Pub Date : 2024-07-03DOI: 10.1016/j.jcjq.2024.07.001
{"title":"A Half Century of Quality and Safety","authors":"","doi":"10.1016/j.jcjq.2024.07.001","DOIUrl":"10.1016/j.jcjq.2024.07.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141716789","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.02.009
Cori C. Grant PhD, MBA (is Assistant Professor, Department of Preventive Medicine, and Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.) , Fawaz Mzayek MD, PhD (is Associate Professor, Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, and Tennessee Population Health Consortium.) , Hadii M. Mamudu PhD, MPA (is Professor, Department of Health Services Management and Policy, and Center for Cardiovascular Risk Research, College of Public Health, East Tennessee State University.), Satya Surbhi PhD (is Assistant Professor, Center for Health System Improvement, Department of Medicine, and Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.), Umar Kabir PhD, MPH (is Research Leader, Center for Health System Improvement, and Director of Operations, Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.), James E. Bailey MD, MPH (is Professor, Department of Preventive Medicine, and Director, Center for Health Systems Improvement, University of Tennessee Health Science Center, Memphis. Please address correspondence to Cori C. Grant)
Driving Forces
Many states with high rates of cardiovascular disease (CVD) lack statewide quality improvement (QI) infrastructure (for example, resources, leadership, community) to address relevant health needs of the population. Academic health centers are well positioned to play a central role in addressing this deficiency. This article describes early experience and lessons learned in building statewide QI infrastructure through the Tennessee Heart Health Network (Network).
Approach
A statewide, multistakeholder network composed of primary care practices (PCPs), health systems, health plans, QI organizations, patients, and academic institutions was led by the University of Tennessee Health Science Center (UTHSC), an academic health center, to improve cardiovascular health by supporting dissemination and implementation of patient-centered outcomes research (PCOR) evidence-based interventions in primary care. PCPs were required to select and implement at least one of three interventions (health coaching, tailored health-related text messaging, and pharmacist-physician collaboration).
Outcomes and Key Insights
Thirty statewide organizational partners joined the Network in year one, including 18 health systems representing 77 PCPs (30.0% of 257 potentially eligible PCPs identified) with approximately 300,000 patients. The organizational partners share EHRs for the ongoing tracking and reporting of key health metrics, including hypertension control and delivery of tobacco cessation counseling. Of the 77 PCPs, 62 continue participation after year two (80.5% retention). Main barriers to participation and reasons for discontinuing participation included reluctance to share data and changes in leadership at the health system level. These 62 PCPs selected the following interventions to implement: health coaching (41.9%), tailored health-related text messages (48.4%), and pharmacist-physician collaboration (40.3%).
Conclusion and What's Next
Academic health centers have broad reach and high acceptability by diverse stakeholders. Tennessee's experience illustrates how academic health centers can serve as platforms for building a statewide infrastructure for disseminating, implementing, and sustaining QI interventions at the practice level. Assessment of Network impact is ongoing.
{"title":"Building Statewide Quality Improvement Capacity to Improve Cardiovascular Care and Health Equity: Lessons from the Tennessee Heart Health Network","authors":"Cori C. Grant PhD, MBA (is Assistant Professor, Department of Preventive Medicine, and Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.) , Fawaz Mzayek MD, PhD (is Associate Professor, Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, and Tennessee Population Health Consortium.) , Hadii M. Mamudu PhD, MPA (is Professor, Department of Health Services Management and Policy, and Center for Cardiovascular Risk Research, College of Public Health, East Tennessee State University.), Satya Surbhi PhD (is Assistant Professor, Center for Health System Improvement, Department of Medicine, and Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.), Umar Kabir PhD, MPH (is Research Leader, Center for Health System Improvement, and Director of Operations, Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.), James E. Bailey MD, MPH (is Professor, Department of Preventive Medicine, and Director, Center for Health Systems Improvement, University of Tennessee Health Science Center, Memphis. Please address correspondence to Cori C. Grant)","doi":"10.1016/j.jcjq.2024.02.009","DOIUrl":"10.1016/j.jcjq.2024.02.009","url":null,"abstract":"<div><h3>Driving Forces</h3><p>Many states with high rates of cardiovascular disease (CVD) lack statewide quality improvement (QI) infrastructure (for example, resources, leadership, community) to address relevant health needs of the population. Academic health centers are well positioned to play a central role in addressing this deficiency. This article describes early experience and lessons learned in building statewide QI infrastructure through the Tennessee Heart Health Network (Network).