Quality and the Nursing Workforce
Linda Aiken, PhD, RN
Researcher Linda Aiken, PhD, RN, a former heart surgery nurse, is professor of nursing and sociology and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. She also is arguably the most well-known investigator of how nursing workforce issues affect hospital quality and outcomes, specifically inpatient mortality and nursing shortages.
Her three key subject areas are patient-nurse ratios (lower them), nursing educational levels (raise them), and the nurse work environment (include nurses in decisions).
In 2002, Aiken's research revealed that every time another general surgical patient is added to a nurse's workload, there's a 7% higher mortality rate for the patients, and the nurses have more burnout and job dissatisfaction.
On education, her paper in 2003 found that every 10% increase in the proportion of nurses with a bachelor's degree was associated with a 4% decline in mortality. Her team looked at hospitals where the proportion of nurses with bachelor's degrees varied from 90% to none, a wide variation throughout the country.
Her third issue may be the most challenging: the nursing work environment. "We found that if you put aside ratios and educational level, the work environment itself is highly associated with differences in mortality across hospitals," she says.
In an ideal work environment, nurses and physicians should have good communication, trust, and teamwork; management should listens to nurses' concerns and act to solve problems; and the organization should have adequate staffing for all types of jobs, invest in nurses' continuing education, and involve nurses in its major decisions.
"We consistently find that it doesn't cost a lot of money to change the work environment. It's the No. 1 thing hospitals should be doing rather than just throwing a lot of money into staffing without
changing some of these other factors," Aiken says.
Variations in Care and the Constant Search for a Better Way
John E. Wennberg, MD
While living in Vermont in the 1970s, John E. Wennberg, MD, MPH, was flabbergasted when his studies revealed that, in one area, children might have a 75% chance of their tonsils being removed, but if they lived 100 feet away, within the border of another school district, that chance was only 20%.
Wennberg, founder of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., has repeated this seminal story about his findings on the variation of healthcare delivery many times over the past 40 years, since it shaped his view of healthcare in America—and his life's work. Wennberg's mantra has become indelibly stamped in healthcare: "More care doesn't mean better care."
In 1988, Wennberg started the Dartmouth Institute for Health Policy and Clinical Practice, which has been the driver of the research and studies. After stepping down several years ago from running the institute on a daily basis, Wennberg continues his passion to study the foibles of healthcare delivery. He is the Peggy Y. Thomson Professor Emeritus in the evaluative clinical sciences.
Wennberg is also founding editor of The Dartmouth Atlas of Health Care, which examines patterns of medical resource intensity and utilization in the United States.
Wennberg and his colleagues have generated many headlines and continue to reach a wide audience as an integral part of the nation's burgeoning discussion on healthcare reform. While healthcare leaders are listening about the problems of variation of care, that doesn't mean the problems are solved, he says.
"There's been a lot of progress. Not that there has been a substantial change in the variation problem," Wennberg says, "but there's been a lot better understanding of the causes of it, and the remedies we need to put into place to actually reduce variation."
Lessons on Childhood Obesity, for Kids and Adults
Ginny Ehrlich, MPH, D.Ed
Childhood obesity is preventable if you can connect with the children and teach them good habits early. That's what Ginny Ehrlich, MPH, D.Ed, CEO of the Portland, Ore.–based Alliance for a Healthier Generation is doing by taking her organization's programs to the schools and beyond.
"Changing childhood obesity is both cultural and systemic," says Ehrlich. "We learn our eating habits from our families and our community. Schools and communities help reinforce those behaviors."
Ehrlich joined the Alliance in 2006 and has been working to increase children's access to healthy foods and physical activity at schools and communities nationwide. The Alliance was founded by the American Heart Association and the William J. Clinton Foundation and has been led by Ehrlich since 2008. The Healthy Schools Program, one of several initiatives the organization supports, includes more than 15,000 schools across the United States and offers expert advice and resources for school professionals, teachers, students, and parents to encourage healthy eating and exercise.
Ehrlich says a big challenge the Alliance had faced was getting onto the priority list of school administrators, who already have an abundance of demands. Its Healthy Schools Program "mirrors the training and processes schools are already using so we can put our program seamlessly into place." And it is producing results. "Eighty percent of schools in this program are making measurable changes, like adding more fruits and vegetables to school breakfast and lunch menus and eliminating sugar beverages in vending machines."
To make it easier for the school cafeterias to get affordable healthy food options, the Alliance has also worked with group purchasing organizations and collaborated with a technology firm to create a free online tool to streamline the healthy food procurement process for schools.
The Genius of the Community Health House
Aaron Shirley, MD
Aaron Shirley, MD, a retired Jackson, Miss., pediatrician, believes that a primary healthcare model developed in Iran can be used to improve the health of the residents of Mississippi's poverty-stricken Delta Region.
The Iranian health house model, which Shirley witnessed during a 2009 trip to that country, is an integrated network that includes hospitals, primary care facilities, and "health houses" in Iran's poor rural communities.
"The Iranian experience was the driving force for pursuing HealthConnect," which Shirley says he started about two-and-a-half years ago. HealthConnect is designed, in part, to reduce admissions and emergency department visits at the Central Mississippi Medical Center in Jackson.
His goal is to open 15 health houses in the Delta Region north of Jackson. To date two health houses have opened in schools.
A hallmark of the Iranian system is that the healthcare workers are part of the community they serve. Shirley says the school locations provide the neighborhood connections that are particularly important in the Delta Region, where a patient may have the best of intentions to follow doctor's orders but may lack the resources to do so. That's not something a person might be comfortable confiding to a physician, he explains, but community health workers are from the Delta and more likely to be aware of a patient's personal situation.
Shirley says the two health houses have already helped reduce hospital admissions, and he's eager to get more health houses up and running. He says politics—both state and federal—has limited the project's reach so far. "I hear a lot about studies, but the people here have been studied enough. They need medical care."
—Margaret Dick Tocknell