JAMA Pediatrics: Quality of Care Topic Collection

Application of Business Model Innovation to Enhance Value in Health Care Delivery Application of Business Model Innovation

Fieldston E, Terwiesch C, Altschuler S. — Wed, 01 May 2013 00:00:00 GMT

Faced with the need to improve quality, health care enterprises have used principles from highly reliable industries to make tactical progress. As the health care system faces growing challenges to transform itself, we propose business model innovation as a strategic framework for improving the delivery of health care. We believe that this approach will unify the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) with the need to enhance value by emphasizing innovation in a manner not traditionally seen in health care.

Nurse Staffing and NICU Infection Rates Nurse Staffing and NICU Infection Rates

Rogowski JA, Staiger D, Patrick T, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights.

Objective

To study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes.

Design

Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010).

Setting

Sixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs.

Participants

All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630). All staff-registered nurses with infant assignments.

Exposures

We measured nurse understaffing relative to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010.

Main Outcomes and Measures

An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection.

Results

Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviation–higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.19-1.62; P < .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P < .001) in 2009.

Conclusions and Relevance

Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants.

JAMA Pediatrics Hospital Medicine Theme Issue JAMA Pediatrics Hospital Medicine Theme Issue

Keren R, Shah SS. — Wed, 01 May 2013 00:00:00 GMT

The hospital is a site of increasingly complex and resource-intensive care for children. It is also a clinical setting that in recent years has undergone major changes in the organization, delivery, and financing of care, with reduction in resident work hours, requirements for greater attending oversight of trainees, increased scrutiny of clinical outcomes, new payment models that shift financial risk to health care providers, and new delivery models that attempt to provide greater value for money. This issue of JAMA Pediatrics focuses on hospital medicine, highlighting many of the issues that hospitals will face as they adapt to the rapidly changing health care delivery and financing landscape.