</p></div><div><h3>Approach</h3><p>A statewide, multistakeholder network composed of primary care practices (PCPs), health systems, health plans, QI organizations, patients, and academic institutions was led by the University of Tennessee Health Science Center (UTHSC), an academic health center, to improve cardiovascular health by supporting dissemination and implementation of patient-centered outcomes research (PCOR) evidence-based interventions in primary care. PCPs were required to select and implement at least one of three interventions (health coaching, tailored health-related text messaging, and pharmacist-physician collaboration).</p></div><div><h3>Outcomes and Key Insights</h3><p>Thirty statewide organizational partners joined the Network in year one, including 18 health systems representing 77 PCPs (30.0% of 257 potentially eligible PCPs identified) with approximately 300,000 patients. The organizational partners share EHRs for the ongoing tracking and reporting of key health metrics, including hypertension control and delivery of tobacco cessation counseling. Of the 77 PCPs, 62 continue participation after year two (80.5% retention). Main barriers to participation and reasons for discontinuing participation included reluctance to share data and changes in leadership at the health system level. These 62 PCPs selected the following interventions to implement: health coaching (41.9%), tailored health-related text messages (48.4%), and pharmacist-physician collaboration (40.3%).</p></div><div><h3>Conclusion and What's Next</h3><p>Academic health centers have broad reach and high acceptability by diverse stakeholders. Tennessee's experience illustrates how academic health centers can serve as platforms for building a statewide infrastructure for disseminating, implementing, and sustaining QI interventions at the practice level. Assessment of Network impact is ongoing.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140329819","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 : 2024-07-01DOI: 10.1016/j.jcjq.2023.12.002
Samantha L. Bernstein PhD, RN (is Registered Nurse–Postpartum Unit, Massachusetts General Hospital, Boston, and Assistant Professor, School of Nursing, MGH Institute of Health Professions, Boston.), Maya Picciolo BSN, RN (is Labor and Delivery Registered Nurse, Massachusetts General Hospital.), Elisabeth Grills BSN, RN (is Postpartum Registered Nurse, Massachusetts General Hospital.), Kenneth Catchpole PhD (is Professor, Clinical Practice and Human Factors, College of Medicine, Medical University of South Carolina. Please address correspondence to Samantha L. Bernstein)
Background
Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.
Methods
The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (n = 7) and physicians (n = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190.
Findings
Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians’ multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet.
Conclusion
Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.
{"title":"A Qualitative Study of Systems-Level Factors That Affect Rural Obstetric Nurses’ Work During Clinical Emergencies","authors":"Samantha L. Bernstein PhD, RN (is Registered Nurse–Postpartum Unit, Massachusetts General Hospital, Boston, and Assistant Professor, School of Nursing, MGH Institute of Health Professions, Boston.), Maya Picciolo BSN, RN (is Labor and Delivery Registered Nurse, Massachusetts General Hospital.), Elisabeth Grills BSN, RN (is Postpartum Registered Nurse, Massachusetts General Hospital.), Kenneth Catchpole PhD (is Professor, Clinical Practice and Human Factors, College of Medicine, Medical University of South Carolina. Please address correspondence to Samantha L. Bernstein)","doi":"10.1016/j.jcjq.2023.12.002","DOIUrl":"10.1016/j.jcjq.2023.12.002","url":null,"abstract":"<div><h3>Background</h3><p>Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.</p></div><div><h3>Methods</h3><p>The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (<em>n</em> = 7) and physicians (<em>n</em> = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190.</p></div><div><h3>Findings</h3><p>Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians’ multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet.</p></div><div><h3>Conclusion</h3><p>Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725023002982/pdfft?md5=444411057d9b39cba80a78536ecc72fa&pid=1-s2.0-S1553725023002982-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139193611","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.005
Karen Trang MD (is General Surgery Resident and Resident Research Fellow, Department of Surgery, University of California, San Francisco (UCSF).), Logan Pierce MD (is Assistant Clinical Professor, Department of Medicine, UCSF.), Elizabeth C. Wick MD (is Professor, and Vice Chair of Quality and Safety, Department of Surgery, UCSF. Please address correspondence to Karen Trang)
Background
Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP).
Methods
The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022.
Results
A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (p < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent.
Conclusion
The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.
