Pub Date : 2025-12-01DOI: 10.1016/j.jcjq.2025.09.005
Peter Pronovost MD, PhD, FCCM (is Chief Quality and Transformation Officer, University Hospitals Cleveland Medical Center, Cleveland, Ohio.), Leslie J. Pelton MPA (is Senior Program Officer, The John A. Hartford Foundation, New York, New York.), Hooman Azmi MD, FAANS (is Vice Chair of Neurosurgery for Quality and Safety, Hackensack University Medical Center, Hackensack, New Jersey.), Annie Brooks MSW (is Senior Director, Strategic Initiatives, Parkinson’s Foundation, Miami.), Eboné Carrington MPA (is Managing Director, Manatt Health Strategies, New York, New York.), Michael Siao Tick Chong MPH (is Senior Manager, Manatt Health Strategies.), Sheera Rosenfeld MHS (is Vice President, Chief Strategic Initiatives Officer, Parkinson’s Foundation. Please address correspondence to Sheera Rosenfeld)
{"title":"Advancing Parkinson’s Care and Patient Safety Through CMS’s Age-Friendly Hospital Measure","authors":"Peter Pronovost MD, PhD, FCCM (is Chief Quality and Transformation Officer, University Hospitals Cleveland Medical Center, Cleveland, Ohio.), Leslie J. Pelton MPA (is Senior Program Officer, The John A. Hartford Foundation, New York, New York.), Hooman Azmi MD, FAANS (is Vice Chair of Neurosurgery for Quality and Safety, Hackensack University Medical Center, Hackensack, New Jersey.), Annie Brooks MSW (is Senior Director, Strategic Initiatives, Parkinson’s Foundation, Miami.), Eboné Carrington MPA (is Managing Director, Manatt Health Strategies, New York, New York.), Michael Siao Tick Chong MPH (is Senior Manager, Manatt Health Strategies.), Sheera Rosenfeld MHS (is Vice President, Chief Strategic Initiatives Officer, Parkinson’s Foundation. Please address correspondence to Sheera Rosenfeld)","doi":"10.1016/j.jcjq.2025.09.005","DOIUrl":"10.1016/j.jcjq.2025.09.005","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 12","pages":"Pages 772-777"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145623197","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 : 2025-12-01DOI: 10.1016/j.jcjq.2025.09.001
Daniel E. Hall MD, MDiv, MHSc, FACS , Carly A. Jacobs MPH , Katherine M. Reitz MD, MSc , Shipra Arya MD, SM, FACS , Michael A. Jacobs MS , John Cashy PhD , Jason M. Johanning MD, MS, FACS
{"title":"Corrigendum to: “Frailty Screening Using the Risk Analysis Index: A User Guide” [The Joint Commission Journal on Quality and Patient Safety Volume 51, Issue 3 (2025) Pages 178-191]","authors":"Daniel E. Hall MD, MDiv, MHSc, FACS , Carly A. Jacobs MPH , Katherine M. Reitz MD, MSc , Shipra Arya MD, SM, FACS , Michael A. Jacobs MS , John Cashy PhD , Jason M. Johanning MD, MS, FACS","doi":"10.1016/j.jcjq.2025.09.001","DOIUrl":"10.1016/j.jcjq.2025.09.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 12","pages":"Page 788"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145206493","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 : 2025-12-01DOI: 10.1016/j.jcjq.2025.09.004
Lucy Schulson MD, MPH (is Assistant Professor, Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine.), Mari-Lynn Drainoni PhD, MEd (is Research Professor, Section of Infectious Disease, Boston University Chobanian and Avedisian School of Medicine, and Department of Health Law, Policy & Management, Boston University School of Public Health, and Co-Director, Evans Center for Implementation and Improvement Sciences, Boston University.), Kirsten Austad MD, MPH (is Assistant Professor, Department of Family Medicine, Boston University Chobanian and Avedisian School of Medicine, and Co-Director, Evans Center for Implementation and Improvement Sciences. Please address correspondence to Lucy Schulson)
