National Opinion Research Center, Washington, DC (Ms Cheung and Mr Moiduddin) and Chicago, Ill (Dr Graber); Department of Health Studies (Dr Drum); Department of Medicine, the University of Chicago, Chicago, Ill (Mss Brown and Schlotthauer and Drs Huang, Chin, and Quinn); the University of North Dakota, Grand Forks (Dr Heuer); and the University of Evansville, Evansville, Ind (Ms Schaefer).

Commentary on VanDeusen Lukas et al\’s \”Implementation of a Clinical Innovation\”: Improving Implementation Strategies for Clinical Innovations.

The ability to successfully implement clinical innovation is a significant and critical challenge for all healthcare organizations. The Department of Veterans Affairs has provided insight into isolating those factors that are most strongly associated with successful implementation. Using their experience with spreading advanced clinic access to multiple clinics at multiple sites, they were able to study key components of successful implementation in a variety of settings. Advanced clinic access is a complex set of principles that require widespread involvement and support. The goal of advanced clinic access is to dramatically reduce waits and delays for appointments. In using this particular example to study, the VA provided a rigorous case study.

Tantau C.

From the Tantau & Associates, Chicago Park, Calif.

Implementation of a Clinical Innovation: The Case of Advanced Clinic Access in the Department of Veterans Affairs.

Healthcare organizations seeking to improve clinical practices often have disappointing results because the planned innovations are not successfully implemented. To increase the understanding of implementation, we analyzed the national spread of an ambulatory innovation in the Department of Veterans Affairs. This study provides support for a conceptual model that posits that the extent to which a clinical innovation is implemented will be affected by factors in 3 domains: (1) intentional activities to introduce, spread, and support the innovation; (2) the attitudes and capabilities of clinic staff responsible for implementing the innovation; and (3) the context of the facility in which the innovation is being introduced. Among the strongest predictors of successful implementation, management support for the innovation and clinic team knowledge and skills to make changes successfully were significant across both primary care and specialty clinics.

Lukas CV, Meterko MM, Mohr D, Seibert MN, Parlier R, Levesque O, Petzel RA.

From the Center for Organization, Leadership and Management Research, Department of Veterans Affairs (152M), Boston, Mass (Drs Lukas and Ms Seibert and Drs Meterko and Mohr); Department of Health Policy and Management, Boston University School of Public Health (Drs Lukas, Meterko and Mohr); Department of Veterans Affairs, Office of Deputy Under Secretary for Health for Operations and Management, Minneapolis, Minn (Ms Parlier); Department of Veterans Affairs, Office of Deputy Under Secretary for Health for Operations and Management, Washington, DC (Ms Levesque); and VA Midwest Health Care System, Department of Veterans Affairs, Minneapolis, Minn (Dr Petzel).

From the editor.

Goldfield N.

Workplace relational factors and physicians\’ intention to withdraw from practice.

BACKGROUND: Physician turnover threatens continuity of care for patients and is a huge expense for health care organizations. Health care organizations have been advised to help physicians build positive relations with colleagues, staff, and patients as a strategy to socially integrate physicians in the workplace and to increase physician retention. Although these recommendations are touted as \”evidence-based\” practices, the importance of workplace relationships for physician retention has not been established empirically. PURPOSE: The purpose of this study is to examine two questions: Are physicians who report better relationships with colleagues, staff, and patients less likely to intend to withdraw from practice? Do the effects of these relational factors differ for large-group and solo/small-group practice physicians? METHODOLOGY: Using data from the Physician Worklife Survey, we analyzed the associations between physicians\’ reported relationships with colleagues, staff, and patients and intention to withdraw from practice within 2 years using logistic regression. FINDINGS:: Relationships with colleagues had a significant and negative association with intended withdrawal from practice for large-group practice physicians. The joint effect of relationships with colleagues, staff, and patients was significant for large-group practice physicians, but it only approached significance for solo/small-group practice physicians. PRACTICE IMPLICATIONS: This study suggests that workplace relationships may influence physicians\’ intention to withdraw from practice, but the mechanisms by which they do so are unclear. Possible interventions to improve physician retention include promotion of informal mentoring and efforts to support community involvement of physicians and their families. Further research examining the role of these and other programs in promoting physician retention can help employers to foster positive workplace relationships and improve retention.

