Quality Management in Health Care最新文献

Background and objective: Unnecessary care delays of hospitalized patients increase the risk of hospital-related complications and drive up health care costs. While health systems focus on reducing the length of stay of hospitalized patients, not many studies looked at specific causes of the care delays that prolong length of stay. In this study, we sought to systematically identify and categorize the various care delays that contribute to prolonged length of stay on a hospital medicine service.

Methods: We conducted a retrospective observational study looking at all inpatient encounters to the hospitalist service (N = 6633) for the fiscal year 2021. Observation status, COVID-19 positive, and other services' discharged patients were excluded (N = 2849) leaving 3784 eligible encounters. The resulting 5% stratified random sample accounted for 190 encounters accounting for a total of 1152 patient-days. Using a standardized data extraction tool, a day-by-day review of the sample encounters was performed for all care delays. These care delays were categorized into specific groups (System, Discharge, Provider, Patient/Family, or Consultant related) and subgroups based on predetermined criteria.

Results: The stratified sample was found to be comparable to the total patient population, with no statistically significant differences in key demographic and clinical metrics. About 30% of all patient-days had a care delay; 33% of these delays were attributable to system delays internal to the hospital such as waiting for imaging/procedures; 28% of delays were due to discharge barriers, driven overwhelmingly by a lack of available post-acute care beds, and about 20% of delays were attributable to the provider.

Conclusion: Our study systematically looked at care delays that led to prolonged hospital length of stay. Most of these care delays were caused by either wait times for procedures and imaging studies or by a lack of post-acute care bed availability. Hospitals and health systems can use this approach to better determine which systemic changes are likely to be the most effective at reducing length of stay.

Background and objectives: Fever is a frequent cause of consultation in the pediatric emergency department (PED). Adequate discharge instructions are essential to guarantee good management at home and can reduce caregivers' anxiety and re-consultations. This study compares the improvement of caregivers' knowledge regarding fever between verbal discharge instructions and the addition of a video to verbal information. As a secondary outcome, we compared the rate of return visits.

Methods: An experimental, prospective, single-center study was conducted in a tertiary hospital PED. Patients between 3 months and 5 years old with febrile syndrome were enrolled. Patients with comorbidities or SARS-COV2 infection were excluded. First, caregivers answered a written test concerning fever characteristics, management, and warning signs. Patients were assigned by simple randomization to a control group (standard verbal and written instructions) or to an intervention group (which additionally received video instructions). After discharge, investigators contacted caregivers by telephone. Caregivers were asked to answer the same questions as in the written test in addition to the need for subsequent visits (at the PED or any other healthcare facility) after discharge.

Results: Seventy-three patients were randomized to the intervention group and 77 to the control group (2 were lost during follow-up). There were no differences in the acquisition of caregiver's knowledge, with a median score improvement of 2 points in both groups (control group interquartile range (IQR) 1-2; intervention group IQR 1-3) (P = .389). In the intervention group, we observed a significant increase of correct answers in 4 out of 7 questions compared to 3 out of 7 questions in the control group. In the control group, 18.7% reconsulted compared to 10.9% in the intervention group (P = .188).

Conclusions: Video instructions were not superior to verbal instructions at improving caregivers' knowledge of fever overall. However, more questions obtained a significant score increase in those that received video and verbal instructions. Our results suggest that the addition of video instructions could help reduce return visits.

Introduction: Antimicrobial resistance (AMR) is a global problem, which is particularly challenging in developing countries like India. This study attempts to determine the competencies of health care professionals and to update evidence-based policies to address AMR.

Method: A survey-based educational interventional study was conducted using a validated structured survey and knowledge questionnaire under 3 domains through an antimicrobial stewardship program. Pooled data were analyzed using SPSS version 16.0.

Results: Out of 58 participants, 53 (91%) have observed an increasing trend of multidrug-resistant infections over the last 5 years. There is a significant difference between the overall pretest mean scores (8.12 ± 2.10) and posttest mean scores (12.5 ± 1.49) of clinicians' knowledge with a mean difference of 4.38 ± 0.61, 95% CI of 5.003-3.92, t(57) = 16.62, P < .001).

Discussion: The antimicrobial stewardship program was effective in improving the competencies of clinical physicians to improve antimicrobial prescribing and reduce AMR. Moreover, improving the knowledge and competencies among health care professionals will minimize neonatal morbidity and mortality.