{"title":"Leveraging Implementation Science to Address Diagnostic Disparities and Promote Equity in Healthcare","authors":"Lucy Schulson MD, MPH (is Assistant Professor, Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine.), Mari-Lynn Drainoni PhD, MEd (is Research Professor, Section of Infectious Disease, Boston University Chobanian and Avedisian School of Medicine, and Department of Health Law, Policy & Management, Boston University School of Public Health, and Co-Director, Evans Center for Implementation and Improvement Sciences, Boston University.), Kirsten Austad MD, MPH (is Assistant Professor, Department of Family Medicine, Boston University Chobanian and Avedisian School of Medicine, and Co-Director, Evans Center for Implementation and Improvement Sciences. Please address correspondence to Lucy Schulson)","doi":"10.1016/j.jcjq.2025.09.004","DOIUrl":"10.1016/j.jcjq.2025.09.004","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 12","pages":"Pages 778-782"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145444730","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 : 2025-12-01DOI: 10.1016/j.jcjq.2025.09.002
Alison Lehane MD (is Pediatric Surgical Research Fellow, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, and Ann & Robert H. Lurie Children’s Hospital of Chicago.), Mallory Perez MD (is Pediatric Surgical Research Fellow, NQUIRES, Northwestern University Feinberg School of Medicine, and Ann & Robert H. Lurie Children’s Hospital of Chicago.), Gwyneth A. Sullivan MD, MS (is General Surgical Resident, Rush University Medical Center, Chicago.), Jennifer Dunn PhD, MSE (is Professor of Chemical and Biological Engineering, and Director, Center for Engineering Sustainability and Resilience, Northwestern University McCormick School of Engineering.), Timothy B. Lautz MD (is Associate Professor, Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, and Ann & Robert H. Lurie Children’s Hospital of Chicago.), Mehul V. Raval MD, MS (is Professor, Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, and Ann & Robert H. Lurie Children’s Hospital of Chicago. Please address correspondence to Alison Lehane)
Background
Operating rooms (ORs) generate substantial waste and greenhouse gas (GHG) emissions, in part due to common reliance on single-use disposable items widely used in prefabricated surgical kits. This study evaluates the environmental and economic benefits of streamlining surgical kits in a children’s hospital.
Method
Life cycle assessment (LCA) was used to assess the cradle-to-grave impact of surgical kits, quantifying GHG emissions from raw material extraction through disposal. GHG emissions were modeled using the Greenhouse gases, Regulated Emissions, and Energy use in Transportation (GREET) model and openLCA software, scaled to annual surgical volumes, and converted using the US Environmental Protection Agency’s (EPA) Greenhouse Gas Equivalencies Calculator. Iterative stakeholder consultation identified items for removal to minimize waste while maintaining operative needs. Cost savings were calculated from medical supplier data.
Results
Optimizing three surgical kits (Pediatric Major, Pediatric Minor, and Pediatric Minor–Outpatient) by removing select items (for example, large ring basins, preparation trays, suction tubing, extra gowns) resulted in annual cost savings of $8,608 and GHG reductions of 30,654 g across 2,676 pediatric surgical cases. GHG reductions ranged from 6.9 g to 13.0 g per pack. If applied across all surgical service lines (cases = 26,000), projected GHG reductions would be between 179,400 g and 338,000 g, with a median of 288,600 g, equivalent to 783 miles (1,260 kilometers) driven, or a journey between Chicago and New York City.
Conclusion
Streamlining pediatric surgical kits offers a scalable, cost-effective strategy for reducing the environmental impact of ORs. LCA provides a robust framework for evaluating sustainability in healthcare, supporting informed decision-making to enhance resource efficiency.