Masselink LE, Lee SY, Konrad TR.

Department of Health Policy and Administration, University of North Carolina School of Public Health, Chapel Hill, USA. leah_masselink@unc.edu

Role of multihospital system membership in electronic medical record adoption.

BACKGROUND: Health information technology (HIT) is designed to help reduce medical errors and improve quality of care and efficiency by providing the right information for the right patients in the right place at the right time. Nevertheless, substantial variation currently exists in the adoption of electronic medical records (EMRs) resulting in differences in hospital HIT capacity. PURPOSE: The purpose of this article is to examine the impact of different types of multihospital system affiliation on EMR adoption in hospitals in the United States. METHODOLOGY: A cross-sectional design was used with a sample of 4,017 hospitals in the United States. Secondary data were retrieved from the Health Information and Management Systems Society Analytics Database. Multiple regression analysis was used to examine the impact of multihospital system affiliation on EMR level of adoption. FINDINGS: The mean EMR adoption level varies significantly between independent hospitals and hospitals owned by a system for small hospitals. After adjusting for the number of operating rooms, the number of emergency room visits, and the number of hospital total full-time equivalent staff, small hospitals owned by multihospital systems were associated with 0.25 higher mean EMR adoption level (p < .05) than independent hospitals and no significant relationship was observed for hospitals that were leased/managed by a system. There was no significant effect of multihospital system membership on EMR level of adoption for medium and large hospitals. PRACTICE IMPLICATIONS: Small hospitals owned by multihospital systems had a significantly higher EMR level compared with independent hospitals. These findings have significant implications for small hospitals that are struggling to improve their HIT capacity. Smaller hospitals in ownership arrangements with larger health care systems have an advantage over small independent hospitals in HIT capacity possibly because of the greater availability of capital, access to shared HIT capacity, and other resources including technical expertise.

Li P, Bahensky JA, Jaana M, Ward MM.

Division of General Internal Medicine, University of Pennsylvania, Philadelphia, USA. penli@mail.med.upenn.edu

Servicescape: physical environment of hospital pharmacies and hospital pharmacists\’ work outcomes.

BACKGROUND: In health care, architects, interior designers, engineers, and health care administrators need to pay attention to the construction and design of health care facilities. Research is needed to better understand how health professionals and employees perceive their work environment to improve the physical environment in which they work. PURPOSE: The purpose of this study was to test the effect of the physical environment of hospital pharmacies on hospital pharmacists\’ work outcomes. METHODOLOGY: This cross-sectional mailed survey study of individual hospital pharmacists used a structured questionnaire developed to cover perceptions of the ambient conditions and the space/function(s) of pharmacists\’ work environments. It included aspects such as dispensing areas, pharmaceuticals areas, storage areas, and administrative offices. Work outcomes were job satisfaction, intentions to leave or reduce job working hours, and job-related stress. Hospital pharmacists in Taiwan (n = 182) returned the mailed surveys. Structural equation modeling was performed to validate the construct of the physical environment of a hospital pharmacy and the causal model for testing the effect of the physical environment on pharmacists\’ work outcomes. FINDINGS: For hospital pharmacy workplaces, more favorable perceptions of the workplace\’s physical environment were positively associated with overall job satisfaction, but such perceptions were also negatively related to intentions to quit employment or to reduce working hours. However, the effect of the physical environment on job stress within the workplace was not supported. PRACTICE IMPLICATIONS: The designs of physical environments deserve attention to create more appropriate and healthier environments for hospital pharmacies. Further research should be devoted to trace more psychological responses to the physical environment from a longitudinal perspective.

Lin BY, Leu WJ, Breen GM, Lin WH.

Institute of Health Service Administration, China Medical University, Taichung, Taiwan, ROC. yenju1115@hotmail.com