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In Hospitals, a trade-off between patient safety and patient experience

Balance

Hospitals that adopt strategies to reduce errors and meet government requirements face an initial tradeoff between improved patient safety and a decline in the quality of individual patients’ experiences, according to new research.  Quality process management, a practice associated with the private sector, is becoming more common in hospitals as they set up operating systems in response to federal and state mandates to reduce medical errors and improve patient safety, the researchers say. It is not surprising to find that the implementation of these techniques led to improved safety outcomes. But finding that these improvements sometimes came at the expense of the quality of the patient experience was unexpected. Also referred to as experiential quality, the quality of the patient experience is gauged by how patients perceive their personal interactions with health-care providers.  “Patient Safety is about doing things correctly – strict guidelines, standardization and checklists, for example – so when you consider experiential quality is about customizing health-care delivery to an individual patient’s needs, there is a tension there,” said Aravind Chandrasekaran, associate professor of management sciences at Ohio State and lead author of the study.

“When leaders were more patient-centric, our analysis showed that they were able to overcome that tension between patient safety and the quality of the patient experience,” Chandrasekaran said. “Leaders have to be thinking about patients when they design their operations. That way they can cater many of their design principles to individual patients.”

How might this tension play out? Consider a patient  safety guideline of giving a beta blocker prescription for patients who have had a heart attack, but offer no suggestions for how to effectively relay that information to a patient. So the hospital gets a good mark for prescribing the drug, but a patient may not understand the instructions and possibly won’t even fill the prescription.

Chandrasekaran and colleagues assert that setting up standardized quality management systems is the most effective way for hospitals to meet state and federal mandates geared toward patient safety. Quality process management entails a systematic approach to map, improve and adhere to given sets of guidelines with a goal to minimize an organization’s variation in its processes.  Federal and state regulations in health care have become more stringent since 1999, when the Institute of Medicine released a milestone report stating that almost 100,000 people died every year as a result of preventable medical errors in U.S. hospitals.

In a move toward standardization, the U.S. Centers for Medicare and Medicaid Services (CMS) in 2003 issued hospital care guidelines related to four health conditions: heart attack, heart failure, pneumonia and surgical care. CMS requires hospitals to report their care practices with these types of cases, and has provided financial incentives to hospitals that are best at adhering to the standards of care outlined in these guidelines. In addition, many states have passed patient-safety legislation calling for reductions in hospital-acquired infections, also beginning in 2003. In the study, the researchers used this legislation as an example of state leadership focused on improving patient safety.

These regulations have led many hospitals to adopt quality process management practices to improve their safety outcomes as quickly as possible. But the researchers also wanted to examine what happened to the patient experience as hospitals focused on new techniques to improve their clinical quality. To determine these relationships, they analyzed four sources of data: a survey of 284 acute care hospitals in 44 states; CMS patient safety scores publicly reported between April 2009 and March 2010; state legislative mandates for reduced hospital-acquired infections passed between 2003 and 2008 in a portion of those 44 surveyed states; and April 2009-March 2010 reports from the Hospital Consumer Assessment of Healthcare Providers and Systems survey as a measure of patient experience quality. Directors of quality or chief nursing officers at 284 hospitals in 44 states were surveyed to determine how extensively respondents were using a data-driven, quality management system to design operations and train staff with the goal of adhering to CMS guidelines. Additional questions examined the leadership style and culture of each hospital.

The analysis showed that a focus on quality process management was simultaneously associated with an increase in patient safety as reported by hospitals and a decrease in the quality of the patient experience as reported by patients. State legislative mandates to improve patient safety initially reinforced this tradeoff. However, the earlier these laws were passed, the sooner hospital environments adjusted to operational changes so they could improve the patient experience as well.  When analyzing the  survey data about hospital leaders’ traits, we found that patient-focused leadership could soften the negative association between quality process management and experiential quality, allowing hospitals to excel in both areas.

Hospitals also commonly survey patients after their stays to gauge their satisfaction with their care. These surveys collect information about patients’ overall impression of their care and whether they would return to the hospital or recommend its services to friends and family. This suggests that patients are able to understand and appreciate the standardization in hospitals if they experience better levels of communication during their care. In other words, treating patients well enables them to better perceive when they are getting the ‘correct’ clinical care.

