<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_422"
                     title="Nurses Often Silent About Workplace Violence (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/HospitalBasedMedicine/WorkForce/tb/18335?impressionId=1265757011369"
                     
      The physical and verbal abuse nurses face on the job often goes unreported, according to an Australian survey.&lt;br&gt;
&lt;br&gt;Over the prior year, 52% of nurses in one community hospital said they had been physically assaulted and 69% reported being threatened with violence, according to Rose Chapman, PhD, of the University of Western Australia in Perth, and colleagues.&lt;br&gt;
&lt;br&gt;Verbal abuse was almost universal, being reported by 92% of respondents, the researchers wrote in the February issue of the &lt;em&gt;Journal of Clinical Nursing&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;However, only half mentioned the incidents to senior staff or co-workers, and just 16% filed an official report.&lt;br&gt;
&lt;br&gt;&quot;The reasons for not reporting are many and may include lack of time and management support and the belief that being attacked is &apos;just part of the job,&apos;&quot; they wrote.&lt;br&gt;
&lt;br&gt;The same is true in the U.S., where assaults and under-reporting appear just as common as suggested in the Australian survey, commented Kathleen M. McPhaul, PhD, RN, MPH, of the University of Maryland School of Nursing in Baltimore, who has been involved in such research in the U.S.&lt;br&gt;
&lt;br&gt;A culture change would likely be needed to make a real difference for nurses, Chapman&apos;s group suggested.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Hospitals would have to ensure that nurses have necessary support, education, encouragement, and time to complete official reports. Nurses who report abuse should get positive feedback from all levels of nursing, they said.&lt;/p&gt;
&lt;p&gt;&quot;If administrators and governments are serious in their intention to reduce workplace violence and provide staff with safe work environments, they should be seen to act on all reported [incidents],&quot; which is rare today, Chapman&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;However, currently there&apos;s no strong lever or incentive to address this kind of workplace abuse since hospitals focus mainly on patient safety as part of accreditation, and national and state workplace safety organizations have little mechanism for monitoring such incidents, McPhaul noted.&lt;/p&gt;
&lt;p&gt;The researchers&apos; survey was intended to reach all 332 nurses working at one nontertiary hospital across all departments  --  emergency, medical, surgical, maternity, pediatric, and mental health.&lt;/p&gt;
&lt;p&gt;The 113 nurses who responded were mainly women in their early 40s who worked part time.&lt;/p&gt;
&lt;p&gt;Among them, about three-quarters reported at least one incident of workplace violence over the preceding 12 months  --  25% said it occurred weekly, 27% said monthly, and for 25% it was rarer, at once every six months. &lt;ul&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Fully 30% of the nurses said they had been involved in an episode involving a weapon  --  often hospital equipment and more rarely a knife or gun.&lt;/p&gt;
&lt;p&gt;The number of total incidents was lowest among nurse midwives, with a mean of 1.67 per year.&lt;/p&gt;
&lt;p&gt;Not surprisingly, the rate was highest among emergency department and mental health staff, who reported an average of 46.43 and 40.39 episodes over 12 months.&lt;/p&gt;
&lt;p&gt;One reason behind the high risk in these two departments may be the &quot;shift to a community-based approach to mental health care and a reduction in mental health beds&quot; such that the same psychiatric patients that assault mental health department nurses are mainstreamed to the emergency department as their point of entry to the hospital, the researchers said.&lt;/p&gt;
&lt;p&gt;However, more years of experience or higher educational qualification didn&apos;t appear to protect nurses. Senior nurse unit managers and clinical nurse specialists actually reported more physical assaults than less senior nurses.&lt;/p&gt;
&lt;p&gt;Age and gender didn&apos;t predict occurrence or type of incident either.&lt;/p&gt;
&lt;p&gt;When nurses did report workplace violence or verbal abuse, it was most often to their immediate manager (29%), other senior nursing staff (14.5%), or to their friends and colleagues (6%).&lt;/p&gt;
&lt;p&gt;Overall, 30% of nurses who responded to the survey gave as their reason for not reporting that workplace violence happens all the time and is simply part of the job.&lt;/p&gt;
&lt;p&gt;Even among those who did make a report of some sort, half said they thought hospital management failed to act on it.&lt;/p&gt;
&lt;p&gt;In fact, when the researchers audited hospital records, they found that 42 official incident reports had been filed by nurses over the prior one year period, nearly always involving injuries.&lt;/p&gt;
&lt;p&gt;In 95% of the cases, the only action taken by the hospital was making staff in the area aware of the incident. No other actions had been documented.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the voluntary nature and limited scope of the study may have limited generalizability, although the occurrence of violence against nurses is likely similar across developed countries.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers provided no information on conflicts of interest.&lt;/p&gt;&lt;p&gt;McPhaul reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_464"
                     title="COLUMN: &apos;Meaningful Use&apos; -- You Can Do This!"
