Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.10.014
Glenn Seela (is a Medical Student, University of Minnesota Medical School.), David Satin MD (is an Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, and Affiliate Faculty Center for Bioethics, University of Minnesota.), Cathy Centola (is Division Administrator, Department of Pediatrics, University of Minnesota Medical School.), Sameer Gupta MD, MBA (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School.), Paul Hodges MPP (is Director of Process Improvement and Clinical Quality, M Health Fairview, University of Minnesota Medical Center.), Jeff Louie MD (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School.), Tanya E. Melnik MD, MS (is an Associate Professor, Department of Medicine, University of Minnesota Medical School.), David Pelletier MSE, ICBB (is Principal Consultant, Quality Improvement, M Health Fairview.), Christina Russell MD (is an Assistant Professor, Department of Pediatrics, University of Minnesota Medical School.), Andrew Thompson MBA, MBB (Principal Consultant, Performance Improvement, M Health Fairview.), Jordan Marmet MD (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School. Please address correspondence to Jordan Marmet)
Background
Many medical boards require quality improvement (QI) projects for Maintenance of Certification Part IV (MOC4) credits. The American Board of Medical Specialties (ABMS) allows health care organizations that can demonstrate sufficient QI standards to become Portfolio Program Sponsors. This enables internal review and approval of QI projects, crediting all sufficiently contributing physicians. The University of Minnesota's M Health Fairview MOC4 Review Board (MMRB) was approved as an ABMS Portfolio Program Sponsor; the impact was surveyed from inception in 2016 to 2022. The objective was to examine the impact of a Portfolio Sponsor program on scholarship, sustainability, and spread of QI projects.
Methods
The authors developed and validated an eight-question survey directed at MOC4 principal investigators (PIs) who were awarded credits through the MMRB from 2016 to 2022. Participants reported on numbers of peer-reviewed publication or presentation, and their perception of increased preparedness for scholarship due to the application process. They also reported on sustainment or spread following their original QI project.
Results
Fifty projects were reviewed over a seven-year span. Of these, 44 were approved as demonstrating sufficient QI rigor per ABMS standards. Of 41 PIs, 27 (65.9%) responded to the survey; 15 (55.6%) agreed that the MMRB process helped prepare them for scholarly dissemination, 19 (70.4%) delivered oral or poster presentations, and 10 (37.0%) submitted a total of 14 manuscripts for publication, 10 of which were accepted. A total of 23 QI projects (85.2%) were sustained, and 10 (37.0%) had spread.
Conclusion
In addition to generating essential MOC4 credits for participating physicians, an MMRB process can help PIs prepare for scholarship, project sustainment, and spread.
背景：许多医学委员会要求质量改进（QI）项目来维护认证第四部分（MOC4）学分。美国医学专业委员会（ABMS）允许能够证明足够的QI标准的卫生保健组织成为投资组合计划的赞助商。这使得QI项目能够进行内部审查和批准，并将所有充分贡献的医生归功于自己。明尼苏达大学M Health Fairview MOC4审查委员会（MMRB）被批准为ABMS投资组合项目赞助商；从2016年开始到2022年，对其影响进行了调查。目的是检查投资组合赞助计划对奖学金、可持续性和QI项目传播的影响。方法：作者开发并验证了一项针对2016年至2022年通过MMRB获得学分的MOC4首席研究员（pi）的8个问题调查。参与者报告了同行评审的出版物或演讲的数量，以及他们对申请过程提高奖学金准备程度的看法。他们还报告了原始QI项目之后的维持或传播情况。结果：在7年的时间里对50个项目进行了审查。其中，44个被批准为证明了足够的符合ABMS标准的QI严格性。41个pi中，27个（65.9%）回应了调查；15人（55.6%）认为MMRB过程帮助他们为学术传播做好了准备，19人（70.4%）进行了口头或海报演讲，10人（37.0%）提交了14篇论文供发表，其中10篇被接受。共有23个项目（85.2%）得到维持，10个项目（37.0%）得到扩展。结论：除了为参与项目的医生产生必要的MOC4学分外，MMRB流程还可以帮助pi为奖学金、项目维持和推广做好准备。
{"title":"The Scholarly Upside to MOC4","authors":"Glenn Seela (is a Medical Student, University of Minnesota Medical School.), David Satin MD (is an Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, and Affiliate Faculty Center for Bioethics, University of Minnesota.), Cathy Centola (is Division Administrator, Department of Pediatrics, University of Minnesota Medical School.), Sameer Gupta MD, MBA (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School.), Paul Hodges MPP (is Director of Process Improvement and Clinical Quality, M Health Fairview, University of Minnesota Medical Center.), Jeff Louie MD (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School.), Tanya E. Melnik MD, MS (is an Associate Professor, Department of Medicine, University of Minnesota Medical School.), David Pelletier MSE, ICBB (is Principal Consultant, Quality Improvement, M Health Fairview.), Christina Russell MD (is an Assistant Professor, Department of Pediatrics, University of Minnesota Medical School.), Andrew Thompson MBA, MBB (Principal Consultant, Performance Improvement, M Health Fairview.), Jordan Marmet MD (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School. Please address correspondence to Jordan Marmet)","doi":"10.1016/j.jcjq.2024.10.014","DOIUrl":"10.1016/j.jcjq.2024.10.014","url":null,"abstract":"<div><h3>Background</h3><div>Many medical boards require quality improvement (QI) projects for Maintenance of Certification Part IV (MOC4) credits. The American Board of Medical Specialties (ABMS) allows health care organizations that can demonstrate sufficient QI standards to become Portfolio Program Sponsors. This enables internal review and approval of QI projects, crediting all sufficiently contributing physicians. The University of Minnesota's M Health Fairview MOC4 Review Board (MMRB) was approved as an ABMS Portfolio Program Sponsor; the impact was surveyed from inception in 2016 to 2022. The objective was to examine the impact of a Portfolio Sponsor program on scholarship, sustainability, and spread of QI projects.</div></div><div><h3>Methods</h3><div>The authors developed and validated an eight-question survey directed at MOC4 principal investigators (PIs) who were awarded credits through the MMRB from 2016 to 2022. Participants reported on numbers of peer-reviewed publication or presentation, and their perception of increased preparedness for scholarship due to the application process. They also reported on sustainment or spread following their original QI project.</div></div><div><h3>Results</h3><div>Fifty projects were reviewed over a seven-year span. Of these, 44 were approved as demonstrating sufficient QI rigor per ABMS standards. Of 41 PIs, 27 (65.9%) responded to the survey; 15 (55.6%) agreed that the MMRB process helped prepare them for scholarly dissemination, 19 (70.4%) delivered oral or poster presentations, and 10 (37.0%) submitted a total of 14 manuscripts for publication, 10 of which were accepted. A total of 23 QI projects (85.2%) were sustained, and 10 (37.0%) had spread.</div></div><div><h3>Conclusion</h3><div>In addition to generating essential MOC4 credits for participating physicians, an MMRB process can help PIs prepare for scholarship, project sustainment, and spread.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 101-107"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142864222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.10.013
Matthew R. Michienzi DO (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas.), Dakota K. Tomasini DO (is Neonatology Fellow, Department of Pediatrics, Brooke Army Medical Center.), Carleigh C. Fisher DO (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center.), Adharsh P. Ponnapakkam MD (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center. Please address correspondence to Matthew Michienzi)
Background
The initial hyperbilirubinemia management recommendations published by the American Academy of Pediatrics (AAP) in 2004 and updated in 2009 led to wide variations in clinical practice among providers, with variable results. In August 2022 AAP published updated clinical practice guidelines for the management of hyperbilirubinemia. The aim of this project was to determine the effect of adaptation of the AAP guidelines on laboratory testing, readmission rates, and phototherapy.
