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Background There is widespread interest in measuring organizational readiness to implement evidence-based practices in clinical care. However, there are a number of challenges to validating organizational measures, including inferential bias arising from the halo effect and method bias - two threats to validity that, while well-documented by organizational scholars, are often ignored in health services research. We describe a protocol to comprehensively assess the psychometric properties of a previously developed survey, the Organizational Readiness to Change Assessment. Objectives Our objective is to conduct a comprehensive assessment of the psychometric properties of the Organizational Readiness to Change Assessment incorporating methods specifically to address threats from halo effect and method bias. Methods and Design We will conduct three sets of analyses using longitudinal, secondary data from four partner projects, each testing interventions to improve the implementation of an evidence-based clinical practice. Partner projects field the Organizational Readiness to Change Assessment at baseline (n = 208 respondents; 53 facilities), and prospectively assesses the degree to which the evidence-based practice is implemented. We will conduct predictive and concurrent validities using hierarchical linear modeling and multivariate regression, respectively. For predictive validity, the outcome is the change from baseline to follow-up in the use of the evidence-based practice. We will use intra-class correlations derived from hierarchical linear models to assess inter-rater reliability. Two partner projects will also field measures of job satisfaction for convergent and discriminant validity analyses, and will field Organizational Readiness to Change Assessment measures at follow-up for concurrent validity (n = 158 respondents; 33 facilities). Convergent and discriminant validities will test associations between organizational readiness and different aspects of job satisfaction: satisfaction with leadership, which should be highly correlated with readiness, versus satisfaction with salary, which should be less correlated with readiness. Content validity will be assessed using an expert panel and modified Delphi technique. Discussion We propose a comprehensive protocol for validating a survey instrument for assessing organizational readiness to change that specifically addresses key threats of bias related to halo effect, method bias and questions of construct validity that often go unexplored in research using measures of organizational constructs.

Background Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. However, many cases treated as hospital-acquired CAUTI are actually asymptomatic bacteriuria (ABU). Evidence-based guidelines recommend that providers neither screen for nor treat ABU in most catheterized patients, but there is a significant gap between these guidelines and clinical practice. Our objectives are (1) to evaluate the effectiveness of an audit and feedback intervention for increasing guideline-concordant care concerning catheter-associated ABU and (2) to measure improvements in healthcare providers' knowledge of and attitudes toward the practice guidelines associated with the intervention. Methods/Design The study uses a controlled pre/post design to test an intervention using audit and feedback of healthcare providers to improve their compliance with ABU guidelines. The intervention and the control sites are two VA hospitals. For objective 1 we will review medical records to measure the clinical outcomes of inappropriate screening for and treatment of catheter-associated ABU. For objective 2 we will survey providers' knowledge and attitudes. Three phases of our protocol are proposed: the first 12-month phase will involve observation of the baseline incidence of inappropriate screening for and treatment of ABU at both sites. This surveillance for clinical outcomes will continue at both sites throughout the study. Phase 2 consists of 12 months of individualized audit and feedback at the intervention site and guidelines distribution at both sites. The third phase, also over 12 months, will provide unit-level feedback at the intervention site to assess sustainability. Healthcare providers at the intervention site during phase 2 and at both sites during phase 3 will complete pre/post surveys of awareness and familiarity (knowledge), as well as of acceptance and outcome expectancy (attitudes) regarding the relevant practice guidelines. Discussion Our proposal to bring clinical practice in line with published guidelines has significant potential to decrease overdiagnosis of CAUTI and associated inappropriate antibiotic use. Our study will also provide information about how to maximize effectiveness of audit and feedback to achieve guideline adherence in the inpatient setting. Trial Registration NCT01052545

Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the \"hidden curriculum.\" However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools. To examine patient-centered characteristics of learning environments at 9 U.S. medical schools. Cross-sectional internet-based survey. Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003. We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school's environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students' experiences, and support for students' patient-centered behaviors), and is designed to measure these areas independent of respondents' attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents. The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school. The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Objectives. We sought to identify the functional, cognitive, and social factors associated with self-neglect among the elderly to aid the development of etiologic models to guide future research. Methods. A cross-sectional chart review was conducted at Baylor College of Medicine Geriatrics Clinic in Houston, Tex. Patients were assessed using standardized comprehensive geriatric assessment tools. Results. Data analysis was performed using the charts of 538 patients; the average patient age was 75.6 years, and 70% were women. Further analysis in 460 persons aged 65 years and older showed that 50% had abnormal Mini Mental State Examination scores, 15% had abnormal Geriatric Depression Scale scores, 76.3% had abnormal physical performance test scores, and 95% had moderate-to-poor social support per the Duke Social Support Index. Patients had a range of illnesses; 46.4% were taking no medications. Conclusions. A model of self-neglect was developed wherein executive dyscontrol leads to functional impairment in the setting of inadequate medical and social support. Future studies should aim to provide empirical evidence that validates this model as a framework for self-neglect. If validated, this model will impart a better understanding of the pathways to self-neglect and provide clinicians and public service workers with more effective prevention and intervention strategies.

Sequence-based cancer susceptibility testing results are described as negative, deleterious mutation or variant of uncertain significance. We studied the impact of different types of test results on clinical decision making. Practicing physicians from five specialties in Texas completed an online case-based survey (n = 225). Respondents were asked to make genetic testing and management recommendations for healthy at-risk relatives of patients with cancer. When the patient carried a deleterious BRCA1 mutation or variant of uncertain significance, 98% and 82% of physicians, respectively, recommended testing of at-risk relatives (P < 0.0001). In both situations, comprehensive BRCA1/2 analysis was selected most with a corresponding 9-fold increase in unnecessary genetic testing costs. There was no difference in physicians with (n = 81) or without (n = 144) prior BRCA1/2 testing experience (P = 0.3869). Cancer risk management recommendations were most intense for the relative with a deleterious mutation compared with variant of uncertain significance, negative, or no testing with 63%, 13%, 5%, and 2%, respectively, recommending oophorectomy (P < 0.0001). Independent of experience, or specialty, physicians chose more comprehensive testing for healthy relatives than current guidelines recommend. In contrast, management decisions demonstrated the uncertainty associated with a variant of uncertain significance. Utilization of genetic professionals and education of physicians on family-centered genetic testing may improve efficacy and substantially reduce costs. Genet Med 2011:13(2):148–154.

Despite growing concerns toward maintaining participants' privacy, individual investigators collecting tissue and other biological specimens for genomic analysis are encouraged to obtain informed consent for broad data sharing. Our purpose was to assess the effect on research enrollment and data sharing decisions of three different consent types (traditional, binary, or tiered) with varying levels of control and choices regarding data sharing. A single-blinded, randomized controlled trial was conducted with 323 eligible adult participants being recruited into one of six genome studies at Baylor College of Medicine in Houston, Texas, between January 2008 and August 2009. Participants were randomly assigned to one of three experimental consent documents (traditional, n = 110; binary, n = 103; and tiered, n = 110). Debriefing in follow-up visits provided participants a detailed review of all consent types and the chance to change data sharing choices or decline genome study participation. Before debriefing, 83.9% of participants chose public data release. After debriefing, 53.1% chose public data release, 33.1% chose restricted (controlled access database) release, and 13.7% opted out of data sharing. Only one participant declined genome study participation due to data sharing concerns. Our findings indicate that most participants are willing to publicly release their genomic data; however, a significant portion prefers restricted release. These results suggest discordance between existing data sharing policies and participants' judgments and desires.

