Pub Date : 2025-07-17DOI: 10.1016/j.jcjq.2025.07.005
Dojna Shearer (Dojna Shearer is Senior Managing Editor for The Joint Commission Journal on Quality and Patient Safety, Joint Commission Resources, Oakbrook Terrace, IL. Please address correspondence to Dojna Shearer)
{"title":"The Joint Commission Journal on Quality and Patient Safety Welcomes New Editors","authors":"Dojna Shearer (Dojna Shearer is Senior Managing Editor for The Joint Commission Journal on Quality and Patient Safety, Joint Commission Resources, Oakbrook Terrace, IL. Please address correspondence to Dojna Shearer)","doi":"10.1016/j.jcjq.2025.07.005","DOIUrl":"10.1016/j.jcjq.2025.07.005","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 9","pages":"Pages 520-522"},"PeriodicalIF":2.4,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144896605","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 : 2025-07-11DOI: 10.1016/j.jcjq.2025.07.002
Margery Dell Smith DNP, FNP-C (is a Nurse Practitioner at Onvida Health Transitional Care Clinic in Yuma, Arizona), Kimberly A. Couch DNP, CNM, FNP-BC (is a Clinical Faculty Member at Frontier Nursing University in Versailles, Kentucky. Please address correspondence to Margery Dell Smith, DNP, FNP-C)
Background
Alpha-1 antitrypsin deficiency (AATD) is an underrecognized hereditary condition affecting approximately 2% of patients with chronic obstructive pulmonary disease (COPD) in the United States. Studies show a correlation between AATD and COPD progression, with a five-year mortality rate of 19% in severe AATD. National costs attributed to COPD were approximately $32.1 billion in 2010 and an estimated $49 billion in 2020. Chart audits at Onvida Health revealed that only 2.0% of patients diagnosed with COPD were tested for AATD. The authors aimed to improve effective care through AATD testing in adult patients with COPD in the primary care setting to 75% in an eight-week time frame.
Methods
Baseline data were obtained from chart audits for patients with COPD and patient/staff surveys. The implementation spanned eight weeks using a Plan-Do-Study-Act (PDSA) process consisting of four cycles and two core interventions analyzed every two weeks. A shared decision-making checklist was developed for AATD screening and testing. A standard of care log constructed from current evidence was implemented for all patients with COPD.
Results
Testing rates improved to 38.1% from a baseline of 2.0%. Although there was a 0.0% positivity rate for the diagnosis of AATD (two abnormal alleles), 19.7% (n = 12 of 61) of patients were identified as AATD carriers (one abnormal and one normal allele).
Conclusion
Utilizing standard of care can aid in disease prevention and prevent progression with early identification of patients with AATD. Suggested next steps include lengthier studies to evaluate the carriers and their offspring.
{"title":"Improving Screening for Alpha-1 Antitrypsin Deficiency in Adults with COPD","authors":"Margery Dell Smith DNP, FNP-C (is a Nurse Practitioner at Onvida Health Transitional Care Clinic in Yuma, Arizona), Kimberly A. Couch DNP, CNM, FNP-BC (is a Clinical Faculty Member at Frontier Nursing University in Versailles, Kentucky. Please address correspondence to Margery Dell Smith, DNP, FNP-C)","doi":"10.1016/j.jcjq.2025.07.002","DOIUrl":"10.1016/j.jcjq.2025.07.002","url":null,"abstract":"<div><h3>Background</h3><div>Alpha-1 antitrypsin deficiency (AATD) is an underrecognized hereditary condition affecting approximately 2% of patients with chronic obstructive pulmonary disease (COPD) in the United States. Studies show a correlation between AATD and COPD progression, with a five-year mortality rate of 19% in severe AATD. National costs attributed to COPD were approximately $32.1 billion in 2010 and an estimated $49 billion in 2020. Chart audits at Onvida Health revealed that only 2.0% of patients diagnosed with COPD were tested for AATD. The authors aimed to improve effective care through AATD testing in adult patients with COPD in the primary care setting to 75% in an eight-week time frame.</div></div><div><h3>Methods</h3><div>Baseline data were obtained from chart audits for patients with COPD and patient/staff surveys. The implementation spanned eight weeks using a Plan-Do-Study-Act (PDSA) process consisting of four cycles and two core interventions analyzed every two weeks. A shared decision-making checklist was developed for AATD screening and testing. A standard of care log constructed from current evidence was implemented for all patients with COPD.