Methods
Existing institutional protocol was updated to incorporate the revised AAP guidelines. The primary outcome was percentage of serum bilirubin labs obtained. Balancing measures included monthly readmission rate, need for escalation of care, and percentage of patients requiring additional labs or phototherapy. Statistical process control charts measured changes in quality over time. Chi-square analysis evaluated differences between pre- and postintervention periods.
Results
A total of 2,301 infants were evaluated, 1,662 of which were included in the postintervention analysis. A clinically and statistically significant decrease was seen in the percentage of patients with serum bilirubin evaluation, from 21.3% to 8.8% (p < 0.001). There was a decrease in need for phototherapy, from 4.2% to 1.4% (p < 0.001), but duration of treatment was longer when initiated. The authors simultaneously saw no changes in readmission rate or additional laboratory evaluation, with no incidence of bilirubin-induced encephalopathy or escalation of care.
Conclusion
Implementation of the revised 2022 AAP guidelines was associated with a decrease in serum bilirubin evaluation and phototherapy initiation. This integrated protocol may represent a sustainable standardized approach to management of hyperbilirubinemia.
{"title":"Implementation of the Revised American Academy of Pediatrics Clinical Practice Guidelines for Hyperbilirubinemia Decreases Necessity for Serum Bilirubin and Phototherapy","authors":"Matthew R. Michienzi DO (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas.), Dakota K. Tomasini DO (is Neonatology Fellow, Department of Pediatrics, Brooke Army Medical Center.), Carleigh C. Fisher DO (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center.), Adharsh P. Ponnapakkam MD (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center. Please address correspondence to Matthew Michienzi)","doi":"10.1016/j.jcjq.2024.10.013","DOIUrl":"10.1016/j.jcjq.2024.10.013","url":null,"abstract":"<div><h3>Background</h3><div>The initial hyperbilirubinemia management recommendations published by the American Academy of Pediatrics (AAP) in 2004 and updated in 2009 led to wide variations in clinical practice among providers, with variable results. In August 2022 AAP published updated clinical practice guidelines for the management of hyperbilirubinemia. The aim of this project was to determine the effect of adaptation of the AAP guidelines on laboratory testing, readmission rates, and phototherapy.</div></div><div><h3>Methods</h3><div>Existing institutional protocol was updated to incorporate the revised AAP guidelines. The primary outcome was percentage of serum bilirubin labs obtained. Balancing measures included monthly readmission rate, need for escalation of care, and percentage of patients requiring additional labs or phototherapy. Statistical process control charts measured changes in quality over time. Chi-square analysis evaluated differences between pre- and postintervention periods.</div></div><div><h3>Results</h3><div>A total of 2,301 infants were evaluated, 1,662 of which were included in the postintervention analysis. A clinically and statistically significant decrease was seen in the percentage of patients with serum bilirubin evaluation, from 21.3% to 8.8% (<em>p</em> < 0.001). There was a decrease in need for phototherapy, from 4.2% to 1.4% (<em>p</em> < 0.001), but duration of treatment was longer when initiated. The authors simultaneously saw no changes in readmission rate or additional laboratory evaluation, with no incidence of bilirubin-induced encephalopathy or escalation of care.</div></div><div><h3>Conclusion</h3><div>Implementation of the revised 2022 AAP guidelines was associated with a decrease in serum bilirubin evaluation and phototherapy initiation. This integrated protocol may represent a sustainable standardized approach to management of hyperbilirubinemia.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 95-100"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142854204","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.10.004
Lisa T. Barker MD, MHPE (is Clinical Associate Professor of Emergency Medicine, OSF HealthCare, University of Illinois College of Medicine at Peoria, and Medical Director, Jump Simulation, an OSF HealthCare and University of Illinois College of Medicine at Peoria Collaboration.), William F. Bond MD, MS (is Professor of Clinical Emergency Medicine, University of Illinois College of Medicine at Peoria, and Director of Research, Jump Simulation.), Ann M. Willemsen-Dunlap CRNA, PhD (is Director of Education Development, Jump Simulation.), Kimberly L. Cooley MSN, RN, CCRC (is Research Education Facilitator, OSF HealthCare.), Jeremy S. McGarvey MS (is Senior Statistician, Division of Healthcare Analytics, OSF HealthCare.), Rebecca L. Ruger (is Graduate Student, Department of Psychology, Pennsylvania State University.), Adam Kohlrus MS, CPHQ, CPPS (is Partner and Business Designer, Do Tank, Springfield, Illinois.), Michael J. Kremer PhD, CRNA, CHSE, FAAN (is Professor and Interim Chair, Department of Adult Health and Gerontological Nursing, College of Nursing, and Co-Director, Rush Center for Clinical Skills and Simulation, Rush University.), Michelle Sergel MD (is Co-Director, Rush Center for Clinical Skills and Simulation, Rush University and Assistant Professor of Emergency Medicine, Rush Medical College.), John A. Vozenilek MD (is Vice President and Chief Medical Officer for Innovation, OSF HealthCare. Please address correspondence to Lisa T. Barker)
Simulation-Debriefing Enhanced Needs Assessment (SDENA) is a simulation-based approach to prospective hazard analysis that uses simulation and debriefing as a unit-level diagnostic tool. Scenarios address failure modes for health care improvement targets, and debriefing explores unit-specific barriers and resiliencies. Debriefing guides are structured to explore how six drivers of a behavior engineering framework (data, tools/resources, incentives, knowledge/skills, capacity, motivation) influence clinical behaviors. Illinois Hospital Association members who deployed SDENA to address specific hospital-acquired conditions found motivation to be a more significant barrier than anticipated before deployment. SDENA represents a novel approach to improving safety and may refine intervention targets.