Background Overtreatment of catheter-associated bacteriuria is a quality and safety problem, despite the availability of evidence-based guidelines. Little is known about how guidelines-based knowledge is integrated into clinicians’ mental models for diagnosing catheter-associated urinary tract infection (CA-UTI). The objectives of this research were to better understand clinicians’ mental models for CA-UTI, and to develop and validate an algorithm to improve diagnostic accuracy for CA-UTI. Methods We conducted two phases of this research project. In phase one, 10 clinicians assessed and diagnosed four patient cases of catheter associated bacteriuria (n= 40 total cases). We assessed the clinical cues used when diagnosing these cases to determine if the mental models were IDSA guideline compliant. In phase two, we developed a diagnostic algorithm derived from the IDSA guidelines. IDSA guideline authors and non-expert clinicians evaluated the algorithm for content and face validity. In order to determine if diagnostic accuracy improved using the algorithm, we had experts and non-experts diagnose 71 cases of bacteriuria. Results Only 21 (53%) diagnoses made by clinicians without the algorithm were guidelines-concordant with fair inter-rater reliability between clinicians (Fleiss’ kappa = 0.35, 95% Confidence Intervals (CIs) = 0.21 and 0.50). Evidence suggests that clinicians’ mental models are inappropriately constructed in that clinicians endorsed guidelines-discordant cues as influential in their decision-making: pyuria, systemic leukocytosis, organism type and number, weakness, and elderly or frail patient. Using the algorithm, inter-rater reliability between the expert and each non-expert was substantial (Cohen’s kappa = 0.72, 95% CIs = 0.52 and 0.93 between the expert and non-expert #1 and 0.80, 95% CIs = 0.61 and 0.99 between the expert and non-expert #2). Conclusions Diagnostic errors occur when clinicians’ mental models for catheter-associated bacteriuria include cues that are guidelines-discordant for CA-UTI. The understanding we gained of clinicians’ mental models, especially diagnostic errors, and the algorithm developed to address these errors will inform interventions to improve the accuracy and reliability of CA-UTI diagnoses.

Since some of us were experienced Team-Based Learning practitioners, and others were not, the innovation also created an opportunity to disseminate knowledge about the pedagogy. The success of a collaborative effort depends on a variety of factors described in published reports, including the environment, membership, process and structure, communication, purpose, and resources. [...]under one component of our instructional materials defined as “application activities,” peer reviewers were prompted with the question of whether or not each “application question” met the criteria of having what is known in the Team-Based Learning literature [2] as the “4S’s”: “Are the 4S’s clearly incorporated such that each application can demonstrate that it represents A Significant problem? Following pilot testing, we continued to revise modules while obtaining feedback from clerkship students and teaching faculty. Because a new cohort of clerkship students began every 6 weeks, we were able to constantly administer, receive feedback, and hone the modules.

Objective: The authors performed this study to determine whether clerkship peer evaluations, initiated as part of our \"team-based learning\" curriculum in 2002, correlated with other student performance measures, and to determine what qualities students rate in their peer evaluations. Method: The authors correlated peer evaluation scores with other student performance measures and performed a qualitative examination of student comments to assess reasons students gave for giving high and low scores. Results: Peer evaluation scores correlated modestly with the National Board of Medical Examiners' (NBME) subject test, in-class quiz, and clinical scores. Qualitative comments demonstrated that students made assessments based on three thematic areas: personal attributes, team contributions, and cognitive abilities. Conclusions: Peers' evaluation scores modestly predict which students will perform well on other measures. However, there may be other qualities that are also important factors in peer evaluation. For example, most students value qualities of preparation and participation. Though students sometimes dislike peer evaluations, their assessments may enhance traditional course assessments and complement a comprehensive evaluation strategy.

Capacity for safe and independent living (SAIL) refers to an individual’s ability to solve problems associated with everyday life and perform activities necessary to live independently. Little guidance exists on the assessment of capacity for SAIL among nursing home residents. As a result, capacity for SAIL is not fully considered in the development of discharge plans to ensure safety and independence in the community. The Making and Executing Decisions for Safe and Independent Living (MEDSAIL) tool was developed to screen for capacity for SAIL among community-dwelling older adults. In this cross sectional pilot study, we tested the validity of MEDSAIL for use with nursing home residents. Participants were twenty-four residents of a Veterans Health Affairs nursing home. Exclusion criteria were cognitive impairment too severe to complete the protocol, diagnosis of serious mental illness or developmental disability, inability to hear, and inability to communicate verbally. Participants completed two assessments: the MEDSAIL interview administered by a research assistant and the criterion standard capacity interview administered by a geriatric psychiatrist. We examined internal consistency, convergent validity, divergent validity, and criterion-based validity. Five of seven MEDSAIL scenarios approximated acceptable levels of internal consistency (α>0.70). MEDSAIL scores were positively correlated with the criterion standard (0.88, p=0.001), and the Wilcoxon Rank Sum Test statistic was also statistically significant (p=0.001). MEDSAIL has promise as a user-friendly brief screening tool in nursing homes to understand resident capacity for SAIL and to inform development of discharge plans to keep the resident safe and independent in the community.