</div></div><div><h3>Results</h3><div>Testing rates improved to 38.1% from a baseline of 2.0%. Although there was a 0.0% positivity rate for the diagnosis of AATD (two abnormal alleles), 19.7% (<em>n</em> = 12 of 61) of patients were identified as AATD carriers (one abnormal and one normal allele).</div></div><div><h3>Conclusion</h3><div>Utilizing standard of care can aid in disease prevention and prevent progression with early identification of patients with AATD. Suggested next steps include lengthier studies to evaluate the carriers and their offspring.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 10","pages":"Pages 659-665"},"PeriodicalIF":2.4,"publicationDate":"2025-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144804109","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 : 2025-07-08DOI: 10.1016/j.jcjq.2025.07.001
Elizabeth Mort MD, MPH (is Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety, and Vice President and Chief Medical Officer, Joint Commission, Oakbrook Terrace, Illinois)
{"title":"The Next 50 Years","authors":"Elizabeth Mort MD, MPH (is Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety, and Vice President and Chief Medical Officer, Joint Commission, Oakbrook Terrace, Illinois)","doi":"10.1016/j.jcjq.2025.07.001","DOIUrl":"10.1016/j.jcjq.2025.07.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 9","pages":"Page 513"},"PeriodicalIF":2.4,"publicationDate":"2025-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144717868","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 : 2025-07-01DOI: 10.1016/j.jcjq.2025.04.005
Jeannette Tsuei MPhil (is Assistant Policy Researcher, RAND Corporation, Santa Monica, California, and PhD Student, RAND School of Public Policy.), Julia I. Bandini PhD (is Behavioral/Social Scientist, RAND Corporation, Boston.), Angela D. Thomas DrPH, MPH, MBA (is Vice President, Healthcare Delivery Research, MedStar Health Research Institute, Columbia, Maryland.), Kortney Floyd James PhD, RN, PNP (is Associate Policy Researcher, RAND Corporation, Santa Monica, California.), Jason Michel Etchegaray PhD (is Associate Director, Disaster Management & Resilience Program, RAND Homeland Security Research Division, and Senior Behavioral and Social Scientist, RAND Corporation, Santa Monica, California.), Lucy Schulson MD, MPH (is Assistant Professor of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Associate Physician Policy Researcher, RAND Corporation, Boston. Please address correspondence to Jeannette Tsuei)
Research is needed to better understand inequities in patient safety, to develop interventions to improve safety and equity together, and to measure the efficacy of such interventions. Although measures of disparities in health outcomes, health care access, and quality of care are common, patient safety equity measurement remains underdeveloped. For example, disparities have often been documented in chronic diseases or access to preventive care but are less frequently studied for adverse drug events or postoperative complications. Patients of minority backgrounds experience higher rates of preventable harm—Black patients face increased risk of hospital-acquired infections and medication errors compared to white patients, yet most health systems lack specific tools to systematically measure and address these safety disparities. Based on a literature review and expert panel conducted between January 2023 and December 2023, the authors identified health system–level measures of equity in patient safety and present a preliminary maturity framework for health systems working toward equity in patient safety. This review found several tools for measuring health disparities and health equity more broadly, but few are specifically designed to evaluate equity in patient safety events and processes. To address this critical gap, the authors leveraged feedback from a panel of eight subject matter experts to develop a preliminary framework designed to support health systems in assessing their maturity levels and integrating equity in patient safety in a stepwise manner. The framework consists of three maturity levels (fundamental, intermediate, advanced) and six domains: (1) data collection and training, (2) data validation, (3) data stratification and analysis, (4) communicating findings, (5) addressing and resolving equity gaps in patient safety, and (6) organizational infrastructure and culture.