The Common Mistakes that you make in your R&D

Optimize-and-Align-Your-Project-Portfolio-smaller-TEST

 

A new study from a Fisher College of Business professor suggests research and development teams could use some more outside-the-box thinking in how they structure and manage their own innovation projects.

The research appeared in Production and Operations Management journal titled:  “The Role of Project and Organization Context in Managing High-Tech R& D Projects.” This study employs both qualitative case data and survey data from more than 100 R&D projects at nearly 34 high-tech organizations is authored by Aravind Chandrasekaran, an associate professor of management sciences at Fisher.

In his research, Chandrasekaran found that companies are making a very common mistake in managing their R&D projects, and the consequences can range from an internal preference towards cut-and-dry, quick-turnaround innovation projects to loss of market share and competitive edge.

Product Portfolios

 

 

Context is key

At the root of this increasingly troubling trend among R&D teams is a common villain: The tried-and-true approach, backed by decades of research and results. Projects typically are categorized and managed by the extent of change in the product, process, technology and market dimensions. A routine iPhone upgrade from a 3G to a 3GS, for example, falls at one end of a continuum as a so-called incremental innovation project.

“If you’re going from a CD player to an iPhone, though, that’s radical innovation,” Prof. Chandrasekaran said.

This research posits that R&D project management shouldn’t be determined on a sliding scale of eventual change, big or small. Rather, it should be driven by project goals, whether they’re to explore a new technology or to exploit opportunities for efficiencies, cost savings or faster time to market, Prof. Chandrasekaran said.

The research found that incremental and radical innovation projects thrive under two entirely different sets of so-called project and organizational contexts. Incremental projects need diligent, transactional leaders at the helm, low levels of team-member autonomy and well-defined goals that are tied to outcome-driven incentives. Radical innovation projects, meanwhile, need a leader who’s willing to promote risk-taking and experimentation, give team members more latitude and reward them at milestones, not just the finish line.

Crossing these wires, the research found, can be deadly for project success. Put a rigid, transactional leader in front of a radical project team and the creative juices stop flowing. Give incremental project teams more autonomy and a hands-off approach and deadlines are missed.

A one-size-fits-all approach to project tracking, all too common in the companies surveyed, spells trouble, too. Teams juggling a mixed bag of projects, all with the same metrics and reporting structure will develop a Pavlovian affinity for the fast and predictable incremental ones and leave the long-term radical ones on the to-do list.

Double-dipping

Here’s the nuance that even the savviest high-tech companies miss in their ongoing R&D project management efforts: Some projects in these environments are driven by goals typically associated with radical innovation and incremental innovation, but existing research doesn’t offer much help on how to deal with them, Prof. Chandrasekaran’s research found.

These so-called “hybrid projects” aren’t new to post-recession R&D departments, but they’re making more appearances as companies are asked to do more with less or – at best – the same.

“In this day and age, budget cuts are more and more visible in R&D environments, and companies are being asked to make big leaps in projects, pushing up deadlines without giving additional resources,” he said.

The growing stakes of maintaining competitive edge are outpacing overall R&D spending, too. An annual Battelle report on R&D expenditures found U.S. spending is set to grow about 2.5 percent this year, on par with the growth in the national Gross Domestic Product but slower than the global growth rate of 3.4 percent.

The key to nurturing these hybrid projects, Prof. Chandrasekaran found, is first not to let them get incorrectly classified as radical innovation projects, the most frequent mistake. Key red flags to look out for include the addition of deadline or cost pressure to an otherwise radical innovation project.

“In practice, organizations are pretty good at making changes between radical and incremental projects,” he said. “They often fail to make that change for hybrid projects.”

What these projects need, according to the study, is a so-called “ambidextrous leader” who knows when to shift between hands-off management during bursts of team creativity to taking the reins and steering the project on time and on budget.  For instance, an ambidextrous project leader from one of hybrid project remarked the following:

“And the expectations are certainly higher to meet our project timelines, since these timelines rarely gets expanded by the senior management. So my role is to drive my team members to meet these deadlines [transactional]….. However, there were occasions when we encountered a lot of unknowns wherein I need to step back and allow my team to tackle these unknowns. Definitely, I am more tolerant and flexible during these times [transformational].”

Not just for tech

Tapping into high-tech companies for this study, Prof. Chandrasekaran said, wasn’t an act of random selection. The tech sector remains the R&D industry’s most fertile ground for growth, but that doesn’t mean this research is valuable only to them.