                     score="0.012"
                     href="http://www.medpagetoday.com/Columns/18394?impressionId=1265757011369"
                     
      &lt;p&gt;Certified EHR technology used in a meaningful way is one piece of a broader Health Information Technology (HIT in techie jargon) infrastructure intended to reform the healthcare system and improve healthcare quality, efficiency, and patient safety.&lt;/p&gt;
&lt;p&gt;Under the HITECH Act, the Medicare EHR incentive programs provide payments up to $44,000 over five years to eligible professionals who are &quot;meaningful&quot; users of certified electronic health records.&lt;/p&gt;
&lt;p&gt;The Medicaid EHR program provides even bigger incentives  --  up to $63,750 over five years to practices with a 30% or higher Medicaid population for efforts to adopt, implement, or upgrade certified EHR technology or for meaningful use in the first year and up to another five years. (Pediatricians need only a 20% Medicaid patient volume to qualify.)&lt;/p&gt;
&lt;p&gt;The stimulus dollars have gotten our attention, especially in light of the eventual cuts to reimbursement scheduled to take effect in 2015 and beyond for those who don&apos;t use EHR technology.&lt;/p&gt;
&lt;p&gt;On Jan. 13, 2010 two rules were published defining the certification criteria and the criteria for meaningful use of electronic health records. (The rules are available at &lt;a href=&quot;http://www.gpoaccess.gov/fr/index.html&quot; mce_href=&quot;http://www.gpoaccess.gov/fr/index.html&quot; target=&quot;_blank&quot;&gt;www.gpoaccess.gov/fr/index.html&lt;/a&gt;.) A forthcoming rule will establish an EHR certification program. With the EHR vendors offering stimulus guarantees, the EHR certification program seems less of a concern.&lt;/p&gt;
&lt;p&gt;CMS proposed three stages of &quot;meaningful use&quot; criteria over the initial years of the program given the ongoing advancement in EHR technology and standards, as well as changes in quality measurement and other healthcare-related reporting.&lt;/p&gt;
&lt;p&gt;The focus in Meaningful Use Stage 1 is on the capture of health information in coded format and: 
&lt;ul&gt; 
&lt;li&gt;The use of it to track key clinical conditions&lt;/li&gt; 
&lt;li&gt;The communication of coded health information for care coordination purposes&lt;/li&gt; 
&lt;li&gt;Initial reporting of clinical quality measures and public health information&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The good news is that all results for all measures to be reported to CMS (for Medicare) or to the states (for Medicaid) will be done through attestation for the year 2011. In 2012, we&apos;ll be running all reports through certified EHR technology.&lt;/p&gt;
&lt;p&gt;Attestation can be achieved &quot;through a secure mechanism, such as through claims-based reporting or an online portal.&quot; But providers will still be required to &quot;use certified EHR technology to capture the data elements and calculate the results for the applicable clinical quality measures,&quot; the CMS rule said.&lt;/p&gt;
&lt;p&gt;Practices that have already implemented an EHR must ensure that their software is appropriately certified and that their clinicians are fulfilling all of the meaningful-use requirements to qualify for the incentives.&lt;/p&gt;
&lt;p&gt;So, you have just about two years to implement, iterate, rehearse, pilot, and test your own implementation against the meaningful use criteria.&lt;/p&gt;
&lt;p&gt;The initial criteria are presented in health outcomes policy priorities with associated care goals. Here are just six of the 25 criteria for Stage 1 Meaningful Use:&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Health Outcomes Policy Priority:&lt;/strong&gt;&lt;br&gt;
Improving quality, safety, efficiency, and reducing health disparities.&lt;br&gt;
&lt;strong&gt;Care Goals:&lt;/strong&gt;&lt;br&gt;
&amp;bull; Provide access to comprehensive patient health data for patient&apos;s healthcare team&lt;br&gt;
&amp;bull; Use evidence-based order sets and CPOE&lt;br&gt;
&amp;bull; Apply clinical decision support at the point of care&lt;br&gt;
&amp;bull; Generate lists of patients who need care and use them to reach out to patients&lt;br&gt;
