Academic Appointments

Program Affiliations

  • Center for Latin American Studies

Professional Education

  • Ph.D., Harvard Univeristy, Health Policy/Management (2007)
  • M.B.A., Stanford University Graduate School of Business, M.B.A. with Certificate in Public Management (1993)
  • A.B., Princeton University, English with Certificate in European Cultural Studies (1986)

2023-24 Courses

Stanford Advisees

All Publications

  • Promoting Equity, Diversity, and Inclusion in Surveys: Insights from a Patient-engaged Study to Assess Long COVID Healthcare Needs in Brazil. Journal of clinical epidemiology Caldas, B., Portela, M., Stelson, E., Singer, S., Amaral, T., Amaral, C., Escosteguy, C., Martins, M., Tavares de Andrade, C. L., Soares, L., Cornish, F., Rosenthal, M., Aveling, E. L. 2024: 111423


    Long COVID (LC) refers to persistent symptoms after acute COVID-19 infection, which may endure for months or years. LC affects millions of people globally, with substantial impacts on quality of life, employment, and social participation. Ensuring access to effective, patient-centered care for LC demands evidence, grounded in inclusive representation of those affected by the condition. Yet survey studies frequently under-represent people with the most disabling disease presentations and racially and socio-economically marginalized groups. We aimed to describe a patient-engaged approach to developing a survey to inform public LC healthcare, and to assess its implementation in terms of enabling participation by diverse LC patients in Brazil.Survey development was iterative, achieved through an interdisciplinary collaboration among researchers including people living with LC, and grounded in three guiding principles: (1) evidence-based; (2) inclusive, intersectional, and patient-centered understanding of chronic illness and research participation; and (3) sensitivity to the context of healthcare access.The product of our collaboration was a longitudinal survey using a questionnaire assessing: LC symptoms; their clinical and functional evolution; and impacts on quality of life, household income, health service access, utilization, and out-of-pocket expenses. We illustrate how we operationalized our three principles through survey content, instrument design, and administration. 651 participants with diverse LC symptoms, demography, and socio-economic status completed the survey. We successfully included participants experiencing disabling symptoms, Black and mixed race participants, and those with lower education and income.By centering patient experience, our novel, principles-based approach succeeded in promoting equity, diversity, and inclusion in LC survey research. These principles guiding patient-engaged collaboration have broad transferability. We encourage survey researchers working on chronic illness and in other contexts of marginalization and inequality to adopt them.

    View details for DOI 10.1016/j.jclinepi.2024.111423

    View details for PubMedID 38880435

  • Crisis leadership behaviors in healthcare: survey validation and influence on staff outcomes in primary care clinics during the COVID-19 pandemic. BMC health services research Yang, M., Evans, J. M., Singer, S. J., Gutberg, J., Porter, T. H., Grudniewicz, A. 2024; 24 (1): 590


    The COVID-19 pandemic triggered an unprecedented transition from in-person to virtual delivery of primary health care services. Leaders were at the helm of the rapid changes required to make this happen, yet outcomes of leaders' behaviours were largely unexplored. This study (1) develops and validates the Crisis Leadership and Staff Outcomes (CLSO) Survey and (2) investigates the leadership behaviours exhibited during the transition to virtual care and their influence on select staff outcomes in primary care.We tested the CLSO Survey amongst leaders and staff from four Community Health Centres in Ontario, Canada. The CLSO Survey measures a range of crisis leadership behaviors, such as showing empathy and promoting learning and psychological safety, as well as perceived staff outcomes in four areas: innovation, teamwork, feedback, and commitment to change. We conducted an exploratory factor analysis to investigate factor structure and construct validity. We report on the scale's internal consistency through Cronbach's alpha, and associations between leadership scales and staff outcomes through odds ratios.There were 78 staff and 21 middle and senior leaders who completed the survey. A 4-factor model emerged, comprised of the leadership behaviors of (1) "task-oriented leadership" and (2) "person-oriented leadership", and select staff outcomes of (3) "commitment to sustaining change" and (4) "performance self-evaluation". Scales exhibited strong construct and internal validity. Task- and person-oriented leadership behaviours positively related to the two staff outcomes.The CLSO Survey is a reliable measure of leadership behaviours and select staff outcomes. Our results suggest that crisis leadership is multifaceted and both person-oriented and task-oriented leadership behaviours are critical during a crisis to improve perceived staff performance and commitment to change.

    View details for DOI 10.1186/s12913-024-11061-5

    View details for PubMedID 38715045

    View details for PubMedCentralID PMC11075262

  • More isn't always better: Technology in the intensive care unit HEALTH CARE MANAGEMENT REVIEW Olsen, E., Novikov, Z., Sakata, T., Lambert, M. H., Lorenzo, J., Bohn, R., Singer, S. J. 2024; 49 (2): 127-138


    Clinical care in modern intensive care units (ICUs) combines multidisciplinary expertise and a complex array of technologies. These technologies have clearly advanced the ability of clinicians to do more for patients, yet so much equipment also presents the possibility for cognitive overload.The aim of this study was to investigate clinicians' experiences with and perceptions of technology in ICUs.We analyzed qualitative data from 30 interviews with ICU clinicians and frontline managers within four ICUs.Our interviews identified three main challenges associated with technology in the ICU: (a) too many technologies and too much data; (b) inconsistent and inaccurate technologies; and (c) not enough integration among technologies, alignment with clinical workflows, and support for clinician identities. To address these challenges, interviewees highlighted mitigation strategies to address both social and technical systems and to achieve joint optimization.When new technologies are added to the ICU, they have potential both to improve and to disrupt patient care. To successfully implement technologies in the ICU, clinicians' perspectives are crucial. Understanding clinicians' perspectives can help limit the disruptive effects of new technologies, so clinicians can focus their time and attention on providing care to patients.As technology and data continue to play an increasingly important role in ICU care, everyone involved in the design, development, approval, implementation, and use of technology should work together to apply a sociotechnical systems approach to reduce possible negative effects on clinical care for critically ill patients.

    View details for DOI 10.1097/HMR.0000000000000398

    View details for Web of Science ID 001174535500008

    View details for PubMedID 38393982

  • The Lancet Psychiatry Commission: transforming mental health implementation research. The lancet. Psychiatry McGinty, E. E., Alegria, M., Beidas, R. S., Braithwaite, J., Kola, L., Leslie, D. L., Moise, N., Mueller, B., Pincus, H. A., Shidhaye, R., Simon, K., Singer, S. J., Stuart, E. A., Eisenberg, M. D. 2024

    View details for DOI 10.1016/S2215-0366(24)00040-3

    View details for PubMedID 38552663

  • Engaging Interdisciplinary Innovation Teams in Federally Qualified Health Centers. Medical care research and review : MCRR Jung, O. S., Satterstrom, P., Singer, S. J. 2024: 10775587241235244


    To foster bottom-up innovations, health care organizations are leveraging interdisciplinary frontline innovation teams. These teams include workers across hierarchical levels and professional backgrounds, pooling diverse knowledge sources to develop innovations that improve patient and worker experiences and care quality, equity, and costs. Yet, these frontline innovation teams experience barriers, such as time constraints, being new to innovation, and team-based role hierarchies. We investigated the practices that such teams in federally qualified health centers (FQHCs) used to overcome these barriers. Our 20-month study of two FQHC innovation teams provides one of the first accounts of how practices that sustained worker engagement in innovation and supported their ideas to implementation evolve over time. We also show the varied quantity of engagement practices used at different stages of the innovation process. At a time when FQHCs face pressure to innovate amid staff shortages, our study provides recommendations to support their work.

    View details for DOI 10.1177/10775587241235244

    View details for PubMedID 38450441

  • Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Amat, M. J., Anderson, T. S., Shafiq, U., Sternberg, S. B., Salant, T., Fernandez, L., Schiff, G. D., Aronson, M. D., Benneyan, J. C., Singer, S. J., Graham, K. L., Phillips, R. S. 2024; 50 (3): 177-184


    A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure.This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure.Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups.Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.

    View details for DOI 10.1016/j.jcjq.2023.10.005

    View details for Web of Science ID 001200044000001

    View details for PubMedID 37996308

  • Variation in Hospital Neuraxial Labor Analgesia Rates in California. Anesthesiology Parameshwar, P., Guo, N., Bentley, J., Main, E., Singer, S. J., Peden, C. J., Morris, T., Ansari, J., Butwick, A. J. 2024


    Neuraxial analgesia provides effective pain relief during labor. However, it is unclear whether neuraxial analgesia prevalence differs across US hospitals. Our aim was to assess hospital variation in neuraxial analgesia prevalence in California.A retrospective cross-sectional study analyzed birthing patients who underwent labor in 200 California hospitals from 2016 to 2020. The primary exposure was the delivery hospital. The outcomes were hospital neuraxial analgesia prevalence and between-hospital variability, before and after adjustment for patient and hospital factors. Median odds ratio and intraclass correlation coefficients (ICC) quantified between-hospital variability. The median odds ratio estimated the odds of a patient receiving neuraxial analgesia when moving between hospitals. The ICC quantified the proportion of the total variance in neuraxial analgesia use due to variation between hospitals.Among 1,510,750 patients who underwent labor, 1,040, 483 (68.9%) received neuraxial analgesia. Both unadjusted and adjusted hospital prevalence exhibited a skewed distribution characterized by a long-left tail. The unadjusted and adjusted prevalence at the 1 st percentile were 5.4% and 6.0%; 5 th percentile were 21.0% and 21.2%; 50 th percentile were 70.6% and 70.7%; 95 th percentile were 75.8% and 76.6%; and 99 th percentile were 75.9% and 78.6%. The adjusted median odds ratio (2.3; 95% CI, 2.1 - 2.5) indicated a substantially increased odds of a patient receiving neuraxial analgesia if they moved from a hospital with a lower to higher odds of neuraxial analgesia. The hospital explained only a moderate portion of the overall variability in neuraxial analgesia (ICC=19.1%; 95% CI, 18.8 - 20.5%).A long left tail in the distribution and wide variation exist in the neuraxial analgesia prevalence across California hospitals, not explained by patient and hospital factors. Addressing the low prevalence among hospitals in the left tail requires exploration of the interplay between patient preferences, staffing availability, and care providers' attitudes towards neuraxial analgesia.

    View details for DOI 10.1097/ALN.0000000000004961

    View details for PubMedID 38412054

  • Innovation Diffusion Across 13 Specialties and Associated Clinician Characteristics. Advances in health care management Novikov, Z., Singer, S. J., Milstein, A. 2024; 22


    Diffusion of innovations, defined as the adoption and implementation of new ideas, processes, products, or services in health care, is both particularly important and especially challenging. One known problem with adoption and implementation of new technologies is that, while organizations often make innovations immediately available, organizational actors are more wary about adopting new technologies because these may impact not only patients and practices but also reimbursement. As a result, innovations may remain underutilized, and organizations may miss opportunities to improve and advance. As innovation adoption is vital to achieving success and remaining competitive, it is important to measure and understand factors that impact innovation diffusion. Building on a survey of a national sample of 654 clinicians, our study measures the extent of diffusion of value-enhancing care delivery innovations (i.e., technologies that not only improve quality of care but has potential to reduce care cost by diminishing waste, Faems et al., 2010) for 13 clinical specialties and identifies healthcare-specific individual characteristics such as: professional purview, supervisory responsibility, financial incentive, and clinical tenure associated with innovation diffusion. We also examine the association of innovation diffusion with perceived value of one type of care delivery innovation - artificial intelligence (AI) - for assisting clinicians in their clinical work. Responses indicate that less than two-thirds of clinicians were knowledgeable about and aware of relevant value-enhancing care delivery innovations. Clinicians with broader professional purview, more supervisory responsibility, and stronger financial incentives had higher innovation diffusion scores, indicating greater knowledge and awareness of value-enhancing, care delivery innovations. Higher levels of knowledge of the innovations and awareness of their implementation were associated with higher perceptions of the value of AI-based technology. Our study contributes to our knowledge of diffusion of innovation in healthcare delivery and highlights potential mechanisms for speeding innovation diffusion.

    View details for DOI 10.1108/S1474-823120240000022005

    View details for PubMedID 38262012

  • Safe Surgery Checklist Implementation: Associations of Management Practice and Safety Culture Change. Advances in health care management Tietschert, M., Higgins, S., Haynes, A., Sadun, R., Singer, S. J. 2024; 22


    Designing and developing safe systems has been a persistent challenge in health care, and in surgical settings in particular. In efforts to promote safety, safety culture, i.e., shared values regarding safety management, is considered a key driver of high-quality, safe healthcare delivery. However, changing organizational culture so that it emphasizes and promotes safety is often an elusive goal. The Safe Surgery Checklist is an innovative tool for improving safety culture and surgical care safety, but evidence about Safe Surgery Checklist effectiveness is mixed. We examined the relationship between changes in management practices and changes in perceived safety culture during implementation of safe surgery checklists. Using a pre-posttest design and survey methods, we evaluated Safe Surgery Checklist implementation in a national sample of 42 general acute care hospitals in a leading hospital network. We measured perceived management practices among managers (n = 99) using the World Management Survey. We measured perceived preoperative safety and safety culture among clinical operating room personnel (N = 2,380 (2016); N = 1,433 (2017)) using the Safe Surgical Practice Survey. We collected data in two consecutive years. Multivariable linear regression analysis demonstrated a significant relationship between changes in management practices and overall safety culture and perceived teamwork following Safe Surgery Checklist implementation.

    View details for DOI 10.1108/S1474-823120240000022006

    View details for PubMedID 38262013

  • Qualitative interview study of strategies to support healthcare personnel mental health through an occupational health lens. BMJ open Brown-Johnson, C., DeShields, C., McCaa, M., Connell, N., Giannitrapani, S. N., Thanassi, W., Yano, E. M., Singer, S. J., Lorenz, K. A., Giannitrapani, K. 2024; 14 (1): e075920


    Employee Occupational Health ('occupational health') clinicians have expansive perspectives of the experience of healthcare personnel. Integrating mental health into the purview of occupational health is a newer approach that could combat historical limitations of healthcare personnel mental health programmes, which have been isolated and underused.We aimed to document innovation and opportunities for supporting healthcare personnel mental health through occupational health clinicians. This work was part of a national qualitative needs assessment of employee occupational health clinicians during COVID-19 who were very much at the centre of organisational responses.This qualitative needs assessment included key informant interviews obtained using snowball sampling methods.We interviewed 43 US Veterans Health Administration occupational health clinicians from 29 facilities.This analysis focused on personnel mental health needs and opportunities, using consensus coding of interview transcripts and modified member checking.Three major opportunities to support mental health through occupational health involved: (1) expanded mental health needs of healthcare personnel, including opportunities to support work-related concerns (eg, traumatic deployments), home-based concerns and bereavement (eg, working with chaplains); (2) leveraging expanded roles and protocols to address healthcare personnel mental health concerns, including opportunities in expanding occupational health roles, cross-disciplinary partnerships (eg, with employee assistance programmes (EAP)) and process/protocol (eg, acute suicidal ideation pathways) and (3) need for supporting occupational health clinicians' own mental health, including opportunities to address overwork/burn-out with adequate staffing/resources.Occupational health can enact strategies to support personnel mental health: to structurally sustain attention, use social cognition tools (eg, suicidality protocols or expanded job descriptions); to leverage distributed attention, enhance interdisciplinary collaboration (eg, chaplains for bereavement support or EAP) and to equip systems with resources and allow for flexibility during crises, including increased staffing.

    View details for DOI 10.1136/bmjopen-2023-075920

    View details for PubMedID 38216178

  • Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study. Journal of the American Medical Informatics Association : JAMIA Bell, S. K., Amat, M. J., Anderson, T. S., Aronson, M. D., Benneyan, J. C., Fernandez, L., Ricci, D. A., Salant, T., Schiff, G. D., Shafiq, U., Singer, S. J., Sternberg, S. B., Zhang, C., Phillips, R. S. 2024


    OBJECTIVES: The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care.MATERIALS AND METHODS: Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression.RESULTS: Among 12849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P<.001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P=.002).DISCUSSION AND CONCLUSION: Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.

    View details for DOI 10.1093/jamia/ocad250

    View details for PubMedID 38164964

  • Assessing health care leadership and management for resilience and performance during crisis: The HERO-36 HEALTH CARE MANAGEMENT REVIEW Atkinson, M., Biddinger, P. D., Chughtai, M., Hayirli, T. C., Hick, J. L., Cagliuso, N. V., Singer, S. J. 2024; 49 (1): 14-22
  • Screening for Social Determinants of Health During Primary Care and Emergency Department Encounters. JAMA network open Vilendrer, S., Thomas, S. C., Belnap, T., Burnisholz, K., Song, N., Srivastava, R., Singer, S. 2023; 6 (12): e2348646

    View details for DOI 10.1001/jamanetworkopen.2023.48646

    View details for PubMedID 38113046

    View details for PubMedCentralID PMC10731480

  • Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits. JAMA network open Zhong, A., Amat, M. J., Anderson, T. S., Shafiq, U., Sternberg, S. B., Salant, T., Fernandez, L., Schiff, G. D., Aronson, M. D., Benneyan, J. C., Singer, S. J., Phillips, R. S. 2023; 6 (11): e2343417


    Use of telehealth has increased substantially in recent years. However, little is known about whether the likelihood of completing recommended tests and specialty referrals-termed diagnostic loop closure-is associated with visit modality.To examine the prevalence of diagnostic loop closure for tests and referrals ordered at telehealth visits vs in-person visits and identify associated factors.In a retrospective cohort study, all patient visits from March 1, 2020, to December 31, 2021, at 1 large urban hospital-based primary care practice and 1 affiliated community health center in Boston, Massachusetts, were evaluated.Prevalence of diagnostic loop closure for (1) colonoscopy referrals (screening and diagnostic), (2) dermatology referrals for suspicious skin lesions, and (3) cardiac stress tests.The study included test and referral orders for 4133 patients (mean [SD] age, 59.3 [11.7] years; 2163 [52.3%] women; 203 [4.9%] Asian, 1146 [27.7%] Black, 2362 [57.1%] White, and 422 [10.2%] unknown or other race). A total of 1151 of the 4133 orders (27.8%) were placed during a telehealth visit. Of the telehealth orders, 42.6% were completed within the designated time frame vs 58.4% of those ordered during in-person visits and 57.4% of those ordered without a visit. In an adjusted analysis, patients with telehealth visits were less likely to close the loop for all test types compared with those with in-person visits (odds ratio, 0.55; 95% CI, 0.47-0.64).The findings of this study suggest that rates of loop closure were low for all test types across all visit modalities but worse for telehealth. Failure to close diagnostic loops presents a patient safety challenge in primary care that may be of particular concern during telehealth encounters.

    View details for DOI 10.1001/jamanetworkopen.2023.43417

    View details for PubMedID 37966837

    View details for PubMedCentralID PMC10652149

  • Rethinking Health and Health Care: How Clinicians and Practice Groups Can Better Promote Whole Health and Well-Being for People and Communities. The Medical clinics of North America Krist, A. H., South Paul, J. E., Hudson, S. V., Meisnere, M., Singer, S. J., Kudler, H. 2023; 107 (6): 1121-1144


    A new National Academies of Sciences, Engineering, and Medicine report, "Achieving Whole Health: A New Approach for Veterans and the Nation," redefines what it means to be healthy and creates a roadmap for health systems, including the Veterans Health Administration and the nation, to scale and spread a whole health approach to care. The report identifies 5 foundational elements for whole health care and sets 6 national, state, and local policy goals for change. This article summarizes the report, emphasizes the importance of preventive medicine, and identifies concrete actions clinicians and practices can take now to deliver whole health care.

