Quality Management in Health Care最新文献

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.

Preoccupation with failure is a foundational component of high reliability organizations. However, this can work in opposition to a simultaneous and arguably conflicting priority, the promotion of self-efficacy, which is linked to healthcare worker satisfaction, performance and wellness. This commentary posits that focusing on failures can undermine self-efficacy, which may lead to decreased task performance. This results in today's healthcare quality and safety leaders facing a catch-22 and a preoccupation with failure-wellness paradox. We propose that institutional quality improvement initiatives, when well-structured with appropriate training and focused resources, can serve as a buffer between the preoccupation with failure and a confident, engaged, and productive workforce.

Background and objective: Disease management (DM) programs are a promising strategy to reduce readmissions after hospitalization for acute heart failure (HF). Although commercial health insurers (payers) often offer DM programs, engaging patients early after discharge can be challenging. To better support the use of payers' DM programs, we developed a referral process for hospital teams to identify and refer patients prior to discharge by educating them about the benefits of DM and to anticipate contact from their insurer, while also alerting the payers to the treatment plans for individual patients.

Methods: A pilot of the referral program was tested between a non-profit hospital and 2 regional payers from August 2020 to May 2022. Collaboratively designed by payers, clinicians, and researchers, the process aimed to educate and refer patients being discharged after HF hospitalization. Screening and referral logs tracked referral rates over time, and monthly stakeholder calls were conducted among payers and hospital clinicians to identify barriers and facilitators to iteratively improve the process.

Results: Among 331 patients hospitalized for HF, 76% (N = 257) were screened. Of those screened, 77.8% (N = 200) were eligible for referral, and 74.5% (N = 149) of patients chose to be referred. Of those referred, 17.4% (N = 26) enrolled in the program. Initially, staff shortages were associated with delayed or incomplete referrals, leading to a centralized process of a single person assuming responsibility for screening and referral, which significantly increased screening rates from 51.9% to 82.4% (P < 0.001). Enhanced referral forms containing additional clinical data, alongside payers' electronic health record access, improved enrollment. The lack of a central enrollment registry led to data reconciliation challenges.

Conclusion: This study underscores the potential effectiveness of dedicated staffing to support screening and effectively make referrals to insurers' DM programs. Future initiatives should consider facilitating payers' access to patients' electronic health records, deploying dedicated staff for screening and referral, and creating registries for real-time referral and enrollment tracking.

Background and objectives: Maintaining current and accurate problem and medication lists improves quality of care. Reviewing and updating these lists can be time-consuming and add to clinicians' cognitive load, thus increasing risk of clinician burnout. Maintaining these lists were core measures in the Centers for Medicare and Medicaid Services' Meaningful Use electronic health record (EHR) incentive program. It may appear that the easiest way to indicate that problem or medication lists are up-to-date is to have clinicians attest to the review by checking a box in the EHR. Yet, whether these reviews and maintenance are actually taking place or if they are merely "check-the-box" activities remains unclear. This study aimed to understand the relationship between clinician attestation of problem and medication list review and the length of these lists.

Methods: This multi-method study retrospectively analyzed EHR data from 24 Federally Qualified Health Centers to characterize problem and medication lists, and survey data to gauge the cognitive burden due to list review activities. EHR data were collected on patients with at least 2 visits between June 1, 2021 and May 30, 2022. The provides visited were from two health centers and they were surveyed from December 20, 2022 to March 3, 2023.

Results: Our EHR data sample consisted of 362 436 patients seen by 2054 providers at 1 346 645 encounters. Eighteen percent of patients had a problem list with over 20 items; one percent had a medication list with over 20 items. Six patients had over 100 problems on their list, with the longest being 145. Twenty-three percent of patients had 1 or more duplicate diagnoses. Clinicians attested to reviewing problem and medication lists in the vast majority of encounters. There was no meaningful correlation between list lengths and attestation or between problem list duplication and attestation. Among the 49 survey respondents, the mean rating of mental effort for a comprehensive review of the problem list was 8.3 on a 9-point scale and 8.0 for medication list review.

Conclusion: Our findings revealed that problem and medication lists are sometimes long with unnecessary items. Attestation that the list has been reviewed does not equate to shorter and less duplicative lists. These findings may indicate that the clinician attestation process during clinical encounters is often done whether or not a problem and medication list has, in fact, been updated. Attestation may be a "check-the-box" activity imposing cognitive burden on clinicians to meet a metric while missing the goal of a focused and uncluttered list.

Background and objectives: Proper lighting in hospitals is essential for patient care and operational efficiency. This study assessed lighting compliance in a tertiary care hospital, considering both objective measurements and subjective evaluations.

Methods: This observational study was conducted in various hospital departments, including operating theatre, intensive care unit (ICU), accident and emergency (A&E), and wards. Two methods were used: illuminance measurement with a lux meter and checklist-based compliance assessment. Results were compared to national standards (Bureau of Indian Standards, SP 72).

Results: The study found that over 90% of areas had lighting below the recommended standards. Operating theatre compliance was 20%, ICU compliance was 18%, and A&E had 0%. Compliance based on checklist assessment was highest in operating theatres (54%) and lowest in acute medical wards (12.5%).

Conclusions: The study revealed significant gaps in hospital lighting compliance. The study suggests optimizing lighting placement and types (eg, light emitting diode (LEDs)) and incorporating lighting standards into hospital accreditation guidelines.

