Pub Date : 2023-12-08DOI: 10.1016/j.jcjq.2023.12.001
Amy K. Rosen PhD (is Senior Research Career Scientist, Center for Healthcare Organization and Implementation Research (CHOIR), US Department of Veterans Affairs (VA) Boston Healthcare System, and Professor, Department of Surgery, Chobian & Avedisian School of Medicine, Boston University.), Erin Beilstein-Wedel MA (is Data Analyst, CHOIR, VA Boston Healthcare System.), Jeffrey Chan BS (is Senior Project Manager, CHOIR, VA Boston Healthcare System.), Ann Borzecki MD, MPH (is Research Investigator, CHOIR, VA Bedford Healthcare System, Bedford, Massachusetts, and Research Associate Professor, Section of Internal Medicine, Chobian & Avedisian School of Medicine, Boston University.), Edward J. Miech EdD (is Research Investigator, VA Center for Health Information and Communication, VA EXTEND [Expanding Expertise Through E-health Network Development] QUERI [Quality Enhancement Research Initiative], VA Indiana Healthcare System, Indianapolis.), David C. Mohr PhD (is Research Associate Professor, Department of Health Law, Policy & Management, School of Public Health, Boston University.), Edward E. Yackel DNP (is Executive Director, Veterans Health Administration (VHA) National Center for Patient Safety, Ann Arbor, Michigan.), Julianne Flynn MD (formerly Acting Deputy Assistant Under Secretary for Health, VHA Office of Integrated Veteran Care, Washington, DC, is Executive Director, South Texas Veterans Health Care System, San Antonio, Texas.), Michael Shwartz PhD (is Research Investigator, CHOIR, VA Boston Healthcare System. Please address correspondence to Amy K. Rosen)
Background
Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation.
Methods
In this retrospective study using patient safety event data from VHA's event reporting system (2020–2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant.
Results
A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively).
Conclusion
Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.
背景:退伍军人越来越多地使用社区护理(CC),这给退伍军人健康管理局(VHA)和社区护理中心提供综合护理带来了新的挑战。退伍军人医疗管理局广受认可的患者安全计划在社区护理人员的采纳和实施方面尤其具有挑战性。为了规范退伍军人健康管理局在两种环境中的安全实践,VHA 于 2018 年实施了《患者安全指南手册》。作者比较了《指南》实施后 VHA 和 CC 安全事件报告的国家级和设施级趋势:在这项回顾性研究中,研究小组使用了来自 VHA 事件报告系统(2020-2022 年)的患者安全事件数据,使用线性回归模型研究了 VHA 和 CC 的患者安全事件、不良事件、险情(险情)和恢复率(险情与不良事件加险情的比率)的趋势,以确定 VHA 和 CC 安全事件在国家和机构层面每季度的平均变化是否显著:结果:VHA 和 CC 共报告了 499,332 起安全事件。尽管 VHA 患者安全事件的趋势并不显著(p > 0.05),但不良事件呈显著的负趋势(p = 0.02),千钧一发(p = 0.003)和康复率(p = 0.004)呈正趋势。在 CC,患者安全事件和不良事件呈显著的负趋势(p = 0.02),康复率呈显著的正趋势(p = 0.03)。与CC设施相比,VHA设施的差异较小,且有明显下降(例如,VHA和CC的四分位数间范围分别为0.03和0.05):结论:随着时间的推移,不同安全事件的波动可能是由于 COVID-19 引起的护理中断以及组织因素造成的。值得注意的是,恢复率的增加反映出工作人员对有害事件的关注减少,而对险情(可预防事件)的关注增加。虽然从 VHA 到 CC 采用安全实践是可行的,但还需要更多的实施策略来维持不同环境下的标准化安全报告。
{"title":"Standardizing Patient Safety Event Reporting between Care Delivered or Purchased by the Veterans Health Administration (VHA)","authors":"Amy K. Rosen PhD (is Senior Research Career Scientist, Center for Healthcare Organization and Implementation Research (CHOIR), US Department of Veterans Affairs (VA) Boston Healthcare System, and Professor, Department of Surgery, Chobian & Avedisian School of Medicine, Boston University.), Erin Beilstein-Wedel MA (is Data Analyst, CHOIR, VA Boston Healthcare System.), Jeffrey Chan BS (is Senior Project Manager, CHOIR, VA Boston Healthcare System.), Ann Borzecki MD, MPH (is Research Investigator, CHOIR, VA Bedford Healthcare System, Bedford, Massachusetts, and Research Associate Professor, Section of Internal Medicine, Chobian & Avedisian School of Medicine, Boston University.), Edward J. Miech EdD (is Research Investigator, VA Center for Health Information and Communication, VA EXTEND [Expanding Expertise Through E-health Network Development] QUERI [Quality Enhancement Research Initiative], VA Indiana Healthcare System, Indianapolis.), David C. Mohr PhD (is Research Associate Professor, Department of Health Law, Policy & Management, School of Public Health, Boston University.), Edward E. Yackel DNP (is Executive Director, Veterans Health Administration (VHA) National Center for Patient Safety, Ann Arbor, Michigan.), Julianne Flynn MD (formerly Acting Deputy Assistant Under Secretary for Health, VHA Office of Integrated Veteran Care, Washington, DC, is Executive Director, South Texas Veterans Health Care System, San Antonio, Texas.), Michael Shwartz PhD (is Research Investigator, CHOIR, VA Boston Healthcare System. Please address correspondence to Amy K. Rosen)","doi":"10.1016/j.jcjq.2023.12.001","DOIUrl":"10.1016/j.jcjq.2023.12.001","url":null,"abstract":"<div><h3>Background</h3><p><span>Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the </span><em>Patient Safety Guidebook</em> in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation.</p></div><div><h3>Methods</h3><p><span><span>In this retrospective study using patient safety event data from VHA's event reporting system (2020–2022), the research team examined trends </span>in patient<span> safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using </span></span>linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant.</p></div><div><h3>Results</h3><p>A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (<em>p</em> > 0.05), there was a significant negative trend for adverse events (<em>p</em> = 0.02) and positive trends for close calls (<em>p</em> = 0.003) and recovery rates (<em>p</em> = 0.004). In CC there were significant negative trends for patient safety events and adverse events (<em>p</em> = 0.02) and a significant positive trend for recovery rates (<em>p</em> = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively).</p></div><div><h3>Conclusion</h3><p>Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-12-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139477273","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 : 2023-12-06DOI: 10.1016/j.jcjq.2023.11.006
Susan E. Hickman PhD (is Professor, School of Nursing, Indiana University, and Director, Center for Aging Research, Regenstrief Institute, Indianapolis.), Erik K. Fromme MD (is Physician, Outpatient Palliative Care Clinic, Dana-Farber Cancer Institute, Boston, and Director, Serious Illness Care Program, Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston. Please address correspondence to Susan E. Hickman)
{"title":"Realizing the Promise of Advance Care Planning Will Require Health System Accountability to Quality Standards","authors":"Susan E. Hickman PhD (is Professor, School of Nursing, Indiana University, and Director, Center for Aging Research, Regenstrief Institute, Indianapolis.), Erik K. Fromme MD (is Physician, Outpatient Palliative Care Clinic, Dana-Farber Cancer Institute, Boston, and Director, Serious Illness Care Program, Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston. Please address correspondence to Susan E. Hickman)","doi":"10.1016/j.jcjq.2023.11.006","DOIUrl":"10.1016/j.jcjq.2023.11.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725023002891/pdfft?md5=99cb7a78865135a848ef15b65399ec1a&pid=1-s2.0-S1553725023002891-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139086888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-26DOI: 10.1016/j.jcjq.2023.11.005
Joanne DeSanto Iennaco PhD, APRN, PMHNP-BC, FAAN (is Professor and Director, Clinical DNP Program, Yale University School of Nursing.), Elizabeth Molle PhD, RN (is Nurse Scientist, Middlesex Health, Middletown, Connecticut, and Lecturer, Yale University School of Nursing.), Mary Allegra DNP, RN, NPD-BC, NEA-BC (is Director of Nursing Professional Practice, Research, Magnet Designation, and Pregnancy and Birth Center, Middlesex Health, and Lecturer, Yale University School of Nursing.), David Depukat PhD, RN, PMH-BC (is Director, Accreditation and Regulatory Affairs, Yale New Haven Health System.), Janet Parkosewich DNSc, RN, FAHA (is Nurse Researcher, Yale New Haven Hospital. Please address correspondence to Joanne DeSanto Iennaco)
Background
Rates of aggressive events and workplace violence (WPV) exposure are often represented by proxy measures (restraint, incident, injury reports) in health care settings. Precise measurement of nurse and patient care assistant exposure rates to patient aggression on inpatient medical units in acute care hospitals advances knowledge, promoting WPV prevention and intervention.
Methods
This prospective, multisite cohort study examined the incidence of patient and visitor aggressive events toward patient care staff on five inpatient medical units in a community hospital and an academic hospital setting in the northeastern United States. Data were collected with event counters, Aggressive Incident and Management Logs (AIM-Logs), and demographic forms over a 14-day period in early 2017.
