Joint Commission journal on quality and patient safety最新文献

Voluntary event reporting (VER) systems underestimate the incidence of safety events and often capture only serious events. A limited amount of data is collected through these systems, and they may be inadequate to characterize disparities in reported safety events. We conducted a scoping review of the literature to summarize the state of the evidence as it relates to differences in safety events and safety event reporting by age, gender, and race. Using a broad-based query, a systematic search for published, peer-reviewed literature that discusses patient safety event reporting and differences by age, gender, race, and socioeconomic status was conducted. Based on modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 283 studies underwent title and abstract review, yielding 56 studies for full text review. After full text review, 23 studies were carefully reviewed individually, grouped thematically, and summarized to highlight the most pertinent findings. The studies reviewed yielded important insights, particularly with regard to race, gender, and the ways events are identified. Patients from minoritized groups may be less likely to have events reported and more likely to suffer serious events. Some studies found differences in rates of reporting safety events for female vs. male providers. The rate of VER is consistently lower than the rate of events identified through identified using automated detection. The current literature describing VER data shows disparities by race, language, age, and gender for patients and providers. Further research and systematic change are needed to specifically study these disparities to guide health care institutions on ways to mitigate bias and deliver more equitable care.

Background

Disasters exacerbate health inequities, with historically marginalized populations experiencing unjust differences in health care access and outcomes. Health systems plan and respond to disasters using the Hospital Incident Command System (HICS), an organizational structure that centralizes communication and decision-making. The HICS does not have an equity role or considerations built into its standard structure. The authors conducted a narrative review to identify and summarize approaches to embedding equity into the HICS.

Methods

The peer-reviewed (PubMed, SCOPUS) and gray literature was searched for articles from high-income countries that referenced the HICS or Incident Command System (ICS) and equity, disparities, or populations that experience inequities in disasters. The primary focus of the search strategy was health care, but the research also included governmental and public health system articles. Two authors used inductive thematic analysis to assess commonalities and refined the themes based on feedback from all authors.

Results

The database search identified 479 unique abstracts; 76 articles underwent full-text review, and 11 were included in the final analysis. The authors found 5 articles through cited reference searching and 13 from the gray literature search, which included websites, organizations, and non-indexed journal articles. Three themes from the articles were identified: including equity specialists in the HICS, modifying systems to promote equity, and sensitivity to the local community.

Conclusion

Several efforts to embed equity into the HICS and disaster preparedness and response were discovered. This review provides practical strategies health system leaders can include in their HICS and emergency preparedness plans to promote equity in their disaster response.

Background

The collection of health-related social needs (HRSN) data at one large health system has historically been inconsistent. This project was aimed to increase annual HRSN screening rates by standardizing data collection in the electronic health record (EHR) through optimized clinical workflows.

Methods

The authors designed a standard screening questionnaire in alignment with the Accountable Health Communities model, and they conducted interviews with eleven US-based health systems and one medical center on best practices for ambulatory HRSN screening and interventions, which identified five possible methods to administer the questionnaire. After testing, the authors opted to send questionnaires to patients through the patient portal three days prior to an ambulatory visit. For inpatients, in-person interviews were implemented. Staff implementing the updated processes included registered nurses, social workers, preventive health coordinators, and community health workers.

Results

The annual screening rate for all active ambulatory patients increased from 0.4% to 15.9% (p < 0.001), and 10.7% of all patients had at least one health-related social need. The annual screening rate for inpatients was estimated to be zero at baseline and increased by 66 percentage points (p < 0.001). The most prevalent health-related social need in both settings was financial resource strain, followed closely by food insecurity.

Conclusion

Well-designed interventions and technology support were effective in achieving improved screening and data collection. Leadership support, building interventions within preexisting workflows, and ensuring standard data capture in the EHR were key factors leading to successful process improvement.

Background

Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports.

Methods

The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated.

Results

Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as “other” accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01–1.54).

Conclusion

Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

Performance improvement methodologies do not currently include any structures that encourage analysis of how bias, inequity, or social determinants of health (SDOH) contribute to outcomes. The Montefiore Center for Performance Improvement developed a novel quality improvement (QI) toolkit that ingrains issues of diversity, equity, and inclusion (DEI) and SDOH into the Institute for Healthcare Improvement's tools. The toolkit prompts QI teams to evaluate DEI and SDOH at each step of the journey, including an updated charter and stratified baseline tool, a new fishbone diagram for the discovery phase with a tail to include DEI and SDOH, and additions in the Study and Act sessions of the Plan-Do-Study-Act worksheet to address these issues. After development and dissemination of this toolkit, the authors conducted a pre-post analysis of projects conducted by QI fellows in their institution. Prior to introducing the new toolkit, 22.9% of projects from 2016 to 2021 incorporated DEI/SDOH into any stage of the QI process. After implementing the amended tools, this increased to 88.9% in the 2022 fellowship. These results show that this simple approach can hardwire consideration of DEI and SDOH into improvement projects.

