Joint Commission journal on quality and patient safety最新文献

Background

Methods

Results

Conclusion

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.

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.

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.

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.

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.

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.