{"title":"Simulation-Debriefing Enhanced Needs Assessment to Address Quality Markers in Health Care: An Innovation for Prospective Hazard Analysis","authors":"Lisa T. Barker MD, MHPE (is Clinical Associate Professor of Emergency Medicine, OSF HealthCare, University of Illinois College of Medicine at Peoria, and Medical Director, Jump Simulation, an OSF HealthCare and University of Illinois College of Medicine at Peoria Collaboration.), William F. Bond MD, MS (is Professor of Clinical Emergency Medicine, University of Illinois College of Medicine at Peoria, and Director of Research, Jump Simulation.), Ann M. Willemsen-Dunlap CRNA, PhD (is Director of Education Development, Jump Simulation.), Kimberly L. Cooley MSN, RN, CCRC (is Research Education Facilitator, OSF HealthCare.), Jeremy S. McGarvey MS (is Senior Statistician, Division of Healthcare Analytics, OSF HealthCare.), Rebecca L. Ruger (is Graduate Student, Department of Psychology, Pennsylvania State University.), Adam Kohlrus MS, CPHQ, CPPS (is Partner and Business Designer, Do Tank, Springfield, Illinois.), Michael J. Kremer PhD, CRNA, CHSE, FAAN (is Professor and Interim Chair, Department of Adult Health and Gerontological Nursing, College of Nursing, and Co-Director, Rush Center for Clinical Skills and Simulation, Rush University.), Michelle Sergel MD (is Co-Director, Rush Center for Clinical Skills and Simulation, Rush University and Assistant Professor of Emergency Medicine, Rush Medical College.), John A. Vozenilek MD (is Vice President and Chief Medical Officer for Innovation, OSF HealthCare. Please address correspondence to Lisa T. Barker)","doi":"10.1016/j.jcjq.2024.10.004","DOIUrl":"10.1016/j.jcjq.2024.10.004","url":null,"abstract":"<div><div>Simulation-Debriefing Enhanced Needs Assessment (SDENA) is a simulation-based approach to prospective hazard analysis that uses simulation and debriefing as a unit-level diagnostic tool. Scenarios address failure modes for health care improvement targets, and debriefing explores unit-specific barriers and resiliencies. Debriefing guides are structured to explore how six drivers of a behavior engineering framework (data, tools/resources, incentives, knowledge/skills, capacity, motivation) influence clinical behaviors. Illinois Hospital Association members who deployed SDENA to address specific hospital-acquired conditions found motivation to be a more significant barrier than anticipated before deployment. SDENA represents a novel approach to improving safety and may refine intervention targets.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 144-158"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142970973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.10.010
David Alfandre MD, MSPH (is an Internist and Senior Health Care Ethicist, US Department of Veterans Affairs (VA) National Center for Ethics in Health Care, and Associate Professor, Departments of Medicine and Population Health, New York University Grossman School of Medicine.), Mary Beth Foglia PhD, MA, RN (is Health Care Ethicist, VA National Center for Ethics in Health Care, and Affiliate Faculty, Department of Bioethics and Humanities, School of Medicine, University of Washington.), Mark Holodniy MD (is Director, VA Public Health National Program Office and Public Health Reference Laboratory, and Professor, Department of Medicine, Stanford University School of Medicine.), A. Rani Elwy PhD, MSc (is Research Career Scientist, Center for Health Optimization and Implementation Research, VA Boston Healthcare System, and VA Bedford Healthcare System, and Professor, Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University. Please address correspondence to David Alfandre)
{"title":"How Do We Know When We Have Done Enough? Ensuring Sufficient Patient Notification Efforts After a Large-Scale Adverse Event","authors":"David Alfandre MD, MSPH (is an Internist and Senior Health Care Ethicist, US Department of Veterans Affairs (VA) National Center for Ethics in Health Care, and Associate Professor, Departments of Medicine and Population Health, New York University Grossman School of Medicine.), Mary Beth Foglia PhD, MA, RN (is Health Care Ethicist, VA National Center for Ethics in Health Care, and Affiliate Faculty, Department of Bioethics and Humanities, School of Medicine, University of Washington.), Mark Holodniy MD (is Director, VA Public Health National Program Office and Public Health Reference Laboratory, and Professor, Department of Medicine, Stanford University School of Medicine.), A. Rani Elwy PhD, MSc (is Research Career Scientist, Center for Health Optimization and Implementation Research, VA Boston Healthcare System, and VA Bedford Healthcare System, and Professor, Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University. Please address correspondence to David Alfandre)","doi":"10.1016/j.jcjq.2024.10.010","DOIUrl":"10.1016/j.jcjq.2024.10.010","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 159-163"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142872141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.11.001
Mari Somerville PhD, MPH (formerly Canadian Institutes of Health Research (CIHR) Health System Impact Fellow, IWK Health, Halifax, Nova Scotia, is Senior Policy Analyst, Nova Scotia Health Authority, and Health Systems Researcher, School of Nursing, Dalhousie University.), Christine Cassidy PhD, RN (is Associate Professor, School of Nursing, Dalhousie University.), Shannon MacPhee MD (is Pediatric Emergency Physician, IWK Health.), Douglas Sinclair MD (is Vice President, Medicine, Quality and Safety, IWK Health.), Jane Palmer MN, RN (is Director, Quality, Patient Safety and Patient Experience, IWK Health.), Daniel Keefe MD (is Associate Professor, Department of Urology, Dalhousie University, and Pediatric Urologist, IWK Health.), Shauna Best RN (is Manager, IWK Health Centre, Halifax, Nova Scotia.), Janet Curran PhD (is Research Chair, Quality and Patient Safety, IWK Health, and Professor, School of Nursing, Dalhousie University. Please address correspondence to Mari Somerville)
Background
Precursor-level safety events (PSEs) pose greater patient risk than no-harm events but are not as severe as serious safety events. Despite their potential for harm, the underlying determinants associated with PSEs are poorly understood. This study aimed to use a behavior change framework to understand the underlying determinants of PSEs and whether associated action items aligned with the behavior.