&amp;bull; Report information for quality improvement and public reporting&lt;br&gt;

&lt;p&gt;&lt;strong&gt;Health Outcomes Policy Priority:&lt;/strong&gt;&lt;br&gt;
Engage patients and families in their healthcare.&lt;br&gt;
&lt;strong&gt;Care Goals:&lt;/strong&gt;&lt;br&gt;
Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Health Outcomes Policy Priority:&lt;/strong&gt;&lt;br&gt;
Improve care coordination.&lt;br&gt;
&lt;strong&gt;Care Goals:&lt;/strong&gt;&lt;br&gt;
Exchange meaningful clinical information among professional healthcare team.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Health Outcomes Policy Priority:&lt;/strong&gt;&lt;br&gt;
Improve care coordination.&lt;br&gt;
&lt;strong&gt;Care Goals:&lt;/strong&gt;&lt;br&gt;
Exchange meaningful clinical information among professional healthcare team.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Health Outcomes Policy Priority:&lt;/strong&gt;&lt;br&gt;
Improve population and public health.&lt;br&gt;
&lt;strong&gt;Care Goals:&lt;/strong&gt;&lt;br&gt;
Communicate with public health agencies.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Health Outcomes Policy Priority:&lt;/strong&gt;&lt;br&gt;
Ensure adequate privacy and security protections for personal health information.&lt;br&gt;
&lt;strong&gt;Care Goals:&lt;/strong&gt;&lt;br&gt;
&amp;bull; Ensure privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law&lt;br&gt;
&amp;bull; Provide transparency of data sharing to patient&lt;/p&gt;

&lt;p&gt;Each of the Care Goals has defined objectives with specific measures that must be achieved to demonstrate meaningful use.&lt;/p&gt;
&lt;p&gt;Following are examples of some of the objectives and what you&apos;ll have to do to meet each.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; Maintain up-to-date problem list in ICD-9-CM or SNOMED-CT.&lt;br&gt;
&lt;strong&gt;Measure:&lt;/strong&gt; 80% for unique patients.&lt;br&gt;
This objective will enable the user to manage problem lists that span multiple visits. If you&apos;ve been billing electronically, you&apos;ve already been capturing problems in ICD-9-CM format.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; Generate and transmit prescriptions electronically.&lt;br&gt;
&lt;strong&gt;Measure:&lt;/strong&gt; Transmit 75% of noncontrolled drug prescriptions electronically.&lt;br&gt;
Did you hop on the e-prescribing incentives? You&apos;re ahead of this one! If not, you&apos;ll need to enable e-prescribing.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; Drug screening.&lt;br&gt;
&lt;strong&gt;Measure:&lt;/strong&gt; Drug screening is enabled.&lt;br&gt;
Another easy objective to meet if you&apos;ve already implemented e-prescribing. If not, you&apos;ll need to be sure your system provides real-time alerts for drug-drug interactions and drug allergy contraindications, has an electronic formulary check, maintains drug-drug and drug-allergy warnings, and tracks the number of alerts that were responded to.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; Maintain active medication list.&lt;br&gt;
&lt;strong&gt;Measure:&lt;/strong&gt; 80% for unique patients.&lt;br&gt;
You&apos;ve been doing this too with your e-prescribing implementation. The system must be able to manage an active medication list and a medication history that spans multiple visits.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; Record demographics.&lt;br&gt;
&lt;strong&gt;Measure:&lt;/strong&gt; 80% for unique patients, including ALL data elements. Denominator is the number of patients seen.&lt;br&gt;
For each of your patients you should be aware of gender, race, ethnicity, date of birth, preferred language, and insurance type. You&apos;ll probably need to add fields for &quot;race&quot; and &quot;ethnicity&quot; to supplement the demographics you&apos;re already collecting.&lt;/p&gt;

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; Record vital signs.&lt;br&gt;
&lt;strong&gt;Measure:&lt;/strong&gt; 80% of patients seen age 2 and over, including ALL data elements. Denominator is total of unique patients age 2 and over seen.&lt;br&gt;
Your system must allow you to record height, weight, and blood pressure, calculate and display BMI, and plot and display growth charts for patients 2 to 20 years old, including BMI. If your system doesn&apos;t calculate BMI, ask your vendor when that will be updated in a release to your software.&lt;/p&gt;