Human error (HE) is one of the main causes of accidents in different organizations and industries. Dentistry is a medical branch with a high risk of error since it involves complex manual tasks that must be performed with a high degree of accuracy. To understand the various aspects of HE in dentistry, which is crucial for developing strategies to mitigate its impact on patients' safety, it is necessary to perform a human reliability analysis (HRA). However, there is scarce data on the use of HRA in dentistry. In this paper, we give a brief description of the main phases of HRA with an emphasis on HRA methods that could be used in dentistry. Since HRA methods have been designed for diverse industrial applications, we discuss their possible application in dentistry. Among the discussed methods, the Systematic Human Error Reduction and Prediction Approach (SHERPA) and the Human Error Assessment and Reduction Technique were identified as the best candidates for performing HRA in dentistry. This is of great importance since understanding and addressing HEs is crucial for improving patient safety and the overall quality of dental care.

Background and objectives: This study aimed to examine the development of clinical competence of novice physical therapists (PTs) during their first year of employment, following the implementation of an original in-house educational program. The educational program was designed to offer diverse training opportunities at an early stage, during the first year of employment.

Methods: Thirty-eight novice PTs (21 males and 17 females, mean age 23.4 ± 3.2 years) participated in this study. All participants underwent educational programs and a self-assessment using the Clinical Competence Evaluation Scale in Physical Therapy (CEPT) on the first day of employment (entry-level) and after 1, 3, 6, and 12 months of employment. The total score and CEPT component-wise scores-"knowledge," "clinical reasoning," "skill," "communication," "attitude," "self-education," and "self-management"-at the 4 assessment points (1, 3, 6, and 12 months) were compared with values on the first day.

Results: The total scores at 3, 6, and 12 months of employment were significantly higher than those on the first day of employment (P < .05). Among the total scores on the 7 components, those for "knowledge," "clinical reasoning," "skill," and "communication" at 3, 6, and 12 months after employment were also significantly higher than those on the first day of employment (P < .05). The scores for "attitude" and "self-education" 12 months after employment were significantly higher than those on the first day of employment. However, the "self-management" scores at 1, 3, 6, and 12 months after employment did not significantly change compared with those on the first day of employment.

Conclusions: The total score was significantly higher after 3 months. The participant's clinical competence may have improved because they participated in an educational program related to "knowledge," "clinical reasoning," "skills," and "communication" at an earlier stage in the first year. However, their progress was comparatively slower in other areas, suggesting that the content might not have been sufficient. This study revealed the effectiveness of the educational program on novice PTs' clinical competence at a single institution in Japan. Positive outcomes were obtained for several parameters. Furthermore, the results reveal the need for content modifications within the educational program to improve PTs' performance across all evaluated items.

Background and objectives: Healthcare is increasingly being delivered in the outpatient setting, but robust quality improvement programs and performance metrics are lacking in ambulatory care, particularly specialty-based ambulatory care.

Methods: To promote quality improvement in ambulatory care, we developed an infrastructure to create specialty-specific quality measures and dashboards that could be used to display providers' performance across relevant measures to individual providers and institutional leaders.

Results: The products of this program include a governance and infrastructure for specialty-specific ambulatory quality metrics as well as two distinct dashboards for data display. One dashboard is provider-facing, displaying provider's performance on specialty-specific measures as compared to institutional standards. The second dashboard is a leadership dashboard that provides overall and provider-level information on performance across measures.

Conclusions: The Specialty-based Ambulatory Quality program reflects a systematic, institutionally-supported quality improvement framework that can be applied across diverse ambulatory specialties. As next steps, we plan to evaluate the program's impact on provider performance across measures and expand this program to other specialties practicing in the outpatient setting.

Background and objectives: Medical risks are considered to endanger patients and impact the health care system. Such iatrogenic risks necessitate hospitals taking a more proactive method to quantitatively analyze medical risk, and then to implement more targeted precautions. To address this problem, a novel quantitative risk assessment framework is proposed and further applied in radiotherapy risk assessment.

Methods: A framework combining DMAIC (Define, Measure, Analyze, Improve, Control) and bow-tie model is used to assess health care risk. The uncertainty of medical risks is quantified with fuzzy set theory. The impact and the priority of medical risks were classified based on the risk matrix, and then the precautions were implemented to mitigate their impact. A case study of radiation treatment is provided.

