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, Whartons 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 making and 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) GoalCollaborate withChallenges to collaboration Unit management ManagersDeparts from est. roles Perception of differ. priorities Patient careCo-workersMultidisciplinary group Hierarchical culture Process improvement Managers and co-workers In addition to above... Requires extra-role behavior

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. Interdisciplinary rounds Number of disciplines regularly present on rounds Collaborative communication Nurses and respiratory therapists survey responses to 6 items (=.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. Measuring: Collaboration in Patient Care

9. 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 (=.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 staffs perception of the impact of performance improvement projects (Tucker et al, 2007) Measuring: Collaboration in Process Improv.

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 Significant VariablesOdds Ratio (95% CI) Individual-level control variables Small for gestational age2.64***(1.33 - 5.25) 1- minute APGAR score0.91**(0.83 - 0.99) Unit-level control variables 2003 ELBW patient volume0.99* (0.99 - 1.00) Type of NICU (cardiac surg.)0.51***(0.36 - 0.74) Improvement team size0.94***(0.91 - 0.98) Prior mortality (2001 SMR)2.11***(1.25 - 3.56) Independent variables Shared governance (H1)1.70**(1.08 - 2.68) Interdisciplinary rounds (H2)1.04 (0.98 - 1.10) Collab. communication (H2)0.73* (0.53 - 1.02) Shared identification of projects (H3)0.98 (0.65 - 1.47) Learn-how (H3)0.59** (0.36 - 0.97) * = 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 VariableMeanSD123456789 12004 Infant mortality.16.36 22003 ELBW volume6127.6-.10* 3NICU type (cardiac =1).49.50-.05-.07* 4Improvement team size14.6.3-.08*.17*-.14* 52001 SMR.96.38.04-.25*-.12*.13* 6Shared governance.77.42-.03-.07*.36*.32*-.14* 7Team meetings63.3-.05-.12*.03.46*.18*.15* 8Collab. communication5.2.53-.10*.15*.03 -.11*.03.10* 9 Shared identification of projects.63.48-.06*.28*.27*.12*.07*.19* 0.25*.21* 10Learn-how3.4.44-.05-.28*-.01.29*.46*.32*.25*.23*.20*

18. Summary Statistics: Patient Level

19. Comparison of participants and non- participants CharacteristicsParticipant (N=23) Non-Participant (N=17) Hospital ownership 22 Not-for-profit 1 Government 13 Not-for-profit 1 Government 2 For-profit 1 Other Hospital type 17 Teaching 6 Non-teaching 13 Teaching 4 Non-teaching Level of care in NICU a, b, c 2 No major surgery 9 No cardiac surgery 12 All surgeries 2.4 (.7) 0 No major surgery 13 No cardiac surgery 4 All surgeries 2.2 (.4) No. of past collaboratives a, b 8 None 11 one prior 4 two prior.8 (.7) 8 None 7 one prior 2 two prior.7(.7) Target AreaNICU-OB relations, Pain and sedation Infection, Respiratory care, Discharge Staffing, Family-centered care NICU-OB relation, Pain and sedation, Infection, Respiratory care, Discharge Staffing, Family-centered care # of NICU Beds41.4 (12.2) Not available No. of ELBW babies in 2001 b 45.2 (22.4)47.6 (29.5) % of babies with APGAR score < 333.9 (10.8)30.8 (10.4) % of babies born outside the NICU29.5 (33.9)18.5 (24.6) Babies birthweight (grams)772.6 (29.7)775.9 (37.2) Gestational age at birth (weeks) a, b, e 26 (.5)26 (0.7) Length of stay (days) a, b, e 74 (12.5)74.8 (9.5)

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