Background

The telementoring Project ECHO (Extension for Community Healthcare Outcomes) model has been shown to improve disease management in diabetes in many underserved communities. The authors aim to evaluate if ECHO could also be an effective tool for quality improvement (QI) of diabetes care in these communities.

Methods

Thirteen clinics in underserved communities in California and Florida participating in Project ECHO Diabetes were recruited for a 12-month QI program. The program provided weekly tele-education sessions, including a didactic presentation and case-based discussion. In addition, clinics chose their own set of quality measures to improve and met remotely to discuss their efforts, successes, and setbacks every quarter with mentorship from QI experts.

Results

Of the 31 QI initiatives attempted by different clinics, all had either made improvements (25 initiatives, 80.6%) or were in the process of making improvements (6 initiatives, 19.4%) in structural, process, and outcome measures. Examples of these measures include whether clinics have protocols to identify high-risk patients (structure), numbers of continuous glucose monitor prescriptions submitted by the clinics (process), and percentage of patients with diabetes whose most recent HbA1c are > 9% (outcome). For one measure, 40.0% of the clinics had achieved a higher percentage of cumulative HbA1c measurement in the third quarter of the year, compared to the fourth quarter in the previous year. The cost of QI implementation varied widely due to different number of personnel involved across sites.

Conclusion

A QI program delivered via Project ECHO Diabetes can facilitate quality improvements in underserved communities.

Background

People with disabilities experience barriers to engaging with health care due to inaccessible social and physical environments at primary care clinics. Despite legal mandates, identification and provision of necessary accommodations for this population at primary care clinics are poor. The objective of this cross-sectional study was to assess patient-reported disability status and accommodation needs among patients at a primary care clinic.

Methods

An electronic health record–based Disability and Accommodations Questionnaire assessing disability status, types, and accommodation needs was developed by subject matter experts at Michigan Medicine and the University of Michigan Council for Disability Concerns. The questionnaire underwent multiple rounds of reviews and revisions before its use in clinical settings. A paper-based questionnaire was administered to all patients presenting for a wellness-based visit at an academic health system primary care clinic in southeast Michigan. Data were collected between March 2022 and August 2022.

Results

Approximately 13% of the 541 patients self-reported a disability, with 54.2% indicating at least one needed accommodation. The most commonly reported disabilities were mental health and hearing-related disabilities, by 4.8% and 4.6% of patients, respectively. The most frequently requested accommodations were communication- or language-based (for example, presence of an American Sign Language interpreter, assistive listening devices), cognitive-based (for example, inclusion of a support person with care decisions), and mobility-based (for example, assistance with transfers).

Conclusion

The Disability and Accommodations Questionnaire helped identify the presence of a disability, its types, and any requested accommodations requested at a primary care health center.

Background

The transfer of information at the change of shift is a critical point for patient experience during the care process. The aim of this study was to evaluate caregivers’ perceptions before and after the implementation of a multidisciplinary bedside handoff in a pediatric emergency department (PED).

Methods

This was a quality improvement pre-post intervention, single-center study. The authors included caregivers of patients allocated in the observation unit of a PED during health care provider shift change. The study was made up of the following phases: (1) preintervention survey distribution, (2) implementation of the bedside handoff, involving all health care professionals (including nurses, nursing assistants, and pediatricians) and caregivers, and (3) postintervention survey distribution. The survey explored the three dimensions of patient experience defined as main study outcomes: information received and communication with professionals, participation, and continuity of care.

Results

A total of 102 surveys were collected (51 each in the preintervention and postintervention phases). In the preintervention phase, 94.1% of caregivers would have wished to be actively involved in the change of shift. In the postintervention phase, more caregivers felt that professionals had proper introductions (49.0% vs. 84.3%; p < 0.01), had kept them informed of the plan to be followed (58.8% vs. 84.3%; p = 0.02), and encouraged questions (45.1% vs. 82.4%; p < 0.01). Caregivers of the postintervention phase perceived less disorganization during the change of shift (25.5% vs. 5.9%; p = 0.01) and a greater sense of continuity (64.7% vs. 86.3%; p = 0.02).

Conclusion

The bedside handoff is a useful strategy to improve patient and family perceptions of communication with professionals, information received, and continuity of care at health care providers shift change. Future lines of research and improvement include ensuring equity in participation in the bedside handoff for all caregivers, monitoring the handoffs to determine how often patients/caregivers participate and correct mistakes in information transfer. and exploring professionals’ perceptions.