&lt;p&gt;With the specific criteria objectives and measures such as these in hand you can implement the EHR and achieve meaningful use, improved healthcare quality and efficiency in operations.&lt;/p&gt;
&lt;p&gt;It will take work, but it can be done!&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_416"
                     title="For Diabetes, P4P Improves Patient Care, Outcomes (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/PracticeManagement/Reimbursement/tb/18328?impressionId=1265757011369"
                     
      &lt;p&gt;Measures of quality of care and clinical outcomes improved significantly when diabetic patients in a large private health plan were treated by physicians receiving pay-for-performance incentives, researchers said.&lt;/p&gt;
&lt;p&gt;The risk that diabetic patients would be hospitalized was 25% lower (incidence rate ratio 0.75, 95% CI 0.61 to 0.93) among those seen for three consecutive years by physicians who received extra pay for meeting quality-of-care targets, compared with the risk for patients whose physicians did not receive such incentives, reported Judy Ying Chen, MD, MSHS, of IMS Health in Woodland Hills, Calif., and colleagues.&lt;/p&gt;
&lt;p&gt;High-quality care  --  defined as receiving at least two tests for glycated hemoglobin (HbA1c) and one for LDL cholesterol during a given year  --  was delivered 16% more often by physicians in the pay-for-performance system (rate ratio 1.16, 95% CI 1.11 to 1.22), the researchers also reported online in the &lt;em&gt;American Journal of Managed Care&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This study showed a robust, consistent, significant, and positive association between increased receipt of appropriate laboratory monitoring of A1c and LDL cholesterol levels and decreased hospitalization rates,&quot; Chen and colleagues declared.&lt;/p&gt;
&lt;p&gt;On the other hand, the researchers also found that quality of care diminished when patients saw multiple primary care physicians during a given year.&lt;/p&gt;
&lt;p&gt;&quot;This finding supports the hypothesis that patients have better outcomes when they have a medical home,&quot; Chen and colleagues indicated.&lt;/p&gt;
&lt;p&gt;The researchers examined records of diabetic patients enrolled with Hawaii Medical Services Association, a large preferred provider organization, from 1999 to 2006. The plan had about 19,600 such patients in 1999 and 32,365 in 2006.&lt;/p&gt;
&lt;p&gt;The plan offered physicians in the network the opportunity to earn bonuses of 1.5% to 7.5% of their base fees for meeting care-quality targets including HbA1c and LDL cholesterol testing of diabetic patients. Bonuses ranged from $10,000 to $16,000 annually. Starting in 2001, physicians could earn an extra $6,000 if their adherence to care-quality processes improved over the previous year.&lt;/p&gt;
&lt;p&gt;Bonuses were paid each year on the basis of administrative records for the previous year.&lt;/p&gt;
&lt;p&gt;The proportion of diabetic patients seen by physicians in the pay-for-performance plan increased from 78.7% in 1999 to 94.6% in 2006.&lt;/p&gt;
&lt;p&gt;As a result of the bonus structure, Chen and colleagues observed, improvements in care quality lagged implementation of these incentives by a year or two.&lt;/p&gt;
&lt;p&gt;The most substantial improvements in quality of care and patient outcomes were seen among patients seen continuously by a physician participating in the pay-for-performance system from 2004 to 2006.&lt;/p&gt;
&lt;p&gt;Compared with patients seen by physicians who chose not to participate in the system, those whose treatment was subject to the incentives were seen by primary care physicians and endocrinologists far more often: &lt;ul&gt; &lt;li&gt;Six to 10 outpatient visits in a year: odds ratio 2.16 (95% CI 2.00 to 2.33)&lt;/li&gt; &lt;li&gt;Eleven or more outpatient visits in a year: OR 2.35 (95% CI 2.14 to 2.57)&lt;/li&gt; &lt;li&gt;Visit to an endocrinologist: OR 1.56 (95% CI 1.38 to 1.75)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Among patients receiving quality care continuously from 2004 to 2006, the chance of being hospitalized in 2006 was reduced by 33% compared with patients whose care failed to meet the quality target at some point (rate ratio 0.67, 95% CI 0.61 to 0.75).&lt;/p&gt;