Results
Participants recorded a total of 179 aggressive events using event counters, resulting in a rate of 2.54 aggressive events per 20 patient-days. Patient verbal aggression rates (2.00 events per 20 patient-days) were higher compared to physical aggression rates (0.85 events per 20 patient-days). The staff aggression exposure rate was 1.17 events per 40 hours worked (verbal aggression exposure rate: 0.92 events per 40 hours; physical aggression exposure rate: 0.39 events per 40 hours). The most common precipitants included medication administration (18.6%), waiting for care (17.2%), and delivering food/drinks (15.9%). Most events were managed with verbal de-escalation (75.2%). The number of patients assigned to patient care staff was significantly greater during a shift when an aggressive event occurred compared to when no event occurred (6.3 vs. 5.7, t = -2.12, df = 201.6, p = 0.0348).
Conclusion
Event counters and AIM-Logs offer greater information about patterns of aggression and preventive interventions used and provide information on the need for debriefing and worker support after aggressive events. Additional studies of this methodology in other settings are needed to evaluate the value of this technology for improving worker and patient safety.
{"title":"The Aggressive Incidents in Medical Settings (AIMS) Study: Advancing Measurement to Promote Prevention of Workplace Violence","authors":"Joanne DeSanto Iennaco PhD, APRN, PMHNP-BC, FAAN (is Professor and Director, Clinical DNP Program, Yale University School of Nursing.), Elizabeth Molle PhD, RN (is Nurse Scientist, Middlesex Health, Middletown, Connecticut, and Lecturer, Yale University School of Nursing.), Mary Allegra DNP, RN, NPD-BC, NEA-BC (is Director of Nursing Professional Practice, Research, Magnet Designation, and Pregnancy and Birth Center, Middlesex Health, and Lecturer, Yale University School of Nursing.), David Depukat PhD, RN, PMH-BC (is Director, Accreditation and Regulatory Affairs, Yale New Haven Health System.), Janet Parkosewich DNSc, RN, FAHA (is Nurse Researcher, Yale New Haven Hospital. Please address correspondence to Joanne DeSanto Iennaco)","doi":"10.1016/j.jcjq.2023.11.005","DOIUrl":"10.1016/j.jcjq.2023.11.005","url":null,"abstract":"<div><h3>Background</h3><p>Rates of aggressive events and workplace violence (WPV) exposure are often represented by proxy measures (restraint, incident, injury reports) in health care settings. Precise measurement of nurse and patient care assistant exposure rates to patient aggression on inpatient medical units in acute care hospitals advances knowledge, promoting WPV prevention and intervention.</p></div><div><h3>Methods</h3><p>This prospective, multisite cohort study examined the incidence of patient and visitor aggressive events toward patient care staff on five inpatient medical units in a community hospital and an academic hospital setting in the northeastern United States. Data were collected with event counters, Aggressive Incident and Management Logs (AIM-Logs), and demographic forms over a 14-day period in early 2017.</p></div><div><h3>Results</h3><p>Participants recorded a total of 179 aggressive events using event counters, resulting in a rate of 2.54 aggressive events per 20 patient-days. Patient verbal aggression rates (2.00 events per 20 patient-days) were higher compared to physical aggression rates (0.85 events per 20 patient-days). The staff aggression exposure rate was 1.17 events per 40 hours worked (verbal aggression exposure rate: 0.92 events per 40 hours; physical aggression exposure rate: 0.39 events per 40 hours). The most common precipitants included medication administration (18.6%), waiting for care (17.2%), and delivering food/drinks (15.9%). Most events were managed with verbal de-escalation (75.2%). The number of patients assigned to patient care staff was significantly greater during a shift when an aggressive event occurred compared to when no event occurred (6.3 vs. 5.7, <em>t</em> = -2.12, df = 201.6, <em>p</em> = 0.0348).</p></div><div><h3>Conclusion</h3><p>Event counters and AIM-Logs offer greater information about patterns of aggression and preventive interventions used and provide information on the need for debriefing and worker support after aggressive events. Additional studies of this methodology in other settings are needed to evaluate the value of this technology for improving worker and patient safety.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S155372502300288X/pdfft?md5=bd2d06b0d639d94006ee06f22ecc0a98&pid=1-s2.0-S155372502300288X-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139074128","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-23DOI: 10.1016/j.jcjq.2023.11.004
Brooke Hassan BA, Marc-Mina Tawfik BS;, Elliot Schiff BA (and), Roxanna Mosavian BA (are Medical Students, Albert Einstein College of Medicine, Bronx, New York.), Zachary Kelly MD (formerly Resident, Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, is Pediatric Otolaryngology Fellow, Boston Children's Hospital.), Daniel Li MD (formerly Resident, Albert Einstein College of Medicine, is Hospital Resident, Division of Otolaryngology, Yale School of Medicine.), Alexander Petti MD (formerly Critical Care Fellow, Albert Einstein College of Medicine, is Intensivist and Emergency Medicine Physician, Salem Hospital, Salem Massachusetts.), Maneesha Bangar MD (is Assistant Professor, Department of Medicine, and Director, Simulation for Education and Patient Safety in Critical Care, Albert Einstein College of Medicine, Montefiore Medical Center.), Bradley A. Schiff MD (is a Professor, Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, Montefiore Medical Center.), Christina J. Yang MD, MS (is Associate Professor, Department of Otorhinolaryngology–Head and Neck Surgery and Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center. Please address correspondence to Christina J. Yang)
Background
Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. In situ simulation has been used as a quality improvement tool to audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care.