Any company investing in R&D should take notice of the opportunities they’re missing as they organize and deploy project teams, he said.

“This research shows management has to make key changes,” Prof. Chandrasekaran said, with the following questions: “How do you reward these people? How do you lead these teams? When do you give them decision – making autonomy? When do you take back the same decision-making autonomy?”

In short, effective senior management support in R&D doesn’t stop after signing off on a budget. That’s just the beginning.

 

  • Chandrasekaran, A., Linderman, K., Schroeder, R.G.2015. The Role of Project and Organizational Context in Managing High-Tech R&D Projects. Production and Operations Management 24(4) 560-586.

Scope Creep: How the best companies navigate seismic shifts in R&D

 

 

 

Shifting

 

For all the far-reaching complexity inherent in high-tech companies, decades of research and practice have helped simplify the crucial research and development process into two principal roads taken. Some projects set their sights on version 2.0, tweaking and improving an existing product or technology, while others start from scratch, riding the tide of technological advances and market demand to create something radical and new.

The management approaches guiding these two types of innovation have guided countless products to successful updates or launches. The problem? These same projects can unexpectedly change scope, and companies that don’t pivot accordingly can wind up at very costly dead ends.

Research from a forthcoming article1 in Production and Operations Management sheds light on how traditional approaches to managing R&D projects are failing companies when they face a sudden shift that brings new complexity to a seemingly simple problem.  Looking at two multi-billion dollar companies – one a cautionary tale, the other a benchmark of success – we’ve uncovered key measures that other high-tech organizations can learn from to avoid product launch delays, excessive costs and market share loss.

These insights are rooted in a study where we tracked a dozen R&D projects in three high-tech business units across two companies over three years. One company, which we will call MicroTech, is a $1 billion-a-year disk-drive maker. The other is a Fortune 500 communications tech giant we’ll call CommNet. Each company followed existing R&D best practices on budgeting time and resources, sorting projects into two major “buckets.” One consists of less complex, so-called incremental innovation projects (think of a new iPhone release with slight modifications) while the other requires more complex, so-called radical innovation, launching a new product following exhaustive experimentation, testing and market research (think of Apple’s leap from the iPod to iPhone). As such, these two kinds of projects necessitate different management techniques: Top management, for example, typically keeps a closer eye on radical projects, which are high-risk and high-reward.

For MicroTech and CommNet, eight of their 12 projects we studied began with one level of complexity and never shifted; the remaining four, however, saw scope shift from incremental to radical after a change in customer requirements or emerging technology. MicroTech set out to update a disk drive and leveraged its seamless and flexible project management system, ultimately basking in commercial success.  CommNet’s journey to upgrade a durable tablet designed for police and firefighters, meanwhile, ended in failure.

At first glance, both companies’ approaches to product development don’t appear radically different. Its three key mechanisms MicroTech had in place that helped it pivot and stick the landing.

 

 

Responsive Search

 

 

 

 

 

 

Weekly Risk tracking: Research on R&D project management largely recommends keeping close tabs on risk for radical product development and taking a more hands-off approach for incremental changes. MicroTech flatly ignored this conventional wisdom – and for the better. Senior managers here used the same risk-tracking framework for all R&D, completing simple risk scorecards on a weekly basis that gauged risk factors and flagged problem areas. These scorecards were deployed as visual dashboards accessible that provided up-to-date information to multiple management levels (even up to the Chief Technology Officer). CommNet, by comparison, eschewed this routine risk-tracking and found itself mired in meetings, kicking off a chain reaction of ultimately fatal delays.

Continuous planning: MicroTech’s risk-tracking tools fit seamlessly into a broader effort to tighten its strategic planning horizon. Long-range planning was maintained at a lean one year, contrary to the recommended three to five, while monthly strategy touchpoints allowed leaders to use fresh risk-tracking data to revisit and revise decisions. CommNet, meanwhile, updated risk Intel on an annual basis from their strategic plans, which ultimately proved no match for the changing fortunes of its tablet.

Seamless Communication: MicroTech successfully created a continuous and frequent top-down and bottom-up flow of communication that connected project teams and senior – even C-suite – leadersThese communication channels were very “lean” and “visual” and did not require excessive time commitments from everyone. At CommNet, meanwhile, product leaders only received updates at major project milestones (or gate reviews), which ultimately contributed to product-killing delays.