{"title":"Optimizing Pediatric Surgical Kits: A Cost-Effective Approach to Reducing Environmental Impact in Healthcare","authors":"Alison Lehane MD (is Pediatric Surgical Research Fellow, Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, and Ann & Robert H. Lurie Children’s Hospital of Chicago.), Mallory Perez MD (is Pediatric Surgical Research Fellow, NQUIRES, Northwestern University Feinberg School of Medicine, and Ann & Robert H. Lurie Children’s Hospital of Chicago.), Gwyneth A. Sullivan MD, MS (is General Surgical Resident, Rush University Medical Center, Chicago.), Jennifer Dunn PhD, MSE (is Professor of Chemical and Biological Engineering, and Director, Center for Engineering Sustainability and Resilience, Northwestern University McCormick School of Engineering.), Timothy B. Lautz MD (is Associate Professor, Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, and Ann & Robert H. Lurie Children’s Hospital of Chicago.), Mehul V. Raval MD, MS (is Professor, Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, and Ann & Robert H. Lurie Children’s Hospital of Chicago. Please address correspondence to Alison Lehane)","doi":"10.1016/j.jcjq.2025.09.002","DOIUrl":"10.1016/j.jcjq.2025.09.002","url":null,"abstract":"<div><h3>Background</h3><div>Operating rooms (ORs) generate substantial waste and greenhouse gas (GHG) emissions, in part due to common reliance on single-use disposable items widely used in prefabricated surgical kits. This study evaluates the environmental and economic benefits of streamlining surgical kits in a children’s hospital.</div></div><div><h3>Method</h3><div>Life cycle assessment (LCA) was used to assess the cradle-to-grave impact of surgical kits, quantifying GHG emissions from raw material extraction through disposal. GHG emissions were modeled using the Greenhouse gases, Regulated Emissions, and Energy use in Transportation (GREET) model and openLCA software, scaled to annual surgical volumes, and converted using the US Environmental Protection Agency’s (EPA) Greenhouse Gas Equivalencies Calculator. Iterative stakeholder consultation identified items for removal to minimize waste while maintaining operative needs. Cost savings were calculated from medical supplier data.</div></div><div><h3>Results</h3><div>Optimizing three surgical kits (Pediatric Major, Pediatric Minor, and Pediatric Minor–Outpatient) by removing select items (for example, large ring basins, preparation trays, suction tubing, extra gowns) resulted in annual cost savings of $8,608 and GHG reductions of 30,654 g across 2,676 pediatric surgical cases. GHG reductions ranged from 6.9 g to 13.0 g per pack. If applied across all surgical service lines (cases = 26,000), projected GHG reductions would be between 179,400 g and 338,000 g, with a median of 288,600 g, equivalent to 783 miles (1,260 kilometers) driven, or a journey between Chicago and New York City.</div></div><div><h3>Conclusion</h3><div>Streamlining pediatric surgical kits offers a scalable, cost-effective strategy for reducing the environmental impact of ORs. LCA provides a robust framework for evaluating sustainability in healthcare, supporting informed decision-making to enhance resource efficiency.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 12","pages":"Pages 753-757"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145318316","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 : 2025-12-01DOI: 10.1016/j.jcjq.2025.09.003
Dylan J. Parker MD (is Research Fellow, Department of Dermatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.), Iman M. Salem MD (is Resident, Department of Dermatology, Dartmouth Hitchcock Medical Center.), Dylan J. Badin MD (is Resident, Department of Dermatology, Dartmouth Hitchcock Medical Center.), Brian J. Simmons MD (is Assistant Professor, Department of Dermatology, Geisel School of Medicine at Dartmouth, and Director of Clinical Trials, Dartmouth Hitchcock Medical Center.), M. Shane Chapman MD, MBA (is Professor and Chair, Department of Dermatology, Geisel School of Medicine at Dartmouth, and Medical Director, Supply Chain Value Analysis, Dartmouth Hitchcock Medical Center. Please address correspondence to Dylan J. Parker)
Background
New patient waitlists across the United States continue to grow. This trend is exacerbated in rural areas. Dartmouth Dermatology is a unique tertiary care center serving approximately 50,000 patients annually. In September 2023 the center’s waitlist consisted of 3,654 unseen patients.
Methods
During Dartmouth Dermatology’s Big Access Week, which took place December 11–15, 2023, the center saw 1,532 patients (1,180 new patients) using a four-pronged approach: categorization, community sensitization, patient expectations, and operations.
Results
Patient ages ranged from 10 months to 98 years. Average referral to visit time was 98.7 days. Full skin exams were performed on 406 patients, and focused exams were performed on 607 patients. Primary diagnoses included malignant/premalignant lesions for 279 patients, autoimmune-related skin disease for 57 patients, inflammatory lesions for 396 patients, and infectious lesions for 82 patients. Notably, 124 malignancies were confirmed (67 basal cell carcinomas, 39 squamous cell carcinomas, and 18 melanomas). Mohs referrals totaled 87 cases. The average patient satisfaction rating was 3.8/4.