&lt;p&gt;But patients who saw more than two different primary care physicians in 2006 had a dramatically increased rate of hospitalizations (RR 6.13, 95% CI 5.33 to 7.04).&lt;/p&gt;
&lt;p&gt;Chen and colleagues noted several limitations to the study, including the fact that it was conducted in a PPO setting and might not be generalizable to health maintenance organizations or other frameworks.&lt;/p&gt;
&lt;p&gt;The researchers also had no data for years before the program started, leaving open the possibility that physicians participating in the pay-for-performance program were those who were already following treatment guidelines.&lt;/p&gt;
&lt;p&gt;The study also included only one clinical outcome; effects on others such as hypoglycemic episodes, cardiovascular events, and meeting HbA1c targets were not measured and might have been different.&lt;/p&gt;
&lt;p&gt;The researchers also acknowledged that the claims data underlying the study might not have been totally accurate, and they noted that it did not include other factors known to affect hospitalizations such as cardiovascular risk factors.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Hawaii Medical Service Association, the health plan that was the focus of the work.&lt;/p&gt;&lt;p&gt;IMS Health is a healthcare consulting firm that, among other services, advises health insurers on performance and quality programs.&lt;/p&gt;&lt;p&gt;Several co-authors were employees of the Hawaii Medical Service Association, and officials of the group reviewed the manuscript before submission. But the authors declared that the association had no influence on the study design, analysis, or results reported. No other potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_287"
                     title="COLUMN: Outliers: The Story of Success"
                     score="0.003"
                     href="http://www.medpagetoday.com/Columns/18148?impressionId=1265757011369"
                     
      &lt;p&gt;Popular author Malcolm Gladwell has become something of a fixture on the healthcare speaking circuit and it&apos;s easy to understand why. Taken collectively, his books go further than most in explaining the factors that influence and facilitate societal change.&lt;/p&gt;
&lt;p&gt;In his groundbreaking book, &lt;em&gt;The Tipping Point&lt;/em&gt;, Gladwell challenged  --  and eventually changed  --  the way we understand the world. He contends that one imaginative person applying a well-placed lever can move the world.&lt;/p&gt;
&lt;p&gt;His second book, &lt;em&gt;Blink&lt;/em&gt;, examined the power of intuition and its influence on our thinking. One concept that particularly struck me was the idea of &quot;thin slicing&quot;  --  filtering the few factors that matter from an overwhelming number of variables. In the context of medical malpractice, Gladwell advises readers to &quot;thin slice&quot; new physicians, trusting their intuition if they sense a physician is not listening to them.&lt;/p&gt;
&lt;p&gt;Gladwell has done it again! His newest book, &lt;em&gt;Outliers&lt;/em&gt;, is destined to transform the way we understand success.&lt;/p&gt;
&lt;p&gt;In &lt;em&gt;Outliers&lt;/em&gt;, Gladwell explains the extraordinary success of the Beatles and Bill Gates in the context of generation, family, culture, and class. The lives of these Outliers  --  people whose achievements fall outside normal experience  --  actually follow a peculiar and unexpected logic, suggesting that context and background matter a great deal.&lt;/p&gt;
&lt;p&gt;How does this apply to healthcare? The answer is in a chapter entitled, &quot;The Ethnic Theory of Plane Crashes.&quot;&lt;/p&gt;
&lt;p&gt;In the late 1990s, Korean Air was internationally admonished following a series of dramatic cockpit failures and subsequent crashes. Multiple investigations led to the same conclusion: poor cockpit communication, rooted in deep cultural barriers, led to circumstances that became deadly.&lt;/p&gt;
&lt;p&gt;The chapter discusses three important messages regarding communication: mitigation, crew resource management (CRM), and a concept known as the power distance index (PDI).&lt;/p&gt;
