Pub Date : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.005
Karen Trang MD (is General Surgery Resident and Resident Research Fellow, Department of Surgery, University of California, San Francisco (UCSF).), Logan Pierce MD (is Assistant Clinical Professor, Department of Medicine, UCSF.), Elizabeth C. Wick MD (is Professor, and Vice Chair of Quality and Safety, Department of Surgery, UCSF. Please address correspondence to Karen Trang)
Background
Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP).
Methods
The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022.
Results
A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (p < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent.
Conclusion
The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.
{"title":"The Impact of Using Electronic Consents on Documentation of Language-Concordant Surgical Consent for Patients with Limited English Proficiency","authors":"Karen Trang MD (is General Surgery Resident and Resident Research Fellow, Department of Surgery, University of California, San Francisco (UCSF).), Logan Pierce MD (is Assistant Clinical Professor, Department of Medicine, UCSF.), Elizabeth C. Wick MD (is Professor, and Vice Chair of Quality and Safety, Department of Surgery, UCSF. Please address correspondence to Karen Trang)","doi":"10.1016/j.jcjq.2024.03.005","DOIUrl":"10.1016/j.jcjq.2024.03.005","url":null,"abstract":"<div><h3>Background</h3><p>Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP).</p></div><div><h3>Methods</h3><p>The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022.</p></div><div><h3>Results</h3><p>A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (<em>p</em> < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent.</p></div><div><h3>Conclusion</h3><p>The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 528-532"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725024000758/pdfft?md5=e14af92ed2c52547db1aae81073fd1ba&pid=1-s2.0-S1553725024000758-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140268335","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.010
Zoe Grabinski MD (is Assistant Professor, Ronald O. Perelman Department of Emergency Medicine and Department of Pediatrics, New York University Grossman School of Medicine.), Kar-mun Woo MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Olumide Akindutire MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Cassidy Dahn MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Lauren Nash PA (is Senior Physician Assistant, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Inna Leybell MD (is Clinical Assistant Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Yelan Wang MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Danielle Bayer MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Jordan Swartz MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Catherine Jamin MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Silas W. Smith MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine and Institute for Innovations in Medical Education, New York University Grossman School of Medicine. Please address correspondence to Zoe Grabinski)
Background
Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.
Methods
The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.
Results
The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.
Conclusion
The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.
{"title":"Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission","authors":"Zoe Grabinski MD (is Assistant Professor, Ronald O. Perelman Department of Emergency Medicine and Department of Pediatrics, New York University Grossman School of Medicine.), Kar-mun Woo MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Olumide Akindutire MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Cassidy Dahn MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Lauren Nash PA (is Senior Physician Assistant, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Inna Leybell MD (is Clinical Assistant Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Yelan Wang MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Danielle Bayer MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Jordan Swartz MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Catherine Jamin MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Silas W. Smith MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine and Institute for Innovations in Medical Education, New York University Grossman School of Medicine. Please address correspondence to Zoe Grabinski)","doi":"10.1016/j.jcjq.2024.03.010","DOIUrl":"10.1016/j.jcjq.2024.03.010","url":null,"abstract":"<div><h3>Background</h3><p>Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.</p></div><div><h3>Methods</h3><p>The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.</p></div><div><h3>Results</h3><p>The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (<em>p</em> < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (<em>p</em> < 0.001) but not by language (<em>p</em> = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (<em>p</em> = 0.446) or language (<em>p</em> = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.</p></div><div><h3>Conclusion</h3><p>The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 516-527"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140276367","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.02.008
Harrison Sims (is Human Factors Engineering researcher, Department of Biomedical Engineering, Johns Hopkins University.), David Neyens PhD, MS, MPH (is Associate Professor, Departments of Industrial Engineering and Bioengineering, Clemson University.), Ken Catchpole PhD (is Professor and S.C. SmartState Endowed Chair in Clinical Practice and Human Factors, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), Joshua Biro PhD, MS (is Research Fellow, MedStar Health National Center for Human Factors in Healthcare, Washington, DC.), Connor Lusk PhD, MS (is Assistant Professor, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), James Abernathy III MD, MPH (is Associate Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University. Please send correspondence to Harrison Sims)