Decision time

In one of its routine monthly planning forums, leaders at MicroTech pointed out that advances in a new material technology would heighten the risk of the disk-drive project over the next couple years. By leveraging its regular risk-tracking, flexible strategic planning and free-flowing communication, MicroTech ignited a chain reaction of decisions to increase manpower, budget and project scope. CommNet, meanwhile, discovered six months into its project that the upgraded tablet design wouldn’t survive the rough conditions it’s designed for. Instead of pivoting, senior leaders dug in, requesting additional tests that contributed to months of delays before acquiescing.

The fortunes of each product come as no surprise. MicroTech announced its upgraded disk drive to investors in 2008 and saw shipments triple over the next three years. CommNet’s tablet, meanwhile, hit the market in 2008 after months of delays, only to receive poor business-press reviews and sales – leaders yanked it from the market the next year.

These might be two products in a sea of high-tech devices companies roll out each year, but their journeys – and the decisions made along the way – are hardly unique. Our research compared the experiences of MicroTech and CommNet to 10,000 other projects through simulations to find that success or failure is inextricably linked to how risk, strategy and communication are managed in times of crisis. It’s not dashboards or scorecards alone, however, that equip companies to change course when the time comes. They must be part of a broader R&D culture that encourages feedback, inspires experimentation and develops agility and lean practices. Without it, scope creep can kill and can be extremely costly to handle in today’s economic climate.

 

  1. Chandrasekaran, A., Linderman, K., Sting, F., Benner, M., “Managing R&D Project Shifts in High-Tech Organizations: A Multi-Method Study“. Forthcoming at Production and Operations Management

Five Star Treatment – Moving the Needle on Patient Safety and Experience

Moving the needle

Whether they like it or not, hospitals today can’t solely measure success by properly treating patients according to established standards of care. Moving a patient through surgery to recovery with no complications or hospital-borne bugs, for example, is only part of the equation in the eyes of the government agencies holding the purse strings for critical Medicare and Medicaid reimbursement dollars. Now, patience experience also matters – and hospitals must wrangle with age-old cultural tensions to avoid getting hit where it hurts.

To avoid penalties and bring in maximum federal reimbursement funds, hospitals since 2013 have had to show high marks in evidence-based standards of clinical care and the Hospital Consumer of Healthcare Providers and Systems, or HCAHPS, survey. This survey measures patients’ experience, driven largely by how they grade their interaction with physicians and nurses. Pressure is mounting, as reimbursement penalties are set to potentially double next year if hospitals don’t show improvement on clinical care and patient experience under terms of Obamacare, the Patient Protection and Affordable Care Act passed in 2010. In addition to these penalties, we also find that improving both these dimensions can actually reduce the occurrence of 30-day readmission rates1.

Physicians greet this newfound emphasis on patient experience with skepticism at best and outright resentment at worse, largely due to the subjective nature of the HCAHPS survey. This, however, perfectly illustrates the challenge therein: It’s difficult to simultaneously improve these two measures in a notoriously hierarchical culture where doctors focus relentlessly on disease and nurses fear challenging them, even while carrying the torch as the patient advocate. Luckily, it’s possible, and our forthcoming research2 points to key measures that can drive the culture change needed to make it happen.

Magnet

The Magnet matters

These findings come five distinct case studies that involve more than 50 interviews we conducted at five large acute-care hospitals. This was paired with data drawn from more than 3,000 hospitals from 2006-12, before and after Obamacare kicked in. Strikingly obvious is the sheer difficulty of improving clinical care and patient experience without trade-offs (also evidenced in a different study3 conducted in 2012). Clinical care is comparably easier to operationalize and roll out through top-down directives: keep quality consistent, keep patients safe, and keep variation during care delivery minimal. The problem? These directives can make little room for the customized patient care in nurses’ hands. At the same time, providing a patient with a Ritz Carlton-quality experience means nothing if it interferes with doctors working to keep them alive and well.

A winning strategy a number of hospitals are beginning to adopt, we found, starts with clinching “Magnet” hospital status through the American Nurses Credentialing Center (ANCC). Its Magnet Recognition Program® is the stamp of a high-quality program, denoting they are involved in decision making from the highest strategic levels to the patient’s bedside. The presence of this “bottom-up” decision making, we found, is a crucial factor in hospitals’ ability to improve on “hard,” evidence-based patient care and the “soft” patient experience side. In fact, we found hospitals with ANCC Magnet status were 24 percent more likely than their peers to show improvement in both of these measures, according to federal data from the Centers for Medicare and Medicaid (CMS).