    View details for DOI 10.1016/j.mcna.2023.06.001

    View details for PubMedID 37806727

  • The role of small, locally-owned businesses in advancing community health and health equity: a qualitative exploration in a historically Black neighborhood in the USA CRITICAL PUBLIC HEALTH Ramanadhan, S., Werts, S., Knight, C., Kelly, S., Morgan, J., Taylor, L., Singer, S., Geller, A., Aveling, E. 2023
  • A Multifaceted Intervention to Improve Teamwork on an Inpatient Pediatric Neurosurgery Service. Joint Commission journal on quality and patient safety Levoy, E., Sperber, A., Poon, D., Casazza, M., Vargas, J., Yang, S., Grant, G., Singer, S., Srinivas, N. 2023


    BACKGROUND: Increased safety reports related to interprofessional teamwork on an acute care unit at a quaternary children's hospital prompted a teamwork-focused improvement effort on the pediatric neurosurgery service.METHODS: An interprofessional workgroup was formed and met twice monthly throughout the project. A survey using modified validated items was disseminated to pediatric neurosurgery nurses, advanced practice providers (APPs), and physicians in March 2021 to identify opportunities for improvement. Structured debriefs on survey results promoted discourse on teamwork. The researchers implemented two interventions: (1) nursing-centered interprofessional education and (2) a rounding checklist before redistributing the survey in December 2021.RESULTS: Baseline and follow-up survey response rates were 84.1% (58/69) and 71.4% (50/70), respectively. Nurses at baseline perceived lower teamwork scores for 12 items compared to physicians and APPs (p < 0.05). Nurse perceptions improved after interventions in: "using 'we' rather than 'they'" (21.3% vs. 51.2% agree, p = 0.003), "I am confident that this team works effectively" (46.8% vs. 80.5%, p = 0.001), "shared understanding of each other's role on the team" (48.9% vs. 73.2% agree, p = 0.02), and "getting others on the team to listen" (46.8% vs. 75.6%, p = 0.004). Mean teamwork effectiveness improved from 4.12 to 5.25 (out of 7; p < 0.0001). Nurses ranked three interventions as most effective: interprofessional training (35/41, 85.4%), educational clinical pearls (14/41, 34.1%), and structured opportunities to discuss teamwork (10/41, 24.4%).CONCLUSION: Interprofessional training, a teamwork survey, and structured debriefing improved nurse perceptions of teamwork. Interventions targeting social components of change can improve teamwork even without process changes.

    View details for DOI 10.1016/j.jcjq.2023.08.010

    View details for PubMedID 37806797

  • The association between care integration and care quality. Health services research Aaron, M. B., Kerrissey, M., Novikov, Z., Tietschert, M. V., Scherling, A., Bahadurzada, H., Phillips, R. S., Sinaiko, A. D., Singer, S. J. 2023


    OBJECTIVE: The study aims to analyze the relationship between care integration and care quality, and to examine if the relationship varies by patient risk.DATA SOURCES AND STUDY SETTING: The key independent variables used validated measures derived from a provider survey of functional (i.e., administrative and clinical systems) and social (i.e., patient integration, professional cooperation, professional coordination) integration. Survey responses represented data from a stratified sample of 59 practice sites from 17 health systems. Dependent variables included three quality measures constructed from patient-level Medicare data: colorectal cancer screening among patients at risk, patient-level 30-day readmission, and a practice-level Healthcare Effectiveness Data and Information Set (HEDIS) composite measure of publicly reported, individual measures of ambulatory clinical quality performance.DATA COLLECTION/EXTRACTION METHOD: We obtained quality- and beneficiary-level covariate data for the 41,966 Medicare beneficiaries served by the 59 practices in our survey sample.STUDY DESIGN: We estimated hierarchical linear models to examine the association between care integration and care quality andthe moderating effect of patients' clinical risk score. We graphically visualized the moderating effects at ±1 standard deviation of our z-standardized independent and moderating variables and performed simple slope tests.PRINCIPAL FINDINGS: Our analyses uncovered a strong positive relationship between social integration, specifically patient integration, and the quality of care a patient receives (e.g., a 1-point increase in a practice's patient integration was associated with 0.31-point higher HEDIS composite score, p<0.01). Further, we documented positive and significant associations between aspects of social and functional integration on quality of care based on patient risk.CONCLUSIONS: The findings suggest social integration matters for improving the quality of care and that the relationship of integration to quality is not uniform for all patients. Policymakers and practitioners considering structural integrations of health systems should direct attention beyond structure to consider the potential for social integration to impact outcomes and how that might be achieved.

    View details for DOI 10.1111/1475-6773.14214

    View details for PubMedID 37605429

  • Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study. Frontiers in health services Hynes, D. M., Govier, D. J., Niederhausen, M., Tuepker, A., Laliberte, A. Z., McCready, H., Hickok, A., Rowneki, M., Waller, D., Cordasco, K. M., Singer, S. J., McDonald, K. M., Slatore, C. G., Thomas, K. C., Maciejewski, M., Battaglia, C., Perla, L. 2023; 3: 1211577


    For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients' needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients' full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs.In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey.Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.

    View details for DOI 10.3389/frhs.2023.1211577

    View details for PubMedID 37654810

    View details for PubMedCentralID PMC10465329

  • The 'Product Environment' is an Important Driver of Health. It's Time to Measure It. American journal of health promotion : AJHP Singer, S., Downs, S. J. 2023: 8901171231195368


    Through their products and services, businesses have a meaningful impact on their customers' health. When markets reward products that induce unhealthy behaviors, like poor diet and limited physical activity, they fuel the chronic disease epidemic. For market mechanisms to reward positive, and to punish negative, influences on healthy behaviors, companies' influences will need to be measured. Inspired by the technique of health impact assessment, we propose an approach to measuring these influences, based on examining usage patterns and the activities that result from a given product or service and then mapping those experiences to a core set of health behaviors.

    View details for DOI 10.1177/08901171231195368

    View details for PubMedID 37578433

  • Ideas from the Frontline: Improvement Opportunities in Federally Qualified Health Centers. Journal of general internal medicine Jung, O. S., Begum, F., Dorbu, A., Singer, S. J., Satterstrom, P. 2023


    BACKGROUND: Engaging frontline clinicians and staff in quality improvement is a promising bottom-up approach to transforming primary care practices. This may be especially true in federally qualified health centers (FQHCs) and similar safety-net settings where large-scale, top-down transformation efforts are often associated with declining worker morale and increasing burnout. Innovation contests, which decentralize problem-solving, can be used to involve frontline workers in idea generation and selection.OBJECTIVE: We aimed to describe the ideas that frontline clinicians and staff suggested via organizational innovation contests in a national sample of 54 FQHCs.INTERVENTIONS: Innovation contests solicited ideas for improving care from all frontline workers-regardless of professional expertise, job title, and organizational tenure and excluding those in senior management-and offered opportunities to vote on ideas.PARTICIPANTS: A total of 1,417 frontline workers across all participating FQHCs generated 2,271 improvement opportunities.APPROACHES: We performed a content analysis and organized the ideas into codes (e.g., standardization, workplace perks, new service, staff relationships, community development) and categories (e.g., operations, employees, patients).KEY RESULTS: Ideas from frontline workers in participating FQHCs called attention to standardization (n=386, 17%), staffing (n=244, 11%), patient experience (n=223, 10%), staff training (n=145, 6%), workplace perks (n=142, 6%), compensation (n=101, 5%), new service (n=92, 4%), management-staff relationships (n=82, 4%), and others. Voting results suggested that staffing resources, standardization, and patient communication were key issues among workers.CONCLUSIONS: Innovation contests generated numerous ideas for improvement from the frontline. It is likely that the issues described in this study have become even more salient today, as the COVID-19 pandemic has had devastating impacts on work environments and health/social needs of patients living in low-resourced communities. Continued work is needed to promote learning and information exchange about opportunities to improve and transform practices between policymakers, managers, and providers and staff at the frontlines.

    View details for DOI 10.1007/s11606-023-08294-1

    View details for PubMedID 37460922

  • Enabling System Functionalities of Primary Care Practices for Team Dynamics in Transformation to Team-Based Care: A Qualitative Comparative Analysis (QCA). Healthcare (Basel, Switzerland) Liu, L., Chien, A. T., Singer, S. J. 2023; 11 (14)


    Team-based primary care has been shown to be an important initiative for transforming primary care to achieve whole-person care, enhance health equity, and reduce provider burnout. Organizational approaches have been explored to better implement team-based care but a thorough understanding of the role of system functions is lacking. We aimed to identify the combinations of system functionalities in primary care practices that most enable effective teamwork. We used a novel method, qualitative comparative analysis (QCA), to identify cross-case patterns in 19 primary care practices in the Harvard Academic Innovations Collaborative (AIC), an initiative for transforming primary care practices by establishing teams and implementing team-based care. QCA findings identified that primary care practices with strong team dynamics exhibited strengths in three operational care process functionalities, including management of abnormal test results, cancer screening and medication management for high-priority patients, care transitions, and in health information technology (HIT) functionality. HIT functionality alone was not sufficient to achieve the desired outcomes. System functionalities in a primary care practice that support physicians and their teams in identifying patients with urgent and complex acute illnesses requiring immediate response and care and overcoming barriers to collaboration within and across institutional settings, may be essential for sustaining strong team-based primary care.

    View details for DOI 10.3390/healthcare11142018

    View details for PubMedID 37510459

  • Awakening and breathing coordination: A mixed-methods analysis of determinants of implementation. Annals of the American Thoracic Society Olsen, G. H., Gee, P. M., Wolfe, D., Winberg, C., Carpenter, L., Jones, C., Jacobs, J. R., Leither, L., Peltan, I. D., Singer, S. J., Asch, S. M., Grissom, C. K., Srivastava, R., Knighton, A. J. 2023


    RATIONALE: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers and facilitators (implementation determinants) to consistent daily use of SAT/SBT can guide the development of implementation strategies to increase adherence to these evidence-based interventions.OBJECTIVE(S): We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system.METHODS: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January-June 2021, selecting 4 sites with varied adherence levels for semi-structured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n=55) from these four sites between October - December 2021 and performed content analysis to identify implementation determinants to SAT/SBT use.RESULTS: The 15 sites had 1901 ICU admissions receiving invasive mechanical ventilation (IMV) ≥24 hours during the measurement period. Mean IMV patient age was 58 years with median IMV duration of 5.3 days [IQR: 2.5-11.9] Coordinated SAT/SBT adherence (within two hours) was estimated at 21% systemwide (site range: 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance.CONCLUSION: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges around workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.CLINICAL TRIAL REGISTRATION: None Primary Source of Funding: National Heart, Lung, Blood Institute (U01HL159878) and the National Center for Advancing Translational Science (KL2TR002539) of the National Institutes of Health, and the National Science Foundation Future of Work at the Human Technology Frontier (#2026498).

    View details for DOI 10.1513/AnnalsATS.202212-1048OC

    View details for PubMedID 37413692

  • High-performing primary care clinics across high-need, high-cost Medicare populations. BMJ open quality Beckman, A. L., Tietschert, M., Old, A., Orav, E. J., Singer, S. J., Figueroa, J. F. 2023; 12 (3)


    BACKGROUND: To reduce spending and improve quality, some primary care clinics in the USA have focused on high-need, high-cost (HNHC) Medicare beneficiaries, which include clinically distinct subpopulations: older adults with frailty, adults under 65 years with disability and beneficiaries with major complex chronic conditions. Nationally, the extent to which primary care clinics are high-performing 'Bright Spots'-clinics that achieve favourable outcomes at lower costs across HNHC beneficiary subpopulations-is not known.OBJECTIVE: To determine the prevalence of primary care clinics that perform highly on commonly used cost or quality measures for HNHC subpopulations.DESIGN AND PARTICIPANTS: Cross-sectional study using Medicare claims data from 2014 to 2015.MAIN MEASURES: Annual spending, avoidable hospitalisations for ambulatory care-sensitive conditions, treat-and-release emergency department visits, all-cause 30-day unplanned hospital readmission rates and healthy days at home. Clinics were high performing when they ranked in the top quartile of performance for ≥4 measures for an HNHC subpopulation. 'Bright Spot' clinics were in the top quartile of performance for ≥4 measures across all the HNHC subpopulations.KEY RESULTS: A total of 2770 primary care clinics cared for at least 10 beneficiaries from each of the three HNHC subpopulations (adults under 65 with disability, older adults with frailty and beneficiaries with major complex chronic conditions). Less than 4% of clinics were high performing for each HNHC subpopulation; <0.5% of clinics were in the top quartile for all five measures for a given subpopulation. No clinics met the definition of a primary care 'Bright Spot'.CONCLUSIONS: High-performing primary care clinics that achieved favourable health outcomes or lower costs across subpopulations of HNHC beneficiaries in the Medicare programme in 2015 were rare. Efforts are needed to support primary care clinics in providing optimal care to HNHC subpopulations.

    View details for DOI 10.1136/bmjoq-2023-002271

    View details for PubMedID 37491105

  • Business-nonprofit hybrid organizing: a dynamic approach to balancing benefits and costs. Frontiers in health services Aveling, E. L., Roberts, J. E., Taylor, L. A., Bhuiya, N., Singer, S. J. 2023; 3: 1164072


    Efforts to address complex public health challenges can benefit from cross-sector collaboration, while also fostering growing business sector engagement in promoting health equity. What form business-nonprofit collaboration should take, however, is a difficult question for managers and leaders. Hybrid organizational forms, which combine for-profit and nonprofit elements within a single organization in unconventional ways, offer an innovative and potentially promising approach. Yet, while existing typologies of cross-sector collaboration have identified hybrid forms at one end of a continuum of possible forms of collaboration, these typologies do not differentiate the diversity such hybrid forms may take, and the costs and benefits of these innovative hybrid forms are poorly understood. This leaves managers interested in promoting public health through business-nonprofit hybrid organizing with limited guidance about how to maximize potential merits while mitigating drawbacks.We performed a qualitative comparative case study of three examples of business-nonprofit hybrid organizing. Data collection included 113 interviews with representatives from 42 organizations and observation of case study activities. We used thematic analysis within and across cases to characterize the form of hybrid organizing in each case and to examine benefits and costs of different forms for supporting initiatives.We identified two hybrid, collaborative forms - Appended and Blended forms. Each form had benefits and costs, the significance of which shifted over time contingent on changing strategic priorities and operating environments. Benefits and costs of particular forms become more or less important for establishing and sustaining initiatives under different conditions, requiring a dynamic view.No particular form of business-nonprofit hybrid organizing is inherently better than another. Optimizing hybrid organizing and ensuring resilient collaborations may mean allowing collaborative forms to evolve. Practitioners can manage tradeoffs between benefits and costs through an ongoing process of assessing the fit between a given collaborative form, strategic priorities, and relevant features of the operating environment. This dynamic view offers important insights for ensuring the resilience of business-nonprofit collaborative efforts to enhance public health.

    View details for DOI 10.3389/frhs.2023.1164072

    View details for PubMedID 37287498

    View details for PubMedCentralID PMC10242097

  • Factors affecting collaboration between clinical and community service organizations HEALTH CARE MANAGEMENT REVIEW Kerrissey, M. J., Singer, S. J. 2023; 48 (2): 130-139


    Collaboration between clinical and community-based social service organizations is increasingly seen as vital for preventing and managing chronic diseases but has been challenging to establish and sustain.The aim of this study was to identify organizational barriers and facilitators for clinic-community collaboration.We employed multiple methods to study a national sample of nonprofit community-based organizations that each collaborated with local clinical organizations for diabetes prevention in the United States. We used qualitative data collected longitudinally through 65 semistructured interviews from 2016 to 2017 at seven of these organizations and their clinical collaborators to understand their relationships. We employed survey data ( N = 247 with 73% response rate) to measure and explore relationships among qualitatively identified themes and collaboration performance.We documented three levels of organizational challenges to community-clinic collaboration. Interorganizational challenges pertain to facing only weakly aligned interests across organizations. Interpersonal challenges pertain to misperceptions and miscommunications that occur as frontline employees from differing organizations seek to work together. Task-related challenges pertain to the inadequacy of current processes to effectively link services across clinical and community settings. We found that bridging leadership , provisional teamwork, and learning processes helped to overcome these challenges by enabling iterative progress. Follow-up national survey results indicated that these facilitators were significantly associated with collaboration performance.Because community-clinic collaboration presents substantial interorganizational, interpersonal, and task-related challenges, financial incentives alone are likely insufficient for success.Resources that help develop capacity to work across community and clinical settings may be vital and warrant dedicated funding.

    View details for DOI 10.1097/HMR.0000000000000359

    View details for Web of Science ID 000936984100004

    View details for PubMedID 36728459

  • The ambiguity of "we": Perceptions of teaming in dynamic environments and their implications. Social science & medicine (1982) Kerrissey, M., Novikov, Z., Tietschert, M., Phillips, R., Singer, S. J. 2023; 320: 115678


    In healthcare, organizations increasingly call on clinicians and staff to team up fluidly to deliver integrated services across disciplines and settings. Yet little is known about how clinicians and staff perceive of team membership in healthcare environments where team boundaries are often ambiguous and continually shifting. We draw on the context of primary care in the United States, where fluid multi-disciplinary teamwork is commonly exhorted, to investigate the extent to which clinicians and staff perceive of various roles (e.g., physician, front desk) as members in their teams, and to identify potential implications. Using a survey fielded within 59 clinics (n=828), we find substantial variation in individuals' perceptions of the roles they consider as team members during an episode of care (e.g., mean team size=10.60 roles; standard deviation=5.09). Perceiving more expansive sets of roles as team members exhibits a positive association with performance as measured by care quality (b=0.02; p<.01) but a curvilinear association with job satisfaction. Separating an individual's perceived core (roles always perceived as part of the team) and periphery (roles sometimes perceived as part of the team), perceiving a larger core is positively associated with performance (b=0.03 p<.01). In contrast, perceiving a larger periphery is marginally negatively associated with performance (b=-0.02, p<.10). This appears to be driven by divergence from the norm perception of the core, i.e., when individuals attribute to the periphery the roles that are considered by most others to be core. Our findings suggest that individuals viewing the roles they must team with more expansively may generate higher quality output but experience a personal toll. Delivering on the ideal of team-based care in dynamic environments may require helping team members gain clarity about their teammates and implementing policies that attend to job satisfaction as team boundaries shift and expand.

    View details for DOI 10.1016/j.socscimed.2023.115678

    View details for PubMedID 36682086

  • The dynamics of integration and integrated care: An exploratory study of physician organizations HEALTH CARE MANAGEMENT REVIEW Clark, J. R., Tietschert, M., Kerrissey, M., Friedberg, M., Singer, S. J. 2023; 48 (1): 92-108


    Substantial variation exists in how well health care is integrated, even across similarly structured organizations, yet research about what physician organizations (POs) do that enables or inhibits integrated care is limited.The aim of this study was to explore the dynamics that enable POs to integrate care.We ranked a stratified sample of POs according to patient perceptions of integrated care, as measured in a survey. We interviewed professionals, patients, and family members in 10 higher and 3 lower ranked POs about the process of caring for patients with complex conditions. We derived integration-related themes from the interview data and quantified their prevalence. Using a quasi-statistical approach, we explored relationships among themes and their associations with patient perceptions of integrated care.From 6,104 coded references, we derived a set of themes representing integration perspectives, integration engagement mechanisms, and integration failures. POs experienced frequent integration failures. Higher ranked POs experienced these failures less often because of a combination of functional, interpersonal, and stakeholder engagement mechanisms, which appear to complement one another. Integration perspectives, including both people-oriented and systems-oriented mindsets, appear to play a role in generating these integration dynamics.Delivering integrated care depends on a PO's ability to limit integration failures, keeping provider attention focused on patients. Building on the attention-based view, we present a framework suggesting that this ability is a function of both integration perspectives and integration engagement mechanisms.POs interested in delivering more integrated care should employ a variety of complementary integration engagement mechanisms and facilitate these efforts by nurturing both people-oriented and system-oriented mindsets among PO decision-makers.