{"title":"The Impact of a Novel Syringe Organizational Hub on Operating Room Workflow During a Surgical Case","authors":"Harrison Sims (is Human Factors Engineering researcher, Department of Biomedical Engineering, Johns Hopkins University.), David Neyens PhD, MS, MPH (is Associate Professor, Departments of Industrial Engineering and Bioengineering, Clemson University.), Ken Catchpole PhD (is Professor and S.C. SmartState Endowed Chair in Clinical Practice and Human Factors, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), Joshua Biro PhD, MS (is Research Fellow, MedStar Health National Center for Human Factors in Healthcare, Washington, DC.), Connor Lusk PhD, MS (is Assistant Professor, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina.), James Abernathy III MD, MPH (is Associate Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University. Please send correspondence to Harrison Sims)","doi":"10.1016/j.jcjq.2024.02.008","DOIUrl":"10.1016/j.jcjq.2024.02.008","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 542-544"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140305669","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.003
Courtney W. Mangus MD (is Clinical Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan.), Tyler G. James PhD (is Assistant Professor, Department of Family Medicine, University of Michigan.), Sarah J. Parker MPH (is Research Area Specialist, Department of Emergency Medicine, University of Michigan.), Elizabeth Duffy MPH (is Clinical Research Coordinator, Department of Emergency Medicine, University of Michigan.), P. Paul Chandanabhumma PhD, MPH (is Assistant Professor, Department of Family Medicine, University of Michigan.), Caitlin M. Cassady LMSW, LCSW (is PhD Candidate, Social Work and Anthropology Doctoral Program, Wayne State University.), Fernanda Bellolio MD, MS (is Emergency Medicine Physician and Health Sciences Researcher, Departments of Emergency Medicine and Health Science Research, Mayo Clinic, Rochester, Minnesota.), Kalyan S. Pasupathy PhD (is Professor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago.), Milisa Manojlovich PhD, RN (is Professor, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan.), Hardeep Singh MD, MPH (is Professor, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA (US Department of Veterans Affairs) Medical Center and Baylor College of Medicine, Houston.), Prashant Mahajan MD, MBA, MPH (is Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan. Please address correspondence to Courtney W. Mangus)
Background
Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety.
Methods
Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED–Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews.
Results
The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED–Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused.
Conclusion
Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.
背景很少有研究描述一线医疗服务提供者和患者对如何改进急诊科（ED）诊断流程的见解，而急诊科是诊断错误的高发场所。作者旨在确定医疗服务提供者和患者对诊断过程的看法，并确定潜在的干预措施，以提高诊断安全性。访谈问题以 ED 适应美国国家科学、工程和医学院诊断流程框架为指导，探讨了参与者对 ED 诊断流程的看法，发现了漏洞，并寻求干预措施以提高诊断安全性。作者对转录的访谈进行了定性专题分析。结果研究小组根据 ED 适应框架将诊断过程中的薄弱环节和干预机会分为五个领域：(1) 团队动力和沟通（例如，转诊医生和急诊室团队之间的沟通欠佳）；(2) 与患者表现相关的信息收集（例如，从患者或其看护人处获取病史；(3) 急诊室组织、系统和流程（例如，员工日程安排和交接）；(4) 患者教育和自我管理（例如，急诊室出院时的患者教育）；以及 (5) 电子病历和患者门户网站的使用（例如，自动将检查结果发布到患者门户网站）。作者确定了 33 项潜在干预措施，其中 17 项以医疗服务提供者为重点，16 项以患者为重点。需要对这些干预措施进行改进、实施和效果评估。
{"title":"Frontline Providers’ and Patients’ Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study","authors":"Courtney W. Mangus MD (is Clinical Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan.), Tyler G. James PhD (is Assistant Professor, Department of Family Medicine, University of Michigan.), Sarah J. Parker MPH (is Research Area Specialist, Department of Emergency Medicine, University of Michigan.), Elizabeth Duffy MPH (is Clinical Research Coordinator, Department of Emergency Medicine, University of Michigan.), P. Paul Chandanabhumma PhD, MPH (is Assistant Professor, Department of Family Medicine, University of Michigan.), Caitlin M. Cassady LMSW, LCSW (is PhD Candidate, Social Work and Anthropology Doctoral Program, Wayne State University.), Fernanda Bellolio MD, MS (is Emergency Medicine Physician and Health Sciences Researcher, Departments of Emergency Medicine and Health Science Research, Mayo Clinic, Rochester, Minnesota.), Kalyan S. Pasupathy PhD (is Professor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago.), Milisa Manojlovich PhD, RN (is Professor, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan.), Hardeep Singh MD, MPH (is Professor, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA (US Department of Veterans Affairs) Medical Center and Baylor College of Medicine, Houston.), Prashant Mahajan MD, MBA, MPH (is Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan. Please address correspondence to Courtney W. Mangus)","doi":"10.1016/j.jcjq.2024.03.003","DOIUrl":"10.1016/j.jcjq.2024.03.003","url":null,"abstract":"<div><h3>Background</h3><p>Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety.</p></div><div><h3>Methods</h3><p>Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED–Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews.</p></div><div><h3>Results</h3><p>The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED–Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused.</p></div><div><h3>Conclusion</h3><p>Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 480-491"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140280474","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.012
Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.), Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.), Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.), Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.), Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)
Background
Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.
Methods
Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.
Results
In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (p < 0.0001).