{"title":"The Impact of Using Electronic Consents on Documentation of Language-Concordant Surgical Consent for Patients with Limited English Proficiency","authors":"Karen Trang MD (is General Surgery Resident and Resident Research Fellow, Department of Surgery, University of California, San Francisco (UCSF).), Logan Pierce MD (is Assistant Clinical Professor, Department of Medicine, UCSF.), Elizabeth C. Wick MD (is Professor, and Vice Chair of Quality and Safety, Department of Surgery, UCSF. Please address correspondence to Karen Trang)","doi":"10.1016/j.jcjq.2024.03.005","DOIUrl":"10.1016/j.jcjq.2024.03.005","url":null,"abstract":"<div><h3>Background</h3><p>Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP).</p></div><div><h3>Methods</h3><p>The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022.</p></div><div><h3>Results</h3><p>A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (<em>p</em> < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent.</p></div><div><h3>Conclusion</h3><p>The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725024000758/pdfft?md5=e14af92ed2c52547db1aae81073fd1ba&pid=1-s2.0-S1553725024000758-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140268335","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.05.013
{"title":"The Joint Commission Journal on Quality and Patient Safety 50th Anniversary Article Collections: Maternal and Perinatal Care","authors":"","doi":"10.1016/j.jcjq.2024.05.013","DOIUrl":"https://doi.org/10.1016/j.jcjq.2024.05.013","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725024001752/pdfft?md5=289c0dc54c63bd5bafc6a4d6746ae601&pid=1-s2.0-S1553725024001752-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141482516","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.010
Zoe Grabinski MD (is Assistant Professor, Ronald O. Perelman Department of Emergency Medicine and Department of Pediatrics, New York University Grossman School of Medicine.), Kar-mun Woo MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Olumide Akindutire MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Cassidy Dahn MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Lauren Nash PA (is Senior Physician Assistant, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Inna Leybell MD (is Clinical Assistant Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Yelan Wang MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Danielle Bayer MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Jordan Swartz MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Catherine Jamin MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Silas W. Smith MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine and Institute for Innovations in Medical Education, New York University Grossman School of Medicine. Please address correspondence to Zoe Grabinski)
Background
Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.
Methods
The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.
Results
The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.
Conclusion
The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.
{"title":"Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission","authors":"Zoe Grabinski MD (is Assistant Professor, Ronald O. Perelman Department of Emergency Medicine and Department of Pediatrics, New York University Grossman School of Medicine.), Kar-mun Woo MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Olumide Akindutire MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Cassidy Dahn MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Lauren Nash PA (is Senior Physician Assistant, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Inna Leybell MD (is Clinical Assistant Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Yelan Wang MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Danielle Bayer MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Jordan Swartz MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Catherine Jamin MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Silas W. Smith MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine and Institute for Innovations in Medical Education, New York University Grossman School of Medicine. Please address correspondence to Zoe Grabinski)","doi":"10.1016/j.jcjq.2024.03.010","DOIUrl":"10.1016/j.jcjq.2024.03.010","url":null,"abstract":"<div><h3>Background</h3><p>Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.</p></div><div><h3>Methods</h3><p>The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.</p></div><div><h3>Results</h3><p>The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (<em>p</em> < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (<em>p</em> < 0.001) but not by language (<em>p</em> = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (<em>p</em> = 0.446) or language (<em>p</em> = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.</p></div><div><h3>Conclusion</h3><p>The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140276367","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.02.008
Harrison Sims (is Human Factors Engineering researcher, Department of Biomedical Engineering, Johns Hopkins University.), David Neyens PhD, MS, MPH (is Associate Professor, Departments of Industrial Engineering and Bioengineering, Clemson University.), Ken Catchpole PhD (is Professor and S.C. SmartState Endowed Chair in Clinical Practice and Human Factors, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), Joshua Biro PhD, MS (is Research Fellow, MedStar Health National Center for Human Factors in Healthcare, Washington, DC.), Connor Lusk PhD, MS (is Assistant Professor, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), James Abernathy III MD, MPH (is Associate Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University. Please send correspondence to Harrison Sims)
{"title":"The Impact of a Novel Syringe Organizational Hub on Operating Room Workflow During a Surgical Case","authors":"Harrison Sims (is Human Factors Engineering researcher, Department of Biomedical Engineering, Johns Hopkins University.), David Neyens PhD, MS, MPH (is Associate Professor, Departments of Industrial Engineering and Bioengineering, Clemson University.), Ken Catchpole PhD (is Professor and S.C. SmartState Endowed Chair in Clinical Practice and Human Factors, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), Joshua Biro PhD, MS (is Research Fellow, MedStar Health National Center for Human Factors in Healthcare, Washington, DC.), Connor Lusk PhD, MS (is Assistant Professor, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), James Abernathy III MD, MPH (is Associate Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University. Please send correspondence to Harrison Sims)","doi":"10.1016/j.jcjq.2024.02.008","DOIUrl":"10.1016/j.jcjq.2024.02.008","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140305669","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.003
Courtney W. Mangus MD (is Clinical Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan.), Tyler G. James PhD (is Assistant Professor, Department of Family Medicine, University of Michigan.), Sarah J. Parker MPH (is Research Area Specialist, Department of Emergency Medicine, University of Michigan.), Elizabeth Duffy MPH (is Clinical Research Coordinator, Department of Emergency Medicine, University of Michigan.), P. Paul Chandanabhumma PhD, MPH (is Assistant Professor, Department of Family Medicine, University of Michigan.), Caitlin M. Cassady LMSW, LCSW (is PhD Candidate, Social Work and Anthropology Doctoral Program, Wayne State University.), Fernanda Bellolio MD, MS (is Emergency Medicine Physician and Health Sciences Researcher, Departments of Emergency Medicine and Health Science Research, Mayo Clinic, Rochester, Minnesota.), Kalyan S. Pasupathy PhD (is Professor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago.), Milisa Manojlovich PhD, RN (is Professor, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan.), Hardeep Singh MD, MPH (is Professor, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA (US Department of Veterans Affairs) Medical Center and Baylor College of Medicine, Houston.), Prashant Mahajan MD, MBA, MPH (is Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan. Please address correspondence to Courtney W. Mangus)
Background
Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety.
