Sara J Singer

Harvard University | Harvard · Department of Health Policy and Management

Objectives: Opioid misuse has resulted in significant morbidity and mortality in the United States, and safer opioid use represents an important challenge in the primary care setting. This article describes a research collaborative of health service researchers, systems engineers, and clinicians seeking to improve processes for safer chronic opioi...

Background In August 2021, up to 30% of Americans were uncertain about taking the COVID-19 vaccine, including some healthcare personnel (HCP). Objective Our objective was to identify barriers and facilitators of the Veterans Health Administration (VHA) HCP vaccination program. Design We conducted key informant interviews with employee occupationa...

Large-scale (e.g., national) programs could strengthen safety culture, which is foundational to patient safety, yet we know little about how to optimize this potential. In 2013, Brazil’s Ministry of Health launched the National Patient Safety Program, involving hospital-level safety teams and targeted safety protocols. We conducted in-depth qualita...

More is known about the structural features of health system integration than the social features—elements of normative integration (alignment of norms) and interpersonal integration (collaboration among professionals and with patients). We surveyed practice managers and 1,360 staff and physicians at 59 practice sites within 17 health systems (828...

Background: Integrated care that is continuous, coordinated and patient-centered is vital for Medicare beneficiaries, but its relationship to health care expenditures remains unclear. Research objective: This study explores-for the first time-the relationship between integrated care, as measured from the patient's perspective, and health care ex...

Background Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers.Objectives To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer–related pain in a large integrated healthcare system.DesignQualitative r...

Background Patients with chronic cancer or non-cancer pain often struggle with physical, emotional, and psychological problems not easily addressed by a single clinician. Current pain management recommendations emphasize leveraging interdisciplinary teams. We aim to describe how we intend to identify key features of interdisciplinary team structure...

Objective: To explore sequential steps of employee engagement in wellness interventions and the impact of wellness interventions on employee health. Methods: Using previously collected survey data from 23,667 UK employees, we tabulated intervention availability, awareness, participation, and associated health improvement and compared engagement...

Background: Negative experiences contribute to provider dissatisfaction and burnout. Prior research suggests that negative experiences have greater impact on individuals than positive experiences. Methods: Interviews were conducted with surgical and oncology care providers (107 MDs, 253 non-MDs) working in 10 geographically diverse, academic and...

Aim To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis. Methods Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children’s hospita...

Objective: This study sought to identify potential disparities among racial/ethnic groups in patient perceptions of integrated care (PPIC) and to explore how methodological differences may influence measured disparities. Data source: Data from Medicare beneficiaries who completed the 2015 Medicare Current Beneficiary Survey (MCBS) and were enrol...

Fragmented healthcare causes information loss, duplicative tests, and unwieldy self-care regimens. These challenges may be amplified among older, high-risk patients with co-occurring mental health conditions (MHC). We compared healthcare fragmentation for chronic physical conditions among Veterans with and without MHC (depression, PTSD, schizophren...

Family perspectives on short-term recovery after spinal fusion for neuromuscular scoliosis are essential for improving patient outcomes. Semistructured interviews were conducted with 18 families of children within 3 months after spinal fusion performed August 2017 to January 2019 at a children’s hospital. Interviews were recorded, transcribed, and...

Background: Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare. Objective: To characterize patient experie...

Objective Examine care integration—efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them—to understand whether and at which organizational level health systems impact care quality and staff experience. Data Sources Surveys administered to one practice manager (56/59) a...

We explore how members of a community of practice learn new tools and techniques when environmental shifts undermine existing expertise. In our 20-month comparative field study of medical assistants and patient-service representatives learning to use new digital technology in five primary care sites, we find that the traditional master-apprentice t...

Objectives: This study aimed to narratively summarize the literature reporting on the effect of teamwork and communication training interventions on culture and patient safety in emergency department (ED) settings. Methods: We searched PubMed, EMBASE, Psych Info CINAHL, Cochrane, Science Citation Inc, the Web of Science, and Educational Resource...

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated pr...

Objective: Employers affect the health of employees and their families through work environments and employee benefits. We sought to understand employer decisions around those topics. Methods: Interviews with 21 executives from diverse, purposely-sampled, progressive companies with transcripts analyzed using inductive and deductive methods. Res...

Background: Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination. Objective...

Though increasingly useful for developing complex healthcare innovations, interdisciplinary teams are prone to resistance and other organizational challenges. However, how teams are affected by and manage external constraints over the lifecycle of their innovation project is not well understood. We used a multimethod qualitative approach consisting...

Introduction: Organisational culture is believed to be an important facilitator for better integrated care, yet how organisational culture impacts integrated care remains underspecified. In an exploratory study, we assessed the relationship between organisational culture in primary care centres as perceived by primary care teams and patient-percei...