Flattening this hierarchy doesn’t mean the end of administrative oversight, but it does require a newly measured approach to it. What emerged in our research was a “sweet spot” of administrative duties for nurses. Hospitals whose nurses average more than 25 percent of their shifts completing checklists and managing electronical medical records instead of patient are more likely to show weaker trends in improving on both dimensions. But so are hospitals whose nurses spend scarcely more than 10 percent of their time on the same tasks. Administrative oversight and an empowering culture for nurses can peacefully exist, but only if both are carefully balanced.

Playing matchmaker

To maintain the culture needed to treat patients and treat them well, providers can learn much from the physician-nurse interaction in the five hospitals we closely studied. Collaboration between doctors and nurses at the same rung on the ladder – Chief Nursing Officers and Chief Medical Officers or Medical Director – Nursing Director – is a longstanding best practice, but it’s not enough. In another forthcoming research4 on collaboration, we found that the best hospitals took this a step further, routinely pairing experienced, high-level nursing staff with low-level doctors, aiming to instill the importance of patient experience early in their careers. The reverse happens, too: One hospital, for example, paired a chief medical officer with an entry-level nurse and noted success in breaking down the hierarchy that can prevent nurses from speaking up. Taken together, these cross-level collaborations can drive major gains in the improving both the clinical and patient experience measures that matter most.

These crucial collaborations can take many forms. Hospitals we studied reported placing nursing leaders on physician-hiring committees or sending medical directors to work with nurses on day-to-day tasks. One even borrowed from iconic General Electric CEO Jack Welch, issuing a “get on board or get out” policy for its new collaborative culture. These surely move the needle, but they’re also formal measures that “force” physician-nurse interactions. The most successful hospitals see these collaborations form and grow organically, whether it’s nurses inviting physicians to their meetings or informal touch-base discussions in hallways. These connections might not be in the service of scratching another item off a checklist, but their impact can be just as powerful.

 

Articles

  1. C. Senot, A. Chandrasekaran, P. Ward, A. Tucker, and S. Moffat-Bruce, “The Impact of Combining Conformance Quality and Experiential Quality on Readmissions and Cost Performance,” Management Science (2016).
  2. Senot, C., Chandrasekaran, A., Ward, P. 2016. “Role of Bottom-Up Decision Process in Improving the Quality of Health Care Delivery: A Contingency Perspective“. Forthcoming at Production and Operations Management
  3. A. Chandrasekaran, C. Senot, K. Boyer, “Process Management Impact on Clinical and Experiential Quality: Managing Tensions Between Safe and Patient-Centered Healthcare,” Manufacturing and Service Operations Management 14, no. 4 (2012): 548-566.
  4. C. Senot, A. Chandrasekaran, P. Ward. 2016. Collaboration between Service Professionals during the Delivery of Health Care: Evidence from a Multiple- Case Study in U.S. HospitalsForthcoming in Journal of Operations Management. 

 

Do we understand Lean Deployment in Healthcare?

Patient Safety                                             Lean

Anyone who has taught lean principles grounded in the famous Toyota Production System (TPS) to organizations outside the manufacturing industry has – at least once – heard this common refrain: “(Insert industry here) isn’t cars on an assembly line. This doesn’t apply to my work.”

Leading lean thinkers, of course, have learned how to work with individuals and teams to move past this roadblock and garner buy-in – that’s why the practices and tools intrinsic to TPS have made their way into countless industries. Lean still can be a target for criticism, though, and one need look no further for proof than an article published earlier this year in the New England Journal of Medicine – and the debate it ignited.

The January issue of NEJM featured an article called “Medical Taylorism” where authors and physicians Pamela Hartzband and Jerome Groopman assert that lean principles “cannot be applied to many vital aspects of medicine. If patients were cars, we would all be used cars of different years and models …” This tipped off a flurry of rebuttals, including one from Lean Enterprise Institute CEO John Shook boldly titled “Malpractice in the New England Journal of Medicine.” In his piece, which itself attracted widespread attention, Shook writes that the foundational lean principles of continuous improvement and respect for people are critically important in the health-care system.