Methods
This cross-sectional study took place in a maternal/pediatric hospital. A total of 58 prerecorded PSEs were analyzed using the Behaviour Change Wheel (BCW); a behavioral framework that identifies sources of behavior and proposes intervention types that address said behavior. Researchers and clinicians independently coded each PSE's underlying determinant and action items using the relevant components of the BCW. The types and frequency of underlying behavioral determinants and intervention types for each PSE were documented. A matrix, based on the BCW, reflected how often the underlying behavior aligned with the corresponding action item.
Results
Of the 58 PSEs, six behavioral determinants and seven intervention types were identified. Environmental context/resources was the behavioral determinant coded most often (25.4%); education was the most common intervention type (45.8%). Several underlying determinants (24.6%) and action items (8.3%) received no code due to limited information. Based on the BCW matrix, 34.2% of behavioral determinants were addressed with interventions that would target the underlying behavior, while 37.8% did not align, and 28.1% could not be coded due to missing behavioral information.
Conclusion
This study identified poor alignment between types of interventions and underlying determinants in more than one third of analyzed PSEs. This included using educational interventions in about 50% of events, despite this type of intervention being ineffective for most of the coded behaviors. Further, alignment of many safety events could not be determined due to limited reported information. This highlights a need to design more systematic, behavior-informed approaches to reporting PSEs and identifying interventions to effectively change behavior.
背景：前体级安全事件（PSE）对患者造成的风险比无害事件更大，但不如严重安全事件严重。尽管它们可能造成伤害，但人们对与 PSE 相关的潜在决定因素却知之甚少。本研究旨在使用行为改变框架来了解 PSE 的基本决定因素以及相关行动项目是否与行为一致：这项横断面研究在一家母婴医院进行。共使用行为改变轮（BCW）分析了 58 个预先录制的 PSE；行为改变轮是一个行为框架，可识别行为来源并提出针对所述行为的干预类型。研究人员和临床医生使用 BCW 的相关组件对每个 PSE 的基本决定因素和行动项目进行独立编码。每个 PSE 的基本行为决定因素和干预类型的类型和频率都记录在案。基于《行为守则》的矩阵反映了基本行为与相应行动项目的一致性：结果：在 58 项 PSE 中，确定了六种行为决定因素和七种干预类型。环境背景/资源是最常见的行为决定因素（25.4%）；教育是最常见的干预类型（45.8%）。由于信息有限，一些基本决定因素（24.6%）和行动项目（8.3%）没有编码。根据 BCW 矩阵，34.2% 的行为决定因素与针对基本行为的干预措施相一致，37.8% 的行为决定因素与干预措施不一致，28.1% 的行为决定因素因行为信息缺失而无法编码：本研究发现，在超过三分之一的被分析的 PSE 中，干预类型与基本决定因素之间的一致性较差。这包括在约 50% 的事件中使用了教育干预，尽管这种类型的干预对大多数编码行为无效。此外，由于报告的信息有限，许多安全事件的一致性无法确定。这凸显出需要设计更系统的、行为知情的方法来报告 PSE，并确定有效改变行为的干预措施。
{"title":"Examining Patient Safety Events Using the Behaviour Change Wheel: A Cross-Sectional Analysis","authors":"Mari Somerville PhD, MPH (formerly Canadian Institutes of Health Research (CIHR) Health System Impact Fellow, IWK Health, Halifax, Nova Scotia, is Senior Policy Analyst, Nova Scotia Health Authority, and Health Systems Researcher, School of Nursing, Dalhousie University.), Christine Cassidy PhD, RN (is Associate Professor, School of Nursing, Dalhousie University.), Shannon MacPhee MD (is Pediatric Emergency Physician, IWK Health.), Douglas Sinclair MD (is Vice President, Medicine, Quality and Safety, IWK Health.), Jane Palmer MN, RN (is Director, Quality, Patient Safety and Patient Experience, IWK Health.), Daniel Keefe MD (is Associate Professor, Department of Urology, Dalhousie University, and Pediatric Urologist, IWK Health.), Shauna Best RN (is Manager, IWK Health Centre, Halifax, Nova Scotia.), Janet Curran PhD (is Research Chair, Quality and Patient Safety, IWK Health, and Professor, School of Nursing, Dalhousie University. Please address correspondence to Mari Somerville)","doi":"10.1016/j.jcjq.2024.11.001","DOIUrl":"10.1016/j.jcjq.2024.11.001","url":null,"abstract":"<div><h3>Background</h3><div>Precursor-level safety events (PSEs) pose greater patient risk than no-harm events but are not as severe as serious safety events. Despite their potential for harm, the underlying determinants associated with PSEs are poorly understood. This study aimed to use a behavior change framework to understand the underlying determinants of PSEs and whether associated action items aligned with the behavior.</div></div><div><h3>Methods</h3><div>This cross-sectional study took place in a maternal/pediatric hospital. A total of 58 prerecorded PSEs were analyzed using the Behaviour Change Wheel (BCW); a behavioral framework that identifies sources of behavior and proposes intervention types that address said behavior. Researchers and clinicians independently coded each PSE's underlying determinant and action items using the relevant components of the BCW. The types and frequency of underlying behavioral determinants and intervention types for each PSE were documented. A matrix, based on the BCW, reflected how often the underlying behavior aligned with the corresponding action item.</div></div><div><h3>Results</h3><div>Of the 58 PSEs, six behavioral determinants and seven intervention types were identified. Environmental context/resources was the behavioral determinant coded most often (25.4%); education was the most common intervention type (45.8%). Several underlying determinants (24.6%) and action items (8.3%) received no code due to limited information. Based on the BCW matrix, 34.2% of behavioral determinants were addressed with interventions that would target the underlying behavior, while 37.8% did not align, and 28.1% could not be coded due to missing behavioral information.</div></div><div><h3>Conclusion</h3><div>This study identified poor alignment between types of interventions and underlying determinants in more than one third of analyzed PSEs. This included using educational interventions in about 50% of events, despite this type of intervention being ineffective for most of the coded behaviors. Further, alignment of many safety events could not be determined due to limited reported information. This highlights a need to design more systematic, behavior-informed approaches to reporting PSEs and identifying interventions to effectively change behavior.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 135-143"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142846674","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.10.009
Hedwig Schroeck MD (is Associate Professor of Anesthesiology and Pediatrics, Geisel School of Medicine at Dartmouth College, Dartmouth Hitchcock Medical Center, Lebanon, NH.), Bridget Hatton MPH (formerly with the Dartmouth Institute for Health Policy and Clinical Practice, is DrPH Student, Johns Hopkins Bloomberg School of Public Health.), Pablo Martinez-Camblor PhD (Assistant Professor, Departments of Anesthesiology and Biomedical Data Science, Geisel School of Medicine at Dartmouth College.), Michaela A. Whitty MPH (is Manager, Perioperative Supply Chain, Supply Chain Shared Services, Dartmouth Health, Lebanon, New Hampshire.), Louise Wen MD (is Assistant Professor, Department of Anesthesiology, Geisel School of Medicine at Dartmouth College, and Anesthesiologist, Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center.), Andreas H. Taenzer MD, MS (formerly Professor, Departments of Anesthesiology and Pediatrics, Geisel School of Medicine at Dartmouth College, is Professor, Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Children's National Hospital, George Washington University School of Medicine & Health Sciences. Please address correspondence to Hedwig Schroeck)
Background
Crisis resource management in non-operating room anesthesia (NORA) locations is challenging but can potentially be improved through interprofessional crisis simulation training (ICST). This mixed methods study aimed to evaluate the effect of a one-time training on team coordination in diagnostic and interventional magnetic resonance imaging locations.