{"title":"A Systems-Based Framework for Integrating Health Equity and Patient Safety","authors":"Jeannette Tsuei MPhil (is Assistant Policy Researcher, RAND Corporation, Santa Monica, California, and PhD Student, RAND School of Public Policy.), Julia I. Bandini PhD (is Behavioral/Social Scientist, RAND Corporation, Boston.), Angela D. Thomas DrPH, MPH, MBA (is Vice President, Healthcare Delivery Research, MedStar Health Research Institute, Columbia, Maryland.), Kortney Floyd James PhD, RN, PNP (is Associate Policy Researcher, RAND Corporation, Santa Monica, California.), Jason Michel Etchegaray PhD (is Associate Director, Disaster Management & Resilience Program, RAND Homeland Security Research Division, and Senior Behavioral and Social Scientist, RAND Corporation, Santa Monica, California.), Lucy Schulson MD, MPH (is Assistant Professor of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Associate Physician Policy Researcher, RAND Corporation, Boston. Please address correspondence to Jeannette Tsuei)","doi":"10.1016/j.jcjq.2025.04.005","DOIUrl":"10.1016/j.jcjq.2025.04.005","url":null,"abstract":"<div><div>Research is needed to better understand inequities in patient safety, to develop interventions to improve safety and equity together, and to measure the efficacy of such interventions. Although measures of disparities in health outcomes, health care access, and quality of care are common, patient safety equity measurement remains underdeveloped. For example, disparities have often been documented in chronic diseases or access to preventive care but are less frequently studied for adverse drug events or postoperative complications. Patients of minority backgrounds experience higher rates of preventable harm—Black patients face increased risk of hospital-acquired infections and medication errors compared to white patients, yet most health systems lack specific tools to systematically measure and address these safety disparities. Based on a literature review and expert panel conducted between January 2023 and December 2023, the authors identified health system–level measures of equity in patient safety and present a preliminary maturity framework for health systems working toward equity in patient safety. This review found several tools for measuring health disparities and health equity more broadly, but few are specifically designed to evaluate equity in patient safety events and processes. To address this critical gap, the authors leveraged feedback from a panel of eight subject matter experts to develop a preliminary framework designed to support health systems in assessing their maturity levels and integrating equity in patient safety in a stepwise manner. The framework consists of three maturity levels (fundamental, intermediate, advanced) and six domains: (1) data collection and training, (2) data validation, (3) data stratification and analysis, (4) communicating findings, (5) addressing and resolving equity gaps in patient safety, and (6) organizational infrastructure and culture.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 498-506"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144284384","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 : 2025-07-01DOI: 10.1016/j.jcjq.2025.04.004
Marina E. Robson Chase MD (is a General Surgery Resident at University of Kentucky HealthCare and Lexington Veterans Affairs (VA) Medical Center.), Madeline J. Anderson DO (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.), Wesley A. Stephens MD (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.), Brittany E. Levy MD, MPH (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.), Sherry Lantz RN, MSN (is the Operating Room Nurse Manager at Lexington VA Medical Center.), Jennifer Goforth RN, MBA (is the Operating Room Assistant Nurse Manager at Lexington VA Medical Center.), Melissa R. Newcomb MD, FACS (is an Associate Professor of General Surgery at University of Kentucky HealthCare and Deputy Chief of Surgery at Lexington VA Medical Center.), Andrew M. Harris MD (is an Associate Professor of Urology at University of Kentucky HealthCare and Chief of Surgery at Lexington VA Medical Center. Please address correspondence to Marina E. Robson Chase)
Background
Surgical delays waste time and space and lead to patient safety concerns, staff and patient dissatisfaction, and increased operating room (OR) costs. Preventing delays is crucial to OR safety and efficiency. A quality improvement (QI) initiative was designed to identify common delay causes and implement targeted interventions to reduce overall case delays and first start case delays.
Methods
At a facility with eight full-time ORs, up to 21.5% of cases were delayed per month. Through a preintervention audit, preoperative paperwork issues were determined to be the most common cause of delays. Examination of the current state revealed irregular processes for preoperative paperwork completion and unreliable communication between the provider and preoperative teams. The paperwork completion process and preoperative communication were standardized. Cases were audited for paperwork issues, and rates of delays were analyzed using data collected from the electronic health record and OR scheduling systems.
Results
This project achieved a 39.2% relative reduction in overall delays and a 25.0% relative reduction in first start delays. The proportion of all cases delayed by paperwork was reduced by 60.1%, and the proportion of first start cases delayed due to paperwork was reduced by 49.6%. The rate of paperwork issues in all cases decreased by 43.3%. The project has matured to sustainability with lasting improvement in delay rates despite increasing surgical case volume.
Conclusion
These interventions substantially decreased total and first start delays, as well as delays due to paperwork issues. Understanding current state, designing appropriate interventions, and securing frontline staff buy-in are critical to achieving a QI goal. Through these principles, simple interventions considerably reduced case delays without added cost.
