How to transition care after surgery? Insights from research

Some anxiety is perfectly normal for kidney transplant patients, but new research suggests that medical staff can help patients feel more at ease when they leave the hospital and that could decrease the chances they’ll be readmitted.

High levels of anxiety a week after a kidney transplant patient went home more than doubled the chances he or she would be readmitted within 30 days of release, researchers found.

And anxiety was higher for patients who received inconsistent directions related to post-discharge care while in the hospital and who reported less-than-optimal empathy on the part of nurses, doctors and other caregivers, researchers from The Ohio State University Fisher College of Business and Wexner Medical Center report in September’s Journal of Surgical Research.

Aravind Chandrasekaran

“The more patient-centric the care, the more trust the patient had in the information provided, the lower the anxiety level after discharge,” said Aravind Chandrasekaran, study co-author and an associate professor of operations and associate director of Fisher’s Center for Operational Excellence.

“If you’re anxious, you’re going to come back.”

Readmissions can happen for true medical reasons – such as a patient taking the wrong medications or not adhering to post-transplant safety measures.

Susan Moffatt-Bruce

They can also arise when the worried well return unnecessarily, said Susan Moffatt-Bruce, study co-author, cardiothoracic surgeon and chief quality and patient safety officer at Ohio State’s Wexner Medical Center.

“Sometimes we can make ourselves unwell because we’ve been so anxious,” she said.

Standardizing post-transplant care and training caregivers to convey more empathy during their educational interactions could go a long way toward keeping new kidney recipients well and out of the hospital, the study concluded.

“It comes down to understanding the whole patient,” Moffatt-Bruce said. “With some simple interventions, including being kind and being present, we can make a difference.”

About 17,000 people receive kidney transplants each year in the United States and more than 100,000 are on the waiting list, according to 2014 data from the Health Resources and Services Administration. More than 30 percent of them are readmitted within 30 days of their release, previous research has found.

When patients head home, good self-care – including taking medications properly and avoiding infection risks – is critical for maintaining good health.

But the list of instructions for transplant patients is long and it can be confusing, Chandrasekaran said. On top of that, patients sometimes hear conflicting advice from different members of their care team.

Prior to beginning the study, he and his collaborators reasoned that anxiety after discharge could be a significant player in the high rate of readmissions.

Ohio State’s research team first interviewed 20 patients who received a transplant at the Wexner Medical Center to get a handle on the quality of care delivered during hospitalization. In general, the interviews suggested that information conveyed to patients varied depending on the caregiver and was delivered “in a somewhat rushed manner.”

Researchers also shadowed the care team to listen first-hand to the instructions they gave transplant patients after their surgeries.

One example of inconsistent advice they witnessed: One nurse recommended “a lot of fluids,” another said to drink two liters a day and another told the patient to consume 100 ounces.

“There must have been 16 different ways to tell them to drink a lot of water,” Chandrasekaran said, adding that this wasn’t because the nurses weren’t following protocol. Rather, they were passing along various guidelines they’d been told over the years.

The researchers then used information from those shadowing experiences and the initial 20 interviews to develop surveys given to another 77 kidney recipients, 24 of whom were readmitted within 30 days.

“We wanted to see what was it that caused them to have anxiety and what could we do to alleviate that,” Moffatt-Bruce said.

“We asked patients, ‘What went right, what went wrong?’ ”

The researchers assessed the consistency of patient education using a five-item test that measured the ease of getting information and the level of understanding of symptoms and procedures. To evaluate empathy, they used a three-item scale that asked patients about their comfort level when they interacted with caregivers.

The researchers worked closely with the entire transplant team at Ohio State’s medical center, including 24 nurses and several physicians.

They found a strong association between anxiety levels a week after discharge and readmission within a month. They also found that the odds of getting readmitted increase by 110 percent for a one-unit increase in anxiety levels.

They did not find a direct link between consistency and empathy measured in the surveys and readmissions. But they did find that those elements appeared to play a clear role in raising anxiety, which was linked to readmissions.

The researchers took into account factors that could skew their findings – including age, ethnicity, preexisting health conditions and the function of the transplanted organ upon discharge.

Since conducting this work, the researchers and transplant staff designed interventions to improve pre-discharge care and attempt to reduce preventable readmissions.

The discharge nurses, in particular, played a key role in the changes, which have cut the number of individual instructions given to patients from about 80 to 25, Moffatt-Bruce said.