Conclusion
Dartmouth Dermatology’s workflow model in Big Access Week significantly shortened waitlist time while maintaining high-quality care. This model can be implemented by a wide array of medical and surgical subspecialties, contributing to a seemingly daunting task: improving vital access to healthcare.
{"title":"Big Access Week: Decreasing Dermatology Patient Wait Times in a Strained Healthcare System","authors":"Dylan J. Parker MD (is Research Fellow, Department of Dermatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.), Iman M. Salem MD (is Resident, Department of Dermatology, Dartmouth Hitchcock Medical Center.), Dylan J. Badin MD (is Resident, Department of Dermatology, Dartmouth Hitchcock Medical Center.), Brian J. Simmons MD (is Assistant Professor, Department of Dermatology, Geisel School of Medicine at Dartmouth, and Director of Clinical Trials, Dartmouth Hitchcock Medical Center.), M. Shane Chapman MD, MBA (is Professor and Chair, Department of Dermatology, Geisel School of Medicine at Dartmouth, and Medical Director, Supply Chain Value Analysis, Dartmouth Hitchcock Medical Center. Please address correspondence to Dylan J. Parker)","doi":"10.1016/j.jcjq.2025.09.003","DOIUrl":"10.1016/j.jcjq.2025.09.003","url":null,"abstract":"<div><h3>Background</h3><div>New patient waitlists across the United States continue to grow. This trend is exacerbated in rural areas. Dartmouth Dermatology is a unique tertiary care center serving approximately 50,000 patients annually. In September 2023 the center’s waitlist consisted of 3,654 unseen patients.</div></div><div><h3>Methods</h3><div>During Dartmouth Dermatology’s Big Access Week, which took place December 11–15, 2023, the center saw 1,532 patients (1,180 new patients) using a four-pronged approach: categorization, community sensitization, patient expectations, and operations.</div></div><div><h3>Results</h3><div>Patient ages ranged from 10 months to 98 years. Average referral to visit time was 98.7 days. Full skin exams were performed on 406 patients, and focused exams were performed on 607 patients. Primary diagnoses included malignant/premalignant lesions for 279 patients, autoimmune-related skin disease for 57 patients, inflammatory lesions for 396 patients, and infectious lesions for 82 patients. Notably, 124 malignancies were confirmed (67 basal cell carcinomas, 39 squamous cell carcinomas, and 18 melanomas). Mohs referrals totaled 87 cases. The average patient satisfaction rating was 3.8/4.</div></div><div><h3>Conclusion</h3><div>Dartmouth Dermatology’s workflow model in Big Access Week significantly shortened waitlist time while maintaining high-quality care. This model can be implemented by a wide array of medical and surgical subspecialties, contributing to a seemingly daunting task: improving vital access to healthcare.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 12","pages":"Pages 767-771"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145345306","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 : 2025-12-01DOI: 10.1016/j.jcjq.2025.08.003
Sarah Kandil MD (is Associate Professor of Pediatrics, Section of Critical Care Medicine, Yale School of Medicine, and Deputy Quality and Safety Officer, Yale New Haven Hospital.), Michelle Vonderhaar (is Project Manager, Children’s Hospitals’ Solutions for Patient Safety, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center.), Patsy Sisson MS (is Senior Analyst, Children’s Hospitals’ Solutions for Patient Safety, Cincinnati Children’s Hospital Medical Center.), Lara Wood MN, RN, CPN, CPPS (is Associate Clinical Director, Children’s Hospitals’ Solutions for Patient Safety, Cincinnati Children’s Hospital Medical Center.), Patrick W. Brady MD, MSc (is Co-Director, Division of Hospital Medicine, Children’s Hospitals’ Solutions for Patient Safety, Cincinnati Children’s Hospital Medical Center, and Professor, Department of Pediatrics, University of Cincinnati College of Medicine.), Anne Lyren MD, MSc (is Chief Medical and Strategy Officer, and Clinical Director, Children’s Hospitals’ Solutions for Patient Safety, Cincinnati Children’s Hospital Medical Center. Please address correspondence to Sarah Kandil)
Background
Site visits are commonly used for accreditation and regulatory purposes, but little is known about how hospitals use them for safety improvement or their impact on clinical processes and outcomes.