{"title":"Utilizing Quality Improvement Methodology to Decrease Surgical Delays","authors":"Marina E. Robson Chase MD (is a General Surgery Resident at University of Kentucky HealthCare and Lexington Veterans Affairs (VA) Medical Center.), Madeline J. Anderson DO (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.), Wesley A. Stephens MD (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.), Brittany E. Levy MD, MPH (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.), Sherry Lantz RN, MSN (is the Operating Room Nurse Manager at Lexington VA Medical Center.), Jennifer Goforth RN, MBA (is the Operating Room Assistant Nurse Manager at Lexington VA Medical Center.), Melissa R. Newcomb MD, FACS (is an Associate Professor of General Surgery at University of Kentucky HealthCare and Deputy Chief of Surgery at Lexington VA Medical Center.), Andrew M. Harris MD (is an Associate Professor of Urology at University of Kentucky HealthCare and Chief of Surgery at Lexington VA Medical Center. Please address correspondence to Marina E. Robson Chase)","doi":"10.1016/j.jcjq.2025.04.004","DOIUrl":"10.1016/j.jcjq.2025.04.004","url":null,"abstract":"<div><h3>Background</h3><div>Surgical delays waste time and space and lead to patient safety concerns, staff and patient dissatisfaction, and increased operating room (OR) costs. Preventing delays is crucial to OR safety and efficiency. A quality improvement (QI) initiative was designed to identify common delay causes and implement targeted interventions to reduce overall case delays and first start case delays.</div></div><div><h3>Methods</h3><div>At a facility with eight full-time ORs, up to 21.5% of cases were delayed per month. Through a preintervention audit, preoperative paperwork issues were determined to be the most common cause of delays. Examination of the current state revealed irregular processes for preoperative paperwork completion and unreliable communication between the provider and preoperative teams. The paperwork completion process and preoperative communication were standardized. Cases were audited for paperwork issues, and rates of delays were analyzed using data collected from the electronic health record and OR scheduling systems.</div></div><div><h3>Results</h3><div>This project achieved a 39.2% relative reduction in overall delays and a 25.0% relative reduction in first start delays. The proportion of all cases delayed by paperwork was reduced by 60.1%, and the proportion of first start cases delayed due to paperwork was reduced by 49.6%. The rate of paperwork issues in all cases decreased by 43.3%. The project has matured to sustainability with lasting improvement in delay rates despite increasing surgical case volume.</div></div><div><h3>Conclusion</h3><div>These interventions substantially decreased total and first start delays, as well as delays due to paperwork issues. Understanding current state, designing appropriate interventions, and securing frontline staff buy-in are critical to achieving a QI goal. Through these principles, simple interventions considerably reduced case delays without added cost.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 474-485"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144093702","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 : 2025-07-01DOI: 10.1016/j.jcjq.2025.04.007
Timothy M. Loftus MD, MBA (Assistant Professor of Emergency Medicine, Northwestern University Department of Emergency Medicine, Chicago), Emily G. Wessling Tofovic MD, MBA (Assistant Professor of Emergency Medicine, Northwestern University Department of Emergency Medicine, Chicago. Please address correspondence to Emily G. Wessling Tofovic)
{"title":"Emergency Department Crowding: A Patient Safety Crisis Hidden in Plain Sight","authors":"Timothy M. Loftus MD, MBA (Assistant Professor of Emergency Medicine, Northwestern University Department of Emergency Medicine, Chicago), Emily G. Wessling Tofovic MD, MBA (Assistant Professor of Emergency Medicine, Northwestern University Department of Emergency Medicine, Chicago. Please address correspondence to Emily G. Wessling Tofovic)","doi":"10.1016/j.jcjq.2025.04.007","DOIUrl":"10.1016/j.jcjq.2025.04.007","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 453-455"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144132324","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 : 2025-07-01DOI: 10.1016/j.jcjq.2025.02.007
Briana D Miller MD (is Assistant Professor, Department of Emergency Medicine, School of Medicine, Oregon Health & Science University.), Andrew D Bloom MD (is Assistant Professor, Department of Emergency Medicine, Heersink School of Medicine, University of Alabama at Birmingham.), Helena Kons MD (is Resident Physician, Department of Emergency Medicine, Heersink School of Medicine, University of Alabama at Birmingham.), Marjorie Lee White MD, MA, MPPM (is Professor, Division of Emergency Medicine, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham. Please addrees correspondence to Briana Miller)
Background
In the era of extreme emergency department (ED) boarding, hospital systems are using novel patient care areas to provide ongoing acute care. In any new patient care environment, there is a high risk for latent safety threats (LSTs), which can negatively affect patient outcomes. A series of in situ systems-based simulations were conducted to identify potential LSTs prior to the opening of a novel mobile care unit (MCU) in a tertiary hospital.
Methods
After a needs assessment in conjunction with institutional leadership, a series of in situ interprofessional simulation sessions were developed to represent realistic scenarios in the MCUs. Simulations included low-frequency high-acuity patient care scenarios as well as high-frequency day-to-day encounters. Data were collected in structured systems-based debriefing sessions via trained observers, video recordings, and participant surveys, with a primary outcome of identifying potential LSTs. The LSTs were categorized and then stratified using the Survey Analysis for Evaluating Risk (SAFER) Matrix. One simulation was repeated after mitigation strategies were employed by institutional leadership.
Results
A total of 117 staff participated in five simulation sessions. In the first round of simulations, 37 LSTs were identified, primarily in the categories of Environment/Wayfinding (13/37, 35.1%) and Communication (6/37, 16.2%). LSTs risk stratified using the SAFER Matrix provided prioritized feedback for hospital leadership to guide mitigation strategies prior to the opening of the new units. One LST was initially classified as high likelihood to harm on the SAFER Matrix. The simulated scenario involving this LST was repeated two weeks later with no further high-risk LSTs identified.