    View details for DOI 10.1097/HMR.0000000000000356

    View details for Web of Science ID 001141487200011

    View details for PubMedID 36305748

  • Building resilient partnerships: How businesses and nonprofits create the capacity for responsiveness. Frontiers in health services Taylor, L. A., Aveling, E., Roberts, J., Bhuiya, N., Edmondson, A., Singer, S. 2023; 3: 1155941


    Increasingly, businesses are eager to partner with nonprofit organizations to benefit their communities. In spite of good intentions, differences between nonprofit and business organizations can limit the ability of potential partnerships to respond to a changing economic and public health landscape. Using a retrospective, multiple-case study, we sought to investigate the managerial behaviors that enabled businesses and nonprofits to be themselves together in sustainable partnerships. We recruited four nonprofit-business partnerships in the Boston area to serve as cases for our study. Each was designed to address social determinants of health. We thematically analyzed qualitative data from 113 semi-structured interviews, 9 focus groups and 29.5 h of direct observations to identify organizational capacities that build resilient partnerships. Although it is common to emphasize the similarities between partners, we found that it was the acknowledgement of difference that set partnerships up for success. This acknowledgement introduced substantial uncertainty that made managers uncomfortable. Organizations that built the internal capacity to be responsive to, but not control, one another were able to derive value from their unique assets.

    View details for DOI 10.3389/frhs.2023.1155941

    View details for PubMedID 37256212

  • Computer-aided detection of polyps does not improve colonoscopist performance in a pragmatic implementation trial. Gastroenterology Ladabaum, U., Shepard, J., Weng, Y., Desai, M., Singer, S. J., Mannalithara, A. 2022

    View details for DOI 10.1053/j.gastro.2022.12.004

    View details for PubMedID 36528131

  • Lessons Learned in Implementing a Chronic Opioid Therapy Management System JOURNAL OF PATIENT SAFETY Carlile, N., Fuller, T. E., Benneyan, J. C., Bargal, B., Hunt, L., Singer, S., Schiff, G. D. 2022; 18 (8): E1142-E1149


    Opioid misuse has resulted in significant morbidity and mortality in the United States, and safer opioid use represents an important challenge in the primary care setting. This article describes a research collaborative of health service researchers, systems engineers, and clinicians seeking to improve processes for safer chronic opioid therapy management in an academic primary care center. We present implementation results and lessons learned along with an intervention toolkit that others may consider using within their organization.Using iterative improvement lifecycles and systems engineering principles, we developed a risk-based workflow model for patients on chronic opioids. Two key safe opioid use process metrics-percent of patients with recent opioid treatment agreements and urine drug tests-were identified, and processes to improve these measures were designed, tested, and implemented. Focus groups were conducted after the conclusion of implementation, with barriers and lessons learned identified via thematic analysis.Initial surveys revealed a lack of knowledge regarding resources available to patients and prescribers in the primary care clinic. In addition, 18 clinicians (69%) reported largely "inheriting" (rather than initiating) their chronic opioid therapy patients. We tracked 68 patients over a 4-year period. Although process measures improved, full adherence was not achieved for the entire population. Barriers included team structure, the evolving opioid environment, and surveillance challenges, along with disruptions resulting from the 2019 novel coronavirus.Safe primary care opioid prescribing requires ongoing monitoring and management in a complex environment. The application of a risk-based approach is possible but requires adaptability and redundancies to be reliable.

    View details for DOI 10.1097/PTS.0000000000001039

    View details for Web of Science ID 000893221400011

    View details for PubMedID 35617623

    View details for PubMedCentralID PMC9691784

  • Exploring system features of primary care practices that promote better providers' clinical work satisfaction: A qualitative comparative analysis HEALTH CARE MANAGEMENT REVIEW Liu, L., Chien, A. T., Singer, S. J. 2022; 47 (4): 360-368


    Health care delivery system features can have a profound effect on how frontline physicians and other clinical personnel in primary care practices (primary care providers [PCPs]) view the quality and safety of what they deliver and, ultimately, their clinical work satisfaction.The aim of this study was to investigate the combinations of system features (i.e., team dynamics, provider-perceived safety culture, and patient care coordination between PCPs) that are most conducive to positively enhancing PCPs' clinical work satisfaction.Nineteen Harvard-affiliated primary care practice sites participated in the Academic Innovations Collaborative 2012-2016, which aimed to establish team-based care and improve patient safety. An All-Staff Survey was administered to 854 PCPs in 2015. The survey measured provider experience of team dynamics, provider-perceived safety culture, patient care coordination between PCPs, and providers' clinical work satisfaction. We performed a qualitative comparative analysis to identify "recipes," that is, combinations of conditions necessary and sufficient for enhancing PCPs' clinical work satisfaction.Strong provider-perceived safety culture and effective team dynamics constitute sufficient conditions that, when present in practices, could best support PCPs to achieve greater clinical work satisfaction.Our findings suggest the importance of creating and sustaining a strong safety culture and of establishing and implementing highly functioning teams in primary care practices for enhancing PCPs' clinical work satisfaction.Conducting the qualitative comparative analysis provides a new perspective for informing primary care and encouraging primary care practices to pursue strategic priorities for enhancing PCPs' clinical work satisfaction and providing safe, high-quality care.

    View details for DOI 10.1097/HMR.0000000000000334

    View details for Web of Science ID 000844823900011

    View details for PubMedID 35499397

    View details for PubMedCentralID PMC9427665

  • Care teams misunderstand what most upsets patients about their care. Healthcare (Amsterdam, Netherlands) Conner, A. L., Podtschaske, B. V., Mazza, M. C., Zionts, D. L., Malcolm, E. J., Thomson, C. C., Singer, S. J., Milstein, A. 2022; 10 (4): 100657


    BACKGROUND: Negative healthcare delivery experiences can cause lasting patient distress and medical service misuse and disuse. Yet no multi-site study has examined whether care-team members understand what most upsets patients about their care.METHODS: We interviewed 373 patients and 360 care-team members in the medical oncology and ambulatory surgery clinics of 11 major healthcare organizations across six U.S. census regions. Patients deeply upset by a service-related experience (n= 99, 27%) answered questions about that experience, while care-team members (n=360) answered questions about their beliefs regarding what most upsets patients. We performed content analysis to identify memorably upsetting care (MUC) themes; a generalized estimating equation to explore whether MUC theme mention frequencies varied by participant role (care-team member vs. patient), specialty (oncology vs. surgery), facility (academic vs. community), and gender; and logistic regressions to investigate the effects of participant characteristics on individual themes.RESULTS: MUC themes included three systems issues (inefficiencies, access barriers, and facilities problems) and four care-team issues (miscommunication, neglect, coldness, and incompetence). MUC theme frequencies differed by role (all Ps<0.001), with more patients mentioning care-team coldness (OR=0.37; 95% CI, 0.23-0.60) and incompetence (OR=0.17; 95% CI, 0.09-0.31); but more care-team members mentioning system inefficiencies (OR=7.01; 95% CI, 4.31-11.40) and access barriers (OR, 5.48; 95% CI, 2.81-10.69).CONCLUSIONS: When considering which service experiences most upset patients, care-team members underestimate the impact of their own behaviors and overestimate the impact of systems issues.IMPLICATIONS: Healthcare systems should reconsider how they collect, interpret, disseminate, and respond to patient service reports.LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1016/j.hjdsi.2022.100657

    View details for PubMedID 36191489

  • Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. Journal of general internal medicine Trivedi, R. B., Rossi, F. S., Javier, S. J., Greene, L., Singer, S. J., Vanneman, M. E., Goldstein, M., Zulman, D. M. 2022


    BACKGROUND: Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions.OBJECTIVE: To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions.DESIGN: Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data.PARTICIPANTS: 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization.MAIN OUTCOME AND MEASURES: The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care.KEY RESULTS: In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30).CONCLUSIONS: Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.

    View details for DOI 10.1007/s11606-022-07705-z

    View details for PubMedID 35869316

  • A 360 degree mixed-methods evaluation of a specialized COVID-19 outpatient clinic and remote patient monitoring program. BMC primary care Vilendrer, S., Lestoquoy, A., Artandi, M., Barman, L., Cannon, K., Garvert, D. W., Halket, D., Holdsworth, L. M., Singer, S., Vaughan, L., Winget, M. 2022; 23 (1): 151


    BACKGROUND: Our goals are to quantify the impact on acute care utilization of a specialized COVID-19 clinic with an integrated remote patient monitoring program in an academic medical center and further examine these data with stakeholder perceptions of clinic effectiveness and acceptability.METHODS: A retrospective cohort was drawn from enrolled and unenrolled ambulatory patients who tested positive in May through September 2020 matched on age, presence of comorbidities and other factors. Qualitative semi-structured interviews with patients, frontline clinician, and administrators were analyzed in an inductive-deductive approach to identify key themes.RESULTS: Enrolled patients were more likely to be hospitalized than unenrolled patients (N=11/137 in enrolled vs 2/126 unenrolled, p=.02), reflecting a higher admittance rate following emergency department (ED) events among the enrolled vs unenrolled, though this was not a significant difference (46% vs 25%, respectively, p=.32). Thirty-eight qualitative interviews conducted June to October 2020 revealed broad stakeholder belief in the clinic's support of appropriate care escalation. Contrary to beliefs the clinic reduced inappropriate care utilization, no difference was seen between enrolled and unenrolled patients who presented to the ED and were not admitted (N=10/137 in enrolled vs 8/126 unenrolled, p=.76). Administrators and providers described the clinic's integral role in allowing health services to resume in other areas of the health system following an initial lockdown.CONCLUSIONS: Acute care utilization and multi-stakeholder interviews suggest heightened outpatient observation through a specialized COVID-19 clinic and remote patient monitoring program may have contributed to an increase in appropriate acute care utilization. The clinic's role securing safe reopening of health services systemwide was endorsed as a primary, if unmeasured, benefit.

    View details for DOI 10.1186/s12875-022-01734-7

    View details for PubMedID 35698064

  • Family Safety Reporting in Medically Complex Children: Parent, Staff, and Leader Perspectives. Pediatrics Khan, A., Baird, J., Kelly, M. M., Blaine, K., Chieco, D., Haskell, H., Lopez, K., Ngo, T., Mercer, A., Quinones-Perez, B., Schuster, M. A., Singer, S. J., Viswanath, K., Landrigan, C. P., Williams, D., Luff, D. 2022


    BACKGROUND AND OBJECTIVES: Despite compelling evidence that patients and families report valid and unique safety information, particularly for children with medical complexity (CMC), hospitals typically do not proactively solicit patient or family concerns about patient safety. We sought to understand parent, staff, and hospital leader perspectives about family safety reporting in CMC to inform future interventions.METHODS: This qualitative study was conducted at 2 tertiary care children's hospitals with dedicated inpatient complex care services. A research team conducted approximately 60-minute semistructured, individual interviews with English and Spanish-speaking parents of CMC, physicians, nurses, and hospital leaders. Audio-recorded interviews were translated, transcribed, and verified. Two researchers coded data inductively and deductively developed and iteratively refined the codebook with validation by a third researcher. Thematic analysis allowed for identification of emerging themes.RESULTS: We interviewed 80 participants (34 parents, 19 nurses and allied health professionals, 11 physicians, and 16 hospital leaders). Four themes related to family safety reporting were identified: (1) unclear, nontransparent, and variable existing processes, (2) a continuum of staff and leadership buy-in, (3) a family decision-making calculus about whether to report, and (4) misaligned staff and parent priorities and expectations. We also identified potential strategies for engaging families and staff in family reporting.CONCLUSIONS: Although parents were deemed experts about their children, buy-in about the value of family safety reporting among staff and leaders varied, staff and parent priorities and expectations were misaligned, and family decision-making around reporting was complex. Strategies to address these areas can inform design of family safety reporting interventions attuned to all stakeholder groups.

    View details for DOI 10.1542/peds.2021-053913

    View details for PubMedID 35615941

  • Overlooked Potential of Business-Inclusive Networks to Amplify Anchoring Activity Impact. American journal of health promotion : AJHP Werts, S., Aveling, E., Taylor, L. A., Singer, S. J., Geller, A. C., Ramanadhan, S. 2022: 8901171221085452


    Mobilizing anchor institutions to promote community health and wellbeing is gaining prominence as an approach to systems change. Anchors are often conceptualized as large, locally rooted, nonprofits that leverage their resources for local benefit. However, existing literature underemphasizes 2 opportunities to enhance the systemic impact of anchoring activity: (1) coordinated action by anchoring networks that include diverse, multi-level stakeholders-a hallmark of health promotion and (2) the potential contributions of the business sector to anchoring networks. Our perspective describes the significance of both for amplifying anchoring impact and identifies critical questions for enabling action.

    View details for DOI 10.1177/08901171221085452

    View details for PubMedID 35383468

  • Promising Strategies to Support COVID-19 Vaccination of Healthcare Personnel: Qualitative Insights from the VHA National Implementation. Journal of general internal medicine Giannitrapani, K. F., Brown-Johnson, C., Connell, N. B., Yano, E. M., Singer, S. J., Giannitrapani, S. N., Thanassi, W., Lorenz, K. A. 2022


    BACKGROUND: In August 2021, up to 30% of Americans were uncertain about taking the COVID-19 vaccine, including some healthcare personnel (HCP).OBJECTIVE: Our objective was to identify barriers and facilitators of the Veterans Health Administration (VHA) HCP vaccination program.DESIGN: We conducted key informant interviews with employee occupational health (EOH) providers, using snowball recruitment.PARTICIPANTS: Participants included 43 VHA EOH providers representing 29 of VHA's regionally diverse healthcare systems.APPROACH: Thematic analysis elucidated 5 key themes and specific strategies recommended by EOH.KEY RESULTS: Implementation themes reflected logistics of distribution (supply), addressinganyvaccine concerns orhesitancy (demand), and learning health system strategies/approaches for shared learnings. Specifically, themes included the following: (1) use interdisciplinary task forces to leverage diverse skillsets for vaccine implementation; (2) invest in processes and align resources with priorities, including creating detailed processes, addressing time trade-offs for personnel involved in vaccine clinics by suspending everything non-essential, designating process/authority to shift personnel where needed, and proactively involving leaders to support resource allocation/alignment; (3) expect and accommodate vaccine buy-in occurring over time: prepare for some HCP's slow buy-in, align buy-in facilitation with identities and motivation, and encourage word-of-mouth and hyper-local testimonials; (4) overcome misinformation with trustworthy communication: tailor communication to individuals and address COVID vaccines "in every encounter," leverage proactive institutional messaging to reinforce information, and invite bi-directional conversations about any vaccine concerns. A final overarching theme focused on learning health system needs and structures: (5) use existing and newly developed communication channels to foster shared learning across teams and sites.CONCLUSIONS: Expecting deliberation allows systems to prepare for complex distribution logistics (supply) and make room for conversations that are trustworthy, bi-directional, and identity aligned (demand). Ideally, organizations provide time for conversations that address individual concerns, foster bi-directional shared decision-making, respect HCP beliefs and identities, and emphasize shared identities as healthcare providers.

    View details for DOI 10.1007/s11606-022-07439-y

    View details for PubMedID 35260957

  • Teaming in Interdisciplinary Chronic Pain Management Interventions in Primary Care: a Systematic Review of Randomized Controlled Trials. Journal of general internal medicine Connell, N. B., Prathivadi, P., Lorenz, K. A., Zupanc, S. N., Singer, S. J., Krebs, E. E., Yano, E. M., Wong, H., Giannitrapani, K. F. 2022


    BACKGROUND: Current pain management recommendations emphasize leveraging interdisciplinary teams. We aimed to identify key features of interdisciplinary team structures and processes associated with improved pain outcomes for patients experiencing chronic pain in primary care settings.METHODS: We searched PubMed, EMBASE, and CINAHL for randomized studies published after 2009. Included studies had to report patient-reported pain outcomes (e.g., BPI total pain, GCPS pain intensity, RMDQ pain-related disability), include primary care as an intervention setting, and demonstrate some evidence of teamwork or teaming; specifically, they needed to involve at least two clinicians interacting with each other and with patients in an ongoing process over at least two timepoints. We assessed study quality with the Cochrane Risk of Bias tool. We narratively synthesized intervention team structures and processes, comparing among interventions that reported a clinically meaningful improvement in patient-reported pain outcomes defined by the minimal clinically important difference (MCID).RESULTS: We included 13 total interventions in our review, of which eight reported a clinically meaningful improvement in at least one patient-reported pain outcome. No included studies had an overall high risk of bias. We identified the role of a care manager as a common structural feature of the interventions with some clinical effect on patient-reported pain. The team processes involving clinicians varied across interventions reporting clinically improved pain outcomes. However, when analyzing team processes involving patients, six of the interventions with some clinical effect on pain relied on pre-scheduled phone calls for continuous patient follow-up.DISCUSSION: Our review suggests that interdisciplinary interventions incorporating teamwork and teaming can improve patient-reported pain outcomes in comparison to usual care. Given the current evidence, future interventions might prioritize care managers and mechanisms for patient follow-up to help bridge the gap between clinical guidelines and the implementation of interdisciplinary, team-based chronic pain care.

    View details for DOI 10.1007/s11606-021-07255-w

    View details for PubMedID 35239110

  • A Multi-site Case Study of Care Coordination Between Primary Care and Specialty Care. Medical care Charns, M. P., Benzer, J. K., McIntosh, N. M., Mohr, D. C., Singer, S. J., Gurewich, D. 2022


    BACKGROUND: Care coordination is critical for patients with multiple chronic conditions, but fragmentation of care persists. Providers' perspectives of facilitators and barriers to coordination are needed to improve care.OBJECTIVES: We sought to understand providers' perspectives on care coordination for patients having multiple chronic diseases served by multiple providers.RESEARCH DESIGN: Based upon our earlier survey of patients with multiple chronic conditions, we selected 8 medical centers having high and low coordination. We interviewed providers to identify facilitators and barriers to coordination and compare them between patient-rated high sites and low sites and between primary care (PC)-mental health (MH) and PC-medical/surgical specialty care.SUBJECTS: Physicians, nurses and other clinicians in PC, cardiology, and MH (N=102) in 8 Veterans Affairs medical centers.RESULTS: We identified warm handoffs, professional relationships, and physical proximity as facilitators, and service agreements, reporting relationships and staffing as barriers. PC-MH coordination was reported as better than PC-medical/surgical specialty coordination. Facilitators were more prevalent and barriers less prevalent in sites rated high by patients than sites rated low, and between PC-MH than between PC-specialty care.DISCUSSION: We noted that professional relationships were highly related to coordination and both affected other facilitators and barriers and were affected by them. We suggested actions to improve relationships directly, and to address other facilitators and barriers that affect relationships and coordination. Among these is the use of the Primary Care Mental Health Integration model.

    View details for DOI 10.1097/MLR.0000000000001704

    View details for PubMedID 35239562

  • Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization. Health services research Zulman, D. M., Greene, L., Slightam, C., Singer, S. J., Maciejewski, M. L., Goldstein, M. K., Vanneman, M. E., Yoon, J., Trivedi, R. B., Wagner, T., Asch, S. M., Boothroyd, D. 2022


    OBJECTIVE: To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.DATA SOURCES: Veterans Affairs (VA) and Medicare data.STUDY DESIGN: We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization.DATA EXTRACTION METHODS: We extracted data for 130,704 VA patients ≥65years old with a hospitalization risk ≥90th percentile and≥four outpatient visits in the baseline year.PRINCIPAL FINDINGS: Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI=1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).CONCLUSIONS: Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

    View details for DOI 10.1111/1475-6773.13956

    View details for PubMedID 35178702

  • Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization. Medicine Vanneman, M. E., Yoon, J., Singer, S. J., Wagner, T. H., Goldstein, M. K., Hu, J., Boothroyd, D., Greene, L., Zulman, D. M. 2022; 101 (7): e28864


    ABSTRACT: U.S. Veterans Affairs (VA) patients' multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans' use of non-VA care, including VA-purchased care ("Community Care") and Medicare.To examine the relationship between drive distance and time-key eligibility criteria for Community Care-and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care.Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran's reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility.Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk.Key explanatory variables were patients' drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria).Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05-1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care.VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.