Methods
This mixed methods study describes the key components of safety-focused site visits between hospitals and their impact on hospital safety outcomes, particularly for the visiting hospital. Hospitals were recruited via the Children’s Hospitals’ Solutions for Patient Safety (SPS) Network. A site visit guide was developed, covering pre-visit planning, visit execution, and post-visit debriefing. A post-visit survey and follow-up interviews (6 to 12 months later) were conducted. Themes were identified using a constant comparative approach, and statistical analysis compared rates of hospital-acquired conditions (HACs) between hospitals that participated in site visits and those that did not.
Results
From 2019 to 2021, 27 hospitals (19.6%) participated in site visits, with 14 in-person and 13 virtual. Key themes to drive a successful and useful visit highlighted the importance of peer rapport, interaction with frontline staff, structured planning, clear agendas, and thorough debriefing. Among hospitals that completed a follow-up interview, 76.5% completed at least one action item, with 56.8% of pre-determined SMART aims achieved. However, no significant difference in HAC rates, specifically central line–associated bloodstream infections (CLABSIs) and unplanned extubations (UEs), was found between site visit and non–site visit hospitals.
Conclusion
Safety-focused site visits between hospitals provide a valuable learning experience, fostering the development of improvement strategies and high rates of action item completion. However, no significant differences in safety outcomes were observed, likely due to the small sample size.
{"title":"The Impact of Semistructured Safety-Focused Site Visits Between Children’s Hospitals","authors":"Sarah Kandil MD (is Associate Professor of Pediatrics, Section of Critical Care Medicine, Yale School of Medicine, and Deputy Quality and Safety Officer, Yale New Haven Hospital.), Michelle Vonderhaar (is Project Manager, Children’s Hospitals’ Solutions for Patient Safety, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center.), Patsy Sisson MS (is Senior Analyst, Children’s Hospitals’ Solutions for Patient Safety, Cincinnati Children’s Hospital Medical Center.), Lara Wood MN, RN, CPN, CPPS (is Associate Clinical Director, Children’s Hospitals’ Solutions for Patient Safety, Cincinnati Children’s Hospital Medical Center.), Patrick W. Brady MD, MSc (is Co-Director, Division of Hospital Medicine, Children’s Hospitals’ Solutions for Patient Safety, Cincinnati Children’s Hospital Medical Center, and Professor, Department of Pediatrics, University of Cincinnati College of Medicine.), Anne Lyren MD, MSc (is Chief Medical and Strategy Officer, and Clinical Director, Children’s Hospitals’ Solutions for Patient Safety, Cincinnati Children’s Hospital Medical Center. Please address correspondence to Sarah Kandil)","doi":"10.1016/j.jcjq.2025.08.003","DOIUrl":"10.1016/j.jcjq.2025.08.003","url":null,"abstract":"<div><h3>Background</h3><div>Site visits are commonly used for accreditation and regulatory purposes, but little is known about how hospitals use them for safety improvement or their impact on clinical processes and outcomes.</div></div><div><h3>Methods</h3><div>This mixed methods study describes the key components of safety-focused site visits between hospitals and their impact on hospital safety outcomes, particularly for the visiting hospital. Hospitals were recruited via the Children’s Hospitals’ Solutions for Patient Safety (SPS) Network. A site visit guide was developed, covering pre-visit planning, visit execution, and post-visit debriefing. A post-visit survey and follow-up interviews (6 to 12 months later) were conducted. Themes were identified using a constant comparative approach, and statistical analysis compared rates of hospital-acquired conditions (HACs) between hospitals that participated in site visits and those that did not.</div></div><div><h3>Results</h3><div>From 2019 to 2021, 27 hospitals (19.6%) participated in site visits, with 14 in-person and 13 virtual. Key themes to drive a successful and useful visit highlighted the importance of peer rapport, interaction with frontline staff, structured planning, clear agendas, and thorough debriefing. Among hospitals that completed a follow-up interview, 76.5% completed at least one action item, with 56.8% of pre-determined SMART aims achieved. However, no significant difference in HAC rates, specifically central line–associated bloodstream infections (CLABSIs) and unplanned extubations (UEs), was found between site visit and non–site visit hospitals.</div></div><div><h3>Conclusion</h3><div>Safety-focused site visits between hospitals provide a valuable learning experience, fostering the development of improvement strategies and high rates of action item completion. However, no significant differences in safety outcomes were observed, likely due to the small sample size.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 12","pages":"Pages 758-766"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145058511","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 : 2025-12-01DOI: 10.1016/j.jcjq.2025.09.006