Results: The probabilities and impacts of risk events for radiation treatment were quantified based on the proposed framework, and risk protection measures were proposed to mitigate the undesired consequence.

Conclusion: The proposed framework showing an effective method of quantitative risk assessment of health care. The study also enriches the risk assessment methods in health care by providing a conductive and normalized framework.

Background and objectives: The Transforming Clinical Practices Initiative (TCPI) was a 4-year, large-scale, collaborative, peer-based learning initiative for physician practices of all specialties with broad goals to improve the quality of patient care, spend health care dollars more wisely, and assist practices in being ready to succeed under value-based payment (VBP). We investigated whether the COVID-19 pandemic had erased or diminished practice transformation progress made during the TCPI program period, through a follow-up survey of participating practices fielded in October 2021.

Methods: In October 2021 to April 2022, we surveyed a probability sample of 2207 primary care and specialty practices that participated in the TCPI, receiving 610 responses. We asked about practice characteristics, financial and ownership stability, clinical performance, and quality improvement efforts, both now and prior to COVID-19. The COVID-19 content was part of a larger survey. Responses were weighted to account for sample selection, unknown eligibility status, and nonresponse. We generated weighted univariate descriptive statistics representative of practices with clinicians enrolled in TCPI. These estimated percentages have a 95% confidence interval of about ±5%. Multivariate analysis of unweighted data examined associations between practice characteristics and other variables of interest.

Results: For all but one of 13 practice transformation activities engaged in prior to the COVID-19 public health emergency, a majority of practices (at least 52%) reported that the progress on these activities were either not hurt or were helped by their COVID-19 experience. Compared to January 2020, only about 7% of practices reported that their quality of care or clinical performance was worse due to COVID-19, and 32% reported that their quality of care was better. More rural than urban practices reported that half or more of their transformation activities were hurt by COVID-19 (29% and 14%, respectively). Physician-owned practices were more likely to report quality is better today than prior to COVID-19 relative to practices with other ownership types such as hospitals or health systems (43% vs 24%).

Conclusion: Most practices have been able to recover from the deep stress of the COVID-19 pandemic and continue their efforts to improve patient care and performance to succeed under VBP. These results suggest a high perceived return on investment in value-readiness support along with emergency financial support in times of crisis, as well as room to continue preparation for any future pandemic and the national movement toward increased VBP, especially in rural settings.

Background: A sensation becomes a symptom (a concern) when a person associates it with potential illness. In the absence of objective evidence of a pathophysiological process that has important health consequences without treatment, assigning a diagnosis to the sensation is optional. This is important because labeling of benign bodily sensations as pathophysiology has potential advantages and disadvantages.

Question: We asked what patient and clinician factors are associated with willingness to accept an optional diagnosis.

Methods: In a survey administered using Amazon M-Turk, 536 people anonymously completed validated measures for symptoms of anxiety and depression, intolerance of uncertainty, and skepticism regarding the healthcare system. They then viewed fictional personal medical scenarios in which they were asked to imagine they experienced certain symptoms, and were offered an optional diagnosis of a nerve problem, muscle pain syndrome, or fatigue syndrome, and were asked to rate their willingness to accept the diagnosis on an 12-point ordinal scale from 0 indicating "I do not accept it at all" to 11 indicating "I accept it with enthusiasm." The language of the scenarios was varied to attempt to reflect critical thinking, denigration of other doctors, an alternative mental health focus, or a hopeful outlook. Multilevel linear regression was used to identify factors associated with likelihood of accepting an optional diagnosis.

Results: Threshold likelihood of accepting an optional diagnosis greater than 5.5 on a 0 to 11 ordinal scale was independently associated with greater symptoms of anxiety (regression coefficient [RC] = 0.38, 95% confidence interval [95% CI] = 0.30-0.47, P < .001), greater skepticism regarding the healthcare system (RC = 0.11, 95% CI = 0.076-0.13, P < .001), and delivery tones characterized by either denigration of other doctors (RC = 0.39, 95% CI = 0.19-0.60, P < .001) or a hopeful outlook (RC = 0.50, 95% CI = 0.26-0.73, P < .001).

Conclusion: Likelihood of accepting an optional diagnosis may be a sign of relative vulnerability from feelings of distress or distrust of medical evidence. Given this potential vulnerability, clinicians can take care to limit persuasive communication styles that can influence acceptance of optional diagnoses.

Level of evidence: III prognostic.