“When you go home you’re going to be more confident, you’re going to be safer and you’re going to be less likely to come back to the hospital,” she said.

Overcoming barriers to distributed innovation

 

There was a time not long ago when design teams for products ranging from computer hardware to aircraft carriers were housed within the same four walls of a company. Within the last decade or so, firms began moving away from a centralized design approach to innovation in favor of specialized strategic partners — oftentimes scattered in different locations across the globe.

But with the shift away from centralized design to what is known as the distributed innovation model, what challenges do companies face in the product-design process?

That was the question posed by Dr. Aravind Chandrasekaran, associate professor of operations in the Department of Management Sciences at The Ohio State University Max M. Fisher College of Business, and colleagues Professor Edward G. Anderson Jr., of the University of Texas McCombs School of Business; Professor Alison Davis-Blake, of the University of Michigan’s Ross School of Business; and Geoffrey G. Parker, of Tulane University’s Freeman School of Business.

The researchers’ findings appear in the journal Information Systems Research in a new paper titled Managing Distributed Product Development Projects: Integration Strategies for Time Zone and Language Barriers.

The shift to distributed project teams began in the software development field, but it quickly spread to other industries, including a wide range of physical product manufacturers. To achieve design efficiencies and cost savings, today’s companies often seek out strategic partners with the expertise they need, which typically means working with partners on the other side of the world from various cultures who speak different languages.

The researchers examined some of the challenges inherent among these distributed teams. The main obstacles they discovered were time zone differences, which typically lead to delays in email response times, and language differences, especially with non-native English speakers understanding jargon-heavy engineering concepts.

“We wanted to study what can be done to minimize these barriers within the design process,” Chandrasekaran said.

The research team studied 20 multinational firms that span a variety of industries including aerospace, IT, medical device, commercial goods and food processing. The researchers analyzed some of the tactics these firms employed to overcome the challenges inherent with distributed innovation.

Some common methods firms use include co-locating workers, whereby members from strategic partner teams spend time with teams from the focal company; modularization of product design, which involves producing components in modules and then bringing the respective parts together later for assembly; and IT solutions, such as video conferencing. The researchers’ findings validate what many managers have discovered, which is that these solutions often do little to minimize the challenges of distributed product development.

What does work?

Two tactics stood out to the researchers. First, they found that firms using standardized design-specific IT systems have greater success in their product development projects. For example, firms that use a design structure matrix process to capture the interactions between distributed development teams fared better than those that did not.

The second, often more successful strategy was having a designated person or an entity within the organization serve as the single point of contact between two geographically separated teams. Known as a supply chain integrator, this entity serves as a pivot point between the two locations, even if there are multiple teams within each country. This strategy minimized coordination challenges, the researchers found.

With funding from the National Science Foundation, the team interviewed supply chain integrators and discovered common traits, including an understanding of cause and effect, an ability to coordinate the work, systems thinking ability, and bilingual or multilingual skills.

“They do more than span the geographical boundaries; they have a macro or systems view of the world,” Chandrasekaran said. “They understand that if they’re making a small change to one aspect of the project, they know how that change will affect other teams. That skill of helping people coordinate the work was very unique to these individuals.”

However, the researchers are quick to acknowledge that there is no silver bullet for overcoming the challenges of distributed projects, noting that firms must anticipate the tradeoffs when using distributed product development.

Citing previous research by Professor Kim Clark, former dean of Harvard Business School, Chandrasekaran said his team’s research also found that “heavy weight project managers” have an edge in distributed workforces because they tend to have access to high levels of their organizations’ management and can use that access to resolve issues efficiently.

For firms considering the use of supply chain integrators, Chandrasekaran notes some things to consider. Supply chain integrators are typically employed by the product manufacturing companies, rather than being third parties. In addition to systems knowledge, they often have design and procedural knowledge, as well as an understanding of procurement.

Most importantly, the researchers found that supply chain integrators need to understand that when they’re working with their counterparts, it’s not just that they’re working on a particular aspect of the project, they have to understand how that project actually affects the bigger picture.

“If your firm works on distributed projects, you’re bound to have a lot of coordination issues,” Chandrasekaran said. “The common mechanisms that managers might already be employing may not be effective. Firms will likely have to invest in people with these types of specialized supply chain skills.”