Methods
From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes.
Results
Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36–64) among participants.
Conclusion
An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.
{"title":"Harnessing In Situ Simulation to Identify Human Errors and Latent Safety Threats in Adult Tracheostomy Care","authors":"Brooke Hassan BA, Marc-Mina Tawfik BS;, Elliot Schiff BA (and), Roxanna Mosavian BA (are Medical Students, Albert Einstein College of Medicine, Bronx, New York.), Zachary Kelly MD (formerly Resident, Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, is Pediatric Otolaryngology Fellow, Boston Children's Hospital.), Daniel Li MD (formerly Resident, Albert Einstein College of Medicine, is Hospital Resident, Division of Otolaryngology, Yale School of Medicine.), Alexander Petti MD (formerly Critical Care Fellow, Albert Einstein College of Medicine, is Intensivist and Emergency Medicine Physician, Salem Hospital, Salem Massachusetts.), Maneesha Bangar MD (is Assistant Professor, Department of Medicine, and Director, Simulation for Education and Patient Safety in Critical Care, Albert Einstein College of Medicine, Montefiore Medical Center.), Bradley A. Schiff MD (is a Professor, Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, Montefiore Medical Center.), Christina J. Yang MD, MS (is Associate Professor, Department of Otorhinolaryngology–Head and Neck Surgery and Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center. Please address correspondence to Christina J. Yang)","doi":"10.1016/j.jcjq.2023.11.004","DOIUrl":"10.1016/j.jcjq.2023.11.004","url":null,"abstract":"<div><h3>Background</h3><p><span><span>Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. </span>In situ simulation<span> has been used as a quality improvement tool to </span></span>audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care.</p></div><div><h3>Methods</h3><p>From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes.</p></div><div><h3>Results</h3><p>Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36–64) among participants.</p></div><div><h3>Conclusion</h3><p>An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-11-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139086887","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 : 2023-11-08DOI: 10.1016/j.jcjq.2023.11.002
Caleb J. Murphy MD, MBA (is Clinical Associate, Section of Hospital Medicine, University of Chicago.), Justin S. Bauzon MD (is General Surgery Resident, Cleveland Clinic Foundation, Cleveland, Ohio.), Wilson Chan MD (formerly Chief Internal Medicine Resident, Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, is Internist, MedStar Health, Leonardtown, Maryland.), Vishvaas Ravikumar MD (is Internal Medicine Resident, Oregon Health and Science University, Portland, Oregon.), Sandhya Wahi-Gururaj MD, MPH (is a general internist and Professor of Medicine, Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas. Please address correspondence to Caleb J. Murphy)
{"title":"Evaluation of Objective Appropriateness Criteria for Daily Labs in General Medicine Inpatients","authors":"Caleb J. Murphy MD, MBA (is Clinical Associate, Section of Hospital Medicine, University of Chicago.), Justin S. Bauzon MD (is General Surgery Resident, Cleveland Clinic Foundation, Cleveland, Ohio.), Wilson Chan MD (formerly Chief Internal Medicine Resident, Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, is Internist, MedStar Health, Leonardtown, Maryland.), Vishvaas Ravikumar MD (is Internal Medicine Resident, Oregon Health and Science University, Portland, Oregon.), Sandhya Wahi-Gururaj MD, MPH (is a general internist and Professor of Medicine, Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas. Please address correspondence to Caleb J. Murphy)","doi":"10.1016/j.jcjq.2023.11.002","DOIUrl":"10.1016/j.jcjq.2023.11.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135515480","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 : 2023-11-04DOI: 10.1016/j.jcjq.2023.10.017
Masha Kuznetsova PhD, MPH (formerly PhD Candidate in Health Policy (Management), Harvard Business School, is Senior Manager, Clinical Operations, Devoted Health. Harvard 1), Alice Y. Kim MS, RD (is a research assistant in the Division of General Medicine and Primary Care at Brigham and Women's Hospital.), Darren A. Scully BSN, RN (is Registered Nurse, Brigham and Women's Faulkner Hospital, Boston.), Paula Wolski MSN, RN-BC (is Program Director, Informatics, Brigham and Women's Faulkner Hospital.), Ania Syrowatka PhD (is Lead Investigator, Division of General Internal Medicine, Brigham and Women's Hospital, and Faculty Member, Harvard Medical School.), David W. Bates MD, MSc (is Chief, Division of General Internal Medicine, Brigham and Women's Hospital, and Professor, Harvard Medical School.), Patricia C. Dykes PhD, MA, RN (is Program Director, Research, Center for Patient Safety Research and Practice, Brigham and Women's Hospital, and Associate Professor, Harvard Medical School. Please address correspondence to Alice Y. Kim)
Background
Technology can improve care delivery, patient outcomes, and staff satisfaction, but integration into the clinical workflow remains challenging. To contribute to this knowledge area, this study examined the implementation continuum of a contact-free, continuous monitoring system (CFCM) in an inpatient setting. CFCM monitors vital signs and uses the information to alert clinicians of important changes, enabling early detection of patient deterioration.