Conclusion
In situ simulations can serve as an effective tool to identify potential LSTs prior to the opening of novel patient care spaces.
{"title":"Using In Situ Simulation to Identify Latent Safety Threats Prior to the Opening of Novel Patient Care Spaces in the Emergency Department","authors":"Briana D Miller MD (is Assistant Professor, Department of Emergency Medicine, School of Medicine, Oregon Health & Science University.), Andrew D Bloom MD (is Assistant Professor, Department of Emergency Medicine, Heersink School of Medicine, University of Alabama at Birmingham.), Helena Kons MD (is Resident Physician, Department of Emergency Medicine, Heersink School of Medicine, University of Alabama at Birmingham.), Marjorie Lee White MD, MA, MPPM (is Professor, Division of Emergency Medicine, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham. Please addrees correspondence to Briana Miller)","doi":"10.1016/j.jcjq.2025.02.007","DOIUrl":"10.1016/j.jcjq.2025.02.007","url":null,"abstract":"<div><h3>Background</h3><div>In the era of extreme emergency department (ED) boarding, hospital systems are using novel patient care areas to provide ongoing acute care. In any new patient care environment, there is a high risk for latent safety threats (LSTs), which can negatively affect patient outcomes. A series of in situ systems-based simulations were conducted to identify potential LSTs prior to the opening of a novel mobile care unit (MCU) in a tertiary hospital.</div></div><div><h3>Methods</h3><div>After a needs assessment in conjunction with institutional leadership, a series of in situ interprofessional simulation sessions were developed to represent realistic scenarios in the MCUs. Simulations included low-frequency high-acuity patient care scenarios as well as high-frequency day-to-day encounters. Data were collected in structured systems-based debriefing sessions via trained observers, video recordings, and participant surveys, with a primary outcome of identifying potential LSTs. The LSTs were categorized and then stratified using the <em>Survey Analysis for Evaluating Risk</em> (<em>SAFER</em>) Matrix. One simulation was repeated after mitigation strategies were employed by institutional leadership.</div></div><div><h3>Results</h3><div>A total of 117 staff participated in five simulation sessions. In the first round of simulations, 37 LSTs were identified, primarily in the categories of Environment/Wayfinding (13/37, 35.1%) and Communication (6/37, 16.2%). LSTs risk stratified using the <em>SAFER</em> Matrix provided prioritized feedback for hospital leadership to guide mitigation strategies prior to the opening of the new units. One LST was initially classified as high likelihood to harm on the <em>SAFER</em> Matrix. The simulated scenario involving this LST was repeated two weeks later with no further high-risk LSTs identified.</div></div><div><h3>Conclusion</h3><div>In situ simulations can serve as an effective tool to identify potential LSTs prior to the opening of novel patient care spaces.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 458-465"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780124","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 : 2025-07-01DOI: 10.1016/j.jcjq.2025.04.001
Christopher S. Kim MD, MBA (is Senior Vice President/Chief Quality Officer, Wellstar Health System, Marietta, Georgia.), Kimiyoshi J. Kobayashi MD, MBA (is Chief Quality Officer, UMass Memorial Medical Center, and Associate Professor, Department of Medicine and Population and Quantitative Health Sciences, UMass Chan Medical School.), David M. Safley MD, FACC (is Vice President of Medical Affairs, Quality, Saint Luke’s Health System, University of Missouri–Kansas City.), Bela Patel MD, FCCP, FCCM, ATSF (is Professor of Medicine and Vice Dean of Healthcare Quality, University of Texas Health Science Center and Memorial Hermann Hospital, Houston.), Jennifer Wiler MD, MBA, FACEP (is Professor, Department of Emergency Medicine, University of Colorado School of Medicine.), Mbonu Ikezuagu MD, MHSA, FACP, CPE (is Chief Quality and Safety Officer ThedaCare, Neenah, Wisconsin.), Jodi L. Eisenberg MHA, CPHQ (is Associate Vice President, Member Networks–Quality Executive Network, Vizient Inc., Wauconda, Illinois.), Amy C. Lu MD, MPH (is Professor, Anesthesia and Perioperative Care, University of California, San Francisco (UCSF) School of Medicine, and Chief Quality Officer and Vice President, UCSF Health. Please address correspondence to Jodi L. Eisenberg)
