Joint Commission journal on quality and patient safety最新文献

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.

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.

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.

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.

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.

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.

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.

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.