Conclusion
Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.
{"title":"Putting the “Action” in RCA2: An Analysis of Intervention Strength After Adverse Events","authors":"Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.), Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.), Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.), Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.), Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)","doi":"10.1016/j.jcjq.2024.03.012","DOIUrl":"10.1016/j.jcjq.2024.03.012","url":null,"abstract":"<div><h3>Background</h3><p>Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.</p></div><div><h3>Methods</h3><p>Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.</p></div><div><h3>Results</h3><p>In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (<em>p</em> < 0.0001).</p></div><div><h3>Conclusion</h3><p>Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 492-499"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140870150","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.05.001
Robin R. Hemphill MD, MPH (is Chief of Staff, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. Please address correspondence to Robin Hemphill)
{"title":"The Challenge of Improving Patient Safety: This is Hard","authors":"Robin R. Hemphill MD, MPH (is Chief of Staff, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. Please address correspondence to Robin Hemphill)","doi":"10.1016/j.jcjq.2024.05.001","DOIUrl":"10.1016/j.jcjq.2024.05.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 478-479"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140921353","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.04.006
Benjamin D. Pollock PhD, MSPH (is Assistant Professor of Health Services Research and Senior Associate Consultant II–Research, Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida.), Leslie Carranza MD (is Quality Chair, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.), Elizabeth Braswell-Pickering MPH (is Senior Quality Informatics Analyst, Mayo Clinic, Rochester, Minnesota.), Christine M. Sing DPT, MBA (is Operations Manager, Quality & Value, Mayo Clinic, Rochester, Minnesota.), Lindsay L. Warner MD (is Anesthesiologist and Pediatric Anesthesiologist, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.), Regan N. Theiler MD, PHD (is Associate Professor, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota. Please address correspondence to Benjamin D. Pollock)
Background
The Joint Commission uses nulliparous, term, singleton, vertex, cesarean delivery (NTSV-CD) rates to assess hospitals’ perinatal care quality through the Cesarean Birth measurement (PC-02). However, these rates are not risk-adjusted for maternal health factors, putting this measure at odds with the risk adjustment paradigm of most publicly reported hospital quality measures. Here, the authors tested whether risk adjustment for readily documented maternal risk factors affected hospital-level NTSV-CD rates in a large health system.
Methods
Included were all consecutive NTSV pregnancies from January 2019 to April 2023 across 10 hospitals in one health system. Logistic regression, adjusting for age, obesity, diabetes, and hypertensive disorders. was used to calculate hospital-level risk-adjusted NTSV-CD rates by multiplying observed vs. expected ratios for each hospital by the systemwide unadjusted NTSV-CD rate. The authors calculated intrahospital risk differences between unadjusted and risk-adjusted rates and calculated the percentage of hospitals qualifying for different reporting status after risk adjustment using the 30% Joint Commission reporting threshold rate.
Results
Of 23,866 pregnancies, 6,550 (27.4%) had cesarean deliveries. Across 10 hospitals, the number of deliveries ranged from 393 to 7,671, with unadjusted NTSV-CD rates ranging from 21.0% to 30.5%. Risk-adjusted NTSV-CD rates ranged from 21.5% to 30.4%, with absolute intrahospital differences in risk-adjusted vs. unadjusted rates ranging from −1.33% (indicating lower rate after risk adjustment) to 3.37% (indicating higher rate after risk adjustment). Three of 10 (30.0%) hospitals qualified for different reporting statuses after risk adjustment.
Conclusion
Risk adjustment for age, obesity, diabetes, and hypertensive disorders is feasible and resulted in meaningful changes in hospital-level NTSV-CD rates with potentially impactful consequences for hospitals near The Joint Commission reporting threshold.