{"title":"Navigating the Pathway to Quality Leadership: Perspectives from Contemporary Quality Executives","authors":"Christopher S. Kim MD, MBA (is Senior Vice President/Chief Quality Officer, Wellstar Health System, Marietta, Georgia.), Kimiyoshi J. Kobayashi MD, MBA (is Chief Quality Officer, UMass Memorial Medical Center, and Associate Professor, Department of Medicine and Population and Quantitative Health Sciences, UMass Chan Medical School.), David M. Safley MD, FACC (is Vice President of Medical Affairs, Quality, Saint Luke’s Health System, University of Missouri–Kansas City.), Bela Patel MD, FCCP, FCCM, ATSF (is Professor of Medicine and Vice Dean of Healthcare Quality, University of Texas Health Science Center and Memorial Hermann Hospital, Houston.), Jennifer Wiler MD, MBA, FACEP (is Professor, Department of Emergency Medicine, University of Colorado School of Medicine.), Mbonu Ikezuagu MD, MHSA, FACP, CPE (is Chief Quality and Safety Officer ThedaCare, Neenah, Wisconsin.), Jodi L. Eisenberg MHA, CPHQ (is Associate Vice President, Member Networks–Quality Executive Network, Vizient Inc., Wauconda, Illinois.), Amy C. Lu MD, MPH (is Professor, Anesthesia and Perioperative Care, University of California, San Francisco (UCSF) School of Medicine, and Chief Quality Officer and Vice President, UCSF Health. Please address correspondence to Jodi L. Eisenberg)","doi":"10.1016/j.jcjq.2025.04.001","DOIUrl":"10.1016/j.jcjq.2025.04.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 507-510"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144019453","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 : 2025-07-01DOI: 10.1016/j.jcjq.2025.02.008
Joshua W. Joseph MD, MS, MBE (is Medical Director, Emergency Management Data Analytics, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, and Associate Professor of Emergency Medicine, Harvard Medical School.), Alice K. Bukhman MD, MPH (is Director of Clinical Operations, Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, and Instructor in Emergency Medicine, Harvard Medical School.), Da’Marcus E. Baymon MD (is Senior Clinical Director, Department of Emergency Medicine, Brigham and Women's Hospital, and Instructor in Emergency Medicine, Harvard Medical School.), Melisa W. Lai-Becker MD (is Deputy Chief, Department of Emergency Medicine, Massachusetts General Hospital, Boston, and Assistant Professor of Emergency Medicine, Harvard Medical School.), Dana D. Im MD, MPhil, MPP (is Assistant Chief Medical Officer, Department of Emergency Medicine, Brigham and Women's Hospital, and Assistant Professor of Emergency Medicine, Harvard Medical School.), Lauren M. Nentwich MD (is Vice Chair for Emergency Affairs, Department of Emergency Medicine, Massachusetts General Hospital, and Assistant Professor of Emergency Medicine, Harvard Medical School.), Paul C. Chen MD, MBA (is Associate Chief Medical Officer and Vice President of Medical Affairs, Department of Emergency Medicine, Brigham and Women's Hospital, and Assistant Professor of Emergency Medicine, Harvard Medical School.), León D. Sánchez MD, MPH (is Chief of Emergency Medicine, Brigham and Women's Faulkner Hospital, and Professor of Emergency Medicine, Harvard Medical School. Please address correspondence to Joshua W. Joseph)
Background
The rate of emergency department (ED) patients who leave without being seen (LWBS) is a commonly reported quality metric that increased across the United States in concert with COVID-19. However, it is unclear what proportion of patients leave despite an acute medical need. The authors sought to estimate the rates at which patients who leave return, including hospitalization, relative to patients who are evaluated and discharged.
Methods
This was a retrospective cohort study examining adult patients presenting between January 1, 2019, and January 1, 2023, across an integrated system including 10 EDs. Demographic variables were compared using independent chi-square tests. Clinical outcomes, including rates of return visits at 72 hours and 30 days (including inpatient admission or ICU admission), and 30-day mortality were compared using multivariate logistic regression.
Results
A total of 1,474,395 visits were included, of which 17,523 (1.2%) were LWBS. Patients in the LWBS group were younger (48.1 years [95% confidence interval (CI) 48.1–48.2] vs. 44.8 years [95% CI 44.6–45.1], p < 0.001), more likely to be of Hispanic ethnicity (177,895 [17.7%] vs. 3,884 [22.2%], p < 0.001), and more likely to require a translator (131,510 [13.1%] vs. 3,184 [18.2%], p < 0.001). Independent of other clinical and demographic variables, LWBS was associated with more frequent returns within 72 hours (adjusted odds ratio [AOR] 2.56, 95% CI 2.50–2.62, p < 0.001), 30-day ICU admission (AOR 1.35, 95% CI 1.27–1.66, p < 0.001), and mortality within 30 days (AOR 2.59, 95% CI 1.90–3.53, p <0.001).