Methods
Personnel from anesthesia, radiology, and perioperative services (n = 87) underwent ICST over eight months. Team coordination among participants was assessed and compared at baseline, immediately after, and at three months after ICST using a validated instrument—the relational coordination index (RCI)—and a questionnaire on role perceptions and task confidence. Open-ended interviews on a purposive sample of participants were conducted before and after training and analyzed for recurring themes.
Results
Response rates for the RCI were 71.3% at baseline, 65.5% immediately after, and 36.8% three months after training. For subjects responding at baseline and at the respective post-training time point, there were no statistically significant differences in composite RCI scores immediately after or at three months after ICST. However, some individual RCI domain scores increased from baseline to three months after training. For instance, mutual respect increased from (mean ± standard deviation) 3.67 ± 0.49 to 4.42 ± 0.67 (p = 0.003) among non-anesthesia personnel rating anesthesia personnel; and shared knowledge rose from 3.58 ± 0.79 to 4.08 ± 0.51 (p = 0.010) among non-anesthesia personnel rating anesthesia personnel. Thematic analysis from 15 interviews revealed increased familiarity with roles and crisis procedures after ICST as well as improved communication.
Conclusion
A single interprofessional crisis simulation training in a NORA setting, though it did not change overall relational coordination scores, had positive effects on some aspects of team coordination by improving role clarity, task confidence, trust, and communication.
{"title":"Effect of Interprofessional Crisis Simulation Training in a Non-Operating Room Anesthesia Setting on Team Coordination: A Mixed Methods Study","authors":"Hedwig Schroeck MD (is Associate Professor of Anesthesiology and Pediatrics, Geisel School of Medicine at Dartmouth College, Dartmouth Hitchcock Medical Center, Lebanon, NH.), Bridget Hatton MPH (formerly with the Dartmouth Institute for Health Policy and Clinical Practice, is DrPH Student, Johns Hopkins Bloomberg School of Public Health.), Pablo Martinez-Camblor PhD (Assistant Professor, Departments of Anesthesiology and Biomedical Data Science, Geisel School of Medicine at Dartmouth College.), Michaela A. Whitty MPH (is Manager, Perioperative Supply Chain, Supply Chain Shared Services, Dartmouth Health, Lebanon, New Hampshire.), Louise Wen MD (is Assistant Professor, Department of Anesthesiology, Geisel School of Medicine at Dartmouth College, and Anesthesiologist, Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center.), Andreas H. Taenzer MD, MS (formerly Professor, Departments of Anesthesiology and Pediatrics, Geisel School of Medicine at Dartmouth College, is Professor, Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Children's National Hospital, George Washington University School of Medicine & Health Sciences. Please address correspondence to Hedwig Schroeck)","doi":"10.1016/j.jcjq.2024.10.009","DOIUrl":"10.1016/j.jcjq.2024.10.009","url":null,"abstract":"<div><h3>Background</h3><div>Crisis resource management in non-operating room anesthesia (NORA) locations is challenging but can potentially be improved through interprofessional crisis simulation training (ICST). This mixed methods study aimed to evaluate the effect of a one-time training on team coordination in diagnostic and interventional magnetic resonance imaging locations.</div></div><div><h3>Methods</h3><div>Personnel from anesthesia, radiology, and perioperative services (<em>n</em> = 87) underwent ICST over eight months. Team coordination among participants was assessed and compared at baseline, immediately after, and at three months after ICST using a validated instrument—the relational coordination index (RCI)—and a questionnaire on role perceptions and task confidence. Open-ended interviews on a purposive sample of participants were conducted before and after training and analyzed for recurring themes.</div></div><div><h3>Results</h3><div>Response rates for the RCI were 71.3% at baseline, 65.5% immediately after, and 36.8% three months after training. For subjects responding at baseline and at the respective post-training time point, there were no statistically significant differences in composite RCI scores immediately after or at three months after ICST. However, some individual RCI domain scores increased from baseline to three months after training. For instance, mutual respect increased from (mean ± standard deviation) 3.67 ± 0.49 to 4.42 ± 0.67 (<em>p</em> = 0.003) among non-anesthesia personnel rating anesthesia personnel; and shared knowledge rose from 3.58 ± 0.79 to 4.08 ± 0.51 (<em>p</em> = 0.010) among non-anesthesia personnel rating anesthesia personnel. Thematic analysis from 15 interviews revealed increased familiarity with roles and crisis procedures after ICST as well as improved communication.</div></div><div><h3>Conclusion</h3><div>A single interprofessional crisis simulation training in a NORA setting, though it did not change overall relational coordination scores, had positive effects on some aspects of team coordination by improving role clarity, task confidence, trust, and communication.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 115-125"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142872140","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.10.008
Abigail T. Evans PhD (is Lead Research Scientist, Battelle Memorial Institute, Columbus, Ohio.), Meridith Eastman PhD, MSPH (is Senior Research Scientist, Battelle Memorial Institute.), Mujahed Khan MBA, RDN, FAND (is Senior Research Scientist, Battelle Memorial Institute.), Jeffrey J. Geppert EdM, JD (is Senior Research Leader, Battelle Memorial Institute.), Lydia Stewart-Artz PhD, MHS (is Lead Research Scientist, Battelle Memorial Institute. Please address correspondence to Abigail T. Evans)
Background
Diagnostic errors are harmful and pervasive. The Gordon and Betty Moore Foundation funded the Diagnostic Excellence Initiative (Initiative) to support the development of clinical quality measures needed to inform quality improvement efforts in medical diagnosis. The Initiative leverages a unique cohort structure that combines technical assistance and cohort activities to foster innovation in groups of grantees. This manuscript shares grantee perspectives on their participation in these unique cohorts.