Methods
Data were collected throughout the entire implementation continuum at a community teaching hospital. Throughout the study, 3 group and 24 individual interviews and five process observations were conducted. Postimplementation alarm response data were collected. Analysis was conducted using triangulation of information sources and two-coder consensus.
Results
Preimplementation perceived barriers were alarm fatigue, questions about accuracy and trust, impact on patient experience, and challenges to the status quo. Stakeholders identified the value of CFCM as preventing deterioration and benefitting patients who are not good candidates for telemetry. Educational materials addressed each barrier and emphasized the shared CFCM values. Mean alarm response times were below the desired target of two minutes. Postimplementation interview analysis themes revealed lessened concerns of alarm fatigue and improved trust in CFCM than anticipated. Postimplementation challenges included insufficient training for secondary users and impact on patient experience.
Conclusion
In addition to understanding the preimplementation anticipated barriers to implementation and establishing shared value before implementation, future recommendations include studying strategies for optimal tailoring of education to each user group, identifying and reinforcing positive process changes after implementation, and including patient experience as the overarching element in frameworks for digital tool implementation.
{"title":"Implementation of a Continuous Patient Monitoring System in the Hospital Setting: A Qualitative Study","authors":"Masha Kuznetsova PhD, MPH (formerly PhD Candidate in Health Policy (Management), Harvard Business School, is Senior Manager, Clinical Operations, Devoted Health. Harvard 1), Alice Y. Kim MS, RD (is a research assistant in the Division of General Medicine and Primary Care at Brigham and Women's Hospital.), Darren A. Scully BSN, RN (is Registered Nurse, Brigham and Women's Faulkner Hospital, Boston.), Paula Wolski MSN, RN-BC (is Program Director, Informatics, Brigham and Women's Faulkner Hospital.), Ania Syrowatka PhD (is Lead Investigator, Division of General Internal Medicine, Brigham and Women's Hospital, and Faculty Member, Harvard Medical School.), David W. Bates MD, MSc (is Chief, Division of General Internal Medicine, Brigham and Women's Hospital, and Professor, Harvard Medical School.), Patricia C. Dykes PhD, MA, RN (is Program Director, Research, Center for Patient Safety Research and Practice, Brigham and Women's Hospital, and Associate Professor, Harvard Medical School. Please address correspondence to Alice Y. Kim)","doi":"10.1016/j.jcjq.2023.10.017","DOIUrl":"10.1016/j.jcjq.2023.10.017","url":null,"abstract":"<div><h3>Background</h3><p>Technology can improve care delivery, patient outcomes, and staff satisfaction, but integration into the clinical workflow remains challenging. To contribute to this knowledge area, this study examined the implementation continuum of a contact-free, continuous monitoring system (CFCM) in an inpatient setting. CFCM monitors vital signs and uses the information to alert clinicians of important changes, enabling early detection of patient deterioration.</p></div><div><h3>Methods</h3><p>Data were collected throughout the entire implementation continuum at a community teaching hospital. Throughout the study, 3 group and 24 individual interviews and five process observations were conducted. Postimplementation alarm response data were collected. Analysis was conducted using triangulation of information sources and two-coder consensus.</p></div><div><h3>Results</h3><p>Preimplementation perceived barriers were alarm fatigue, questions about accuracy and trust, impact on patient experience, and challenges to the status quo. Stakeholders identified the value of CFCM as preventing deterioration and benefitting patients who are not good candidates for telemetry. Educational materials addressed each barrier and emphasized the shared CFCM values. Mean alarm response times were below the desired target of two minutes. Postimplementation interview analysis themes revealed lessened concerns of alarm fatigue and improved trust in CFCM than anticipated. Postimplementation challenges included insufficient training for secondary users and impact on patient experience.</p></div><div><h3>Conclusion</h3><p>In addition to understanding the preimplementation anticipated barriers to implementation and establishing shared value before implementation, future recommendations include studying strategies for optimal tailoring of education to each user group, identifying and reinforcing positive process changes after implementation, and including patient experience as the overarching element in frameworks for digital tool implementation.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135455626","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 : 2023-11-02DOI: 10.1016/j.jcjq.2023.10.015
Chelsea M. Ludington MPH, CIC (is Unit Manager for the Infection Prevention Resource and Assessment Team (IPRAT), Infectious Disease Bureau, Michigan Department of Health and Human Services.), Renee E. Brum MSN-IPC, RN, CIC, CPHQ (formerly Infection Preventionist, Michigan Department of Health and Human Services, is Quality, Safety, and Experience Manager, Corewell Health, Grand Rapids, Michigan.), Denise I. Parr MSN-IPC, RN, CIC (is Dialysis and non-AR HAI Outbreak Lead for, IPRAT, Infectious Disease Bureau, Michigan Department of Health and Human Services. Please address correspondence to Chelsea M. Ludington)
Background
Patients who receive hemodialysis are at higher risk of developing health care–associated infections due to multiple factors, including direct and recurrent access to the bloodstream. Therefore, an effective infection prevention program should be in place to decrease the likelihood of these infections. Failure to assess gaps in systems and processes impedes the implementation of quality and performance improvement initiatives.