Conclusion
Patients who left without being seen were more likely to return, to require admission, and to die within 30 days than those discharged. High LWBS rates, most pronounced among disadvantaged groups, should be considered as a source of harm to patients.
{"title":"Mortality and Return Visit Frequency Among Emergency Department Patients Who Leave Without Being Seen at a Regional Health Care System","authors":"Joshua W. Joseph MD, MS, MBE (is Medical Director, Emergency Management Data Analytics, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, and Associate Professor of Emergency Medicine, Harvard Medical School.), Alice K. Bukhman MD, MPH (is Director of Clinical Operations, Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, and Instructor in Emergency Medicine, Harvard Medical School.), Da’Marcus E. Baymon MD (is Senior Clinical Director, Department of Emergency Medicine, Brigham and Women's Hospital, and Instructor in Emergency Medicine, Harvard Medical School.), Melisa W. Lai-Becker MD (is Deputy Chief, Department of Emergency Medicine, Massachusetts General Hospital, Boston, and Assistant Professor of Emergency Medicine, Harvard Medical School.), Dana D. Im MD, MPhil, MPP (is Assistant Chief Medical Officer, Department of Emergency Medicine, Brigham and Women's Hospital, and Assistant Professor of Emergency Medicine, Harvard Medical School.), Lauren M. Nentwich MD (is Vice Chair for Emergency Affairs, Department of Emergency Medicine, Massachusetts General Hospital, and Assistant Professor of Emergency Medicine, Harvard Medical School.), Paul C. Chen MD, MBA (is Associate Chief Medical Officer and Vice President of Medical Affairs, Department of Emergency Medicine, Brigham and Women's Hospital, and Assistant Professor of Emergency Medicine, Harvard Medical School.), León D. Sánchez MD, MPH (is Chief of Emergency Medicine, Brigham and Women's Faulkner Hospital, and Professor of Emergency Medicine, Harvard Medical School. Please address correspondence to Joshua W. Joseph)","doi":"10.1016/j.jcjq.2025.02.008","DOIUrl":"10.1016/j.jcjq.2025.02.008","url":null,"abstract":"<div><h3>Background</h3><div>The rate of emergency department (ED) patients who leave without being seen (LWBS) is a commonly reported quality metric that increased across the United States in concert with COVID-19. However, it is unclear what proportion of patients leave despite an acute medical need. The authors sought to estimate the rates at which patients who leave return, including hospitalization, relative to patients who are evaluated and discharged.</div></div><div><h3>Methods</h3><div>This was a retrospective cohort study examining adult patients presenting between January 1, 2019, and January 1, 2023, across an integrated system including 10 EDs. Demographic variables were compared using independent chi-square tests. Clinical outcomes, including rates of return visits at 72 hours and 30 days (including inpatient admission or ICU admission), and 30-day mortality were compared using multivariate logistic regression.</div></div><div><h3>Results</h3><div>A total of 1,474,395 visits were included, of which 17,523 (1.2%) were LWBS. Patients in the LWBS group were younger (48.1 years [95% confidence interval (CI) 48.1–48.2] vs. 44.8 years [95% CI 44.6–45.1], <em>p</em> < 0.001), more likely to be of Hispanic ethnicity (177,895 [17.7%] vs. 3,884 [22.2%], <em>p</em> < 0.001), and more likely to require a translator (131,510 [13.1%] vs. 3,184 [18.2%], <em>p</em> < 0.001). Independent of other clinical and demographic variables, LWBS was associated with more frequent returns within 72 hours (adjusted odds ratio [AOR] 2.56, 95% CI 2.50–2.62, <em>p</em> < 0.001), 30-day ICU admission (AOR 1.35, 95% CI 1.27–1.66, <em>p</em> < 0.001), and mortality within 30 days (AOR 2.59, 95% CI 1.90–3.53, <em>p</em> <0.001).</div></div><div><h3>Conclusion</h3><div>Patients who left without being seen were more likely to return, to require admission, and to die within 30 days than those discharged. High LWBS rates, most pronounced among disadvantaged groups, should be considered as a source of harm to patients.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 466-473"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780102","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 : 2025-07-01DOI: 10.1016/j.jcjq.2025.04.006
Tara P. Sotak RN, BSN, CPN (is Infection Prevention Registered Nurse, University of North Carolina (UNC) Children’s Hospital.), Heidi B. Troxler RN, MSN, CPN (is Children’s Director of Quality, Safety, and Programs, UNC Health.), Amber M. Kirkley RN, BSN, CPN (is Clinical Nurse and Quality Coach, UNC Children’s Hospital.), Benny L. Joyner Jr. MD, MPH (is Professor of Pediatrics and Chief, Pediatric Critical Care Medicine, Department of Pediatrics, UNC School of Medicine, and Pediatric Intensivist, UNC Children’s Hospital.), Michael J. Steiner MD, MPH (is Professor of Pediatrics, UNC School of Medicine, and Pediatrician in Chief, UNC Children’s Hospital.), Lane F. Donnelly MD (is Professor of Radiology and Pediatrics, UNC School of Medicine, and Chief Quality and Safety Officer, UNC Children’s Hospital. Please address correspondence to Lane F. Donnelly)
Background
The aim of this study was to evaluate one institution’s five-year experience with the frequency of multiple central line–associated bloodstream infections (CLABSIs) occurring in the same child and to discuss the importance of previous CLABSI as a risk factor for future CLABSI and the implications for CLABSI rate calculation.