Methods
The authors conducted interviews with 16 Initiative grantees to understand how technical assistance and cohort activities affected their measure development process. Interviews were recorded, transcribed, and coded using deductive codes.
Results
Grantees reported technical assistance and cohort activities provided as part of the Initiative effectively supported them in developing clinical quality measures. Technical assistance, including one-on-one technical support and work plans, helped meet project milestones and address implementation challenges. Grantees valued cohort activities, including office hours and in-person meetings, because they gave grantees the opportunity to connect with other measure developers and gain new perspectives on their work. Further, grantees reported learning about the measure development process and indicated participation in an Initiative cohort had positive effects on their careers.
Conclusion
Grantees believed the combination of technical assistance and cohort activities provided by the Initiative supported their ability to develop diagnostic quality measures. This suggests collaborative learning activities like those provided to grantees could effectively support other complex problems in health care.
{"title":"The Impact of a Cohort Structure on Grantee Experiences Developing Clinical Quality Measures for Diagnostic Excellence","authors":"Abigail T. Evans PhD (is Lead Research Scientist, Battelle Memorial Institute, Columbus, Ohio.), Meridith Eastman PhD, MSPH (is Senior Research Scientist, Battelle Memorial Institute.), Mujahed Khan MBA, RDN, FAND (is Senior Research Scientist, Battelle Memorial Institute.), Jeffrey J. Geppert EdM, JD (is Senior Research Leader, Battelle Memorial Institute.), Lydia Stewart-Artz PhD, MHS (is Lead Research Scientist, Battelle Memorial Institute. Please address correspondence to Abigail T. Evans)","doi":"10.1016/j.jcjq.2024.10.008","DOIUrl":"10.1016/j.jcjq.2024.10.008","url":null,"abstract":"<div><h3>Background</h3><div>Diagnostic errors are harmful and pervasive. The Gordon and Betty Moore Foundation funded the Diagnostic Excellence Initiative (Initiative) to support the development of clinical quality measures needed to inform quality improvement efforts in medical diagnosis. The Initiative leverages a unique cohort structure that combines technical assistance and cohort activities to foster innovation in groups of grantees. This manuscript shares grantee perspectives on their participation in these unique cohorts.</div></div><div><h3>Methods</h3><div>The authors conducted interviews with 16 Initiative grantees to understand how technical assistance and cohort activities affected their measure development process. Interviews were recorded, transcribed, and coded using deductive codes.</div></div><div><h3>Results</h3><div>Grantees reported technical assistance and cohort activities provided as part of the Initiative effectively supported them in developing clinical quality measures. Technical assistance, including one-on-one technical support and work plans, helped meet project milestones and address implementation challenges. Grantees valued cohort activities, including office hours and in-person meetings, because they gave grantees the opportunity to connect with other measure developers and gain new perspectives on their work. Further, grantees reported learning about the measure development process and indicated participation in an Initiative cohort had positive effects on their careers.</div></div><div><h3>Conclusion</h3><div>Grantees believed the combination of technical assistance and cohort activities provided by the Initiative supported their ability to develop diagnostic quality measures. This suggests collaborative learning activities like those provided to grantees could effectively support other complex problems in health care.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 108-114"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142854219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.11.010
Mohamad G. Fakih MD, MPH (is Chief Quality Officer, Ascension, Professor, Department of Internal Medicine, Wayne State University School of Medicine.), Florian Daragjati PharmD, BCPS (is Senior Director of Quality, Ascension.), Lisa K. Sturm MPH, CIC, FAPIC (is Senior Director, Infection Prevention, Ascension.), Collin Miller MS (is Manager, Data Analytics, Ascension Data Science Institute, Ascension.), Betsy McKenzie MBA (is Senior Director of Quality, Ascension.), Kelly Randall PhD, MSW (is Vice President of Patient Safety and Regulatory, Ascension.), Frederick A. Masoudi MD, MPSH, MACC, FAHA (is Chief Science Officer and Vice President of Research and Analytics, Ascension, and Professor, Department of Internal Medicine, Dell Medical School, University of Texas.), Jamie Moxham MSPH (is Director of Analytics, Ascension.), Subhangi Ghosh PhD, MS (is Senior Data Analyst, Ascension Data Science Institute, Ascension.), Jyothi Karthik Raja MS (is Senior Vice President, Chief Analytics and AI Officer, Ascension Data Science Institute, Ascension.), Allison Bollinger MD (is Vice President, Acute Clinical Care, Ascension.), Stacy Garrett-Ray MD, MPH, MBA (is Senior Vice President–Chief Community Officer, Ascension, and Adjunct Assistant Professor, Department of Epidemiology and Public Health, University of Maryland School of Medicine.), Maureen Chadwick PhD, RN, MSN, NE-BC3 (is Senior Vice President, Nursing, and Chief Nursing Officer, Ascension.), Thomas Aloia MD, MHCM, FACS, FACHE (is Senior Vice President, System Chief Medical Officer, Ascension.), Richard Fogel MD (is Executive Vice President, Chief Clinical Officer, Ascension. Please address correspondence to Mohamad Fakih)
Background
Optimizing outcomes of hospitalized patients anchors on standardizing processes in medical management, interventions to reduce the risk of decompensation, and prompt intervention when a patient decompensates.
Methods
A quality improvement initiative (optimized sepsis and respiratory compromise management, reducing health care–associated infection and medication risk, swift management of the deteriorating patient, feedback on performance, and accountability) was implemented in a multistate health system. The primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included health care–associated infections, patient-days with hypoglycemic and severe hyperglycemic episodes, and hospital onset (HO) acute kidney injury (AKI).
