Quality Management in Health Care最新文献

Background and objectives: Nurses' documentation of communication, including notification of critical laboratory results (CLR), is important to ensure safe, high-quality care. Evidence supports peer audit with feedback as a quality improvement (QI) intervention to improve documentation. Nursing compliance with CLR documentation requirements was below goal for several years in an intensive care unit. To address this problem, a peer audit and feedback intervention was implemented and evaluated.

Methods: Compliance with CLR documentation requirements was evaluated pre- and postintervention, for a total of 12 months. The evaluation also included data from the peer audits and a survey to assess nurses' perceptions. The 5-month intervention was a timely peer audit and feedback of CLR events.

Results: CLR documentation compliance improved from 6.4% to 9.6% (50% improvement), which was clinically meaningful but not statistically significant. Nurses had overall positive perceptions of the peer audit and feedback as a QI tool, perceiving it as nonpunitive and helpful for improving practice.

Conclusion: Results support continued examination of peer audit and feedback to improve nursing documentation. Future projects should address the limited time for nurses to engage in QI projects.

Background and objectives: Retrospective studies examining errors within a surgical scheduling setting do not fully represent the effects of human error involved in transcribing critical patient health information (PHI). These errors can negatively impact patient care and reduce workplace efficiency due to insurance claim denials and potential sentinel events. Previous reports underscore the burden physicians face with prior authorizations which may lead to serious adverse events or the abandonment of treatment due to these delays. This study simulates the process of PHI transfer during surgical scheduling to examine the error rate of experienced schedulers when manually transferring PHI from surgical forms into electronic health records (EHR).

Methods: Participants (n = 50) manually input PHI from four surgical scheduling forms into a simulated EHR form. Eight critical data points were identified and defined as data that delay claim approvals and payments. Subjects were randomly assigned to either a control (18 minutes) or experimental (10 minutes) group. Transcription errors were flagged to measure the percentage of incorrectly inputted data fields. Two-tailed t-tests were used to determine statistical significance ( P < .05).

Results: 100% of subjects in both cohorts had at least one or more errors in every form. The 10-minute cohort had a higher average "critical errors" rate than the 18-minute cohort ( P = .03). Of the 200 forms completed, 171 forms contained 1 or more "critical errors," resulting in a potential 85.5% delay or denial in authorization or payments. The highest incidence of critical errors across all fields occurred with ICD-10 codes, CPT codes, authorization number, procedure, and insurance ID number. As critical errors fields of authorization number and insurance ID often lead to automatic denials, not only are they more susceptible to transcription error due to alphanumeric values but more indicative of delays in treatment.

Conclusions: These findings reveal a clear "pain point" in the routine scheduling process that leads to authorization and payment denials. With various touch points of manual data transfer in surgical scheduling, data degradation due to human error may compound at each step. Health care institutions should consider adopting digital solutions and investing in training programs to optimize clinical practice efficiency and reduce the possibility of inaccurate manual PHI transfer. Future case studies on denied payments will help further elucidate the economic impact on practices, as well as inform strategic decisions by those who directly handle health care management.

Background and objective: Central Line-Associated Bloodstream Infection (CLABSI) remains a leading cause of death among critically ill patients. Implementing preventive measures and adhering to best practices are crucial actions to proactively prevent its occurrence. This project aimed to reduce the overall CLABSI rate in adult medical/surgical Intensive Care Units (ICUs) of hospitals under the Ministry of Defense Health Services (MODHS) in Saudi Arabia. The baseline CLABSI rate was 2 cases per 1000 catheter days during the first quarter of 2020, while the target was to achieve a rate equal to or lower than 0.8 as reported by the American National Healthcare Safety Network (NHSN) in 2013.

Methods: The initiative was carried out across 15 hospitals under the purview of MODHS. Data on CLABSI incidents were collected from the ICUs dedicated to adult medical and surgical care. The project utilized the Institute for Healthcare Improvement collaborative model to achieve breakthrough improvement in a short-term learning system that facilitated the collaboration of participating hospitals in the pursuit of enhancements in CLABSI rates. The project involved 3 cycles, each consisting of a learning session followed by an action period.