Shook is right, but I’d like to approach this discussion from a different angle, namely that this line of criticism has emerged elsewhere – and it’s rooted in a lack of understanding of lean deployment.

One of my initial research areas sought to understand how standardization and “smart application” of Design for Six Sigma (DFSS) principles can aid R&D and innovation efforts. I pursued this as a number of business press publications and industry practitioner blogs lamented the damage Six Sigma does to creativity and praised the need for variation for innovation. Several years of research1,2 at Fortune 500 companies with my colleagues in Fortune 500 companies made us realize such sentiments don’t hold much water. We found ambidex, in fact, that principles of Six Sigma/DFSS – when applied to the innovation process correctly (hence the “smart” in “smart application’) – can help reduce unnecessary variation and stop worthless innovation activities that consume R&D funding (shift).

I’ve more recently collaborated with researchers and physicians to tackle similar questions in health care. Once again, the findings – published in several academic and practitioner outlets – are very similar: The smart application of lean and continuous improvement principles can help develop a safe and patient-centric healthcare system.

In arguing that patients aren’t cars, the NEJM’s authors are absolutely right – but they’re dead-wrong in concluding there’s no place for lean in “many vital aspects of medicine.” As with our R&D research, we’ve found that lean deployment in hospital settings minimizes unnecessary variation that comes from care providers, not patients. In fact, it frees up time and effort to cater to the necessary variability in a population diverse in its illnesses, economic backgrounds, languages and more.

 

Huddle2

As an example, in a recent study, my fellow researchers that include physician leaders and I spent years looking at Ohio State University’s Wexner Medical Center, specifically a lean deployment effort in its kidney transplant discharge process (see right picture). Transplant recipients after discharge must drink at least three liters of fluid a day – failure to do so can spike creatine levels, elevating blood pressure and increasing the likelihood of readmission. This is an evidenced based fact well-grounded in the medical literature7. During our roundings, we found variations in how these instructions were delivered to the patients: One nurse, for example, nonspecifically recommended drinking “a lot of fluids” while another suggested 100 ounces. Interestingly, we found nurses varying instructions between patients and patients who received different instructions from more than one nurse. These nurses weren’t being intentionally deceptive but their inconsistencies confused patients as they took in a tremendous overload of instructions.

Overhauled through the lean deployment via standard work design, nurses in our medical center now clearly explain the specific volume of fluid, use a jug to visually illustrate, and discuss the consequences of not following the instructions. Preliminary findings show this approach soothes patients’ anxiety levels and has reduced the chances of readmissions in the first month after transplant.

This isn’t just a lean approach to a problem – it’s a smart lean approach. And in an environment that, yes, isn’t cars on an assembly line that matters more than ever.

References:

  • Chandrasekaran, A., Linderman, K., Sting, F., Benner, M. 2016, Managing R&D Project Shifts in High-Tech Organizations: Multi-Method Study. Forthcoming at Production and Operations Management
  •  Chandrasekaran, A., Linderman, K., and Schroeder, R.G. 2012. Antecedents to Ambidexterity Competency in High Technology Organizations. Journal of Operations Management, 30(1-2) 134-151.
  •  Chandrasekaran, A., Senot, C., Boyer, K. 2012. Process Management Impact on Clinical and Experiential Quality: Managing Tensions between Safe and Patient-Centered Healthcare. Manufacturing and Service Operations Management, 14(4) 548-566
  •  Senot, C., Chandrasekaran. A. 2015. What has the highest impact on Readmissions Rates? Harvard Business Review (A joint collaboration between HBR-NEJM)
  •  Senot, C., Chandrasekaran, A., Ward, P., Tucker, A., Moffat-Bruce, S (2016) The Impact of Combining Conformance Quality and Experiential Quality on Readmissions and Cost Performance. Forthcoming Management Science
  •  Chandrasekaran, A., Anand. G., Sharma L., Ward, P., Henry M., Pesavento T., Moffatt-Bruce. The relationship between Patient Anxiety, Quality of Discharge Instructions and 30-day Readmission Rates for Kidney Transplant Recipients. (Findings presented at the American Surgical Congress, Feb 2016)
  • Gordon, E.J., Prohaska, T., Gallant, M., Siminoff, L., (2009). Self-care strategies and barriers among kidney transplant recipients: a qualitative study. Chronic Illness. 5(2) 75-91.