Team-based care is considered central to achieving value in primary care, yet results of large-scale primary care transformation initiatives have been mixed. We explore how underlying change processes influence the effectiveness of transition to team-based care. We studied 12 academically affiliated primary care practices participating in a learnin...

Policy Points The private sector has large potential influence over social determinants of health, but we have limited information about how businesses perceive or engage in actions to promote health and well-being. We conducted a national survey of more than 1,000 businesses of varying sizes and industries to benchmark private sector engagement in...

The aim of this study is to assess the impact of preoperative comanagement with complex care pediatricians (CCP) on children with neuromuscular scoliosis undergoing spinal fusion. We performed chart review of 79 children aged 5–21 years undergoing spinal fusion 1/2014–6/2016 at a children’s hospital, with abstraction of clinical documentation from...

Background and Objectives Primary care teamwork has been shown to increase satisfaction and decrease stress for physicians but the impact of outpatient teamwork for primary care residents’ learning has not been described. This study aimed to understand the role of teamwork in residents’ learning during and after the establishment of teams. Methods...

In Reply Despite Mr Cahan’s assertion, we did not argue that traditional corporate social responsibility is, or should be “integral to profit maximization.”¹ There is widespread recognition that older concepts of corporate social responsibility are not intrinsically linked to a company’s fundamental operations or underlying financial success.² Rath...

While the mental healthcare-consumer voice has gained in legitimacy and perceived value, policy initiatives and system improvements still lack input from consumers. This study explores consumers’ suggestions for improving the mental healthcare system. Participants (N = 46) were conveniently recruited and responded to an online survey asking: “What...

Objectives: To convey advice from families whose children recently underwent spinal fusion to families whose children are under consideration for initial spinal fusion for neuromuscular scoliosis and to providers who counsel families on this decision. Study design: We interviewed 18 families of children who underwent spinal fusion between August...

Background Multiple comorbidities thought to be associated with poor coordination due to the need for shared treatment plans and active involvement of patients, among other factors. Cardiovascular and mental health comorbidities present potential coordination challenges relative to diabetes.Objective To determine how cardiovascular and mental healt...

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between interventi...

Background Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships...

Background Care coordination is crucial to avoid potential risks of care fragmentation in people with complex care needs. While there are many empirical and conceptual approaches to measuring and improving care coordination, use of theory is limited by its complexity and the wide variability of available frameworks. We systematically identified and...

Background: The need to expand and better engage patients in primary care improvement persists. Purpose: Recognizing a continuum of forms of engagement, this study focused on identifying lessons for optimizing patient partnerships, wherein engagement is characterized by shared decision-making and practice improvement codesign. Methodology: Twe...

Background Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barrier...

This article describes the development and psychometric testing of the Patient Perceptions of Integrated Care (PPIC 2.1) survey, which we administered to 12,364 Medicare beneficiaries who received treatment from 150 randomly selected physician organizations, receiving 3,067 responses (26%). Psychometric analyses, performed using two methods to adju...

Background: Projecting postoperative recovery in pediatric surgical patients is challenging. We assessed how the patients' number of complex chronic conditions (CCCs) and chronic medications interacted with active health issues to influence the likelihood of postoperative physiologic decline (PoPD). Methods: A prospective study of 3295 patients...

For too long, the worlds of business and health have been mired in a checkered, sometimes contentious, history. Millions of deaths worldwide can be attributed to risk factors including tobacco use, alcohol and drug misuse, and suboptimal dietary intake linked to commercial products. Media (including social media) coverage about the safety and cost...

Importance Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions. Objective To evaluate the association of establishing team-based primary care with patient health care...

Proven patient safety solutions such as the World Health Organization's Surgical Safety Checklist are challenging to implement at scale. A voluntary initiative was launched in South Carolina hospitals in 2010 to encourage use of the checklist in all operating rooms. Hospitals that reported completing implementation of the checklist in their operati...

Background: In health care, hierarchy can facilitate getting work done efficiently. It can also hinder performance by suppressing valuable contributions from lower-positioned individuals. Team-based care could mitigate negative effects by creating space for all team members to contribute their unique expertise. Purpose: This article sought to un...

Background: The World Health Organization's (WHO) surgical safety checklist is meant to be customized to facilitate local implementation, encourage full-team participation, and promote a culture of safety. Although it has been globally adopted, little is known about the extent of checklist modification and the type of changes made. Methods: Nons...

The safe transition of a patient from hospital into the community requires effective coordination between healthcare professionals across organisational boundaries. Preventing transition-associated failures can be especially challenging when multiple disciplines are involved and the patient has extensive care needs. The field of systems engineering...