    View details for DOI 10.1097/MD.0000000000028864

    View details for PubMedID 35363189

  • Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation. Health care management review Atkinson, M. K., Benneyan, J. C., Bambury, E. A., Schiff, G. D., Phillips, R. S., Hunt, L. S., Belleny, D., Singer, S. J. 1800


    BACKGROUND: In response to the complexity, challenges, and slow pace of innovation, health care organizations are adopting interdisciplinary team approaches. Systems engineering, which is oriented to creating new, scalable processes that perform with higher reliability and lower costs, holds promise for driving innovation in the face of challenges to team performance. A patient safety learning laboratory (lab) can be an essential aspect of fostering interdisciplinary team innovation across multiple projects and organizations by creating an ecosystem focused on deploying systems engineering methods to accomplish process redesign.PURPOSE: We sought to identify the role and activities of a learning ecosystem that support interdisciplinary team innovation through evaluation of a patient safety learning lab.METHODS: Our study included three participating learning lab project teams. We applied a mixed-methods approach using a convergent design that combined data from qualitative interviews of team members conducted as teams neared the completion of their redesign projects, as well as evaluation questionnaires administered throughout the 4-year learning lab.RESULTS: Our results build on learning theories by showing that successful learning ecosystems continually create alignment between interdisciplinary teams' activities, organizational context, and innovation project objectives. The study identified four types of alignment, interpersonal/interprofessional, informational, structural, and processual, and supporting activities for alignment to occur.CONCLUSION: Interdisciplinary learning ecosystems have the potential to foster health care improvement and innovation through alignment of team activities, project goals, and organizational contexts.PRACTICE IMPLICATIONS: This study applies to interdisciplinary teams tackling multilevel system challenges in their health care organization and suggests that the work of such teams benefits from the four types of alignment. Alignment on all four dimensions may yield best results.

    View details for DOI 10.1097/HMR.0000000000000330

    View details for PubMedID 35113043

  • Patients' Perceptions of Integrated Care Among Medicare Beneficiaries by Level of Need for Health Services. Medical care research and review : MCRR Song, N., Frean, M., Covington, C. T., Tietschert, M., Ling, E., Bahadurzada, H., Kerrissey, M., Friedberg, M., Singer, S. J. 1800: 10775587211067897


    Requirements for integrating care across providers, settings, and over time increase with patients' needs. Health care providers' ability to offer care that patients experience as integrated may vary among patients with different levels of need. We explore the variation in patients' perceptions of integrated care among Medicare beneficiaries based on the beneficiary's level of need using ordinary least square regression for each of four high-need groups: beneficiaries (a) with complex chronic conditions, (b) with frailties, (c) below 65 with disability, and (d) with any (of the first three) high needs. We control for beneficiary demographics and other factors affecting integrated care, and we conduct sensitivity analyses controlling for multiple individual chronic conditions. We find significant positive associations with level of need for provider support for self-directed care and medication and home health management. Controlling for multiple individual chronic conditions reduces effect sizes and number of significant relationships.

    View details for DOI 10.1177/10775587211067897

    View details for PubMedID 35012390

  • Volunteering Improves Employee Health and Organizational Outcomes through Bonding with Coworkers and Enhanced Identification with Employers. Journal of occupational and environmental medicine Pfeffer, J., Singer, S., Stepanek, M. 2022


    To understand the determinants and consequences of employee volunteering and possible psychological mechanisms that produce these effects.Using data from more than 50,000 responses to Britain's Healthiest Workplace survey, we employed structural equation modeling to investigate the determinants and effects of people volunteering.Company sponsorship and workplace flexibility policies increased the likelihood of individuals volunteering. Net of a number of controls, people who volunteered reported better self-reported health, less risk of depression, and higher levels of engagement and satisfaction. These results were partly explained by volunteering creating higher levels of interpersonal social bonding and greater identification with their employers.Employers should sponsor volunteer activities and provide workplace flexibility, because employees who volunteer have greater individual wellbeing and also higher levels of pro-employer outcomes such as engagement and job satisfaction.

    View details for DOI 10.1097/JOM.0000000000002485

    View details for PubMedID 35051961

  • Use of home pulse oximetry with daily short message service messages for monitoring outpatients with COVID-19: The patient's experience DIGITAL HEALTH Vaughan, L., Eggert, L. E., Jonas, A., Sung, A., Singer, S. 2021; 7: 20552076211067651


    Studies have shown COVID-19 patients may have a low oxygen saturation (SpO2) independent of visible respiratory distress, a phenomenon termed "silent hypoxia." Silent hypoxia creates uncertainty in the outpatient setting for clinicians and patients alike. In this study, we examined the potential for pulse oximeters in identifying early signs of clinical deterioration. We report descriptive results on COVID-positive patients' experiences with a comprehensive home monitoring tool comprised of home SpO2 measurements with a novel symptom-tracking short message service/text messaging application. Of patients who required hospitalization, 83% sought care as a result of low pulse oximeter readings. Nearly all patients who did not require hospitalization reported that having a pulse oximeter provided them with the confidence to stay at home. Essentially all patients found a home pulse oximeter useful. Keeping COVID-19-positive patients at home reduces the potential for disease spread and prevents unnecessary costs and strain on the healthcare system.

    View details for DOI 10.1177/20552076211067651

    View details for Web of Science ID 000731017000001

    View details for PubMedID 34925873

    View details for PubMedCentralID PMC8679026

  • Patient engagement in system redesign teams: a process of social identity. Journal of health organization and management Atkinson, M. K., Benneyan, J. C., Phillips, R. S., Schiff, G. D., Hunt, L. S., Singer, S. J. 2021; ahead-of-print (ahead-of-print)


    PURPOSE: Studies demonstrate how patient roles in system redesign teams reflect a continuum of involvement and influence. This research shows the process by which patients move through this continuum and effectively engage within redesign projects.DESIGN/METHODOLOGY/APPROACH: The authors studied members of redesign teams, consisting of 5-10 members: clinicians, systems engineers, health system staff and patient(s), from three health systems working on separate projects in a patient safety learning lab. Weekly team meetings were observed, January 2016-April 2018, 17 semi-structured interviews were conducted and findings through a patient focus group were refined. Grounded theory was used to analyze field notes and transcripts.FINDINGS: Results show how the social identity process enables patients to move through stages in a patient engagement continuum (informant, partner and active change agent). Initially, patient and team member perceptions of the patient's role influence their respective behaviors (activating, directing, framing and sharing). Subsequently, patient and team member behaviors influence patient contributions on the team, which can redefine patient and team member perceptions of the patient's role.ORIGINALITY/VALUE: As health systems grow increasingly complex and become more interested in responding to patient expectations, understanding how to effectively engage patients on redesign teams gains importance. This research investigates how and why patient engagement on redesign teams changes over time and what makes different types of patient roles valuable for team objectives. Findings have implications for how redesign teams can better prepare, anticipate and support the changing role of engaged patients.

    View details for DOI 10.1108/JHOM-02-2021-0064

    View details for PubMedID 34693670

  • Value of a value culture survey for improving healthcare quality. BMJ quality & safety Singer, S. J. 2021

    View details for DOI 10.1136/bmjqs-2021-014048

    View details for PubMedID 34625485

  • Moving Forward from COVID-19: Organizational Dimensions of Effective Hospital Emergency Management. Health security Atkinson, M. K., Cagliuso, N. V., Hick, J. L., Singer, S. J., Bambury, E. A., Hayirli, T. C., Kuznetsova, M., Biddinger, P. D. 2021


    Federal investment in emergency preparedness has increased notably since the 9/11 attacks, yet it is unclear if and how US hospital readiness has changed in the 20 years since then. In particular, understanding effective aspects of hospital emergency management programs is essential to improve healthcare systems' readiness for future disasters. The authors of this article examined the state of US hospital emergency management, focusing on the following question: During the COVID-19 pandemic, what aspects of hospital emergency management, including program components and organizational characteristics, were most effective in supporting and improving emergency preparedness and response? We conducted semistructured interviews of emergency managers and leaders at 12 urban and rural hospitals across the country. Through qualitative analysis of content derived from examination of transcripts from our interviews, we identified 7 dimensions of effective healthcare emergency management: (1) identify capable leaders; (2) assure robust institutional support; (3) design effective, tiered communications systems; (4) embrace the hospital incident command system to delineate roles and responsibilities; (5) actively promote collaboration and team building; (6) appreciate the necessity of training and exercises; and (7) balance structure and flexibility. These dimensions represent the unique and critical intersection of organizational factors and emergency management program characteristics at the core of hospital emergency preparedness and response. Extending these findings, we provide several recommendations for hospitals to better develop and sustain what we call a response culture in supporting effective emergency management.

    View details for DOI 10.1089/hs.2021.0115

    View details for PubMedID 34597182

  • Enhancing the value to users of machine learning-based clinical decision support tools: A framework for iterative, collaborative development and implementation. Health care management review Singer, S. J., Kellogg, K. C., Galper, A. B., Viola, D. 2021


    BACKGROUND: Health care organizations are integrating a variety of machine learning (ML)-based clinical decision support (CDS) tools into their operations, but practitioners lack clear guidance regarding how to implement these tools so that they assist end users in their work.PURPOSE: We designed this study to identify how health care organizations can facilitate collaborative development of ML-based CDS tools to enhance their value for health care delivery in real-world settings.METHODOLOGY/APPROACH: We utilized qualitative methods, including 37 interviews in a large, multispecialty health system that developed and implemented two operational ML-based CDS tools in two of its hospital sites. We performed thematic analyses to inform presentation of an explanatory framework and recommendations.RESULTS: We found that ML-based CDS tool development and implementation into clinical workflows proceeded in four phases: iterative solution coidentification, iterative coengagement, iterative coapplication, and iterative corefinement. Each phase is characterized by a collaborative back-and-forth process between the technology's developers and users, through which both users' activities and the technology itself are transformed.CONCLUSION: Health care organizations that anticipate iterative collaboration to be an integral aspect of their ML-based CDS tools' development and implementation process may have more success in deploying ML-based CDS tools that assist end users in their work than organizations that expect a traditional technology innovation process.PRACTICE IMPLICATIONS: Managers developing and implementing ML-based CDS tools should frame the work as a collaborative learning opportunity for both users and the technology itself and should solicit constructive feedback from users on potential changes to the technology, in addition to potential changes to user workflows, in an ongoing, iterative manner.

    View details for DOI 10.1097/HMR.0000000000000324

    View details for PubMedID 34516438

  • Public Health and Health Sector Crisis Leadership During Pandemics: A Review of the Medical and Business Literature. Medical care research and review : MCRR Sriharan, A., Hertelendy, A. J., Banaszak-Holl, J., Fleig-Palmer, M. M., Mitchell, C., Nigam, A., Gutberg, J., Rapp, D. J., Singer, S. J. 2021: 10775587211039201


    The global scale and unpredictable nature of the current COVID-19 pandemic have put a significant burden on health care and public health leaders, for whom preparedness plans and evidence-based guidelines have proven insufficient to guide actions. This article presents a review of empirical articles on the topics of "crisis leadership" and "pandemic" across medical and business databases between 2003 (since SARS) and-December 2020 and has identified 35 articles for detailed analyses. We use the articles' evidence on leadership behaviors and skills that have been key to pandemic responses to characterize the types of leadership competencies commonly exhibited in a pandemic context. Task-oriented competencies, including preparing and planning, establishing collaborations, and conducting crisis communication, received the most attention. However, people-oriented and adaptive-oriented competencies were as fundamental in overcoming the structural, political, and cultural contexts unique to pandemics.

    View details for DOI 10.1177/10775587211039201

    View details for PubMedID 34474606

  • Former Inpatient Psychiatric Patients' Past Experiences With Traditional Frontline Staff and Their Thoughts on the Benefits of Peers as Part of Frontline Staff JOURNAL OF PSYCHOSOCIAL NURSING AND MENTAL HEALTH SERVICES Shields, M. C., Trinh, N. T., Borba, C. C., Chen, R., Reddy, A. K., Singer, S. J. 2021: 1-8


    Little is known about how integrating peers into frontline staff might improve the quality of inpatient psychiatric care. In the current study, we interviewed 18 former adult patients of inpatient psychiatric facilities using semi-structured interviews. We first asked about positive and negative past experiences with traditional staff. We then asked participants to share their opinions on the potential benefits of peers as part of frontline staff. We identified themes through a joint inductive and deductive approach. Participants reported past positive experiences with traditional staff as being (a) personable and caring, (b) validating feelings and experiences, (c) de-escalating, and (d) providing agency. Past negative experiences included (a) not sharing information, (b) being inattentive, (c) not providing agency, (d) being dehumanizing/disrespectful, (e) incompetency, (f) escalating situations, and (g) being apathetic. Participants believed that peers as part of frontline staff could champion emotional needs in humanizing and nonjudgmental ways, help navigate the system, and disrupt power imbalances between staff and patients. Further research is needed to understand financial, organizational, and cultural barriers to integrating peers into frontline staff. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

    View details for DOI 10.3928/02793695-20210916-01

    View details for Web of Science ID 000752109000001

    View details for PubMedID 34590985

  • Descriptive Study of Employee Engagement With Workplace Wellness Interventions in the UK. Journal of occupational and environmental medicine Mulaney, B., Bromley-Dulfano, R., McShane, E. K., Stepanek, M., Singer, S. J. 2021; 63 (9): 719-730


    OBJECTIVE: To explore sequential steps of employee engagement in wellness interventions and the impact of wellness interventions on employee health.METHODS: Using previously collected survey data from 23,667 UK employees, we tabulated intervention availability, awareness, participation, and associated health improvement and compared engagement by participation and risk status.RESULTS: Employees' awareness of wellness interventions at their workplaces was often low (mean 43.3%, range 11.6%-82.3%). Participation was highest in diet/nutrition initiatives (94.2%) and lowest in alcohol counseling and smoking cessation interventions (2.1%). Employees with health risks were less likely than lower-risk employees to report awareness, participation, and health improvements from wellness interventions addressing the relevant health concern.CONCLUSION: Employers and policymakers should consider variation in intervention engagement as they plan and implement wellness interventions. Engaging employee populations with higher health risks requires a more targeted approach.

    View details for DOI 10.1097/JOM.0000000000002219

    View details for PubMedID 34491963

  • How Can Implementation of a Large-Scale Patient Safety Program Strengthen Hospital Safety Culture? Lessons From a Qualitative Study of National Patient Safety Program Implementation in Two Public Hospitals in Brazil. Medical care research and review : MCRR Caldas, B. d., Portela, M. C., Singer, S. J., Aveling, E. 2021: 10775587211028068


    Large-scale (e.g., national) programs could strengthen safety culture, which is foundational to patient safety, yet we know little about how to optimize this potential. In 2013, Brazil's Ministry of Health launched the National Patient Safety Program, involving hospital-level safety teams and targeted safety protocols. We conducted in-depth qualitative case studies of National Patient Safety Program implementation in two hospitals, with different readiness, to understand how program implementation affected enabling, enacting, and elaborating processes that produce and sustain safety culture. For both hospitals, external mandates were insufficient for enabling hospital-level action. Internal enabling failures (e.g., little safety-relevant senior leadership) hindered enactment (e.g., safety teams unable to institute plans). Limited enactment and weak elaboration processes (e.g., bureaucratic monitoring) failed to institutionalize protocol use and undermined safety culture. Optimizing the safety culture impact of large-scale programs requires effective multi-level enabling and capitalizing on the productive potential of interacting national- and local-level influences.

    View details for DOI 10.1177/10775587211028068

    View details for PubMedID 34253081

  • PROTECTING THE HEALTH CARE WORKFORCE DURING COVID AND BEYOND: A RAPID QUALITATIVE NEEDS ASSESSMENT OF VA EMPLOYEE OCCUPATIONAL HEALTH Brown-Johnson, C., Mccaa, M., DeShields, C., Singer, S., Lorenz, K., Yano, E., Giannitrapani, S., Thanassi, W., Giannitrapani, K. F. SPRINGER. 2021: S173
  • Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration. Medical care research and review : MCRR Kerrissey, M., Tietschert, M., Novikov, Z., Bahadurzada, H., Sinaiko, A. D., Martin, V., Singer, S. J. 2021: 10775587211024796


    More is known about the structural features of health system integration than the social features-elements of normative integration (alignment of norms) and interpersonal integration (collaboration among professionals and with patients). We surveyed practice managers and 1,360 staff and physicians at 59 practice sites within 17 health systems (828 responses; 61%). Building on prior theory, we developed and established the psychometric properties of survey measures describing normative and interpersonal integration. Normative and interpersonal integration were both consistently related to better provider experience, perceived care quality, and clinical integration (e.g., a 1-point increase in a practice's normative integration was associated with 0.53-point higher job satisfaction and 0.77-point higher perceived care quality in the practice, measured on 1 to 5 scales, p < .01). Variation in social features of integration may help explain why some health systems better integrate care, pointing to normative and interpersonal integration as potential resources for improvement.

    View details for DOI 10.1177/10775587211024796

    View details for PubMedID 34130555

  • Higher Medicare Expenditures Are Associated With Better Integrated Care as Perceived by Patients. Medical care Kerrissey, M. J., Frean, M., Traboulsi, A. A., Singer, S. J. 2021


    BACKGROUND: Integrated care that is continuous, coordinated and patient-centered is vital for Medicare beneficiaries, but its relationship to health care expenditures remains unclear.RESEARCH OBJECTIVE: This study explores-for the first time-the relationship between integrated care, as measured from the patient's perspective, and health care expenditures.METHODS: Subjects include a sample of continuously eligible fee-for-service Medicare beneficiaries (n=8807) in 2015. Analyses draw on 7 previously validated measures of patient-perceived integrated care from the 2015 Medicare Current Beneficiary Survey. These data are combined with 2015 administrative utilization data that measure health care expenditures. Relationships between patient-perceived integrated care and costs are assessed using generalized linear models with comprehensive control measures.RESULTS: Patients who perceive more integrated care have higher expenditures for many, but not all, cost categories examined. Aspects of integrated care pertaining to primary provider and specialist care are associated with higher costs in several areas (particularly inpatient costs associated with specialist knowledge of the patient). Office staff members' knowledge of the patient's medical history is associated with lower home health costs.CONCLUSIONS: Patients who experience their care as more integrated may have higher expenditures on average. Thoughtful policy choices, further research, and innovations that enable patients to perceive integrated care at lower or neutral cost are needed.

    View details for DOI 10.1097/MLR.0000000000001558

    View details for PubMedID 33989247

  • Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis. Journal of perioperative practice Lewen, M. O., Berry, J., Johnson, C., Grace, R., Glader, L., Crofton, C., Leahy, I., Pallikonda, N., Litvinova, A., Staffa, S. J., Glotzbecker, M., Emans, J., Hresko, M. T., Ellen, M., Troy, M., Singer, S. J., Ferrari, L. 2021: 1750458920962634


    AIM: To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis.METHODS: Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children's hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes.RESULTS: In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308*109/L.CONCLUSIONS: Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.