Methods
Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED–Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews.
Results
The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED–Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused.
Conclusion
Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.
背景很少有研究描述一线医疗服务提供者和患者对如何改进急诊科（ED）诊断流程的见解，而急诊科是诊断错误的高发场所。作者旨在确定医疗服务提供者和患者对诊断过程的看法，并确定潜在的干预措施，以提高诊断安全性。访谈问题以 ED 适应美国国家科学、工程和医学院诊断流程框架为指导，探讨了参与者对 ED 诊断流程的看法，发现了漏洞，并寻求干预措施以提高诊断安全性。作者对转录的访谈进行了定性专题分析。结果研究小组根据 ED 适应框架将诊断过程中的薄弱环节和干预机会分为五个领域：(1) 团队动力和沟通（例如，转诊医生和急诊室团队之间的沟通欠佳）；(2) 与患者表现相关的信息收集（例如，从患者或其看护人处获取病史；(3) 急诊室组织、系统和流程（例如，员工日程安排和交接）；(4) 患者教育和自我管理（例如，急诊室出院时的患者教育）；以及 (5) 电子病历和患者门户网站的使用（例如，自动将检查结果发布到患者门户网站）。作者确定了 33 项潜在干预措施，其中 17 项以医疗服务提供者为重点，16 项以患者为重点。需要对这些干预措施进行改进、实施和效果评估。
{"title":"Frontline Providers’ and Patients’ Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study","authors":"Courtney W. Mangus MD (is Clinical Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan.), Tyler G. James PhD (is Assistant Professor, Department of Family Medicine, University of Michigan.), Sarah J. Parker MPH (is Research Area Specialist, Department of Emergency Medicine, University of Michigan.), Elizabeth Duffy MPH (is Clinical Research Coordinator, Department of Emergency Medicine, University of Michigan.), P. Paul Chandanabhumma PhD, MPH (is Assistant Professor, Department of Family Medicine, University of Michigan.), Caitlin M. Cassady LMSW, LCSW (is PhD Candidate, Social Work and Anthropology Doctoral Program, Wayne State University.), Fernanda Bellolio MD, MS (is Emergency Medicine Physician and Health Sciences Researcher, Departments of Emergency Medicine and Health Science Research, Mayo Clinic, Rochester, Minnesota.), Kalyan S. Pasupathy PhD (is Professor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago.), Milisa Manojlovich PhD, RN (is Professor, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan.), Hardeep Singh MD, MPH (is Professor, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA (US Department of Veterans Affairs) Medical Center and Baylor College of Medicine, Houston.), Prashant Mahajan MD, MBA, MPH (is Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan. Please address correspondence to Courtney W. Mangus)","doi":"10.1016/j.jcjq.2024.03.003","DOIUrl":"10.1016/j.jcjq.2024.03.003","url":null,"abstract":"<div><h3>Background</h3><p>Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety.</p></div><div><h3>Methods</h3><p>Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED–Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews.</p></div><div><h3>Results</h3><p>The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED–Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused.</p></div><div><h3>Conclusion</h3><p>Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140280474","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.012
Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.), Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.), Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.), Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.), Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)
Background
Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.
Methods
Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.
Results
In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (p < 0.0001).
Conclusion
Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.
{"title":"Putting the “Action” in RCA2: An Analysis of Intervention Strength After Adverse Events","authors":"Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.), Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.), Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.), Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.), Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)","doi":"10.1016/j.jcjq.2024.03.012","DOIUrl":"10.1016/j.jcjq.2024.03.012","url":null,"abstract":"<div><h3>Background</h3><p>Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.</p></div><div><h3>Methods</h3><p>Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.</p></div><div><h3>Results</h3><p>In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (<em>p</em> < 0.0001).</p></div><div><h3>Conclusion</h3><p>Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140870150","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.05.001
Robin R. Hemphill MD, MPH (is Chief of Staff, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. Please address correspondence to Robin Hemphill)
{"title":"The Challenge of Improving Patient Safety: This is Hard","authors":"Robin R. Hemphill MD, MPH (is Chief of Staff, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. Please address correspondence to Robin Hemphill)","doi":"10.1016/j.jcjq.2024.05.001","DOIUrl":"10.1016/j.jcjq.2024.05.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140921353","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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