Methods
A multidisciplinary team created an infection prevention dialysis evaluation program by using Six Sigma's Define-Measure-Analyze-Design-Verify model. These elements included content within the dialysis-specific Infection Control Assessment and Response Tool from the Centers for Disease Control and Prevention with supporting program assessment items. From August 2021 through August 2022, the team completed 17 inpatient dialysis assessments within the cohort's 17 facilities (long-term and acute care hospitals). Data were analyzed using descriptive statistical analysis, and the final analysis included 1,086 observations from the developed assessment tool.
Results
Deficiencies were grouped into seven major infection prevention categories among the 17 assessments, with the highest number of deficiencies seen within the categories of cleaning and disinfection (100%), hand hygiene (52.9%), and personal protective equipment (PPE) use (52.9%).
Conclusion
Our program was successful at detecting gaps in dialysis-based infection prevention. By conducting data analysis of assessment findings, we can assist organizations in establishing priorities for quality and performance improvement.
{"title":"Creating a Statewide Assessment and Support Service to Prevent Infections in Patients Receiving Hemodialysis","authors":"Chelsea M. Ludington MPH, CIC (is Unit Manager for the Infection Prevention Resource and Assessment Team (IPRAT), Infectious Disease Bureau, Michigan Department of Health and Human Services.), Renee E. Brum MSN-IPC, RN, CIC, CPHQ (formerly Infection Preventionist, Michigan Department of Health and Human Services, is Quality, Safety, and Experience Manager, Corewell Health, Grand Rapids, Michigan.), Denise I. Parr MSN-IPC, RN, CIC (is Dialysis and non-AR HAI Outbreak Lead for, IPRAT, Infectious Disease Bureau, Michigan Department of Health and Human Services. Please address correspondence to Chelsea M. Ludington)","doi":"10.1016/j.jcjq.2023.10.015","DOIUrl":"10.1016/j.jcjq.2023.10.015","url":null,"abstract":"<div><h3>Background</h3><p>Patients who receive hemodialysis are at higher risk of developing health care–associated infections due to multiple factors, including direct and recurrent access to the bloodstream. Therefore, an effective infection prevention program should be in place to decrease the likelihood of these infections. Failure to assess gaps in systems and processes impedes the implementation of quality and performance improvement initiatives.</p></div><div><h3>Methods</h3><p>A multidisciplinary team created an infection prevention dialysis evaluation program by using Six Sigma's Define-Measure-Analyze-Design-Verify model. These elements included content within the dialysis-specific Infection Control Assessment and Response Tool from the Centers for Disease Control and Prevention with supporting program assessment items. From August 2021 through August 2022, the team completed 17 inpatient dialysis assessments within the cohort's 17 facilities (long-term and acute care hospitals). Data were analyzed using descriptive statistical analysis, and the final analysis included 1,086 observations from the developed assessment tool.</p></div><div><h3>Results</h3><p><span>Deficiencies were grouped into seven major infection prevention categories among the 17 assessments, with the highest number of deficiencies seen within the categories of cleaning and disinfection (100%), hand hygiene (52.9%), and </span>personal protective equipment (PPE) use (52.9%).</p></div><div><h3>Conclusion</h3><p>Our program was successful at detecting gaps in dialysis-based infection prevention. By conducting data analysis of assessment findings, we can assist organizations in establishing priorities for quality and performance improvement.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-11-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135371440","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 : 2023-11-02DOI: 10.1016/j.jcjq.2023.10.016
Beth Ripley MD, PhD (is Deputy Director, Office of Healthcare Innovation and Learning, Office of Discovery, Education and Affiliated Networks, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC.), Susan R. Kirsh MD, MPH (is Deputy Assistant Under Secretary for Health, Office of Discovery, Education and Affiliated Networks, Veterans Health Administration, US Department of Veterans Affairs.), Kenneth W. Kizer MD, MPH (is Senior Executive Advisor, The Aegis Group, Washington, DC, and Member, Board of Regents, Uniformed Services University of the Health Sciences, Bethesda, Maryland, Please address correspondence to Kenneth W. Kizer)