    View details for DOI 10.1177/1750458920962634

    View details for PubMedID 33826437

  • Differences in patient perceptions of integrated care among black, hispanic, and white Medicare beneficiaries. Health services research Ling, E. J., Frean, M., So, J., Tietschert, M., Song, N., Covington, C., Bahadurazada, H., Khurana, S., Garcia, L., Singer, S. J. 2021


    OBJECTIVE: This study sought to identify potential disparities among racial/ethnic groups in patient perceptions of integrated care (PPIC) and to explore how methodological differences may influence measured disparities.DATA SOURCE: Data from Medicare beneficiaries who completed the 2015 Medicare Current Beneficiary Survey (MCBS) and were enrolled in Part A benefits for an entire year.STUDY DESIGN: We used 4-point measures of eight dimensions of PPIC and assessed differences in dimensions among racial/ethnic groups. To estimate differences, we applied a "rank and replace" method using multiple regression models in three steps, balancing differences in health status among racial groups and adjusting for differences in socioeconomic status. We reran all analyses with additional SES controls and using standard multiple variable regression.DATA COLLECTION/EXTRACTION METHODS: Not applicable.PRINCIPAL FINDINGS: We found several significant differences in perceived integrated care between Black versus White (three of eight measures) and Hispanic versus White (one of eight) Medicare beneficiaries. On average, Black beneficiaries perceived more integrated support for self-care than did White beneficiaries (mean difference=0.14, SE=0.06, P=.02). Black beneficiaries perceived more integrated specialists' knowledge of past medical history than did White beneficiaries (mean difference=0.12, SE=0.06, P=.01). Black and Hispanic beneficiaries also each reported, on average, 0.18 more integrated medication and home health management than did White beneficiaries (P<.01 and P<.01). These findings were robust to sensitivity analyses and model specifications.CONCLUSIONS: There exist some aspects of care for which Black and Hispanic beneficiaries may perceive greater integrated care than non-Hispanic White beneficiaries. Further studies should test theories explaining why racial/ethnic groups perceive differences in integrated care.

    View details for DOI 10.1111/1475-6773.13637

    View details for PubMedID 33569775

  • Considering Dentists Within the Healthcare Team: a Cross-sectional, Multi-State Analysis of Primary Care Provider and Staff Perspectives. Journal of general internal medicine Ahern, J., Singer, S., Bhanja, A., Barrow, J., Kerrissey, M. 2021

    View details for DOI 10.1007/s11606-020-06564-w

    View details for PubMedID 33515193

  • Protecting the healthcare workforce during COVID-19: a qualitative needs assessment of employee occupational health in the US national Veterans Health Administration. BMJ open Brown-Johnson, C., McCaa, M. D., Giannitrapani, S., Singer, S. J., Lorenz, K. A., Yano, E. M., Thanassi, W. T., DeShields, C., Giannitrapani, K. F. 2021; 11 (10): e049134


    OBJECTIVE: Early in the COVID-19 pandemic, US Veterans Health Administration (VHA) employee occupational health (EOH) providers were tasked with assuming a central role in coordinating employee COVID-19 screening and clearance for duty, representing entirely novel EOH responsibilities. In a rapid qualitative needs assessment, we aimed to identify learnings from the field to support the vastly expanding role of EOH providers in a national healthcare system.METHODS: We employed rapid qualitative analysis of key informant interviews in a maximal variation sample on the parameters of job type, rural versus urban and provider gender. We interviewed 21 VHA EOH providers between July and December 2020. This sample represents 15 facilities from diverse regions of the USA (large, medium and small facilities in the Mid-Atlantic; medium sites in the South; large facilities in the West and Pacific Northwest).RESULTS: Five interdependent needs included: (1) infrastructure to support employee population management, including tools that facilitate infection control measures such as contact tracing (eg, employee-facing electronic health records and coordinated databases); (2) mechanisms for information sharing across settings (eg, VHA listserv), especially for changing policy and protocols; (3) sufficiently resourced staffing using detailing to align EOH needs with human resource capital; (4) connected and resourced local and national leaders; and (5) strategies to support healthcare worker mental health.Our identified facilitators for EOH assuming new challenging and dynamically changing roles during COVID-19 included: (A) training or access to expertise; (B) existing mechanisms for information sharing; (C) flexible and responsive staffing; and (D) leveraging other institutional expertise not previously affiliated with EOH (eg, chaplains to support bereavement).CONCLUSIONS: Our needs assessment highlights local and system level barriers and facilitators of EOH assuming expanded roles during COVID-19. Integrating changes both within and across systems and with alignment of human capital will enable EOH preparedness for future challenges.

    View details for DOI 10.1136/bmjopen-2021-049134

    View details for PubMedID 34607860

  • Understanding memorably negative provider care delivery experiences: Why patient experiences matter for providers. Healthcare (Amsterdam, Netherlands) Ling, E. J., Shanafelt, T. D., Singer, S. J. 2021; 9 (3): 100544


    Negative experiences contribute to provider dissatisfaction and burnout. Prior research suggests that negative experiences have greater impact on individuals than positive experiences.Interviews were conducted with surgical and oncology care providers (107 MDs, 253 non-MDs) working in 10 geographically diverse, academic and community hospitals across the U.S. Using a thematic network approach, we identified core themes describing drivers of memorably negative experiences. We applied logistic regression with adjustments for multiple comparisons to evaluate the relationship between demographic characteristics and types of experiences.We identified 13 themes from 360 experiences and from these, developed a framework describing how work culture, environment, individual factors, and patient experiences lead to memorably, negative provider experiences. Providers most frequently described negative work environment experiences (158/360) and poor communication experiences with patients and other care professionals (151/360). Across themes, one third of respondents attributed memorably negative experiences to patient experiences (119/360). Midwest providers described patient centeredness more than other providers (OR = 3.9, p < 0.001). Providers from the Northeast, MDs compared to non-MDs, and providers with 15+ years of work experience identified negative insurance-related experiences more frequently (OR = 0.2, P = 0.007; OR = 2.9, P = 0.002 OR = 4.2, P < 0.001).We offer a framework for understanding negative experiences among providers. Our study suggests that across a broad set of causes, improving patient experiences could substantially improve the negative, memorable experiences of providers.Addressing negative patient experiences may have the double benefit of improving patient care and reducing provider burnout.Level III.

    View details for DOI 10.1016/j.hjdsi.2021.100544

    View details for PubMedID 33894667

  • Moving Violations: Pairing an Illegitimate Learning Hierarchy with Trainee Status Mobility for Acquiring New Skills When Traditional Expertise Erodes ORGANIZATION SCIENCE Kellogg, K. C., Myers, J. E., Gainer, L., Singer, S. J. 2021; 32 (1): 181–209
  • "Relationship between substance use disorder (SUD) and healthcare fragmentation patterns in veterans at high-risk for hospitalization" (SW19) Rossi, F., Timko, C., Javier, S. J., Zulman, D. M., Greene, L., Singer, S., Vanneman, M. E., Goldstein, M., Trivedi, R. BMC. 2020
  • Care integration within and outside health system boundaries. Health services research Singer, S. J., Sinaiko, A. D., Tietschert, M. V., Kerrissey, M., Phillips, R. S., Martin, V., Joseph, G., Bahadurzada, H., Agniel, D. 2020; 55 Suppl 3: 1033–48


    OBJECTIVE: Examine care integration-efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them-to understand whether and at which organizational level health systems impact care quality and staff experience.DATA SOURCES: Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017-2019).STUDY DESIGN: We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression.PRINCIPAL FINDINGS: Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems-up to 38 percentage points (pp) lower (P<.001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2-pp) increase in use of evidence-based care related to 6.4-pp and 8.9-pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5-pp increase in staff job satisfaction; one SD (9.7-pp) increase in integration of social services and community resources related to a 7.0-pp increase in perceived quality of care by health systems; one SD (6.9-pp) increase in patient engagement related to a 6.4-pp increase in job satisfaction and a 4.6-pp decrease in burnout; and one SD (10.6-pp) increase in integration of diabetic eye examinations related to a 5.5-pp increase in job satisfaction (all P<.05).CONCLUSIONS: Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems.

    View details for DOI 10.1111/1475-6773.13578

    View details for PubMedID 33284521

  • Impact of Teamwork and Communication Training Interventions on Safety Culture and Patient Safety in Emergency Departments: A Systematic Review. Journal of patient safety Alsabri, M., Boudi, Z., Lauque, D., Roger, D. D., Whelan, J. S., Ostlundh, L., Allinier, G., Onyeji, C., Michel, P., Liu, S. W., Jr Camargo, C. A., Lindner, T., Slagman, A., Bates, D. W., Tazarourte, K., Singer, S. J., Toussi, A., Grossman, S., Bellou, A. 2020


    OBJECTIVES: This study aimed to narratively summarize the literature reporting on the effect of teamwork and communication training interventions on culture and patient safety in emergency department (ED) settings.METHODS: We searched PubMed, EMBASE, Psych Info CINAHL, Cochrane, Science Citation Inc, the Web of Science, and Educational Resources Information Centre for peer-reviewed journal articles published from January 1, 1988, to June 8, 2018, that assessed teamwork and communication interventions focusing on how they influence patient safety in the ED. One additional search update was performed in July 2019.RESULTS: Sixteen studies were included from 8700 screened publications. The studies' design, interventions, and evaluation methods varied widely. The most impactful ED training interventions were End-of-Course Critique, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), and crisis resource management (CRM)-based training. Crisis resource management and TeamSTEPPS CRM-based training curriculum were used in most of the studies. Multiple tools, including the Kirkpatrick evaluation model, the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture, the TeamSTEPPS Teamwork Attitudes Questionnaire, the Safety Attitudes Questionnaire, and the Communication and Teamwork Skills Assessment, were used to assess the impact of such interventions. Improvements in one of the domains of safety culture and related domains were found in all studies. Four empirical studies established improvements in patient health outcomes that occurred after simulation CRM training (Kirkpatrick 4), but there was no effect on mortality.CONCLUSIONS: Overall, teamwork and communication training interventions improve the safety culture in ED settings and may positively affect patient outcome. The implementation of safety culture programs may be considered to reduce incidence of medical errors and adverse events.

    View details for DOI 10.1097/PTS.0000000000000782

    View details for PubMedID 33890752

  • Employers' Role in Employee Health: Why They Do What They Do. Journal of occupational and environmental medicine Singer, S. J., Vilendrer, S., Joseph, G., Kim, J., Pfeffer, J. 2020


    OBJECTIVE: Employers affect the health of employees and their families through work environments and employee benefits. We sought to understand employer decisions around those topics.METHODS: Interviews with 21 executives from diverse, purposely-sampled, progressive companies with transcripts analyzed using inductive and deductive methods.RESULTS: Companies often viewed keeping employees healthy primarily as a means to profitability rather than an end in itself and rationalized stressful workplaces as necessary and non-changeable. Many possible actions including job redesign and changing benefits administrators were seen as infeasible. Even large, resource-rich organizations were strikingly nonagentic.CONCLUSIONS: Companies seem less committed to the goal of increasing employee health than they claim or than they should be, given the significant relationship between employee health and economic performance, and see external and internal barriers to improving health that are often self-created.

    View details for DOI 10.1097/JOM.0000000000001967

    View details for PubMedID 32769791

  • A Mixed Methods Study of the Association of Non-Veterans Affairs Care With Veterans' and Clinicians' Experiences of Care Coordination. Medical care Benzer, J. K., Gurewich, D., Singer, S. J., McIntosh, N. M., Mohr, D. C., Vimalananda, V. G., Charns, M. P. 2020; 58 (8): 696–702


    BACKGROUND: Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination.OBJECTIVE: The objective of this study was to determine VA patients' and clinicians' experiences of coordination across VA and non-VA settings.DESIGN: Observational mixed methods using patient surveys and clinician interviews. Sampled patients were diagnosed with type 2 diabetes mellitus and either cardiovascular or mental health comorbidities.PARTICIPANTS AND MEASURES: Patient perspectives on coordination were elicited between April and September 2016 through a national survey supplemented with VA administrative records (N=5372). Coordination was measured with the 8-dimension Patient Perceptions of Integrated Care survey. Receipt of non-VA care was measured through patient self-report. Clinician perspectives were elicited through individual interviews (N=100) between May and October 2017.RESULTS: Veterans who received both VA and non-VA care reported significantly worse care coordination experiences than Veterans who only receive care in VA. Clinicians report limited information exchange capabilities, which, combined with bureaucratic and opaque procedures, adversely impact clinical decision-making.CONCLUSIONS: VA is working through a shift in how Veterans receive health care by increasing access to care from non-VA providers. Study findings suggest that VA should prioritize coordination of care in addition to access. This could include requiring monitoring of patient-experienced care coordination, surveys of referring and consulting clinicians, and pilot testing and evaluation of interventions to improve coordination.

    View details for DOI 10.1097/MLR.0000000000001338

    View details for PubMedID 32692135

  • OUTPATIENT CARE FRAGMENTATION PATTERNS AND ASSOCIATION WITH HOSPITALIZATION IN HIGH-RISK VA PATIENTS Zulman, D. M., Greene, A. L., Wagner, T. H., Maciejewski, M., Singer, S., Slightam, C., Trivedi, R., Vanneman, M., Asch, S., Yoon, J., Goldstein, M. K., Boothroyd, D. SPRINGER. 2020: S216
  • Working around hierarchy: Resident and medical assistant teaming HEALTH CARE MANAGEMENT REVIEW Brooks, J., Sheridan, B., Peters, A. S., Chien, A. T., Singer, S. J. 2020; 45 (3): 232–44
  • A Comprehensive Theory of Integration MEDICAL CARE RESEARCH AND REVIEW Singer, S. J., Kerrissey, M., Friedberg, M., Phillips, R. 2020; 77 (2): 196–207
  • World Health Organization Surgical Safety Checklist Modification: Do Changes Emphasize Communication and Teamwork? JOURNAL OF SURGICAL RESEARCH Solsky, I., Berry, W., Edmondson, L., Lagoo, J., Baugh, J., Blair, A., Singer, S., Haynes, A. B. 2020; 246: 614–22
  • Parent Perspectives on Short-Term Recovery After Spinal Fusion Surgery in Children With Neuromuscular Scoliosis. Journal of patient experience Garrity, B. M., Singer, S. J., Ward, E. n., Bastianelli, L. n., Berry, J. G., Crofton, C. n., Glader, L. n., Casto, E. L., Cox, J. E. 2020; 7 (6): 1369–77


    Family perspectives on short-term recovery after spinal fusion for neuromuscular scoliosis are essential for improving patient outcomes. Semistructured interviews were conducted with 18 families of children within 3 months after spinal fusion performed August 2017 to January 2019 at a children's hospital. Interviews were recorded, transcribed, and coded line-by-line by 2 independent reviewers using grounded theory to identify themes. Five themes emerged among families when reflecting back on the postoperative recovery: (1) communicating and making shared decisions regarding postoperative care in a patient- and family-centered manner, (2) setting hospital discharge goals and being ready for discharge, (3) planning for transportation from hospital to home, (4) acquiring supports for caregiving at home after discharge, and (5) anticipating a long recovery at home. Important family perceptions were elicited about the recovery of children from spinal fusion for neuromuscular scoliosis that will inform better perioperative planning for clinicians, future patients, and their families.

    View details for DOI 10.1177/2374373520972570

    View details for PubMedID 33457589

    View details for PubMedCentralID PMC7786685

  • Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates. Inquiry : a journal of medical care organization, provision and financing Nguyen, K. H., Chien, A. T., Meyers, D. J., Li, Z., Singer, S. J., Rosenthal, M. B. 2020; 57: 46958020952911


    Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P=.02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices' successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

    View details for DOI 10.1177/0046958020952911

    View details for PubMedID 32844691

  • Managing Organizational Constraints in Innovation Teams: A Qualitative Study Across Four Health Systems. Medical care research and review : MCRR Atkinson, M. K., Singer, S. J. 2020: 1077558720925993


    Though increasingly useful for developing complex healthcare innovations, interdisciplinary teams are prone to resistance and other organizational challenges. However, how teams are affected by and manage external constraints over the lifecycle of their innovation project is not well understood. We used a multimethod qualitative approach consisting of over 3 years of participant observation data to analyze how four interdisciplinary teams across different health systems experienced and managed constraints as they pursued process innovations. Specifically, we derived the constraint management process, which demonstrates how teams address constraints at different stages of innovation by applying various tactics. Our findings point to several practical implications concerning innovation processes in healthcare: (a) how conditions in the organizational context, or constraints, can impede team progress at different stages of innovation; and (2) the collective efforts, or tactics, teams use to manage or work around these constraints to further progress on their innovations.

    View details for DOI 10.1177/1077558720925993

    View details for PubMedID 32552540

  • Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-For-Service. Medical care Frean, M. n., Covington, C. n., Tietschert, M. n., Bahadurzada, H. n., So, J. n., Singer, S. J. 2020


    Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare.To characterize patient experiences of integrated care within Medicare and identify whether MA or ACO beneficiaries perceive greater integration than FFS beneficiaries.Retrospective cross-sectional analysis of the 2015 Medicare Current Beneficiary Survey.Nationally representative sample of 11,978 Medicare beneficiaries.Main outcomes included 8 previously derived domains of patient-perceived integrated care (PPIC), measured on a scale of 1-4.The final sample was 55% female with a mean (SD) age of 71.1 (11.3). In unadjusted analyses, we observed considerable variation across PPIC domains in the full sample, but little variation across subsamples defined by coverage type within a given PPIC domain. In linear models adjusting for a rich set of patient characteristics, we observe no significant benefits of ACOs nor MA relative to FFS, a finding which is robust to alternative specifications and adjustment for multiple comparisons. We similarly observed no benefits in subgroup analyses restricted to states with relatively high market penetration of ACOs or MA.Despite characteristics of ACOs and MA that theoretically promote integrated care, we find that PPIC is largely similar across coverage types in Medicare.

    View details for DOI 10.1097/MLR.0000000000001463

    View details for PubMedID 33273291

  • Can Organisational Culture of Teams Be a Lever for Integrating Care? An Exploratory Study. International journal of integrated care Tietschert, M. V., Angeli, F., van Raak, A. J., Clark, J., Singer, S. J., Ruwaard, D. 2019; 19 (4): 10


    Introduction: Organisational culture is believed to be an important facilitator for better integrated care, yet how organisational culture impacts integrated care remains underspecified. In an exploratory study, we assessed the relationship between organisational culture in primary care centres as perceived by primary care teams and patient-perceived levels of integrated care.Theory and methods: We analysed a sample of 2,911 patient responses and 17 healthcare teams in four primary care centres. We used three-level ordered logistic regression models to account for the nesting of patients within health care teams within primary care centres.Results: Our results suggest a non-linear relationship between organisational culture at the team level and integrated care. A combination of different culture types-including moderate levels of production-oriented, hierarchical and team-oriented cultures and low or high levels of adhocracy cultures-related to higher patient-perceived levels of integrated care.Conclusions and discussion: Organisational culture at the level of healthcare teams has significant associations with patient-perceived integrated care. Our results may be valuable for primary care organisations in their efforts to compose healthcare teams that are predisposed to providing better integrated care.

    View details for DOI 10.5334/ijic.4681

    View details for PubMedID 31871439

  • Intentional or Not: Teamwork Learning at Primary Care Clinics. Medical science educator Brooks, J. V., Chien, A. T., Singer, S. J., Peters, A. S. 2019; 29 (4): 969-975


    Primary care teamwork has been shown to increase satisfaction and decrease stress for physicians but the impact of outpatient teamwork for primary care residents' learning has not been described. This study aimed to understand the role of teamwork in residents' learning during and after the establishment of teams.Interviews with 37 primary care residents addressed their experiences at outpatient clinic, including their perceptions about whether team-based care affected their educational experience. Using qualitative thematic analysis, transcripts were coded to identify themes about teamwork and learning, both positive and negative.Residents described learning both about and through teamwork at continuity clinic, despite variation in the speed and extent of initial integration into teams. As residents learned how to work on a team, they realized the importance of face-to-face time together and trusting one another. Team members also taught residents about the clinical system and social aspects of patient care, as well as some procedural skills, which led them to understand how teamwork can improve patient care and efficiency. Finally, residents learned, through both optimal and suboptimal first-hand team experiences, to see team-based care as a model for future primary care practice.While integrating residents into primary care teams, educators should consider the potential value of teamwork as an intentional learning method. Team members, beyond the preceptor, can offer valuable instruction, and team-based workplace learning prepares residents to use teamwork to optimize care for patients.