Carole Lenz Hemmelgarn MS, MS (is Founding Member, Patients for Patient Safety US, and Senior Director of Education, MedStar Institute for Quality and Safety.), Margaret A. McManus MHS (is Co-Director, Got Transition®, and President, National Alliance to Advance Adolescent Health, Washington, DC.), Kiera Peoples MPH (is Policy Analyst, National Partnership for Women & Families, Washington, DC.), Rashmi Singh MBA, MS (is Senior Analyst, National Quality Forum.), Laura Blum Meisnere MA (is Program Director, Membership and Engagement, National Quality Forum. Please address correspondence to Laura Blum Meisnere)
{"title":"Patient Safety in Transition from Pediatric to Adult-Centered Care","authors":"Carole Lenz Hemmelgarn MS, MS (is Founding Member, Patients for Patient Safety US, and Senior Director of Education, MedStar Institute for Quality and Safety.), Margaret A. McManus MHS (is Co-Director, Got Transition®, and President, National Alliance to Advance Adolescent Health, Washington, DC.), Kiera Peoples MPH (is Policy Analyst, National Partnership for Women & Families, Washington, DC.), Rashmi Singh MBA, MS (is Senior Analyst, National Quality Forum.), Laura Blum Meisnere MA (is Program Director, Membership and Engagement, National Quality Forum. Please address correspondence to Laura Blum Meisnere)","doi":"10.1016/j.jcjq.2025.09.006","DOIUrl":"10.1016/j.jcjq.2025.09.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 12","pages":"Pages 783-787"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145458737","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 : 2025-12-01DOI: 10.1016/j.jcjq.2025.08.004
Clémence Marty-Chastan MPA, MSc (is Harkness Fellow 2023–24 and Visiting Scholar, University of California, San Francisco (UCSF).), Claire D. Brindis DrPH (is Distinguished Professor, Department of Pediatrics and Philip R. Lee Institute for Health Policy, and Senior Advisor, Center for Climate, Health and Equity, UCSF.), Sheri D. Weiser MD, MPH, MA (is Professor of Medicine and Internist, Division of HIV, Infectious Diseases and Global Medicine, and Founding Co-Director, Center for Climate, Health and Equity, UCSF.), Sapna Thottathil PhD, MSc (formerly Managing Director, Center for Climate, Health and Equity, UCSF, is Deputy Director, Sustainable Pest Management, California Department of Pesticide Regulation.), Jodi D. Sherman MD (is Associate Professor, Department of Anesthesiology, Yale School of Medicine, and Medical Director of Sustainability, Yale New Haven Health.), Arianne Teherani PhD (is Professor of Medicine, and Founding Co-Director, Center for Climate, Health and Equity, UCSF. Please address correspondence to Clémence Marty-Chastan)
Background
Clinical decarbonization actions are needed to ensure that hospitals achieve commitments to reduce carbon emissions. Elucidating barriers and facilitators is key to developing sustainable and scalable clinical mitigation actions.
Methods
Semistructured interviews with key stakeholders sought to document barriers and opportunities in implementing clinical sustainability initiatives at the University of California Health System. The following Consolidated Framework for Implementation Research (CFIR) domains were used to shape the interview guide and analyses: (1) individual characteristics, (2) innovation characteristics (3) inner setting, and (4) outer setting. Work responsibilities, knowledge of and interest in sustainability, project role, and recommendations for future sustainability and decarbonization efforts were also explored.
Results
Fourteen frontline healthcare workers participated in the study, including 13 clinicians and one supply chain officer. All participants encountered challenges and solutions across CFIR domains. All participants acknowledged, explicitly or implicitly, the existence of multiple competing priorities as the strongest barrier to decarbonization implementation. Participants identified several required resources to achieve and sustain efforts: access to experienced peer professionals, data, dedicated time and funding, commitment to resolving supply chain issues, and embedding sustainability within the hospital’s core mission.
