title: Quality and safety during the off hours in medicine units: a mixed methods study of front-line provider perspectives.
abstract: BACKGROUND
  Hospital off-hours care is associated with poor outcomes. Mutual conceptualization among provider groups may facilitate improvement efforts. Provider-perceived threats to quality are unreported.
  
  
  OBJECTIVE
  The objectives of this study were to identify perceived off-hours quality and safety issues, assess the most significant, and evaluate differences between nurses, and attending and housestaff physicians, and providers with day and night experience.
  
  
  METHODS
  Prospective, sequential, exploratory mixed-methods study.
  
  
  METHODS
  Open-ended descriptions of adverse events/near misses occurring overnight (n = 190) were analyzed using thematic analysis. From these results, a survey was developed to assess perceptions of quality/frequency of each issue (7-point scale, 7 = the highest rating) and highest-quality overnight period (7-10 pm, 10 pm-1 am, 1-4 am, 4-7 am).
  
  
  RESULTS
  Primary issues related to mismanagement, delivery processes, and communication/coordination. Of 214 surveys, 160 responses (75%) were received. Least-optimal issues related to "communication" (2.93) and "timeliness/safety" (3.89) of emergency department transfers; most-optimal issues related to timely lab reporting (4.70). On the 7-point scale, comparisons among nurses, and attending and housestaff physicians revealed differences in quality of "communication between physicians" (4.29 vs 6.00 vs 5.14) and "communication between consultants-primary providers" (3.46 vs 5.75 vs 4.35, P < 0.001). Comparisons between day-night providers revealed lower ratings from day providers in 12/24 items (P < 0.05), including "communication during emergency department transfers" (4.81 vs 3.86). All groups ranked 4 to 7am lowest in quality.
  
  
  CONCLUSIONS
  Nurses, and attending and housestaff physicians lack a shared mental model of off-hours care. Several issues, including emergency department transfers and timeliness of consults, were identified by all providers as problematic, meriting further investigation and intervention.
authors.affiliation: Assistant Professor of Medicine and Public Health Sciences, Assistant Dean for Health Systems Education, Pennsylvania State University College of Medicine, Hershey, Pennsylvania.
authors.forename: Jed D
authors.initials: JD
authors.lastname: Gonzalo
authors.forename: Eileen
authors.initials: E
authors.lastname: Moser
authors.forename: Erik
authors.initials: E
authors.lastname: Lehman
authors.forename: Ethan
authors.initials: E
authors.lastname: Kuperman
mesh_terms: D001291:Attitude of Health Personnel; D003625:Data Collection / Q000379:methods; D006760:Hospitalization / Q000639:trends; D006801:Humans; D008505:Medical Staff, Hospital / Q000592:standards* / Q000639:trends; D019555:Physician-Nurse Relations; D011446:Prospective Studies; D058996:Quality Improvement / Q000592:standards* / Q000639:trends; D011787:Quality of Health Care / Q000592:standards* / Q000639:trends; D014940:Work Schedule Tolerance