{"title":"Digital Stockpiling: An Innovative Strategy for Preparedness and Medical Supply Chain Resilience","authors":"Beth Ripley MD, PhD (is Deputy Director, Office of Healthcare Innovation and Learning, Office of Discovery, Education and Affiliated Networks, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC.), Susan R. Kirsh MD, MPH (is Deputy Assistant Under Secretary for Health, Office of Discovery, Education and Affiliated Networks, Veterans Health Administration, US Department of Veterans Affairs.), Kenneth W. Kizer MD, MPH (is Senior Executive Advisor, The Aegis Group, Washington, DC, and Member, Board of Regents, Uniformed Services University of the Health Sciences, Bethesda, Maryland, Please address correspondence to Kenneth W. Kizer)","doi":"10.1016/j.jcjq.2023.10.016","DOIUrl":"10.1016/j.jcjq.2023.10.016","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-11-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135410676","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 : 2023-10-30DOI: 10.1016/j.jcjq.2023.10.013
Gregory P. Couser MD, MPH (is Occupational Medicine Specialist, Psychiatrist, Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota.), Allyssa M. Stevens MHA (is Strategy Manager, Strategy Department, Mayo Clinic.), Heidi D. Arndt MA, LPCC (is Employee Assistance Counselor, Employee Assistance Program, Mayo Clinic.), Jody L. Nation LPCC (is Employee Assistance Counselor, Employee Assistance Program, Mayo Clinic.), Scott A. Breitinger MD (is Psychiatrist, Division of Integrated Behavioral Health, Mayo Clinic.), Debra S. Lafferty MS (is Director, Continuous Accreditation, Licensure, and Compliance, Department of Education Administration, Mayo Clinic.), Craig N. Sawchuk PhD, LP (is Psychologist, Division of Integrated Behavioral Health, Mayo Clinic. Please address correspondence to Gregory P. Couser)
Background
Professional distress and burnout are increasingly common among health professionals. This trend prompted stakeholders at a large multicenter health care system to survey supervisors for improvement opportunities. The stakeholders learned that workplace leaders lacked tools and direction for appropriately responding to distressed employees. The authors implemented a supervisor training video on providing resources to improve employee mental health.
Methods
Using the DMAIC (Define, Measure, Analyze, Improve, and Control) methodology, the authors conducted key stakeholder interviews to identify strengths, weaknesses, opportunities, and threats. Next, an e-mail survey was administered to a representative sample of supervisors that asked about degree of confidence in responding appropriately to distressed employees, with the response options “very confident,” “somewhat confident,” and “not at all confident.” After identifying factors contributing to low supervisor confidence, the research team developed and disseminated a six-minute, on-demand video to train supervisors to respond appropriately to employees during a mental health crisis. The same group of supervisors were surveyed using the same survey after exposure to the video, and responses were collected from those who had viewed the video but had not answered the preintervention survey.
Results
The proportion of supervisors who responded “not at all confident” in the survey decreased from 7.1% (15/210) of responses to 0.8% (1/123), while the proportion of supervisors who chose “somewhat confident” increased significantly, from 62.9% (132/210) to 69.1% (85/123) (p = 0.03). Of the 28 supervisors who had not participated in the presurvey and viewed the video, none indicated that they were “not at all confident.” The percentage of supervisors who felt distress “sometimes” or more frequently from navigating and supporting employee emotional concerns decreased nonsignificantly from 41.9% (88/210) to 37.4% (46/123) (p = 0.87).
Conclusion
Simple, on-demand supervisor training videos can improve the confidence of supervisors to respond appropriately to distressed employees, which may indirectly contribute to improved employee mental health.