Methods
The infection surveillance system includes data on central line days, CLABSI rate, and CLABSI count, including mucosal barrier injury (MBI) and non-MBI CLABSIs. Using this data, the authors determined the number of children who had more than one inpatient CLABSI during a five-year period. The team then calculated the percentage of total CLABSIs that are represented by patients with more than one CLABSI and the percentage of patients with CLABSI who had multiple CLABSIs.
Results
During the five-year study period, there were 138 CLABSIs in 119 patients. Of the 138 CLABSIs, 36 (26.1%) occurred in children who had more than one CLABSI and 19 (13.8%) of those were repeat. Seventeen patients had more than 1 inpatient CLABSI (15 patients with 2 CLABSIs, and 2 patients with 3 CLABSIs). The CLABSI rate for this period was 1.83 per 1,000 central line days. With exclusion of repeat CLABSIs, the CLABSI rate would be 1.58 per 1,000 central line days, representing a 13.7% difference.
Conclusion
Repeat CLABSI in the same patient is not uncommon and can contribute significantly to overall inpatient CLABSI rates. Prior CLABSI should be considered a risk factor for future CLABSI.
{"title":"The Frequency of Multiple Central Line–Associated Bloodstream Infections (CLABSIs) Occurring in the Same Child: A Five-Year Experience","authors":"Tara P. Sotak RN, BSN, CPN (is Infection Prevention Registered Nurse, University of North Carolina (UNC) Children’s Hospital.), Heidi B. Troxler RN, MSN, CPN (is Children’s Director of Quality, Safety, and Programs, UNC Health.), Amber M. Kirkley RN, BSN, CPN (is Clinical Nurse and Quality Coach, UNC Children’s Hospital.), Benny L. Joyner Jr. MD, MPH (is Professor of Pediatrics and Chief, Pediatric Critical Care Medicine, Department of Pediatrics, UNC School of Medicine, and Pediatric Intensivist, UNC Children’s Hospital.), Michael J. Steiner MD, MPH (is Professor of Pediatrics, UNC School of Medicine, and Pediatrician in Chief, UNC Children’s Hospital.), Lane F. Donnelly MD (is Professor of Radiology and Pediatrics, UNC School of Medicine, and Chief Quality and Safety Officer, UNC Children’s Hospital. Please address correspondence to Lane F. Donnelly)","doi":"10.1016/j.jcjq.2025.04.006","DOIUrl":"10.1016/j.jcjq.2025.04.006","url":null,"abstract":"<div><h3>Background</h3><div>The aim of this study was to evaluate one institution’s five-year experience with the frequency of multiple central line–associated bloodstream infections (CLABSIs) occurring in the same child and to discuss the importance of previous CLABSI as a risk factor for future CLABSI and the implications for CLABSI rate calculation.</div></div><div><h3>Methods</h3><div>The infection surveillance system includes data on central line days, CLABSI rate, and CLABSI count, including mucosal barrier injury (MBI) and non-MBI CLABSIs. Using this data, the authors determined the number of children who had more than one inpatient CLABSI during a five-year period. The team then calculated the percentage of total CLABSIs that are represented by patients with more than one CLABSI and the percentage of patients with CLABSI who had multiple CLABSIs.</div></div><div><h3>Results</h3><div>During the five-year study period, there were 138 CLABSIs in 119 patients. Of the 138 CLABSIs, 36 (26.1%) occurred in children who had more than one CLABSI and 19 (13.8%) of those were repeat. Seventeen patients had more than 1 inpatient CLABSI (15 patients with 2 CLABSIs, and 2 patients with 3 CLABSIs). The CLABSI rate for this period was 1.83 per 1,000 central line days. With exclusion of repeat CLABSIs, the CLABSI rate would be 1.58 per 1,000 central line days, representing a 13.7% difference.</div></div><div><h3>Conclusion</h3><div>Repeat CLABSI in the same patient is not uncommon and can contribute significantly to overall inpatient CLABSI rates. Prior CLABSI should be considered a risk factor for future CLABSI.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 493-497"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144181843","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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