Usually, people are admitted to hospitals as inpatients in order to receive treatment and leave the hospital cured or well on the road to complete recovery, no longer needing inpatient care. They are not supposed to need to be readmitted, especially for the same diagnosis, within a month. Most of the time that is the way the system works. However, with the emphasis during the past decade on reducing length of stay, questions have arisen about the impact of early discharge on clinical outcomes and early readmission less than 30 days postdischarge. One issue is the possibility that the emphasis on short stays may foster inadequate care, leading to early readmission. The other issue is the possibility that short stays may be associated with a high degree of efficiency in the provision of services. With the effective date of Medicare's Readmission Reduction Program looming, the relationship between length of stay and early readmission is examined by Tricia Johnson, Jaydeep Bardhan, Richard Odwazny, Brian Harting, Kimberly Skarupski, and Robert McNutt.

While the literature includes reports of formal quality assurance development projects in individual departments, units, and hospitals, Marita MacKinnon Schifalacqua, Ann Shepard, and Wanda Kelley point out that detailed analyses and reports dealing with systemwide projects are relatively scarce. The authors set about to fill this gap with their detailed account of the development of an evidence-based practice model in the Catholic Health Initiatives system. This system, one of the largest in the United States, includes 70 hospitals and 40 long-term health care facilities. The authors point out that full leadership involvement in the project was a key factor in developing and implementing the plan.

The team approach both to patient care and to the task of improving patient care is well established. Tomas Mullern and Annika Nordin ask why some teams, even within the same provider organization and physical setting, seem to perform better than others in quality improvement projects. Supported by a substantial body of research, they postulate that there may be a demonstrable connection between a team's degree of, and sense of, empowerment and its performance in quality improvement efforts. The authors, in the setting of a large hospital clinic in Sweden, define 5 components that together contribute to a team's degree of, and sense of, empowerment. On the basis of analysis of 21 aspects of intrateam interaction within each team, they derive an empowerment profile of each of the 3 teams in their sample. In a longitudinal process, they compare the relationship of each team's empowerment profile with its observed effectiveness in dealing with quality improvement issues.

Using the Structured Problem and Success Inventory as a structured approach to organizational problem solving, Monica E. Nystrom, Darcey D. Terris, Vibeke Sparring, Sara Tolf, and Claire R. Brown set out to determine whether or not the instrument could capture the perceptions of work-related problems held by health care workers and whether their perceptions of work-related problems corresponded with their positions in the organization. In a pilot test with a convenience sample of health care professionals representing middle management, lower-level management, and nonmanagerial staff, they asked the participants to identify what they considered the 3 most pressing organizational and work-related problems as they saw them. On the basis of the replies, the investigators developed 13 problem categories and analyzed the relationships between the identification of problems and the respondent's organizational level. The authors suggest that the Structured Problem and Success Inventory may prove to be a useful tool in examining organizational problems and issues.

As we were taught in labor economics and social psychology courses, one mark of the professional worker is his or her habit of critically reviewing and evaluating his or her own performance. During the past 2 or 3 decades, even professionals are increasingly drawn out of their lofty independence to function as team members. This is particularly common in health care. So it is a natural, predictable development for the team to engage in the process known as team reflection. Because this activity involves several people of varying backgrounds and viewpoints, you have to provide them with some structure and guidelines in the interest of efficiency in their review and decision making. Eric K. Shaw, Jenna Howard, Rebecca S. Etz, Shawna V. Hudson, and Benjamin F. Crabtree examine the ways in which facilitated team-based reflection affected a quality improvement intervention in each of 4 primary medical practices.

-Jean Gayton Carroll, PhD

Editor