{"title":"Improving Supervisor Confidence in Responding to Distressed Health Care Employees","authors":"Gregory P. Couser MD, MPH (is Occupational Medicine Specialist, Psychiatrist, Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota.), Allyssa M. Stevens MHA (is Strategy Manager, Strategy Department, Mayo Clinic.), Heidi D. Arndt MA, LPCC (is Employee Assistance Counselor, Employee Assistance Program, Mayo Clinic.), Jody L. Nation LPCC (is Employee Assistance Counselor, Employee Assistance Program, Mayo Clinic.), Scott A. Breitinger MD (is Psychiatrist, Division of Integrated Behavioral Health, Mayo Clinic.), Debra S. Lafferty MS (is Director, Continuous Accreditation, Licensure, and Compliance, Department of Education Administration, Mayo Clinic.), Craig N. Sawchuk PhD, LP (is Psychologist, Division of Integrated Behavioral Health, Mayo Clinic. Please address correspondence to Gregory P. Couser)","doi":"10.1016/j.jcjq.2023.10.013","DOIUrl":"10.1016/j.jcjq.2023.10.013","url":null,"abstract":"<div><h3>Background</h3><p>Professional distress and burnout are increasingly common among health professionals. This trend prompted stakeholders at a large multicenter health care system to survey supervisors for improvement opportunities. The stakeholders learned that workplace leaders lacked tools and direction for appropriately responding to distressed employees. The authors implemented a supervisor training video on providing resources to improve employee mental health.</p></div><div><h3>Methods</h3><p>Using the DMAIC (Define, Measure, Analyze, Improve, and Control) methodology, the authors conducted key stakeholder interviews to identify strengths, weaknesses, opportunities, and threats. Next, an e-mail survey was administered to a representative sample of supervisors that asked about degree of confidence in responding appropriately to distressed employees, with the response options “very confident,” “somewhat confident,” and “not at all confident.” After identifying factors contributing to low supervisor confidence, the research team developed and disseminated a six-minute, on-demand video to train supervisors to respond appropriately to employees during a mental health crisis. The same group of supervisors were surveyed using the same survey after exposure to the video, and responses were collected from those who had viewed the video but had not answered the preintervention survey.</p></div><div><h3>Results</h3><p>The proportion of supervisors who responded “not at all confident” in the survey decreased from 7.1% (15/210) of responses to 0.8% (1/123), while the proportion of supervisors who chose “somewhat confident” increased significantly, from 62.9% (132/210) to 69.1% (85/123) (<em>p</em> = 0.03). Of the 28 supervisors who had not participated in the presurvey and viewed the video, none indicated that they were “not at all confident.” The percentage of supervisors who felt distress “sometimes” or more frequently from navigating and supporting employee emotional concerns decreased nonsignificantly from 41.9% (88/210) to 37.4% (46/123) (<em>p</em> = 0.87).</p></div><div><h3>Conclusion</h3><p>Simple, on-demand supervisor training videos can improve the confidence of supervisors to respond appropriately to distressed employees, which may indirectly contribute to improved employee mental health.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136153054","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 : 2023-10-30DOI: 10.1016/j.jcjq.2023.10.014
Bradley W. Weaver PhD (is Human Factors Engineer, Office of Quality, Emory Healthcare.), David J. Murphy MD, PhD, FCCM (is Associate Professor, Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Emory University School of Medicine. Please address correspondence to Bradley Weaver)
Teamwork, communication, and workload issues continue to contribute to patient safety events. The authors developed a diagnostic mixed methods toolkit combining a behavior observation tool, semistructured interview guide, and surveys to proactively identify relevant gaps. Applied across 14 units at three hospitals, this toolkit yielded 344 findings with 156 associated recommendations and took, on average, four days of observation. On a scale from 1 (not at all helpful) to 6 (substantially helpful), leaders indicated that the assessment and its recommendations were very helpful (median 5, interquartile range 5–6, 34 survey respondents, 47.9% individual-level response rate, 85.7% unit-level response rate). Integrating this tool into a broader safety strategy can help inform organizational improvement efforts.
{"title":"A Combined Assessment Tool of Teamwork, Communication, and Workload in Hospital Procedural Units","authors":"Bradley W. Weaver PhD (is Human Factors Engineer, Office of Quality, Emory Healthcare.), David J. Murphy MD, PhD, FCCM (is Associate Professor, Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Emory University School of Medicine. Please address correspondence to Bradley Weaver)","doi":"10.1016/j.jcjq.2023.10.014","DOIUrl":"10.1016/j.jcjq.2023.10.014","url":null,"abstract":"<div><p>Teamwork, communication, and workload issues continue to contribute to patient safety events. The authors developed a diagnostic mixed methods toolkit combining a behavior observation tool, semistructured interview guide, and surveys to proactively identify relevant gaps. Applied across 14 units at three hospitals, this toolkit yielded 344 findings with 156 associated recommendations and took, on average, four days of observation. On a scale from 1 (not at all helpful) to 6 (substantially helpful), leaders indicated that the assessment and its recommendations were very helpful (median 5, interquartile range 5–6, 34 survey respondents, 47.9% individual-level response rate, 85.7% unit-level response rate). Integrating this tool into a broader safety strategy can help inform organizational improvement efforts.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136127907","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}