&lt;p&gt;Mitigation is a term used by linguists to describe an attempt to downplay or sugarcoat the meaning of what is being said. According to Gladwell, &quot;We mitigate when we&apos;re being polite, when we are ashamed or embarrassed, and when we are being deferential to authority.&quot;&lt;/p&gt;
&lt;p&gt;Although mitigation may be appropriate or even desirable in some situations, it can be disastrous in a cockpit on a stormy night, or an operating room or trauma bay. For the past 15 years, combating mitigation has been a major crusade in commercial aviation.&lt;/p&gt;
&lt;p&gt;Gladwell contends that the unprecedented decline in airline accidents in recent years is attributable, in part, to this war on mitigation.&lt;/p&gt;
&lt;p&gt;CRM training is designed to teach junior crew members how to communicate clearly and assertively in order to reduce dangerous mitigation. Airlines teach copilots how to challenge the pilot if he or she thinks something is going awry.&lt;/p&gt;
&lt;p&gt;For example, the copilot might begin with &quot;Captain, I&apos;m concerned about...,&quot; then proceed to &quot;Captain, I&apos;m uncomfortable with...,&quot; and if the Captain still doesn&apos;t respond, &quot;Captain, I believe this situation is unsafe.&quot;&lt;/p&gt;
&lt;p&gt;Today, CRM is also playing a major role in efforts to improve healthcare quality and safety.&lt;/p&gt;
&lt;p&gt;One staunch proponent is John Nance, a decorated Vietnam pilot, attorney, and author of &lt;em&gt;Why Hospitals Should Fly&lt;/em&gt;, a clever book depicting a fictional hospital wherein the tenets of CRM have been completely internalized by the administrative leadership, medical staff, and all front-line caretakers.&lt;/p&gt;
&lt;p&gt;The third key communication concept outlined in &lt;em&gt;Outliers&lt;/em&gt;, PDI, is one aspect of a model developed by Dutch psychologist, Geert Hofstede. It is rooted in cross-cultural psychology and concerns attitudes toward hierarchy, especially those relating to how much a particular culture values and respects authority.&lt;/p&gt;
&lt;p&gt;In cultures with low PDI, power holders try to underplay their power. In cultures with high PDI, the leader&apos;s authority is unassailable.&lt;/p&gt;
&lt;p&gt;Gladwell relates the impact of Hofstede&apos;s findings on aviation industry research. Their battle over mitigated speech and teamwork was actually an attempt to reduce power distance in the cockpit! He notes that Hofstede&apos;s work &quot;suggested something that had not occurred to anyone in the aviation world; that the task of convincing first officers to assert themselves was going to depend ... on their culture&apos;s power distance rating.&quot;&lt;/p&gt;
&lt;p&gt;So, what does PDI have to do with healthcare? I think that lowering the PDI  --  by means as simple as introducing one another and referring to one another by first names  --  can be helpful in improving communication on patient rounds, the intensive care unit, and elsewhere in the hospital setting.&lt;/p&gt;
&lt;p&gt;Surely, this may be provocative and threatening to the status quo. It might not work everywhere, but solid ethnographic research has concluded that when things go awry in a cockpit it is much easier to address a captain by his first name than by his title.&lt;/p&gt;
&lt;p&gt;I am not suggesting that we must suddenly become buddies on rounds, but knowing who is who and taking a moment to recognize everyone&apos;s role on the team would go a long way to improving communication  --  and, perhaps, clinical outcomes.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;Gladwell&apos;s books, and their provocative messages regarding how we think, challenge many of the tightly held, seemingly scientific aspects of our clinical decision-making at the bedside.&lt;/p&gt;
&lt;p&gt;But irrespective of varying reactions to &lt;em&gt;Outliers&lt;/em&gt;, I believe it would enhance our individual and collective ability to improve communication if we knew a little bit more about CRM and PDI.&lt;/p&gt;
&lt;p&gt;Maybe &lt;em&gt;Outliers&lt;/em&gt; and &lt;em&gt;Why Hospitals Should Fly&lt;/em&gt; should be required reading for every medical student and house officer as a part of the training experience.&lt;/p&gt;