OCCUPATIONAL APPLICATIONS A team of systems engineers, clinicians, and healthcare researchers evaluated the Systems-Theoretic Process Analysis (STPA) method to analyze and design a process to ensure safe opioid prescribing at an urban primary care clinic. The STPA framework of losses, hazards, and controls identified two major unacceptable losses,...

Background: Surgical excellence demands teamwork. Poor team behaviors negatively affect team performance and are associated with adverse events and worse outcomes. Interventions to improve surgical teamwork focusing on frontline team members’ nontechnical skills have proliferated but shown mixed results. Literature on teamwork in organizations sugg...

Background: There remains a need to improve patient safety in primary care settings. Studies have demonstrated that creating high-performing teams can improve patient safety and encourage a safety culture within hospital settings, but little is known about this relationship in primary care. Objective: To examine how team dynamics relate to perce...

Efforts to transform health care delivery to improve care have increasingly focused on care integration. However, variation in how integration is defined has complicated efforts to design, synthesize, and compare studies of integration in health care. Evaluations of integration initiatives would be enhanced by describing them according to clear def...

Little is known about how practices reorganize when transitioning from traditional practice organization to team-based care. We compared practice-level (1) configuration as well as practice- and team-level (2) size and (3) composition, before and after establishing teams. We employed a pre-/poststudy using personnel lists of 1571 to 1711 staff (eg,...

Background: Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management dur...

Background: Surgical excellence demands teamwork. Poor team behaviors negatively affect team performance and are associated with adverse events and worse outcomes. Interventions to improve surgical teamwork focusing on frontline team members' nontechnical skills have proliferated but shown mixed results. Literature on teamwork in organizations sug...

Background: Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines. Objective: To assess the degree to which primary care physicians document risk factors for colorectal cancer amo...

This article discusses development and testing of the Provider and Staff Perceptions of Integrated Care Survey, a 21-item questionnaire, informed by Singer and colleagues’ seven-construct framework. Questionnaires were sent to 2,936 providers and staff at 100 federally qualified health centers and other safety net clinics in 10 Midwestern U.S. stat...

Background: Educators hope that residents’ experiences in primary care continuity clinics will influence more trainees to enter primary care careers. Unfortunately, evidence shows that outpatient primary care training in the United States is stressful and fails to promote primary care careers. We conducted qualitative interviews with residents to u...

Background: Global payment is used with surgeries to optimize health, lower costs, and improve quality. We assessed perioperative spending on spinal fusion for scoliosis to inform how this might apply to children. Methods: Retrospective analysis of 1249 children using Medicaid and aged ≥5 years with a complex chronic condition undergoing spinal...

Objective: To test the cross-cultural validity of the U.S. Patient Perception of Integrated Care (PPIC) Survey in a Dutch sample using a standardized procedure. Data sources: Primary data collected from patients of five primary care centers in the south of the Netherlands, through survey research from 2014 to 2015. Study design: Cross-sectiona...

Presented at the 4th World Congress of Integrated Care. TSB Arena, Wellington New Zealand; 23-25 November 2016

Background: Recent literature suggests that middle manager affective commitment (emotional attachment, identification, and involvement) to an improvement program may influence implementation success. However, less is known about the interplay between middle manager affective commitment and frontline worker commitment, another important driver of i...

Background Previous studies have demonstrated that the perception of teamwork and communication differs between healthcare professionals. It is unclear if the perception of safety of surgical practice in ambulatory surgery centers (ASCs) in the United States (US) differ between healthcare professionals that work in the operating room (OR). Methods...

Objective: To evaluate whether the perception of safety of surgical practice among operating room (OR) personnel is associated with hospital-level 30-day postoperative death. Background: The relationship between improvements in the safety of surgical practice and benefits to postoperative outcomes has not been demonstrated empirically. Methods:...

Objective: Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. Study setting: In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. Study design: Controlled trial of a 15-month intervention including exposure to a learning network, webina...

Objective: To examine narrative feedback to understand surgical team perceptions about surgical safety checklists (SSCs) and their impact on the safety of surgical practice. Design: We reviewed free-text comments from surveys administered before and after SSC implementation between 2011 and 2013. We categorized feedback thematically and as posit...

Structural integration is increasing among medical groups, but whether these changes yield care that is more integrated remains unclear. We explored the relationships between structural integration characteristics of 144 medical groups and perceptions of integrated care among their patients. Patients' perceptions were measured by a validated nation...

Rationale, aims, and objectives: Measures of safety climate are increasingly used to guide safety improvement initiatives. However, cost and respondent burden may limit the use of safety climate surveys. The purpose of this study was to develop a 15- to 20-item safety climate survey based on the Patient Safety Climate in Healthcare Organizations s...