Conclusion
Implementing clinical decarbonization actions is complex, requiring alignment between numerous stakeholders. Overcoming implementation challenges requires strategic action at the individual and organizational levels and alignment across internal and external constituents, including supply chain partners, state and federal policymakers, and industry, to build and sustain efforts.
背景：需要采取临床脱碳行动，以确保医院实现减少碳排放的承诺。阐明障碍和促进因素是制定可持续和可扩展的临床缓解行动的关键。方法：与关键利益相关者进行半结构化访谈，试图记录加州大学卫生系统实施临床可持续性倡议的障碍和机会。本文采用以下实施研究整合框架（Consolidated Framework for Implementation Research， CFIR）域来构建访谈指南和分析：(1)个体特征、(2)创新特征、(3)内部环境、(4)外部环境。工作职责、对可持续发展的认识和兴趣、项目作用以及对未来可持续发展和脱碳工作的建议也进行了探讨。结果：14名一线医护人员参与研究，其中临床医生13名，供应链管理人员1名。所有参与者都遇到了跨CFIR领域的挑战和解决方案。所有与会者都或明或暗地承认，存在多个相互竞争的优先事项是实施脱碳的最大障碍。与会者确定了实现和维持努力所需的若干资源：获得经验丰富的同行专业人员、数据、专用时间和资金、致力于解决供应链问题，以及将可持续性纳入医院的核心使命。结论：实施临床脱碳行动是复杂的，需要众多利益相关者之间的协调。克服实施挑战需要在个人和组织层面采取战略行动，并跨内部和外部成分（包括供应链合作伙伴、州和联邦政策制定者以及行业）进行协调，以建立和维持努力。
{"title":"Implementing Clinical Decarbonization Actions: Lessons Learned from the University of California Health System","authors":"Clémence Marty-Chastan MPA, MSc (is Harkness Fellow 2023–24 and Visiting Scholar, University of California, San Francisco (UCSF).), Claire D. Brindis DrPH (is Distinguished Professor, Department of Pediatrics and Philip R. Lee Institute for Health Policy, and Senior Advisor, Center for Climate, Health and Equity, UCSF.), Sheri D. Weiser MD, MPH, MA (is Professor of Medicine and Internist, Division of HIV, Infectious Diseases and Global Medicine, and Founding Co-Director, Center for Climate, Health and Equity, UCSF.), Sapna Thottathil PhD, MSc (formerly Managing Director, Center for Climate, Health and Equity, UCSF, is Deputy Director, Sustainable Pest Management, California Department of Pesticide Regulation.), Jodi D. Sherman MD (is Associate Professor, Department of Anesthesiology, Yale School of Medicine, and Medical Director of Sustainability, Yale New Haven Health.), Arianne Teherani PhD (is Professor of Medicine, and Founding Co-Director, Center for Climate, Health and Equity, UCSF. Please address correspondence to Clémence Marty-Chastan)","doi":"10.1016/j.jcjq.2025.08.004","DOIUrl":"10.1016/j.jcjq.2025.08.004","url":null,"abstract":"<div><h3>Background</h3><div>Clinical decarbonization actions are needed to ensure that hospitals achieve commitments to reduce carbon emissions. Elucidating barriers and facilitators is key to developing sustainable and scalable clinical mitigation actions.</div></div><div><h3>Methods</h3><div>Semistructured interviews with key stakeholders sought to document barriers and opportunities in implementing clinical sustainability initiatives at the University of California Health System. The following Consolidated Framework for Implementation Research (CFIR) domains were used to shape the interview guide and analyses: (1) individual characteristics, (2) innovation characteristics (3) inner setting, and (4) outer setting. Work responsibilities, knowledge of and interest in sustainability, project role, and recommendations for future sustainability and decarbonization efforts were also explored.</div></div><div><h3>Results</h3><div>Fourteen frontline healthcare workers participated in the study, including 13 clinicians and one supply chain officer. All participants encountered challenges and solutions across CFIR domains. All participants acknowledged, explicitly or implicitly, the existence of multiple competing priorities as the strongest barrier to decarbonization implementation. Participants identified several required resources to achieve and sustain efforts: access to experienced peer professionals, data, dedicated time and funding, commitment to resolving supply chain issues, and embedding sustainability within the hospital’s core mission.</div></div><div><h3>Conclusion</h3><div>Implementing clinical decarbonization actions is complex, requiring alignment between numerous stakeholders. Overcoming implementation challenges requires strategic action at the individual and organizational levels and alignment across internal and external constituents, including supply chain partners, state and federal policymakers, and industry, to build and sustain efforts.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 12","pages":"Pages 742-752"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145274557","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 : 2025-11-29DOI: 10.1016/j.jcjq.2025.11.010
