Mind the Gap

Mind the GapHealth Systems Research and the Search for Answers

Heather M. Gilmartin, PhD, NPPost-doctoral Nurse FellowDenver-Seattle Center of InnovationDepartment of Veterans AffairsSeptember 9, 20151

Do not worryAbout things falling into placeWhere they fall is the placeMark Hartley

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GoalsPresent a path from PhD application to graduation and beyondDiscuss my program of researchTo post-doc or not to post-docTop 10 things I learned in my PhD3

PhD applicationOrganizational Culture Change:How can healthcare move from a physician/treatment system to a nursing/caring/prevention/safety system?Can organizational change come from within? Can grass roots to middle management efforts change the focus of an organization?Behavior modification in healthcare workers can old habits be unlearned? What makes a great culture in healthcare?

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There are certain personal characteristics associated with being a successful clinician-scientist investigator:Be intensely curious about [the subject]Be profoundly dissatisfied with the current state of knowledgeCarry a profound desire to know more as a way of helping ones patientsP.S. Having personality characteristics associated with oppositional-defiant disorder can be quite helpful

A pattern of disobedient, hostile, and defiant behavior toward authority figures and requests from adults (re: chairs, deans, management), best treated by mental health professionals (re: mentors) and family therapy (or friends).Oxman, A.D., Sackett, D.L. (2013). Ways to advance your career by saying no part 2: When to say no and why.. Clinical Trials; (10) 181-187.5

The time spent at a patients bedside makes nurses the perfect people to pursue an understanding of the health care system.

We move from the patient, through the systems of care, and back to the patient.6

Central thesis of the patient safety movement is that most medical errors are the results of bad systems, not bad people7

Where is the gap in the literature?Mind the Gap8

"In school, we're rewarded for having the answer, not for asking a good question. Richard Saul Wurman

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Does a proven patient safety program vary in its effectiveness in different contexts?

If so, how and why?Shekelle PG, Pronovost PJ, Wachter RM, et al. Assessing the evidence for context-sensitive effectiveness and safety of patient safety practices: Developing criteria. Rockville, MD: Agency for Healthcare Research and Quality;2010. Prepared under Contract No. HHSA-290-2009-10001C. 10

Context is everythingBate P. Context is everything. London, England: Health Foundation;2014.11

ContextThe soil in which a thousand flowers will bloomAll intervening concepts between the independent and dependent variable

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In health care, there are no outcomes more important or tangible than the outcomes of patients.

There are no outcomes worse than patient injury or death resulting from preventable errors.

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What is your guiding theory?Be Guided into the Gap15

for atheoretical investigations hinder the generalization of findings, delay the development of a coherent body of knowledge, and limit the development of health care policy(Verran, 1997). 16

The Quality Health Outcomes ModelClientContextInterventionOutcomeMitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality health outcomes model. Image - the Journal of Nursing Scholarship, 30(1), 43-46. (with permission)17

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What is your question?Fill a Really Small Gap18

Organizational Context and HAI:Testing the Quality Health Outcomes ModelObjective: Test a middle-range theoretical model to explain the relationships between: Adherence to central line bundle interventionsOrganizational contextCLABSI outcomes Methods:Secondary data analysis614 U.S. hospitals in 2011 PNICER Study (Stone et al., 2014)

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2012Bundle of EBP to improve anticoagulation care: adopt a dosing algorith, prompter follow-up after out of range values, use of guideline concordant target ranges, efforts to reduce loss to follow-up.19

Relational Coordination Survey (Gittell, 2012; Gilmartin et al., 2015)Effective coordination between healthcare workers is determined by the:Quality of communication Quality of underlying relationshipsShared goals, knowledge, and mutual respectPNICER - Work Environment20

PNICER - Organizational ClimateLeading a Culture of Quality (Nembhard et al., 2012)Employee perceptions of unit level:Quality focusChange orientationOpennessWork group cooperationAlignment with leadership and directionAccountabilityPsychological safety

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Healthcare-associated infection dataMonthly compliance rates for central line bundle interventions for 2008-2012 614 hospitalsHand hygieneMaximal barrier precautionsChlorhexidine gluconate skin prepOptimal site selectionMonthly central line infection rates (2008-2012) from CDC National Health Safety Network

R01 - $100,000,000+ prospective study

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Organizational ContextAdherence to Central Line BundleClientXXXLeadershipPsych SafetyClimateMD RCHA RCRN RCEstimator: WLSMVChi-sq (1,315) = 1,986.30P