    View details for DOI 10.1007/s40670-019-00784-4

    View details for PubMedID 34457573

    View details for PubMedCentralID PMC8368961

  • A Mixed Methods Study of Change Processes Enabling Effective Transition to Team-Based Care. Medical care research and review : MCRR Kyle, M. A., Aveling, E., Singer, S. 2019: 1077558719881854


    Team-based care is considered central to achieving value in primary care, yet results of large-scale primary care transformation initiatives have been mixed. We explore how underlying change processes influence the effectiveness of transition to team-based care. We studied 12 academically affiliated primary care practices participating in a learning collaborative, using longitudinal staff survey data to measure progress toward team-based care and qualitative interviews with practice staff to understand practice transformation. Transformation efforts focused on team formation and capacity building for quality improvement. Using thematic analysis, we explored types of change processes undertaken and the relationship between change processes and effective team-based care. We identified three prototypical approaches to change: pursuing functional and cultural change processes, functional only, and cultural only. Practice sites prioritizing both change processes formed the most effective teams: simultaneous functional and cultural change spurred a mutually reinforcing virtuous cycle. We describe implications for research, practice, and policy.

    View details for DOI 10.1177/1077558719881854

    View details for PubMedID 31610742

  • Toward a Corporate Culture of Health: Results of a National Survey. The Milbank quarterly Kyle, M. A., Seegars, L., Benson, J. M., Blendon, R. J., Huckman, R. S., Singer, S. J. 2019


    Policy Points The private sector has large potential influence over social determinants of health, but we have limited information about how businesses perceive or engage in actions to promote health and well-being. We conducted a national survey of more than 1,000 businesses of varying sizes and industries to benchmark private sector engagement in employee, environmental, consumer, and community health, which we collectively refer to as a corporate culture of health. Overall, the private sector is taking steps to foster health and well-being but still has substantial opportunity for growth.CONTEXT: The private sector has a large potential role in advancing health and well-being, but attention to corporate practices around health tends to focus on a narrow range of issues and on large businesses. Systematically describing private sector engagement in health and well-being is a necessary step toward understanding the current state of the field and developing an agenda for businesses going forward.METHODS: We conducted a national survey of 1,017 private sector organizations to assess current levels of engagement in what we term a culture of health (CoH). We measured corporate CoH along four dimensions, which assess the extent to which businesses promote employee, environmental, consumer, and community health and well-being. We also explored potential explanations for the number of health-related actions taken in each dimension.FINDINGS: On average, businesses took 38% of health-related actions included in our survey. For each dimension, we found variation among businesses in the number of actions taken (on average, there were almost fourfold differences between the bottom and top quartiles of businesses in terms of actions taken). Mentioning health and well-being in the corporate mission, having a strategic plan for CoH, and perceiving a positive return on CoH investments were all associated with businesses' actions taken. Fewer than half of businesses, however, perceived a positive return on their CoH investments.CONCLUSIONS: Overall, the private sector is taking steps to foster health and well-being. However, there remains substantial variation among businesses and opportunity for growth, even among those currently taking the most action. Strengthening the business case for a corporate CoH may increase private sector investments in health and well-being. Actions taken by individual businesses, business groups, industries, and regulators have the potential to improve corporate engagement and impact.

    View details for DOI 10.1111/1468-0009.12418

    View details for PubMedID 31502327

  • Pediatric complex care and surgery comanagement: Preparation for spinal fusion. Journal of child health care : for professionals working with children in the hospital and community Berry, J. G., Glaspy, T., Eagan, B., Singer, S., Glader, L., Emara, N., Cox, J., Glotzbecker, M., Crofton, C., Ward, E., Leahy, I., Salem, J., Troy, M., O'Neill, M., Johnson, C., Ferrari, L. 2019: 1367493519864741


    The aim of this study is to assess the impact of preoperative comanagement with complex care pediatricians (CCP) on children with neuromuscular scoliosis undergoing spinal fusion. We performed chart review of 79 children aged 5-21 years undergoing spinal fusion 1/2014-6/2016 at a children's hospital, with abstraction of clinical documentation from preoperative health evaluations performed regularly by anesthesiologists and irregularly by a CCP. Preoperative referrals to specialists, labs, tests, and care plans needed last minute for surgical clearance were measured. The mean age at surgery was 14 (SD 3) years; cerebral palsy (64%) was the most common neuromuscular condition. Thirty-nine children (49%) had a preoperative CCP evaluation a median 63 days (interquartile range (IQR) 33-156) before the preanesthesia visit. Children with CCP evaluation had more organ systems affected by coexisting conditions than children without an evaluation (median 11 (IQR 9-12) vs. 8 (IQR 5-11); p < .001). The rate of last-minute care coordination activities required for surgical clearance was lower for children with versus without CCP evaluation (1.8 vs. 3.6). A lower percentage of children with CCP evaluation required last-minute development of new preoperative plans (26% vs. 50%, p = .002). Children with CCP involvement were better prepared for surgery, requiring fewer last-minute care coordination activities for surgical clearance.

    View details for DOI 10.1177/1367493519864741

    View details for PubMedID 31359785

  • Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study JOURNAL OF GENERAL INTERNAL MEDICINE Pace, L. E., Percac-Lima, S., Nguyen, K. H., Crofton, C. N., Normandin, K. A., Singer, S. J., Rosenthal, M. B., Chien, A. T. 2019; 34 (7): 1146–53
  • Optimizing patient partnership in primary care improvement: A qualitative study. Health care management review Alidina, S., Martelli, P. F., Singer, S. J., Aveling, E. 2019


    BACKGROUND: The need to expand and better engage patients in primary care improvement persists.PURPOSE: Recognizing a continuum of forms of engagement, this study focused on identifying lessons for optimizing patient partnerships, wherein engagement is characterized by shared decision-making and practice improvement codesign.METHODOLOGY: Twenty-three semistructured interviews with providers and patients involved in improvement efforts in seven U.S. primary care practices in the Academic Innovations Collaborative (AIC). The AIC aimed to implement primary care improvement, emphasizing patient engagement in the process. Data were analyzed thematically.RESULTS: Sites varied in their achievement of patient partnerships, encountering material, technical, and sociocultural obstacles. Time was a challenge for all sites, as was engaging a diversity of patients. Technical training on improvement processes and shared learning "on the job" were important. External, organizational, and individual-level resources helped overcome sociocultural challenges: The AIC drove provider buy-in, a team-based improvement approach helped shift relationships from providers and recipients toward teammates, and individual qualities and behaviors that flattened hierarchies and strengthened interpersonal relationships further enhanced "teamness." A key factor influencing progress toward transformative partnerships was a strong shared learning journey, characterized by frequent interactions, proximity to improvement decision-making, and learning together from the "lived experience" of practice improvement. Teams came to value not only patients' knowledge but also changes wrought by working collaboratively over time.CONCLUSION: Establishing practice improvement partnerships remains challenging, but partnering with patients on improvement journeys offers distinctive gains for high-quality patient-centered care.PRACTICE IMPLICATIONS: Engaging diverse patient partners requires significant disruption to organizational norms and routines, and the trend toward team-based primary care offers a fertile context for patient partnerships. Material, technical, and sociocultural resources should be evaluated not only for whether they overcome specific challenges but also for how they enhance the shared learning journey.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

    View details for DOI 10.1097/HMR.0000000000000250

    View details for PubMedID 31135618

  • Organizational Coordination and Patient Experiences of Specialty Care Integration. Journal of general internal medicine Mohr, D. C., Benzer, J. K., Vimalananda, V. G., Singer, S. J., Meterko, M., McIntosh, N., Harvey, K. L., Seibert, M. N., Charns, M. P. 2019


    BACKGROUND: Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes.OBJECTIVE: Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists.DESIGN: Cross-sectional surveys of patients and primary care providers (PCPs).PARTICIPANTS: Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder.MAIN MEASURES: Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient's specialty services used with corresponding PCP ratings of that specialty.KEY RESULTS: Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b=-.20; b=-.17, respectively) or rated feedback coordination lower (b=-.08 for both). Teamwork was significantly related to specialist knowledge management (b=.06), knowledge integration (b=.04); and knowledge fragmentation (b=-.04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b=.09) and (ii) mental health provider (b=.12).CONCLUSIONS: Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness.

    View details for DOI 10.1007/s11606-019-04973-0

    View details for PubMedID 31098971

  • Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study. Journal of general internal medicine Pace, L. E., Percac-Lima, S., Nguyen, K. H., Crofton, C. N., Normandin, K. A., Singer, S. J., Rosenthal, M. B., Chien, A. T. 2019


    BACKGROUND: Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions.OBJECTIVES: To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion.DESIGN: A retrospective cohort study using explicit chart abstraction methods.PARTICIPANTS: Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016.MAIN MEASURES: Rates and timing of test ordering and completion and patterns of visits and communications.KEY RESULTS: At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p<0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1month, versus 31% of patients with rectal bleeding (p<0.01). By 1year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists.LIMITATIONS: The study relied on documented care, and findings may be most generalizable to academically affiliated institutions.CONCLUSIONS: Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.

    View details for PubMedID 31011969

  • Predicting Postoperative Physiologic Decline After Surgery. Pediatrics Berry, J. G., Johnson, C., Crofton, C., Staffa, S. J., DiTillio, M., Leahy, I., Salem, J., Rangel, S. J., Singer, S. J., Ferrari, L. 2019


    BACKGROUND: Projecting postoperative recovery in pediatric surgical patients is challenging. We assessed how the patients' number of complex chronic conditions (CCCs) and chronic medications interacted with active health issues to influence the likelihood of postoperative physiologic decline (PoPD).METHODS: A prospective study of 3295 patients undergoing elective surgery at a freestanding children's hospital. During preoperative clinical evaluation, active health problems, CCCs, and medications were documented. PoPD (compromise of cardiovascular, respiratory, and/or neurologic systems) was measured prospectively every 4 hours by inpatient nurses. PoPD odds were estimated with multivariable logistic regression. Classification and regression tree analysis distinguished children with the highest and lowest likelihood of PoPD.RESULTS: Median age at surgery was 8 years (interquartile range: 2-15); 2336 (70.9%) patients had a CCC; and 241 (7.3%) used ≥11 home medications. During preoperative evaluation, 1556 (47.2%) patients had ≥1 active health problem. After surgery, 882 (26.8%) experienced PoPD. The adjusted odds of PoPD were 1.2 (95% confidence interval [CI]: 1.0-1.4) for presence versus absence of an active health problem; 1.4 (95% CI: 1.0-1.9) for ≥11 vs 0 home medications; and 2.2 (95% CI: 1.7-2.9) for ≥3 vs 0 CCCs. In classification and regression tree analysis, the lowest rate of PoPD (8.6%) occurred in children without an active health problem at the preoperative evaluation; the highest rate (57.2%) occurred in children with a CCC who used ≥11 home medications.CONCLUSIONS: Greater than 1 in 4 pediatric patients undergoing elective surgery experienced PoPD. Combinations of active health problems at preoperative evaluation, polypharmacy, and multimorbidity distinguished patients with a low versus high risk of PoPD.

    View details for PubMedID 30824493

  • Parent-to-Parent Advice on Considering Spinal Fusion in Children with Neuromuscular Scoliosis. The Journal of pediatrics Garrity, B. n., Berry, J. n., Crofton, C. n., Ward, E. n., Cox, J. n., Glader, L. n., Bastianelli, L. n., Emans, J. n., Glotzbecker, M. n., Emara, N. n., Salem, J. n., Jabur, T. n., Higgins, S. n., Shapiro, J. n., Singer, S. n. 2019


    To convey advice from families whose children recently underwent spinal fusion to families whose children are under consideration for initial spinal fusion for neuromuscular scoliosis and to providers who counsel families on this decision.We interviewed 18 families of children who underwent spinal fusion between August 2017 and January 2019 at a freestanding children's hospital. We conducted phone interviews a median of 65 (IQR 51-77) days after surgery. We audio recorded, transcribed, and coded (line-by-line) interviews using grounded theory by 2 independent reviewers, and discussed among investigators to induce themes associated with surgical decision making and preparation.Six themes emerged about decision making and preparation for spinal fusion: (1) simplify risks and benefits; it is easy to get lost in the details; (2) families prolonging the decision whether or not to pursue spinal fusion surgery may not benefit the child; (3) anticipate anxiety and fear when making a decision about spinal fusion; (4) realize that your child might experience a large amount of pain; (5) anticipate a long recovery and healing process after spinal fusion; and (6) be engaged and advocate for your child throughout the perioperative spinal fusion process.Parents of children who had recently undergone spinal fusion had strong perceptions about what information to convey to families considering surgery, which may improve communication between future parents and physicians. Further investigation is needed to assess how best to incorporate the wisdom and experiences of parent peers into shared decision making and preparation for spinal fusion in children with neuromuscular scoliosis.

    View details for DOI 10.1016/j.jpeds.2019.05.055

    View details for PubMedID 31253410

  • Incorporating Theory into Practice: Reconceptualizing Exemplary Care Coordination Initiatives from the US Veterans Health Delivery System. Journal of general internal medicine McDonald, K. M., Singer, S. J., Gorin, S. S., Haggstrom, D. A., Hynes, D. M., Charns, M. P., Yano, E. M., Lucatorto, M. A., Zulman, D. M., Ong, M. K., Axon, R. N., Vogel, D. n., Upton, M. n. 2019


    This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.

    View details for DOI 10.1007/s11606-019-04969-w

    View details for PubMedID 31098965

  • Health Care Coordination Theoretical Frameworks: a Systematic Scoping Review to Increase Their Understanding and Use in Practice. Journal of general internal medicine Peterson, K. n., Anderson, J. n., Bourne, D. n., Charns, M. P., Gorin, S. S., Hynes, D. M., McDonald, K. M., Singer, S. J., Yano, E. M. 2019


    Care coordination is crucial to avoid potential risks of care fragmentation in people with complex care needs. While there are many empirical and conceptual approaches to measuring and improving care coordination, use of theory is limited by its complexity and the wide variability of available frameworks. We systematically identified and categorized existing care coordination theoretical frameworks in new ways to make the theory-to-practice link more accessible.To identify relevant frameworks, we searched MEDLINE®, Cochrane, CINAHL, PsycINFO, and SocINDEX from 2010 to May 2018, and various other nonbibliographic sources. We summarized framework characteristics and organized them using categories from the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. Based on expert input, we then categorized available frameworks on consideration of whether they addressed contextual factors, what locus they addressed, and their design elements. We used predefined criteria for study selection and data abstraction.Among 4389 citations, we identified 37 widely diverse frameworks, including 16 recent frameworks unidentified by previous reviews. Few led to development of measures (39%) or initiatives (6%). We identified 5 that are most relevant to primary care. The 2018 framework by Weaver et al., describing relationships between a wide range of primary care-specific domains, may be the most useful to those investigating the effectiveness of primary care coordination approaches. We also identified 3 frameworks focused on locus and design features of implementation that could prove especially useful to those responsible for implementing care coordination.This review identified the most comprehensive frameworks and their main emphases for several general practice-relevant applications. Greater application of these frameworks in the design and evaluation of coordination approaches may increase their consistent implementation and measurement. Future research should emphasize implementation-focused frameworks that better identify factors and mechanisms through which an initiative achieves impact.

    View details for DOI 10.1007/s11606-019-04966-z

    View details for PubMedID 31098976

  • Business Strategies to Promote Health-Reply. JAMA Koh, H. K., Singer, S. J., Edmondson, A. C. 2019; 321 (21): 2134

    View details for DOI 10.1001/jama.2019.2803

    View details for PubMedID 31162565

  • Understanding Maternity Care Coordination for Women Veterans Using an Integrated Care Model Approach. Journal of general internal medicine Mattocks, K. M., Kroll-Desrosiers, A. n., Kinney, R. n., Singer, S. n. 2019


    An increasing number of women veterans are using VA maternity benefits for their pregnancies. However, because the VA does not offer obstetrical care, women must seek maternity care from non-VA providers. The growing number of women using non-VA care has increased the importance of understanding how this care is integrated with ongoing VA medical and mental health services and how perceptions of care integration impact healthcare utilization. Therefore, we sought to understand these relationships among a sample of postpartum veterans utilizing VA maternity benefits.We fielded a modified version of the Patient Perceptions of Integrated Care survey among a sample of postpartum veterans who had utilized VA maternity benefits for their pregnancies (n = 276). We assessed relationships between perceptions of six domains of patient-reported integrated care, indicating how well-integrated patients perceived the care received from VA and non-VA clinicians, and utilization of mental healthcare following pregnancy.Domain scores were highest for items focused on VA care, including test result communication and VA provider's knowledge of patient's medical conditions. Scores were lower for obstetrician's knowledge of patient's medical history. Women with depressive symptom scores indicative of depression rated test result communication as highly integrated, while women who received mental healthcare following pregnancy had low integrated care ratings for the Support for Medication and Home Health Management domain, indicating a lack of support for mental health conditions following pregnancy.Among a group of postpartum veterans, poor ratings of integrated care across some domains were associated with higher rates of mental healthcare use following pregnancy. Further assessment of integrated care by patients may assist VA providers and policymakers in developing systems to ensure integrated care for veterans who receive care outside the VA.

    View details for DOI 10.1007/s11606-019-04974-z

    View details for PubMedID 31098973

  • Survey of Patient-Centered Coordination of Care for Diabetes with Cardiovascular and Mental Health Comorbidities in the Department of Veterans Affairs. Journal of general internal medicine Benzer, J. K., Singer, S. J., Mohr, D. C., McIntosh, N. n., Meterko, M. n., Vimalananda, V. G., Harvey, K. L., Seibert, M. N., Charns, M. P. 2019


    Multiple comorbidities thought to be associated with poor coordination due to the need for shared treatment plans and active involvement of patients, among other factors. Cardiovascular and mental health comorbidities present potential coordination challenges relative to diabetes.To determine how cardiovascular and mental health comorbidities relate to patient-centered coordinated care in the Department of Veterans Affairs.This observational study used a 2 × 2 factorial design to determine how cardiovascular and mental health comorbidities are associated with patient perceptions of coordinated care among patients with type 2 diabetes mellitus as a focal condition.Five thousand eight hundred six patients attributed to 262 primary care providers, from a national sample of 29 medical centers, who had completed an online survey of patient-centered coordinated care in the Department of Veterans Affairs (VA).Eight dimensions from the Patient Perceptions of Integrated Care (PPIC) survey, a state-of-the-art measure of patients' perspective on coordinated and patient-centered care.Mental health conditions were associated with significantly lower patient experiences of coordinated care. Hypotheses for disease severity were not supported, with associations in the hypothesized direction for only one dimension.Results suggest that VA may be adequately addressing coordination needs related to cardiovascular conditions, but more attention could be placed on coordination for mental health conditions. While specialized programs for more severe conditions (e.g., heart failure and serious mental illness) are important, coordination is also needed for more common, less severe conditions (e.g., hypertension, depression, anxiety). Strengthening coordination for common, less severe conditions is particularly important as VA develops alternative models (e.g., community care) that may negatively impact the degree to which care is coordinated.

    View details for DOI 10.1007/s11606-019-04979-8

    View details for PubMedID 31098975

  • Consumers' Suggestions for Improving the Mental Healthcare System: Options, Autonomy, and Respect. Community mental health journal Shields, M. n., Scully, S. n., Sulman, H. n., Borba, C. n., Trinh, N. H., Singer, S. n. 2019


    While the mental healthcare-consumer voice has gained in legitimacy and perceived value, policy initiatives and system improvements still lack input from consumers. This study explores consumers' suggestions for improving the mental healthcare system. Participants (N = 46) were conveniently recruited and responded to an online survey asking: "What are your suggestions for improving the mental healthcare system?" Eight themes were identified using iterative, inductive and deductive coding. Themes included treatment options, autonomy and empowerment, respect and relationships, medication management, peer support, insurance and access, funding and government support, and treatment environment. Theoretically, there is interdependence among themes where five of the themes are foundational for the three main themes (i.e. treatment options, autonomy and empowerment, respect and relationships). Findings suggest that consumers see the need for improvement in patient-centered care. While access is the focus of much mental healthcare policy discussions, the ultimate goal should be provisioning person-centered mental healthcare.