David R Nerenz, Kari Jarabek, Jamie Myers, Thomas Leyden, John D Syrjamaki, Tanima Basu, Mark Bradshaw, Jianhui Hu, Doris Tong, Ilyas Aleem, Victor Chang, Jad Khalil, Miguelangelo Perez-Cruet, Muwaffak Abdulhak
Background: Quality improvement (QI) collaboratives represent a potentially powerful approach to QI, patient experience, and cost savings. In this article the authors present an estimate of direct cost savings to payers from reductions in the rate of a single adverse event (urinary retention) in the context of the Michigan Spine Surgery Improvement Collaborative (MSSIC).
Methods: Data from the MSSIC clinical registry were used to calculate reductions in rates of urinary retention (with or without readmission) from a 2016 baseline period to a 2017-2024 QI intervention period. The number of those events averted, combined with dollar cost estimates of payments for treatment of adverse events from the Michigan Value Collaborative (MVC) was used to estimate direct cost savings to payers.
Results: Direct cost savings to payers for the 2017-2024 period were estimated at $66.8 million.
Conclusion: Given the combination of direct cost savings of $66.8 million and potential indirect cost savings to employers and caregivers of $130-$180 million, collaborative QI initiatives aimed at reducing rates of adverse outcomes after spine surgery can produce significant cost savings for payers, employers, and patients.
{"title":"Cost Savings Realized Through a Statewide Quality Improvement Collaborative for Spine Surgery.","authors":"David R Nerenz, Kari Jarabek, Jamie Myers, Thomas Leyden, John D Syrjamaki, Tanima Basu, Mark Bradshaw, Jianhui Hu, Doris Tong, Ilyas Aleem, Victor Chang, Jad Khalil, Miguelangelo Perez-Cruet, Muwaffak Abdulhak","doi":"10.1016/j.jcjq.2025.11.010","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.11.010","url":null,"abstract":"<p><strong>Background: </strong>Quality improvement (QI) collaboratives represent a potentially powerful approach to QI, patient experience, and cost savings. In this article the authors present an estimate of direct cost savings to payers from reductions in the rate of a single adverse event (urinary retention) in the context of the Michigan Spine Surgery Improvement Collaborative (MSSIC).</p><p><strong>Methods: </strong>Data from the MSSIC clinical registry were used to calculate reductions in rates of urinary retention (with or without readmission) from a 2016 baseline period to a 2017-2024 QI intervention period. The number of those events averted, combined with dollar cost estimates of payments for treatment of adverse events from the Michigan Value Collaborative (MVC) was used to estimate direct cost savings to payers.</p><p><strong>Results: </strong>Direct cost savings to payers for the 2017-2024 period were estimated at $66.8 million.</p><p><strong>Conclusion: </strong>Given the combination of direct cost savings of $66.8 million and potential indirect cost savings to employers and caregivers of $130-$180 million, collaborative QI initiatives aimed at reducing rates of adverse outcomes after spine surgery can produce significant cost savings for payers, employers, and patients.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145933384","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 : 2025-11-23DOI: 10.1016/j.jcjq.2025.11.009
Lauren Zabel, James Willey, Jennifer McDanel, Ethan Kuperman
{"title":"Reasons for eCQM-Identified Concurrent Opioid and Benzodiazepine Prescribing at Discharge: A Cohort Study.","authors":"Lauren Zabel, James Willey, Jennifer McDanel, Ethan Kuperman","doi":"10.1016/j.jcjq.2025.11.009","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.11.009","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-11-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145846329","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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