&lt;p&gt;Could the way we address one another have an impact on clinical outcomes? If this is the case  --  and I believe it is  --  we should learn how to communicate appropriately in a simulated training environment so that it becomes routine in the hurly burly of everyday work.&lt;/p&gt;
&lt;p&gt;Gladwell asks why it is so difficult to acknowledge the fact that each of us comes from a culture with its own distinctive mix of strengths and weaknesses, tendencies, and predispositions. &quot;Who we are cannot be separated from where we are from  --  and when we ignore that fact, planes crash.&quot;&lt;/p&gt;
&lt;p&gt;And patients die.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Want More on Health Policy?&lt;/strong&gt; &lt;a href=&quot;http://nashhealthpolicy.blogspot.com/&quot; mce_href=&quot;http://nashhealthpolicy.blogspot.com/&quot; target=&quot;_blank&quot;&gt;Read David Nash&apos;s blog&lt;/a&gt;.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_228"
                     title="Nurses Should Have a Bigger Leadership Role in Healthcare"
                     score="0"
                     href="http://www.medpagetoday.com/PracticeManagement/StaffingScheduling/tb/18080?impressionId=1265757011369"
                     
      &lt;p&gt;Opinion leaders across a wide variety of groups think nurses should have more influence in health policy, planning, and management, according to a new Gallup survey.&lt;/p&gt;
&lt;p&gt;Although nurses are viewed as being the most valued source of health information behind physicians, survey respondents rank them as the least likely of healthcare stakeholders  --  including patients  --  to have a great deal of influence in healthcare reform over the next 10 years.&lt;/p&gt;
&lt;p&gt;This despite the fact that among the 1,504 thought leaders in academia, insurance, health services, government, industry, and the corporate world polled, 51% said nurses are very important in reducing medical errors and improving patient safety, and 50% said they are very influential in improving the quality of patient care.&lt;/p&gt;
&lt;p&gt;The major barriers to increased nurse influence, nearly 70% of respondents said, are perceptions that they are lower on the totem pole than physicians when it comes to decision-making and revenue generation.&lt;/p&gt;
&lt;p&gt;When asked what could be done to ensure that nurses take on more leadership responsibility, the first priority, respondents said, was that they make their voices heard  --  56% had said that nursing lacks a single voice in speaking on national issues. More than half of respondents also noted that there was a lack of opportunities for nurses to advance into leadership positions.&lt;/p&gt;
&lt;p&gt;The survey, conducted by Gallup for the Robert Wood Johnson Foundation, examined professional views of nursing, nursing leadership, the future of the industry, and potential barriers to leadership roles for nurses among various healthcare-related groups. It included responses from opinion leaders in academia (276), health services (253), government (253), industry (253), insurance (237), and the corporate world (232).&lt;/p&gt;
&lt;p&gt;Nine out of 10 said nurses should have more influence in increasing the quality of care and reducing medical errors.&lt;/p&gt;
&lt;p&gt;About 85% said they wanted nurses to have more influence in promoting wellness and preventive care, improving efficiency and cost, coordinating care through the healthcare system, and adjusting care to meet an aging population.&lt;/p&gt;
&lt;p&gt;Additionally, 72% thought increased nurse influence would help the healthcare system adapt to the growing change in ethnic, racial, and cultural diversity in patient populations.&lt;/p&gt;
&lt;p&gt;The opinion leaders were also asked whether they feel there is a nursing shortage in the U.S. Just over 80% said Yes and of those, only 2% said it was not a serious problem.&lt;/p&gt;
&lt;p&gt;To blame for the shortage? Respondents cited a stressful/poor work environment (44% see that as a very important reason), not enough openings in nursing schools (40%), and too many nurses leaving the profession (37%). Only 22% cited low pay as very instrumental in causing the shortage.&lt;/p&gt;

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