Results: The data revealed a continuous improvement in the overall CLABSI rate within MODHS hospitals, progressing positively for 4 consecutive quarters and attaining a value of 0.3 during the third quarter of 2021. This signifies an impressive 85% reduction from the initial baseline of 2, and the rate remains below the project benchmark of 0.8.

Conclusion: The project successfully employed collaborative learning cycles, fostering effective knowledge-sharing among teams and promoting active engagement. This approach proved instrumental in achieving learning objectives, identifying gaps, and determining appropriate courses of action. Key factors for the project's success included standardizing the change package, conducting regular training sessions, encouraging open discussions, and sharing experiences.

Background and objective: Unnecessary care delays for 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 among those who received video and verbal instructions. Our results suggest that the addition of video instructions could help reduce return visits.

Background and objectives: Care transitions from hospital to skilled home health care (HH) often pose safety risks, especially for older adults. The Coming Home Intervention (CHI) was developed to enhance these transitions based on the Hospital-to-Home Health Transition Quality (H3TQ) index, a previously validated survey instrument assessing quality issues during hospital-to-HH transitions. This study aimed to pilot CHI and evaluate its impact at 2 large HH agencies in Baltimore, MD, and New York, NY.

Methods: The 2 participating HH agencies implement CHI by providing HH clinicians and patients tools for expectation setting, clarification of healthcare-related roles of family and HH personnel, clinical care guides to support information management, and the H3TQ for identification of quality/safety issues. Using a quasi-experimental, before-and-after difference-in-difference design, changes before and after CHI implementation were compared between intervention and comparison groups. Quality of hospital-to-HH transitions was rated by older adults/caregivers and HH clinicians using the H3TQ before and after CHI implementation. In total, 394 responses were from older adults/caregivers and 604 responses were from HH clinicians. Outcomes including identification of medication issues and 30-day emergency department use or rehospitalization were evaluated using the Outcome and Assessment Information Set with a difference-in-difference approach (n = 3,471 in the Baltimore site; n = 758 in the New York City site). Results were analyzed and reported separately for each HH agency.

Results: CHI implementation in Baltimore was associated with a statistically non-significant, decreasing trend in 30-day emergency department use or rehospitalization (odds ratio = 0.68, 95% confidence interval = 0.45-1.03). After implementation, older adults/caregivers rated quality issues measured by H3TQ less favorably. In New York City, older adults/caregivers reported fewer quality issues (incidence rate ratio = 0.50, 95% confidence interval = 0.27-0.89) after implementation. Assessment of other measures did not show significant changes.

Conclusion: The pilot implementation of CHI demonstrated potential to improve hospital-to-HH transition quality. Study findings can guide future CHI implementation in larger studies in a broader population of older adults receiving HH services after hospital discharge.

Background and objective: To investigate cost-related barriers to medication adherence in patients with uveitis.

Methods: Non-interventional, retrospective study. The study examined the responses to cost-related medication adherence questions of 879 patients with uveitis who were enrolled in the National Institutes of Health All of Us Research Program database. To be eligible for inclusion, patients were required to have successfully completed at least one self-reported survey. Logistic regression analysis was employed to assess the relationship between race/ethnicity and medication adherence, controlling for relevant covariates.

Results: Patients with an annual income of less than $75 000 were significantly more likely than those with an income above $150 000 to report difficulty affording medication, delaying filling prescriptions, skipping doses, taking less medication, and exploring alternative therapies to save money. Patients aged 60 years and above were more likely to report difficulty affording medication, as were those without health insurance.

Conclusion: This study revealed that income and age are barriers to medication adherence. These findings have important implications for health care providers and policymakers, who should consider strategies to address these cost-related barriers to medication adherence.