    View details for DOI 10.1007/s10597-019-00423-7

    View details for PubMedID 31175515

  • Health as a Way of Doing Business. JAMA Koh, H. K., Singer, S. J., Edmondson, A. C. 2018

    View details for PubMedID 30520939

  • Relationship among team dynamics, care coordination and perception of safety culture in primary care FAMILY PRACTICE Blumenthal, K. J., Chien, A. T., Singer, S. J. 2018; 35 (6): 718–23


    There remains a need to improve patient safety in primary care settings. Studies have demonstrated that creating high-performing teams can improve patient safety and encourage a safety culture within hospital settings, but little is known about this relationship in primary care.To examine how team dynamics relate to perceptions of safety culture in primary care and whether care coordination plays an intermediating role.This is a cross-sectional survey study with 63% response (n = 1082).The study participants were attending clinicians, resident physicians and other staff who interacted with patients from 19 primary care practices affiliated with Harvard Medical School.Three domains corresponding with our main measures: team dynamics, care coordination and safety culture. All items were measured on a 5-point Likert scale. We used linear regression clustered by practice site to assess the relationship between team dynamics and perceptions of safety culture. We also performed a mediation analysis to determine the extent to which care coordination explains the relationship between perceptions of team dynamics and of safety culture.For every 1-point increase in overall team dynamics, there was a 0.76-point increase in perception of safety culture [95% confidence interval (CI) 0.70-0.82, P < 0.001]. Care coordination mediated the relationship between team dynamics and the perception of safety culture.Our findings suggest there is a relationship between team dynamics, care coordination and perceptions of patient safety in a primary care setting. To make patients safer, we may need to pay more attention to how primary care providers work together to coordinate care.

    View details for PubMedID 29788350

  • Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients. JAMA internal medicine Meyers, D. J., Chien, A. T., Nguyen, K. H., Li, Z., Singer, S. J., Rosenthal, M. B. 2018


    Importance: Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions.Objective: To evaluate the association of establishing team-based primary care with patient health care use and costs.Design, Setting, and Participants: We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018.Exposures: Practices participated in a 4-year learning collaborative that created and supported team-based primary care.Main Outcomes and Measures: Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care.Results: Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n=51 155 [37.0%] vs n=186 954 [46.6%]), more participants younger than 18 years (n=337 931 [27.5%] vs n=74 691 [18.6%]), higher Medicaid enrollment (n=39 541 [28.6%] vs n=81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P<.001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P=.03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P=.007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P=.009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P<.001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P=.003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P=.02).Conclusions and Relevance: While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.

    View details for PubMedID 30476951

  • Scaling Safety: The South Carolina Surgical Safety Checklist Experience. Health affairs (Project Hope) Berry, W. R., Edmondson, L., Gibbons, L. R., Childers, A. K., Haynes, A. B., Foster, R., Singer, S. J., Gawande, A. A. 2018; 37 (11): 1779–86


    Proven patient safety solutions such as the World Health Organization's Surgical Safety Checklist are challenging to implement at scale. A voluntary initiative was launched in South Carolina hospitals in 2010 to encourage use of the checklist in all operating rooms. Hospitals that reported completing implementation of the checklist in their operating rooms by 2017 had significantly higher levels of CEO and physician participation and engaged more in higher-touch activities such as in-person meetings and teamwork skills trainings than comparison hospitals did. Based on our experience and the participation data collected, we suggest three considerations for hospital, hospital association, state, and national policy makers: Successful programs must be designed to engage all stakeholders (CEOs, physicians, nurses, surgical technologists, and others); offering a variety of program activities-both lower-touch and higher-touch-over the duration of the program allows more hospital and individual participation; and change takes time and resources.

    View details for PubMedID 30395507

  • WHO Surgical Safety Checklist Modification: DoChanges Emphasize Communication andTeamwork? The Journal of surgical research Solsky, I., Berry, W., Edmondson, L., Lagoo, J., Baugh, J., Blair, A., Singer, S., Haynes, A. B. 2018


    BACKGROUND: The World Health Organization's (WHO) surgical safety checklist is meant to be customized to facilitate local implementation, encourage full-team participation, and promote a culture of safety. Although it has been globally adopted, little is known about the extent of checklist modification and the type of changes made.METHODS: Nonsubspecialty surgical checklists were obtained through online search and targeted hospital requests. A detailed coding scheme was created to capture modifications to checklist content and formatting. Descriptive statistics were performed.RESULTS: Of 155 checklists analyzed, all were modified. Compared with the WHO checklist, those in our sample contained more lines of text (median: 63 [interquartile range: 50-73] versus 56) and items (36 [interquartile range: 30-43] versus 28). A median of 13 new items were added. Items most frequently added included implants/special equipment (added by 84%), deep vein thrombosis prophylaxis/anticoagulation (added by 75%), and positioning (added by 63%). Checklists removed a median of 5 WHO items. The most frequently removed item was the pulse oximeter check (removed in 75%), followed by 4 items (each removed in 39%-48%) that comprise part of the WHO Checklist's "Anticipated Critical Events" section, which is intended for exchanging critical information. The surgeon was not explicitly mentioned in the checklist in 12%; the anesthesiologist/certified registered nurse anesthetist in 14%, the circulator in 10%, and the surgical tech/scrub in 79%.CONCLUSIONS: Checklists are highly modified but often enlarged with items that may not prompt discussion or teamwork. Of concern is the frequent removal of items from the WHO's "Anticipated Critical Events" section.

    View details for PubMedID 30528925

  • Working around hierarchy: Resident and medical assistant teaming. Health care management review Brooks, J. V., Sheridan, B., Peters, A. S., Chien, A. T., Singer, S. J. 2018


    BACKGROUND: In health care, hierarchy can facilitate getting work done efficiently. It can also hinder performance by suppressing valuable contributions from lower-positioned individuals. Team-based care could mitigate negative effects by creating space for all team members to contribute their unique expertise.PURPOSE: This article sought to understand how resident-medical assistant (MA) dyads interacted before and after primary care clinics transitioned to team-based care. We also studied how they negotiated changes in interpersonal dynamics given the challenge these changes presented to hierarchical norms.METHODOLOGY: We conducted two qualitative interview studies, with 37 residents and 30 MAs at primary care clinics transitioning to team-based care. Interviews were transcribed, coded, and analyzed together using a thematic networks approach and focused coding.RESULTS: An intervention that promoted teamwork prompted resident-MA dyads to change their interactions to counter traditional hierarchy. Residents increasingly asked MAs questions about patient care, and MAs initiated interactions and volunteered ideas more frequently. We also found that MAs and residents expressed some discomfort with the hierarchical ambiguity that their new interactions produced and used alternate scripts to buffer this discomfort and to collaborate as teammates despite formal hierarchy.CONCLUSION: Among resident-MA dyads, a team-based care intervention changed interpersonal dynamics by blurring hierarchical lines and shifting traditional boundaries in ways that were uncomfortable for both groups. They were able to work around discomfort by using new scripts that downplayed the threat to hierarchy.PRACTICE IMPLICATIONS: Organizational structures that encourage greater interprofessional collaboration may neutralize barriers that formal hierarchy in medicine can pose for effective teamwork, but this process can also bring social discomfort. Our findings suggest that health care professionals may use microlevel strategies, such as alternative scripts, to overcome formal hierarchies without openly engaging them. Together, new organizational structures and interaction techniques can help professionals work around hierarchy and improve team performance.

    View details for PubMedID 30299383

  • Successfully implementing Safety WalkRounds: secret sauce more than a magic bullet BMJ QUALITY & SAFETY Singer, S. J. 2018; 27 (4): 251–53

    View details for PubMedID 29440482

  • Establishing Teams: How Does It Change Practice Configuration, Size, and Composition? The Journal of ambulatory care management Chien, A. T., Kyle, M. A., Peters, A. S., Nguyen, K. H., Tendulkar, S. A., Ryan, M., Hacker, K., Singer, S. J. 2018; 41 (2): 146–55


    Little is known about how practices reorganize when transitioning from traditional practice organization to team-based care. We compared practice-level (1) configuration as well as practice- and team-level (2) size and (3) composition, before and after establishing teams. We employed a pre-/poststudy using personnel lists of 1571 to 1711 staff (eg, job licenses, titles, and team assignment) and practice manager surveys. All personnel (physician and nonphysician) worked within 18 Massachusetts academic primary care practices participating in a 2-year learning collaborative aimed at establishing team-based care. We found that establishing team-based care can involve changing practice configurations and composition without substantially changing practice size.

    View details for DOI 10.1097/JAC.0000000000000229

    View details for PubMedID 29474254

  • A Comprehensive Theory of Integration. Medical care research and review : MCRR Singer, S. J., Kerrissey, M., Friedberg, M., Phillips, R. 2018: 1077558718767000


    Efforts to transform health care delivery to improve care have increasingly focused on care integration. However, variation in how integration is defined has complicated efforts to design, synthesize, and compare studies of integration in health care. Evaluations of integration initiatives would be enhanced by describing them according to clear definitions of integration and specifying which empirical relationships they seek to test-whether among types of integration or between integration and outcomes of care. Drawing on previous work, we present a comprehensive theoretical model of relationships between types of integration and propose how to measure them.

    View details for PubMedID 29606036

  • Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers. Implementation science : IS Alidina, S. n., Goldhaber-Fiebert, S. N., Hannenberg, A. A., Hepner, D. L., Singer, S. J., Neville, B. A., Sachetta, J. R., Lipsitz, S. R., Berry, W. R. 2018; 13 (1): 50


    Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management during unexpected and rare events. While implementation strategies for innovations such as cognitive aids for routine use are becoming better understood, cognitive aids that are rarely used are not yet well understood. We examined organizational context and implementation process factors influencing the use of cognitive aids for OR crises.We conducted a cross-sectional study using a Web-based survey of individuals who had downloaded OR cognitive aids from the websites of Ariadne Labs or Stanford University between January 2013 and January 2016. In this paper, we report on the experience of 368 respondents from US hospitals and ambulatory surgical centers. We analyzed the relationship of more successful implementation (measured as reported regular cognitive aid use during applicable clinical events) with organizational context and with participation in a multi-step implementation process. We used multivariable logistic regression to identify significant predictors of reported, regular OR cognitive aid use during OR crises.In the multivariable logistic regression, small facility size was associated with a fourfold increase in the odds of a facility reporting more successful implementation (p = 0.0092). Completing more implementation steps was also significantly associated with more successful implementation; each implementation step completed was associated with just over 50% higher odds of more successful implementation (p ≤ 0.0001). More successful implementation was associated with leadership support (p < 0.0001) and dedicated time to train staff (p = 0.0189). Less successful implementation was associated with resistance among clinical providers to using cognitive aids (p < 0.0001), absence of an implementation champion (p = 0.0126), and unsatisfactory content or design of the cognitive aid (p = 0.0112).Successful implementation of cognitive aids in ORs was associated with a supportive organizational context and following a multi-step implementation process. Building strong organizational support and following a well-planned multi-step implementation process will likely increase the use of OR cognitive aids during intraoperative crises, which may improve patient outcomes.

    View details for PubMedID 29580243

    View details for PubMedCentralID PMC5870083

  • Engineering safer care coordination from hospital to home: lessons from the USA. Future healthcare journal Das, P. n., Benneyan, J. n., Powers, L. n., Carmody, M. n., Kerwin, J. n., Singer, S. n. 2018; 5 (3): 164–70


    The safe transition of a patient from hospital into the community requires effective coordination between healthcare professionals across organisational boundaries. Preventing transition-associated failures can be especially challenging when multiple disciplines are involved and the patient has extensive care needs. The field of systems engineering is increasingly recognised as useful to help understand, improve and redesign such complex healthcare processes to improve patient experience and outcomes. To illustrate this approach, we describe how a partnership between healthcare professionals, systems engineers, and health services researchers used a series of engineering methods at a large suburban hospital to analyse and address deficiencies in a hospital-to-home transition process. Using this approach, the team designed a new process to perform more reliably despite inherent system complexity, demonstrating the value of systems engineering approaches and clinician-engineer collaborations.

    View details for DOI 10.7861/futurehosp.5-3-164

    View details for PubMedID 31098560

    View details for PubMedCentralID PMC6502610

  • Surgical Team Member Assessment of the Safety of Surgery Practice in 38 South Carolina Hospitals MEDICAL CARE RESEARCH AND REVIEW Singer, S. J., Jiang, W., Huang, L. C., Gibbons, L., Kiang, M. V., Edmondson, L., Gawande, A. A., Berry, W. R. 2015; 72 (3): 298-323


    We assessed surgical team member perceptions of multiple dimensions of safe surgical practice in 38 South Carolina hospitals participating in a statewide initiative to implement surgical safety checklists. Primary data were collected using a novel 35-item survey. We calculated the percentage of 1,852 respondents with strongly positive, positive, and neutral/negative responses about the safety of surgical practice, compared results by hospital and professional discipline, and examined how readiness, teamwork, and adherence related to staff perception of care quality. Overall, 78% of responses were positive about surgical safety at respondent's hospitals, but in each survey dimension, from 16% to 40% of responses were neutral/negative, suggesting significant opportunity to improve surgical safety. Respondents not reporting they would feel safe being treated in their operating rooms varied from 0% to 57% among hospitals. Surgeons responded more positively than nonsurgeons. Readiness, teamwork, and practice adherence related directly to staff perceptions of patient safety (p < .001).

    View details for DOI 10.1177/1077558715577479

    View details for Web of Science ID 000354117900004

    View details for PubMedID 25828528

  • The Surgical Safety Checklist and Teamwork Coaching Tools: a study of inter-rater reliability BMJ QUALITY & SAFETY Huang, L. C., Conley, D., Lipsitz, S., Wright, C. C., Diller, T. W., Edmondson, L., Berry, W. R., Singer, S. J. 2014; 23 (8): 639-650


    To assess the inter-rater reliability (IRR) of two novel observation tools for measuring surgical safety checklist performance and teamwork.Data surgical safety checklists can promote adherence to standards of care and improve teamwork in the operating room. Their use has been associated with reductions in mortality and other postoperative complications. However, checklist effectiveness depends on how well they are performed.Authors from the Safe Surgery 2015 initiative developed a pair of novel observation tools through literature review, expert consultation and end-user testing. In one South Carolina hospital participating in the initiative, two observers jointly attended 50 surgical cases and independently rated surgical teams using both tools. We used descriptive statistics to measure checklist performance and teamwork at the hospital. We assessed IRR by measuring percent agreement, Cohen's κ, and weighted κ scores.The overall percent agreement and κ between the two observers was 93% and 0.74 (95% CI 0.66 to 0.79), respectively, for the Checklist Coaching Tool and 86% and 0.84 (95% CI 0.77 to 0.90) for the Surgical Teamwork Tool. Percent agreement for individual sections of both tools was 79% or higher. Additionally, κ scores for six of eight sections on the Checklist Coaching Tool and for two of five domains on the Surgical Teamwork Tool achieved the desired 0.7 threshold. However, teamwork scores were high and variation was limited. There were no significant changes in the percent agreement or κ scores between the first 10 and last 10 cases observed.Both tools demonstrated substantial IRR and required limited training to use. These instruments may be used to observe checklist performance and teamwork in the operating room. However, further refinement and calibration of observer expectations, particularly in rating teamwork, could improve the utility of the tools.

    View details for DOI 10.1136/bmjqs-2013-002446

    View details for Web of Science ID 000339176900006

    View details for PubMedID 24497526

  • Safety in Numbers: The Development of Leapfrog's Composite Patient Safety Score for U.S. Hospitals. Journal of patient safety Austin, J. M., D'Andrea, G., Birkmeyer, J. D., Leape, L. L., Milstein, A., Pronovost, P. J., Romano, P. S., Singer, S. J., Vogus, T. J., Wachter, R. M. 2014; 10 (1): 64-71


    To develop a composite patient safety score that provides patients, health-care providers, and health-care purchasers with a standardized method to evaluate patient safety in general acute care hospitals in the United States.The Leapfrog Group sought guidance from a panel of national patient safety experts to develop the composite score. Candidate patient safety performance measures for inclusion in the score were identified from publicly reported national sources. Hospital performance on each measure was converted into a "z-score" and then aggregated using measure-specific weights. A reference mean score was set at 3, with scores interpreted in terms of standard deviations above or below the mean, with above reflecting better than average performance.Twenty-six measures were included in the score. The mean composite score for 2652 general acute care hospitals in the United States was 2.97 (range by hospital, 0.46-3.94). Safety scores were slightly lower for hospitals that were publicly owned, rural in location, or had a larger percentage of patients with Medicaid as their primary insurance.The Leapfrog patient safety composite provides a standardized method to evaluate patient safety in general acute care hospitals in the United States. While constrained by available data and publicly reported scores on patient safety measures, the composite score reflects the best available evidence regarding a hospital's efforts and outcomes in patient safety. Additional analyses are needed, but the score did not seem to have a strong bias against hospitals with specific characteristics. The composite score will continue to be refined over time as measures of patient safety evolve.

    View details for DOI 10.1097/PTS.0b013e3182952644

    View details for PubMedID 24080719

  • Comparing safety climate in naval aviation and hospitals: Implications for improving patient safety HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Rosen, A., Zhao, S., Ciavarelli, A. P., Gaba, D. M. 2010; 35 (2): 134-146


    Evidence of variation in safety climate suggests the need for improvement among at least some hospitals. However, comparisons only among hospitals may underestimate the improvement required. Comparison of hospitals with analogous industries may provide a broader perspective on the safety status of our nation's hospitals.The purpose of this study was to compare safety climate among hospital workers with personnel from naval aviation, an organization that operates with high reliability despite intrinsically hazardous conditions.We surveyed a random sample of health care workers in 67 U.S. hospitals and, for generalizability, 30 veterans affairs hospitals using questions comparable with those posed at approximately the same time (2007) to a census of personnel from 35 squadrons of U.S. naval aviators. We received 13,841 (41%) completed surveys in U.S. hospitals, 5,511 (50%) in veterans affairs hospitals, and 14,854 (82%) among naval aviators. We examined differences in respondents' perceptions of safety climate at their institution overall and for 16 individual items.Safety climate was three times better on average among naval aviators than among hospital personnel. Naval aviators perceived a safer climate (up to seven times safer) than hospital personnel with respect to each of the 16 survey items. Compared with hospital managers, naval commanders perceived climate more like frontline personnel did. When contrasting naval aviators with hospital personnel working in comparably hazardous areas, safety climate discrepancies increased rather than decreased. One individual hospital performed as well as naval aviation on average, and at least one hospital outperformed the Navy benchmark for all but three individual survey items.Results suggest that hospitals have not sufficiently created a uniform priority of safety. However, if each hospital performed as well as the top-performing hospital in each area measured, hospitals could achieve safety climate levels comparable with naval aviation. Major interventions to bolster hospital safety climate continue to be required to improve patient safety.

    View details for DOI 10.1097/HMR.0b013e3181c8b20c

    View details for Web of Science ID 000276557800005

    View details for PubMedID 20234220

  • Identifying organizational cultures that promote patient safety HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Falwell, A., Gaba, D. M., Meterko, M., Rosen, A., Hartmann, C. W., Baker, L. 2009; 34 (4): 300-311


    Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate.This study explored how aspects of general organizational culture relate to hospital patient safety climate.In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures.Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate.Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and reduced hierarchy, including use of multidisciplinary team training, continuous quality improvement tools, and human resource practices and policies.