Results
A total of 2,015,408 patients were admitted to 88 hospitals over the 36-month study period. Overall mortality improved from the baseline observed/expected (O/E) of 0.97 in 2021 to 0.74 in 2023 (-23.4%; 4,186 fewer deaths, p < 0.001). Controlling for baseline (2021) mortality O/E ratios, the mean mortality O/E ratio for 2023 was 0.74 for system and 0.84 for peers, representing a difference of -0.10 (p < 0.001, 95% confidence interval [CI] 0.12 – -0.07], with 1,807 fewer deaths). The standardized infection ratio declined for central line–associated blood stream infections by 24.8% (0.58; 88 fewer events), catheter-associated urinary tract infections by 30.6% (0.44; 98 fewer events), HO methicillin-resistant Staphylococcus aureus bacteremia by 29.0% (0.72; 67 fewer events), and HO Clostridioides difficile infection by 35.1% (0.36; 311 fewer events) in 2023 compared to 2021. HO AKI episodes dropped by 6.2% (8.6%; 1,725 fewer events), and patient-days with hypoglycemia and severe hyperglycemia decreased by 5.8% (4.0%; 4,840 fewer events) and 22.8% (5.2%; 30,065 fewer events), respectively.
Conclusion
This systemwide initiative focusing on standardizing processes, feedback on performance, and accountability was associated with sustainable improvements in mortality and a reduction in infectious and safety events.
{"title":"Optimizing and Sustaining Clinical Outcomes in 88 US Hospitals Post-Pandemic: A Quality Improvement Initiative","authors":"Mohamad G. Fakih MD, MPH (is Chief Quality Officer, Ascension, Professor, Department of Internal Medicine, Wayne State University School of Medicine.), Florian Daragjati PharmD, BCPS (is Senior Director of Quality, Ascension.), Lisa K. Sturm MPH, CIC, FAPIC (is Senior Director, Infection Prevention, Ascension.), Collin Miller MS (is Manager, Data Analytics, Ascension Data Science Institute, Ascension.), Betsy McKenzie MBA (is Senior Director of Quality, Ascension.), Kelly Randall PhD, MSW (is Vice President of Patient Safety and Regulatory, Ascension.), Frederick A. Masoudi MD, MPSH, MACC, FAHA (is Chief Science Officer and Vice President of Research and Analytics, Ascension, and Professor, Department of Internal Medicine, Dell Medical School, University of Texas.), Jamie Moxham MSPH (is Director of Analytics, Ascension.), Subhangi Ghosh PhD, MS (is Senior Data Analyst, Ascension Data Science Institute, Ascension.), Jyothi Karthik Raja MS (is Senior Vice President, Chief Analytics and AI Officer, Ascension Data Science Institute, Ascension.), Allison Bollinger MD (is Vice President, Acute Clinical Care, Ascension.), Stacy Garrett-Ray MD, MPH, MBA (is Senior Vice President–Chief Community Officer, Ascension, and Adjunct Assistant Professor, Department of Epidemiology and Public Health, University of Maryland School of Medicine.), Maureen Chadwick PhD, RN, MSN, NE-BC3 (is Senior Vice President, Nursing, and Chief Nursing Officer, Ascension.), Thomas Aloia MD, MHCM, FACS, FACHE (is Senior Vice President, System Chief Medical Officer, Ascension.), Richard Fogel MD (is Executive Vice President, Chief Clinical Officer, Ascension. Please address correspondence to Mohamad Fakih)","doi":"10.1016/j.jcjq.2024.11.010","DOIUrl":"10.1016/j.jcjq.2024.11.010","url":null,"abstract":"<div><h3>Background</h3><div>Optimizing outcomes of hospitalized patients anchors on standardizing processes in medical management, interventions to reduce the risk of decompensation, and prompt intervention when a patient decompensates.</div></div><div><h3>Methods</h3><div>A quality improvement initiative (optimized sepsis and respiratory compromise management, reducing health care–associated infection and medication risk, swift management of the deteriorating patient, feedback on performance, and accountability) was implemented in a multistate health system. The primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included health care–associated infections, patient-days with hypoglycemic and severe hyperglycemic episodes, and hospital onset (HO) acute kidney injury (AKI).</div></div><div><h3>Results</h3><div>A total of 2,015,408 patients were admitted to 88 hospitals over the 36-month study period. Overall mortality improved from the baseline observed/expected (O/E) of 0.97 in 2021 to 0.74 in 2023 (-23.4%; 4,186 fewer deaths, <em>p</em> < 0.001). Controlling for baseline (2021) mortality O/E ratios, the mean mortality O/E ratio for 2023 was 0.74 for system and 0.84 for peers, representing a difference of -0.10 (<em>p</em> < 0.001, 95% confidence interval [CI] 0.12 – -0.07], with 1,807 fewer deaths). The standardized infection ratio declined for central line–associated blood stream infections by 24.8% (0.58; 88 fewer events), catheter-associated urinary tract infections by 30.6% (0.44; 98 fewer events), HO methicillin-resistant <em>Staphylococcus aureus</em> bacteremia by 29.0% (0.72; 67 fewer events), and HO <em>Clostridioides difficile</em> infection by 35.1% (0.36; 311 fewer events) in 2023 compared to 2021. HO AKI episodes dropped by 6.2% (8.6%; 1,725 fewer events), and patient-days with hypoglycemia and severe hyperglycemia decreased by 5.8% (4.0%; 4,840 fewer events) and 22.8% (5.2%; 30,065 fewer events), respectively.</div></div><div><h3>Conclusion</h3><div>This systemwide initiative focusing on standardizing processes, feedback on performance, and accountability was associated with sustainable improvements in mortality and a reduction in infectious and safety events.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 86-94"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142876406","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.10.012
Kathleen McMullen MPH CIC, FAPIC, FSHEA (is Executive Director, Infection Prevention and Sterilization, Mercy Center for Quality and Safety, Chesterfield, Missouri.), Fran Hixson RN, BSN, CIC (is Manager, Clinical Quality, and Clinical Quality Lead, Mercy Center for Quality and Safety.), Megan Peters RN, CIC (is Manager, Infection Prevention, Mercy Center for Quality and Safety.), Kathryn Nelson MHA (is Chief Quality Officer, Mercy Center for Quality and Safety.), William Sistrunk MD, FACP (is Infectious Diseases Physician, Mercy Center for Quality and Safety.), Jeff Reames MD, MBA, FACEP (formerly Regional Director of Emergency Medicine, Mercy Health System of Oklahoma, is Emergency Medicine Consultant, Mercy Center for Quality and Safety.), Cynthia Standlee RN (is Chief Nursing Officer, Mercy Hospital, Ada, Oklahoma.), David Tannehill DO, FACOI, FACP (is Chief Medical Officer, Mercy Hospital, Washington, Missouri.), Keith Starke MD, FACP (is Senior Advisor, Office of Clinical Excellence, Mercy Center for Quality and Safety. Please address correspondence to Kathleen McMullen)
Background
The coronavirus disease 2019 (COVID-19) pandemic affected quality improvement work that was key to hospital-acquired infection (HAI) prevention efforts for many hospitals. Central line–associated bloodstream infection (CLABSI) standardized infection ratios (SIRs) were highly affected by the pandemic.