{"title":"A Simple Risk Adjustment for Hospital-Level Nulliparous, Term, Singleton, Vertex, Cesarean Delivery Rates and Its Implications for Public Reporting","authors":"Benjamin D. Pollock PhD, MSPH (is Assistant Professor of Health Services Research and Senior Associate Consultant II–Research, Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida.), Leslie Carranza MD (is Quality Chair, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.), Elizabeth Braswell-Pickering MPH (is Senior Quality Informatics Analyst, Mayo Clinic, Rochester, Minnesota.), Christine M. Sing DPT, MBA (is Operations Manager, Quality & Value, Mayo Clinic, Rochester, Minnesota.), Lindsay L. Warner MD (is Anesthesiologist and Pediatric Anesthesiologist, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.), Regan N. Theiler MD, PHD (is Associate Professor, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota. Please address correspondence to Benjamin D. Pollock)","doi":"10.1016/j.jcjq.2024.04.006","DOIUrl":"10.1016/j.jcjq.2024.04.006","url":null,"abstract":"<div><h3>Background</h3><p>The Joint Commission uses nulliparous, term, singleton, vertex, cesarean delivery (NTSV-CD) rates to assess hospitals’ perinatal care quality through the Cesarean Birth measurement (PC-02). However, these rates are not risk-adjusted for maternal health factors, putting this measure at odds with the risk adjustment paradigm of most publicly reported hospital quality measures. Here, the authors tested whether risk adjustment for readily documented maternal risk factors affected hospital-level NTSV-CD rates in a large health system.</p></div><div><h3>Methods</h3><p>Included were all consecutive NTSV pregnancies from January 2019 to April 2023 across 10 hospitals in one health system. Logistic regression, adjusting for age, obesity, diabetes, and hypertensive disorders. was used to calculate hospital-level risk-adjusted NTSV-CD rates by multiplying observed vs. expected ratios for each hospital by the systemwide unadjusted NTSV-CD rate. The authors calculated intrahospital risk differences between unadjusted and risk-adjusted rates and calculated the percentage of hospitals qualifying for different reporting status after risk adjustment using the 30% Joint Commission reporting threshold rate.</p></div><div><h3>Results</h3><p>Of 23,866 pregnancies, 6,550 (27.4%) had cesarean deliveries. Across 10 hospitals, the number of deliveries ranged from 393 to 7,671, with unadjusted NTSV-CD rates ranging from 21.0% to 30.5%. Risk-adjusted NTSV-CD rates ranged from 21.5% to 30.4%, with absolute intrahospital differences in risk-adjusted vs. unadjusted rates ranging from −1.33% (indicating lower rate after risk adjustment) to 3.37% (indicating higher rate after risk adjustment). Three of 10 (30.0%) hospitals qualified for different reporting statuses after risk adjustment.</p></div><div><h3>Conclusion</h3><p>Risk adjustment for age, obesity, diabetes, and hypertensive disorders is feasible and resulted in meaningful changes in hospital-level NTSV-CD rates with potentially impactful consequences for hospitals near The Joint Commission reporting threshold.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 500-506"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140780264","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 : 2024-07-01DOI: 10.1016/j.jcjq.2024.05.004
Michael S. Pulia MD, PhD (is Associate Professor, Departments of Emergency Medicine and Industrial and Systems Engineering University of Wisconsin-Madison.), Dimitrios Papanagnou MD, MPH (is Professor, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia.), Pat Croskerry MD, PhD (is Professor, Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Please address correspondence to Michael S. Pulia)
{"title":"The Quest for Diagnostic Excellence in the Emergency Department","authors":"Michael S. Pulia MD, PhD (is Associate Professor, Departments of Emergency Medicine and Industrial and Systems Engineering University of Wisconsin-Madison.), Dimitrios Papanagnou MD, MPH (is Professor, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia.), Pat Croskerry MD, PhD (is Professor, Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Please address correspondence to Michael S. Pulia)","doi":"10.1016/j.jcjq.2024.05.004","DOIUrl":"10.1016/j.jcjq.2024.05.004","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 475-477"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141035737","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 : 2024-06-28DOI: 10.1016/j.jcjq.2024.06.006
Allen Kachalia MD, JD (is Senior Vice President, Patient Safety and Quality, and Director, Director, Armstrong Institute of Patient Safety and Quality; and Professor of Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore.), Carole Hemmelgarn MS, MS (is Program Director, Executive Master's Clinical Quality, Safety and Leadership, Georgetown University, and Senior Director Education, MedStar Health, Washington, DC.), Thomas H. Gallagher MD, MACP (is Executive Director, Collaborative for Accountability and Improvement, and Associate Chair of Medicine for Patient Care, Quality, Safety, and Value, UW Medicine, Seattle; and Professor of Medicine and Professor of Bioethics & Humanities, University of Washington. Please address correspondence to Allen Kachalia)
{"title":"Communication After Medical Error: The Need to Measure the Patient Experience","authors":"Allen Kachalia MD, JD (is Senior Vice President, Patient Safety and Quality, and Director, Director, Armstrong Institute of Patient Safety and Quality; and Professor of Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore.), Carole Hemmelgarn MS, MS (is Program Director, Executive Master's Clinical Quality, Safety and Leadership, Georgetown University, and Senior Director Education, MedStar Health, Washington, DC.), Thomas H. Gallagher MD, MACP (is Executive Director, Collaborative for Accountability and Improvement, and Associate Chair of Medicine for Patient Care, Quality, Safety, and Value, UW Medicine, Seattle; and Professor of Medicine and Professor of Bioethics & Humanities, University of Washington. Please address correspondence to Allen Kachalia)","doi":"10.1016/j.jcjq.2024.06.006","DOIUrl":"10.1016/j.jcjq.2024.06.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Pages 618-619"},"PeriodicalIF":2.3,"publicationDate":"2024-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626824","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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