Provider and Organizational Norms and Care at End of Life (PONCEL): A Study of Tw

描述（由申请人提供）：医院在住院和重症监护室（ICU）入院的频率和时间以及在生命的最后6个月内为慢性病医疗保险受益人咨询的专家数量方面存在显着差异。我们建议的目的是通过深入的医院案例研究来探讨这一现象。目标是确定在高强度医院中可以改变的提供者和组织规范，以提高治疗的效率和以患者为中心。这一R21的具体目标是：1。确定并描述在一家低强度和一家高强度美国医院中，影响ICU中慢性/重症老年人使用LST的组织和提供者实践规范。2.探索这些组织和供应商的做法规范与供应商的士气，家庭满意度，质量和护理成果的相关性。研究设计涉及一名访谈者和现场工作人员，他们根据对提供者、管理者、非临床工作人员和患者或相关代理决策者的半结构化访谈，对ICU病例进行为期4周的阴影观察和深入分析。我们将使用定性内容分析的现场笔记和访谈记录的混合物，接地理论的指导下，医院利用率和结果的数据和供应商，病人和家庭的调查数据的定量分析，以开发假设，并得出结论规范，强度和结果之间的关系。一个专家咨询委员会将与调查人员和医院工作人员合作，为社会营销干预制定想法，未来可以对这种干预进行测试，以改变高强度医院的规范。拟议项目的公共卫生的相关性来自于更好地了解如何提供者和组织规范可能会支持或干扰重症老年人的决策和结果的偏好。我们如何衡量该项目成功的一个例子是确定一种社会规范，鼓励在低强度医院出院时提前制定护理计划，可以使用社会营销将其出口到高强度医院，以减少患有与生命支持相关的严重限制性慢性疾病和在ICU死亡的老年人数量。

DESCRIPTION (provided by applicant): Hospitals vary markedly in the frequency and length of hospitalizations and intensive care unit (ICU) admissions and the number of specialists consulted for chronically ill Medicare beneficiaries during their last 6 months of life. The objective of our proposal is to explore this phenomenon using in-depth hospital case studies. The goal is to identify provider and organizational norms that can be changed in high intensity hospitals to improve efficiency and patient-centeredness of treatment. The specific aims of this R21 are: 1. Identify and describe organizational and provider practice norms that influence the use of LSTs in the ICU for chronically/critically ill elders at one low and one high intensity US hospital. 2. Explore the correlation of these organizational and provider practice norms with provider morale, family satisfaction, quality, and outcomes of care. The research design involves an interviewer and fieldworker engaging in 4 weeks of shadow observation and in-depth analysis of ICU cases based upon semi-structured interviews with the providers, managers, non- clinical staff, and patients or proxy decision makers involved. We will use a mixture of qualitative content analysis of field-notes and interview transcripts, guided by grounded theory, and quantitative analysis of hospital utilization and outcomes data and of provider, patient, and family survey data to develop hypotheses and to draw conclusions about the relationships between norms, intensity, and outcomes. An advisory committee of experts will collaborate with the investigators and hospital staff to develop ideas for a social marketing intervention that could be tested in the future to change norms at the high intensity hospital. The relevance of the proposed project to public health derives from a better understanding of how provider and organizational norms may support or interfere with preferences for decision making and outcomes among critically ill elders. An example of how we would measure success of the project would be the identification of a social norm that encourages advance care planning upon hospital discharge at the low intensity hospital that could be exported using social marketing to the high intensity hospital in order to achieve a reduction in the number of elders with severe limiting chronic illnesses connected to life-support and dying in the ICU.