Joint Commission journal on quality and patient safety最新文献

Background: Burnout, disengagement, and turnover among clinicians is a major challenge for the US health care industry. Research has shown that higher direct supervisor leadership scores correlate with decreased provider burnout and increased professional fulfillment. Safety-net health systems such as Federally Qualified Health Centers (FQHCs) face increased challenges due to limited financial resources, more complex social determinants of health among patients, and often fewer physician leaders who can serve as mentors compared to large, integrated health systems.

Methods: The authors interviewed frontline physician leaders of primary care clinics in a large, urban FQHC network regarding their approach to leadership, prior training and support, opinions related to provider burnout, and ideas for improvement. Qualitative data analysis was completed using the Immersion-Crystallization method, reaching theme saturation.

Results: Key themes were structure of leaders' roles, challenges in daily leadership that outstripped time set aside for leadership activities, and the nature of and response to team members' burnout. Leaders found their roles meaningful and viewed themselves as a bridge between institutional decisions and frontline providers. Longer duration in leadership roles, formal and informal mentoring, and networks of support were related to increased confidence. Variation existed in the amount and perceived value of leadership training, development, and support. Physician leaders emphasized the importance of a high-functioning clinic leadership team and expressed frustration with a lack of connection to institutional decision-making. Leaders were empathetic to the drivers of burnout among their teams and strove to assist individual providers while facing challenges from structural causes of burnout.

Conclusion: Frontline leaders in safety-net clinics play a powerful role in the well-being and resilience of their provider care teams and typically are highly engaged despite facing significant barriers to success. Investing in development and formal support for frontline physician leaders in primary care safety-net settings is important to ensure their longevity and a resilient provider workforce.

Background: Simulation offers an opportunity to practice neonatal resuscitation and test clinical systems to improve safety. The authors used simulation-based clinical systems testing (SbCST) with a Healthcare Failure Mode and Effect Analysis (HFMEA) rubric to categorize and quantify latent safety threats (LSTs) during in situ training in eight rural delivery hospitals. The research team hypothesized that most LSTs would be common across hospitals. LST themes were identified across sites.

Methods: Between May 2019 and May 2023, the neonatal simulation team conducted half-day training sessions including a total of 177 interprofessional delivery room team members. Teams participated in skills stations, followed by in situ simulations with facilitated debriefs. Facilitators included neonatologists and simulation faculty trained in HFMEA. HFMEA rubrics were completed for each site with mitigation strategies captured on follow-up. LSTs were compared across sites.

Results: A total of 67 distinct LSTs were identified. Forty-one of 67 (61.2%) were shared by more than one hospital, and 26 (38.8%) were unique to individual hospitals. LSTs were distributed across five systems categories and three teams categories. The 4 LSTs detected at 75% or more of hospitals were lack of clear newborn blood transfusion protocols, inconsistent use of closed-loop communication, inconsistent processes for accessing additional resources, and inconsistent use of a recorder.

Conclusion: Use of SbCST across a health system allows for comparison of LSTs at each site and identification of common opportunities to mitigate safety threats. Systemwide analysis provides leaders with data needed to guide resource allocation to track and ensure effective implementation of solutions for prioritized LSTs. Identification of themes may allow other hospitals that have not participated in simulation testing to engage in prospective readiness efforts.

Conceptual framework: The Surgical Pause is a rapid, scalable strategy for health care systems to optimize perioperative outcomes for high-risk, frail patients considering elective surgery. The first and most important step is to screen for frailty, thereby identifying the 5% to 10% of patients at most risk for postoperative complications, loss of independence, institutionalization, and mortality. The second step is to take action to improve outcomes. Action may include clarifying perioperative goals, optimizing perioperative decision-making, and mitigating frailty-associated risks through prehabilitation.

History of dissemination: Initially implemented at the Omaha Veterans Affairs (VA) Medical Center in 2012, the Surgical Pause was associated with a nearly three-fold survival advantage among the frail. The program was subsequently replicated at more than 50 VA and private sector hospitals with similarly robust results, leading the Veterans Health Administration (VHA) National Surgery Office to formally adopt the program in January 2024. The Joint Commission and the National Quality Forum recognized the program with the Eisenberg Award for Patient Safety and Quality at the National Level.

Lessons learned: Successful dissemination grew from simultaneous real-world quality projects paralleled by rigorous, high-quality, peer reviewed publications demonstrating the need for and impact of the Surgical Pause. Adoption was facilitated in an iterative process to streamline feasibility and leverage existing resources. Success was accelerated by national infrastructure catalyzing a community of practice.

Conclusion: The Surgical Pause is changing surgical culture by proactively identifying frail patients, aligning treatment plans with patient-defined goals, optimizing perioperative decisions, and mitigating frailty-associated risks to deliver both quality and value.

Background: Communication barriers are known to adversely affect patient safety. Yet few health systems assess and track physician non-English language proficiency for use in clinical settings. Barriers to current assessments (usually simulated clinician oral proficiency interviews) include time constraints and lack of interactivity. This study's objective was to investigate physician perspectives on using direct clinical observation as an alternative form of assessment of their non-English language skills.

Methods: The authors conducted semistructured interviews with 11 fully and partially bilingual primary care physicians (general internists) from a large academic health system to understand physician perspectives on using direct observation as an alternative form of assessing non-English proficiency for use in clinical practice. Two researchers independently and iteratively coded transcripts using thematic analysis with constant comparison to identify themes.

Results: Participants, mostly women (n = 9; 81.8%), reported varying levels of proficiency in Cantonese, Mandarin, Russian, or Spanish. Participants expressed three main themes: (1) benefits of direct observation, including familiar setting, relevant content, and convenience; (2) disadvantages, including discomfort, potential embarrassment, and limitations of observing a single encounter; and (3) suggestions to enhance use of direct observation tools, such as observing multiple encounters, and use of remote observation.

Conclusion: To ensure high-quality language-concordant care, health systems must assess physicians' non-English language proficiency. If validated tools can be developed and disseminated in clinical practice, direct observation may be an acceptable option.

Background: Health care-associated infections are frequent complications for hospitalized patients, and the COVID-19 pandemic exacerbated this issue. This study aimed to explore stakeholders' viewpoints on how patients and families should engage in preventing health care-associated infections in hospital settings.

Methods: The authors employed Q-methodology, a mixed methods approach combining by-person factor analysis with in-depth interviews to capture shared viewpoints among participants. The research was conducted in a university-affiliated adult transplant unit using a purposive sample of staff members, patients, and family members. Participants ranked 40 preselected statements on a tablet using the Q-sorTouch Web application (for example, "Staff members should check that patients and family members wash their hands at key moments") on a continuum from "most agree" (+2) to "most disagree" (-2). Participants then took part in in-depth interviews to elaborate on their rankings. Data analysis included factor extraction and thematic interpretation.

Results: Nineteen participants completed the study. Analysis revealed three distinct viewpoints on patient and family engagement in infection prevention and control: (1) a controlling approach in which health care professionals ensure patient and family compliance, (2) an enabling approach that supports shared responsibility and emphasizes autonomy, and (3) a view of patients and family members as vigilant partners. Seven consensus statements emerged, indicating agreement on strategies in which patients and families are passive rather than proactive.

Conclusion: Although a paternalistic model emphasizing health care professional oversight prevailed, alternative perspectives emerged advocating for greater autonomy and responsibility among patients and families. These differing opinions indicate ongoing debate about how best to involve patients and their families in infection control, particularly during periods of heightened risk.