    View details for Web of Science ID 000270852700002

    View details for PubMedID 19858915

  • Comparing Safety Climate between Two Populations of Hospitals in the United States HEALTH SERVICES RESEARCH Singer, S. J., Hartmann, C. W., Hanchate, A., Zhao, S., Meterko, M., Shokeen, P., Lin, S., Gaba, D. M., Rosen, A. K. 2009; 44 (5): 1563-1584


    To compare safety climate between diverse U.S. hospitals and Veterans Health Administration (VA) hospitals, and to explore the factors influencing climate in each setting.Primary data from surveys of hospital personnel; secondary data from the American Hospital Association's 2004 Annual Survey of Hospitals.Cross-sectional study of 69 U.S. and 30 VA hospitals.For each sample, hierarchical linear models used safety-climate scores as the dependent variable and respondent and facility characteristics as independent variables. Regression-based Oaxaca-Blinder decomposition examined differences in effects of model characteristics on safety climate between the U.S. and VA samples.The range in safety climate among U.S. and VA hospitals overlapped substantially. Characteristics of individuals influenced safety climate consistently across settings. Working in southern and urban facilities corresponded with worse safety climate among VA employees and better safety climate in the U.S. sample. Decomposition results predicted 1.4 percentage points better safety climate in U.S. than in VA hospitals: -0.77 attributable to sample-characteristic differences and 2.2 due to differential effects of sample characteristics.Results suggest that safety climate is linked more to efforts of individual hospitals than to participation in a nationally integrated system or measured characteristics of workers and facilities.

    View details for DOI 10.1111/j.1475-6773.2009.00994.x

    View details for Web of Science ID 000269494600008

    View details for PubMedID 19619250

    View details for PubMedCentralID PMC2754548

  • Relationship of Hospital Organizational Culture to Patient Safety Climate in the Veterans Health Administration MEDICAL CARE RESEARCH AND REVIEW Hartmann, C. W., Meterko, M., Rosen, A. K., Zhao, S., Shokeen, P., Singer, S., Gaba, D. M. 2009; 66 (3): 320-338


    Improving safety climate could enhance patient safety, yet little evidence exists regarding the relationship between hospital characteristics and safety climate. This study assessed the relationship between hospitals' organizational culture and safety climate in Veterans Health Administration (VA) hospitals nationally. Data were collected from a sample of employees in a stratified random sample of 30 VA hospitals over a 6-month period (response rate = 50%; n = 4,625). The Patient Safety Climate in Healthcare Organizations (PSCHO) and the Zammuto and Krakower surveys were used to measure safety climate and organizational culture, respectively. Higher levels of safety climate were significantly associated with higher levels of group and entrepreneurial cultures, while lower levels of safety climate were associated with higher levels of hierarchical culture. Hospitals could use these results to design specific interventions aimed at improving safety climate.

    View details for DOI 10.1177/1077558709331812

    View details for Web of Science ID 000265690500004

    View details for PubMedID 19244094

  • Relationship of Safety Climate and Safety Performance in Hospitals HEALTH SERVICES RESEARCH Singer, S., Lin, S., Falwell, A., Gaba, D., Baker, L. 2009; 44 (2): 399-421


    To examine the relationship between measures of hospital safety climate and hospital performance on selected Patient Safety Indicators (PSIs).Primary data from a 2004 survey of hospital personnel. Secondary data from the 2005 Medicare Provider Analysis and Review File and 2004 American Hospital Association's Annual Survey of Hospitals.A cross-sectional study of 91 hospitals.Negative binomial regressions used an unweighted, risk-adjusted PSI composite as dependent variable and safety climate scores and controls as independent variables. Some specifications included interpersonal, work unit, and organizational safety climate dimensions. Others included separate measures for senior managers and frontline personnel's safety climate perceptions.Hospitals with better safety climate overall had lower relative incidence of PSIs, as did hospitals with better scores on safety climate dimensions measuring interpersonal beliefs regarding shame and blame. Frontline personnel's perceptions of better safety climate predicted lower risk of experiencing PSIs, but senior manager perceptions did not.The results link hospital safety climate to indicators of potential safety events. Some aspects of safety climate are more closely related to safety events than others. Perceptions about safety climate among some groups, such as frontline staff, are more closely related than perceptions in other groups.

    View details for DOI 10.1111/j.1475-6773.2008.00918.x

    View details for Web of Science ID 000264164400006

    View details for PubMedID 19178583

    View details for PubMedCentralID PMC2677046

  • Patient Safety Climate in 92 US Hospitals Differences by Work Area and Discipline MEDICAL CARE Singer, S. J., Gaba, D. M., Falwell, A., Lin, S., Hayes, J., Baker, L. 2009; 47 (1): 23-31


    Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in hospitals would facilitate the design and implementation of interventions.To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline.We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals.We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response).The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines.Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area.Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.

    View details for Web of Science ID 000262186500004

    View details for PubMedID 19106727

  • Patient Safety Climate in US Hospitals Variation by Management Level MEDICAL CARE Singer, S. J., Falwell, A., Gaba, D. M., Baker, L. C. 2008; 46 (11): 1149-1156


    Strengthening hospital safety culture offers promise for reducing adverse events, but efforts to improve culture may not succeed if hospital managers perceive safety differently from frontline workers.To determine whether frontline workers and supervisors perceive a more negative patient safety climate (ie, surface features, reflective of the underlying safety culture) than senior managers in their institutions. To ascertain patterns of variation within management levels by professional discipline.A safety climate survey was administered from March 2004 to May 2005 in 92 US hospitals. Individual-level cross sectional comparisons related safety climate to management level. Hierarchical and hospital-fixed effects modeling tested differences in perceptions.Random sample of hospital personnel (18,361 respondents).Frequency of responses indicating absence of safety climate (percent problematic response) overall and for 8 survey dimensions.Frontline workers' safety climate perceptions were 4.8 percentage points (1.4 times) more problematic than were senior managers', and supervisors' perceptions were 3.1 percentage points (1.25 times) more problematic than were senior managers'. Differences were consistent among 7 safety climate dimensions. Differences by management level depended on discipline: senior manager versus frontline worker discrepancies were less pronounced for physicians and more pronounced for nurses, than they were for other disciplines.Senior managers perceived patient safety climate more positively than nonsenior managers overall and across 7 discrete safety climate domains. Patterns of variation by management level differed by professional discipline. Continuing efforts to improve patient safety should address perceptual differences, both among and within groups by management level.

    View details for Web of Science ID 000260745900004

    View details for PubMedID 18953225

  • Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems HEALTH SERVICES RESEARCH Tucker, A. L., Singer, S. J., Hayes, J. E., Falwell, A. 2008; 43 (5): 1807-1829


    To contrast the safety-related concerns raised by front-line staff about hospital work systems (operational failures) with national patient safety initiatives.Primary data included 1,732 staff-identified operational failures at 20 U.S. hospitals from 2004 to 2006.Senior managers observed front-line staff and facilitated open discussion meetings with employees about their patient safety concerns.Hospitals submitted data on the operational failures identified through managers' interactions with front-line workers. Data were analyzed for type of failure and frequency of occurrence. Recommendations from staff were compared with recommendations from national initiatives.The two most frequent categories of operational failures, equipment/supplies and facility issues, posed safety risks and diminished staff efficiency, but have not been priorities in national initiatives.Our study suggests an underutilized strategy for improving patient safety and staff efficiency: leveraging front-line staff experiences with work systems to identify and address operational failures. In contrast to the perceived tradeoff between safety and efficiency, fixing operational failures can yield benefits for both. Thus, prioritizing improvement of work systems in general, rather than focusing more narrowly on specific clinical conditions, can increase safety and efficiency of hospitals.

    View details for DOI 10.1111/j.1475-6773.2008.00868.x

    View details for Web of Science ID 000259344300003

    View details for PubMedID 18522667

    View details for PubMedCentralID PMC2654160

  • An overview of patient safety climate in the VA HEALTH SERVICES RESEARCH Hartmann, C. W., Rosen, A. K., Meterko, M., Shokeen, P., Zhao, S., Singer, S., Falwell, A., Gaba, D. M. 2008; 43 (4): 1263-1284


    To assess variation in safety climate across VA hospitals nationally.Data were collected from employees at 30 VA hospitals over a 6-month period using the Patient Safety Climate in Healthcare Organizations survey.We sampled 100 percent of senior managers and physicians and a random 10 percent of other employees. At 10 randomly selected hospitals, we sampled an additional 100 percent of employees working in units with intrinsically higher hazards (high-hazard units [HHUs]).Data were collected using an anonymous survey design.We received 4,547 responses (49 percent response rate). The percent problematic response--lower percent reflecting higher levels of patient safety climate--ranged from 12.0-23.7 percent across hospitals (mean=17.5 percent). Differences in safety climate emerged by management level, clinician status, and workgroup. Supervisors and front-line staff reported lower levels of safety climate than senior managers; clinician responses reflected lower levels of safety climate than those of nonclinicians; and responses of employees in HHUs reflected lower levels of safety climate than those of workers in other areas.This is the first systematic study of patient safety climate in VA hospitals. Findings indicate an overall positive safety climate across the VA, but there is room for improvement.

    View details for DOI 10.1111/j.1475-6773.2008.00839.x

    View details for Web of Science ID 000257756000009

    View details for PubMedID 18355257

    View details for PubMedCentralID PMC2517282

  • Workforce perceptions of hospital safety culture: Development and validation of the patient safety climate in healthcare organizations survey HEALTH SERVICES RESEARCH Singer, S., Meterko, M., Baker, L., Gaba, D., Falwell, A., Rosen, A. 2007; 42 (5): 1999-2021


    To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity.Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate.Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers.We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA).We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's alpha coefficients ranged from 0.50 to 0.89.It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.

    View details for DOI 10.1111/j.1475-6773.2007.00706.x

    View details for Web of Science ID 000249429000012

    View details for PubMedID 17850530

    View details for PubMedCentralID PMC2254575

  • Who searches the internet for health information? 4th World Conference of the International-Health-Economics-Association (iHEA) Bundorf, M. K., Wagner, T. H., Singer, S. J., Baker, L. C. WILEY-BLACKWELL PUBLISHING, INC. 2006: 819–36


    To determine what types of consumers use the Internet as a source of health information.A survey of consumer use of the Internet for health information conducted during December 2001 and January 2002.We estimated multivariate regression models to test hypotheses regarding the characteristics of consumers that affect information seeking behavior.Respondents were randomly sampled from an Internet-enabled panel of over 60,000 households. Our survey was sent to 12,878 panel members, and 69.4 percent of surveyed panel members responded. We collected information about respondents' use of the Internet to search for health information and to communicate about health care with others using the Internet or e-mail within the last year.Individuals with reported chronic conditions were more likely than those without to search for health information on the Internet. The uninsured, particularly those with a reported chronic condition, were more likely than the privately insured to search. Individuals with longer travel times for their usual source of care were more likely to use the Internet for health-related communication than those with shorter travel times.Populations with serious health needs and those facing significant barriers in accessing health care in traditional settings turn to the Internet for health information.

    View details for DOI 10.1111/j.1475-6773.2006.00510.x

    View details for PubMedID 16704514

  • Health plans' coverage determinations for technology-based interventions: The case of electrical bone growth stimulation AMERICAN JOURNAL OF MANAGED CARE Huang, A. J., Gemperli, M. P., Bergthold, L., Singer, S. S., Garber, A. 2004; 10 (12): 957-962


    To determine (1) whether commercial health plans' coverage criteria for a costly technology-based medical intervention are consistent with recent clinical effectiveness evidence, (2) whether medical directors adhere to planwide coverage criteria when making coverage determinations for individual patients, and (3) if any organizational characteristics are associated with having more stringent coverage criteria or making more frequent coverage denials.Case-based survey of medical directors of US commercial health plans.A close-ended survey was mailed to 346 medical directors meeting eligibility criteria, asking about the criteria specified in their plans' coverage policies for electrical bone growth stimulation (EBGS) and whether they would cover this intervention for a hypothetical patient with abnormal union of long-bone fracture.Responses from 228 (66%) of the 346 directors indicated that approximately 72% of plans have a formal coverage policy for EBGS for long-bone fractures. More than 30% of plans specify that longer than 4 months must elapse before EBGS is attempted, although clinical studies do not support absolute waiting times. Directors of approximately 61% of plans with policies requiring extended waiting periods would nevertheless authorize EBGS for patients who did not meet this criterion.Health plans apply varied criteria in coverage policies for technology-based treatments such as EBGS, but do not always adhere to stated criteria when determining coverage for individual patients. For-profit status, accreditation status, geographic location, and size of plan are not associated with being more or less likely to authorize EBGS.

    View details for Web of Science ID 000225627700007

    View details for PubMedID 15617371

  • Consumers' use of the Internet for health insurance AMERICAN JOURNAL OF MANAGED CARE Bundorf, M. K., Singer, S. J., Wagner, T. H., Baker, L. 2004; 10 (9): 609-616


    We examined consumers' search for information about health insurance choices and their use of the Internet for that search and to manage health benefits.We surveyed a random sample of more than 4500 individuals aged 21 years and older who were members of a survey research panel during December 2001 and January 2002.The survey included questions about searching for health insurance information in 3 health insurance markets: Medicare, individual or nongroup, and employer-sponsored group. We also asked questions about use of the Internet to manage health benefits. We tabulated means of responses to each question by market and tested for independence across demographic groups using the Pearson chi-square test.We identified important differences across and within markets in the extent to which people look for information about health insurance alternatives and the role of the Internet in their search. Although many individuals were unaware of whether their employer or health plan provided a website to manage health benefits, those who used the sites generally evaluated them favorably.Our results suggest that the Internet is an important source of health insurance information, particularly for individuals purchasing coverage individually in the nongroup and Medicare markets relative to those obtaining coverage from an employer. In the case of Medicare coverage, studies focusing on beneficiaries' use of Internet resources may underestimate the Internet's importance by neglecting caregivers who use the Internet. Many individuals may be unaware of the valuable resources available through employers or health plans.

    View details for PubMedID 15515993

  • Use of the Internet and e-mail for health care information - Results from a national survey JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Baker, L., Wagner, T. H., Singer, S., Bundorf, M. K. 2003; 289 (18): 2400-2406


    The Internet has attracted considerable attention as a means to improve health and health care delivery, but it is not clear how prevalent Internet use for health care really is or what impact it has on health care utilization. Available estimates of use and impact vary widely. Without accurate estimates of use and effects, it is difficult to focus policy discussions or design appropriate policy activities.To measure the extent of Internet use for health care among a representative sample of the US population, to examine the prevalence of e-mail use for health care, and to examine the effects that Internet and e-mail use has on users' knowledge about health care matters and their use of the health care system.Survey conducted in December 2001 and January 2002 among a sample drawn from a research panel of more than 60 000 US households developed and maintained by Knowledge Networks. Responses were analyzed from 4764 individuals aged 21 years or older who were self-reported Internet users.Self-reported rates in the past year of Internet and e-mail use to obtain information related to health, contact health care professionals, and obtain prescriptions; perceived effects of Internet and e-mail use on health care use.Approximately 40% of respondents with Internet access reported using the Internet to look for advice or information about health or health care in 2001. Six percent reported using e-mail to contact a physician or other health care professional. About one third of those using the Internet for health reported that using the Internet affected a decision about health or their health care, but very few reported impacts on measurable health care utilization; 94% said that Internet use had no effect on the number of physician visits they had and 93% said it had no effect on the number of telephone contacts. Five percent or less reported use of the Internet to obtain prescriptions or purchase pharmaceutical products.Although many people use the Internet for health information, use is not as common as is sometimes reported. Effects on actual health care utilization are also less substantial than some have claimed. Discussions of the role of the Internet in health care and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Internet strongly influences health care utilization.

    View details for PubMedID 12746364

  • Prospects for improved decision making about medical necessity HEALTH AFFAIRS Singer, S. J., Bergthold, L. A. 2001; 20 (1): 200-206

    View details for Web of Science ID 000166603000022

    View details for PubMedID 11194842

  • In loco parentis? The purchaser role in managed care CALIFORNIA MANAGEMENT REVIEW Bergthold, L., Koebler, S. O., Singer, S. 2000; 43 (1): 34-?
  • Structural problems of managed care in California and some options for ameliorating them CALIFORNIA MANAGEMENT REVIEW Singer, S. J., Enthoven, A. C. 2000; 43 (1): 50-?
  • What's not to like about HMOs HEALTH AFFAIRS Singer, S. J. 2000; 19 (4): 206-209

    View details for Web of Science ID 000088242700023

    View details for PubMedID 10916976

  • Unrealistic expectations born of defective institutions JOURNAL OF HEALTH POLITICS POLICY AND LAW Enthoven, A. C., Singer, S. J. 1999; 24 (5): 931-939

    View details for Web of Science ID 000083736300006

    View details for PubMedID 10615602

  • The managed care backlash and the task force in California HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1998; 17 (4): 95-110


    Signs of a managed care backlash in California are increasing. This paper reports and interprets the recently completed work of the California Managed Health Care Improvement Task Force, focusing on the managed care backlash and the state's regulatory response. Although cost containment was a contributing factor, the causes of and solutions to the backlash differ among consumers, physicians, health care workers, politicians, and health plans. The recommendations of the task force could improve the market for health insurance. However, lasting solutions to the profound problems causing the backlash will require fundamental cultural and systemic change.

    View details for Web of Science ID 000074933100013

    View details for PubMedID 9691553

  • Economists' perspectives on health care delivery in California as of 1995 WESTERN JOURNAL OF MEDICINE Singer, S. J. 1998; 168 (5): 360-370


    The health care delivery system is made up of providers--hospitals and doctors--increasingly organized into medical groups. Medical groups interact with payors, primarily health maintenance organizations, that increasingly pass through both risk and prices from increasingly demanding purchasers. This article summarizes the present and future prospects for each of these groups.

    View details for Web of Science ID 000073747700010

    View details for PubMedID 9614794

  • Paying more twice: When employers subsidize higher-cost health plans HEALTH AFFAIRS Hunt, K. A., Singer, S. J., Gabel, J., Liston, D., Enthoven, A. C. 1997; 16 (6): 150-156

    View details for Web of Science ID A1997YH06000021

    View details for PubMedID 9444822

  • Markets and collective action in regulating managed care HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1997; 16 (6): 26-32

    View details for Web of Science ID A1997YH06000004

    View details for PubMedID 9444805

  • Managed competition and California's health care economy HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1996; 15 (1): 39-57


    There is evidence in California of a broad decline in health care costs to employment groups adopting managed care and managed competition--premium reductions up to 10 percent. National comparisons and utilization data generally confirm the beginning of lower costs. Large California medical groups and health systems have responded to pressure by finding ways to reduce costs and improve quality. While examples are encouraging, there is room for improvement. Two levels of competition have emerged and continue to evolve: carrier competition and delivery system competition. Each model has strengths and limitations, but the existing mix is driving down costs.

    View details for Web of Science ID A1996VB83800005

    View details for PubMedID 8920568

  • Market-based reform: What to regulate and by whom? Conference on the Problem that Will Not Go Away - Reforming US Health Care Financing Enthoven, A. C., Singer, S. J. BROOKINGS INST. 1996: 185–206
  • Increasing cost-consciousness for managed care: reforming the tax treatment of health insurance expenditures. Health care management (Philadelphia, Pa.) Enthoven, A. C., Singer, S. J. 1995; 2 (1): 109-114


    The current Internal Revenue Code encourages employees who receive health insurance as part of their benefits package to choose more costly coverage than they would buy with their own money. The authors propose an approach that corrects this problem as well as the inequities experienced by self-employed and unemployed people.

    View details for PubMedID 10165625

  • Incentives for a better health care system. Journal of health care benefits Enthoven, A. C., Singer, S. J. 1994; 3 (6): 4-7

    View details for PubMedID 10135309

  • A SINGLE-PAYER SYSTEM IN JACKSON HOLE CLOTHING HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1994; 13 (1): 81-95


    President Clinton's Health Security Act relies on government regulation, not market forces, to control costs. The act creates an entitlement to comprehensive benefits and places the federal budget at risk for total health care costs in order to achieve universal coverage; it creates a system of new state purchasing monopsonies; and it attempts to control costs with price controls on health plan premiums, set and administered by a National Health Board that would be part of the executive branch, not insulated from political considerations. We believe there is a better way.

    View details for Web of Science ID A1994MX78800011

    View details for PubMedID 8188160


    View details for Web of Science ID A1991FV30100013

    View details for PubMedID 1885132