Methods
After seeing an increase in CLABSI SIRs through early 2021, a health care system including 12 acute care hospitals in the midwestern United States focused on processes and process measures for CLABSI prevention. Each hospital was asked to identify a medical provider, nursing, and infection prevention lead to champion the work (identified as a CLABSI triad). CLABSI triads emphasized best practice expectations, standardized technology and products, and implemented reporting and trending of compliance. Work started in July 2021, with multiple initiatives rolled out through the end of 2022. CLABSI SIRs and standardized utilization ratios (SURs) were analyzed with interrupted time series analysis; changes in several process measures were analyzed using Wilcoxon rank sum exact testing.
Results
A 47.5% decrease was seen in CLABSI SIR through the study period, with SIR = 0.61 from 2023 to April 2024. The slope of the trend line for CLABSI SIR and central line utilization had a significant downward trend in the intervention time frame (p = 0.04 and p < 0.01, respectively). CLABSI prevention best practices improved statistically during the study period.
Conclusion
Intense focus by leadership on key CLABSI prevention process measures was associated with lower CLABSI SIRs.
背景：2019年冠状病毒病（COVID-19）大流行影响了许多医院的质量改进工作，而质量改进工作是医院获得性感染（HAI）预防工作的关键。中心静脉相关血流感染（CLABSI）的标准化感染率（SIRs）受到了大流行的严重影响：方法：在 2021 年初 CLABSI SIR 增加之后，美国中西部的一个医疗保健系统（包括 12 家急症医院）将重点放在了 CLABSI 预防的流程和流程措施上。要求每家医院确定一名医疗服务提供者、护理人员和感染预防负责人来支持这项工作（称为 CLABSI 三人组）。CLABSI 三方小组强调最佳实践预期、标准化技术和产品，并实施合规性报告和趋势分析。这项工作于 2021 年 7 月启动，并在 2022 年底前推出多项举措。采用间断时间序列分析法对 CLABSI SIR 和标准化使用率（SUR）进行分析；采用 Wilcoxon 秩和精确检验法对几项流程措施的变化进行分析：在研究期间，CLABSI SIR 下降了 47.5%，从 2023 年到 2024 年 4 月，SIR = 0.61。在干预期间，CLABSI SIR 和中心静脉使用率的趋势线斜率呈显著下降趋势（分别为 p = 0.04 和 p < 0.01）。在研究期间，CLABSI 预防最佳实践在统计上有所改善：结论：领导层对主要 CLABSI 预防流程措施的高度重视与 CLABSI SIR 的降低有关。
{"title":"Prevention of Central Line–Associated Bloodstream Infections by Leadership Focus on Process Measures","authors":"Kathleen McMullen MPH CIC, FAPIC, FSHEA (is Executive Director, Infection Prevention and Sterilization, Mercy Center for Quality and Safety, Chesterfield, Missouri.), Fran Hixson RN, BSN, CIC (is Manager, Clinical Quality, and Clinical Quality Lead, Mercy Center for Quality and Safety.), Megan Peters RN, CIC (is Manager, Infection Prevention, Mercy Center for Quality and Safety.), Kathryn Nelson MHA (is Chief Quality Officer, Mercy Center for Quality and Safety.), William Sistrunk MD, FACP (is Infectious Diseases Physician, Mercy Center for Quality and Safety.), Jeff Reames MD, MBA, FACEP (formerly Regional Director of Emergency Medicine, Mercy Health System of Oklahoma, is Emergency Medicine Consultant, Mercy Center for Quality and Safety.), Cynthia Standlee RN (is Chief Nursing Officer, Mercy Hospital, Ada, Oklahoma.), David Tannehill DO, FACOI, FACP (is Chief Medical Officer, Mercy Hospital, Washington, Missouri.), Keith Starke MD, FACP (is Senior Advisor, Office of Clinical Excellence, Mercy Center for Quality and Safety. Please address correspondence to Kathleen McMullen)","doi":"10.1016/j.jcjq.2024.10.012","DOIUrl":"10.1016/j.jcjq.2024.10.012","url":null,"abstract":"<div><h3>Background</h3><div>The coronavirus disease 2019 (COVID-19) pandemic affected quality improvement work that was key to hospital-acquired infection (HAI) prevention efforts for many hospitals. Central line–associated bloodstream infection (CLABSI) standardized infection ratios (SIRs) were highly affected by the pandemic.</div></div><div><h3>Methods</h3><div>After seeing an increase in CLABSI SIRs through early 2021, a health care system including 12 acute care hospitals in the midwestern United States focused on processes and process measures for CLABSI prevention. Each hospital was asked to identify a medical provider, nursing, and infection prevention lead to champion the work (identified as a CLABSI triad). CLABSI triads emphasized best practice expectations, standardized technology and products, and implemented reporting and trending of compliance. Work started in July 2021, with multiple initiatives rolled out through the end of 2022. CLABSI SIRs and standardized utilization ratios (SURs) were analyzed with interrupted time series analysis; changes in several process measures were analyzed using Wilcoxon rank sum exact testing.</div></div><div><h3>Results</h3><div>A 47.5% decrease was seen in CLABSI SIR through the study period, with SIR = 0.61 from 2023 to April 2024. The slope of the trend line for CLABSI SIR and central line utilization had a significant downward trend in the intervention time frame (<em>p</em> = 0.04 and <em>p</em> < 0.01, respectively). CLABSI prevention best practices improved statistically during the study period.</div></div><div><h3>Conclusion</h3><div>Intense focus by leadership on key CLABSI prevention process measures was associated with lower CLABSI SIRs.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 126-134"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142846686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jcjq.2024.12.006
Brent C. James MD, MStat (Clinical Professor, Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University School of Medicine, Stanford and Adjunct Professor, David S. Eccles School of Business, University of Utah, Salt Lake City. Please address correspndence to Brent C. James)
{"title":"We Count Our Successes in Lives","authors":"Brent C. James MD, MStat (Clinical Professor, Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University School of Medicine, Stanford and Adjunct Professor, David S. Eccles School of Business, University of Utah, Salt Lake City. Please address correspndence to Brent C. James)","doi":"10.1016/j.jcjq.2024.12.006","DOIUrl":"10.1016/j.jcjq.2024.12.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 83-85"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142970975","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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