Background and objectives: Health care institutions must provide equitable quality care for all patient populations. Despite this, data supports that hospitals struggle to do this for patients with non-English language preference (NELP). We describe the efforts of an academic department of medicine at a tertiary care hospital that serves a large number of patients with NELP.

Methods: We describe our stakeholder-engaged approach in developing a strategy for caring for patients with NELP.

Results: The lessons learned during the process of developing a departmental strategy for caring for patients with NELP are described. The paper ends with future directions of our work.

Conclusion: Leveraging multidisciplinary stakeholder engagement, our department raised awareness of the challenges that the patients with NELP can face as they navigate health care, resulting in institutional support for building a program for improving quality of care for the population.

Background and objective: Diagnosis of upper limb illness by upper extremity specialists may be more straightforward when patients relate matter-of-fact descriptions more so than interpretation of symptoms, which can be inaccurate and misleading. This study investigated the accuracy of diagnosis when specialists are presented with interpretations compared to descriptions of symptoms.

Methods: Upper extremity specialists reviewed 4-sentence descriptions of symptoms of 7 nontraumatic upper limb diseases in typical American spoken English. Text for the descriptions was sourced from a set of transcripts of audio and video recorded visits: half matter-of-fact descriptions of common symptoms, and half reflecting common misinterpretations of symptoms. The 4 sentences were randomly presented one at a time and the surgeons provided text descriptions of their guess at the diagnosis and rated the likelihood of symptom misinterpretations.

Results: The number of sentences until correct diagnosis was significantly lower for the matter-of-fact descriptions (median 1 vs median "unable to diagnose") compared to the symptom interpretations. For the matter-of-fact descriptions, most surgeons (>80%) correctly guessed the diagnosis on the first sentence. Specialists detected symptom misinterpretation in the scenario language.

Conclusion: These findings suggest that difficulty in diagnosis is associated with patient interpretation rather than description of symptoms. While interpretation of symptoms is an important part of illness, the pathophysiology may be best discerned when patients provide matter-of-fact descriptions rather than interpretation of their symptoms.

Background and objectives: Globally, healthcare has experienced unsustainable cost inflation. Therefore, innovative approaches must be considered to curb these ever-increasing costs. Hospitals, which play a central role in every healthcare system, contribute significantly to cost increases, largely through the acceleration of operational complexity. Such evolutionary phenomena have rendered Hospital Performance Assessments (HPA) vitally important to healthcare leaders, health service researchers, and policymakers, especially amid the current global revolution in value-based payments. This study aimed to examine the growing importance of HPA in hospital and healthcare system management and to propose the development of a comprehensive HPA framework.

Methods: We conducted a comprehensive literature review considering the historical and current frameworks and operational HPAs. This includes an overview of the most common quantitative methods, global and national health databases, and methodological integration into hospital performance assessments. We propose a new comprehensive framework to develop more effective HPAs.

Results: This study proposes a comprehensive framework that captures the intricate complexities of healthcare evolution that encompasses service area attributes, Hospital Attributes, the Organizational Processes and Managerial Technologies in place, and the measured Domains of Hospital Performance.

Conclusion: There is a critical need to develop innovative HPAs and associated assessment frameworks to facilitate researchers and leaders in studying and managing healthcare systems worldwide.

Background: Targeted temperature management (TTM) is widely used for patients presenting with cardiac arrest for its neuroprotective effects and has been shown to improve neurological outcomes and survival. In keeping with the adage "time is brain" and per prior retrospective studies supporting earlier initiation of TTM, we conducted a quality improvement project to improve Door to TTM initiation time (DTT).

Objectives: Our primary aim was to reduce DTT in patients who presented with Out-of-Hospital Cardiac Arrest (OHCA). Our secondary aims were to determine the factors for the delay in initiation of TTM, determine the knowledge and perspectives regarding TTM, address gaps in knowledge, and identify system issues to reduce time to TTM initiation.

Methods: To assess knowledge and perspectives about TTM and any delays in initiation, a baseline survey of clinicians involved in the direct care of OHCA patients was conducted. A series of interventions followed after which a post-intervention survey was conducted.

Results: Post-intervention there was an increased proportion of participants who had read the TTM protocol (but not significantly different) (69.1% vs 84.6%, P = .07) and a decreased proportion believed that TTM was initiated at a satisfactory time on eligible patients (54.4% vs 30.8%, P = .02). The mean DTT decreased sequentially from a baseline of 5.3 hours to 1 hour, post-interventions. The mean DTT among non-survivors (n = 21) was 5.51 (95% CL: 3.86-7.16) hours and the mean DTT among survivors (n = 6) was 2.58 (95% CL: 0.98-4.19) hours with a difference that was not statistically significant for a 5% level of significance at a P-value of .068.

Conclusion: Our QI project interventions were successful in lowering the DTT for OHCA patients. Larger and longer studies are needed to study associations between TTM initiation time, and neurological and survival outcomes.

Background: Effective discharge planning is an important factor of hospital care and should follow a comprehensive assessment of patients at risk for adverse events during discharge. The study's aim was to analyze whether the use of the Blaylock Risk Assessment Screening Score (BRASS) at admission leads to a reduction in the hospital length of stay (LOS), a reduction in readmission rates, an influence on the discharge destination at the University Hospital of Graz, and an increase of end user's satisfaction.

Methods: BRASS was implemented into the routine nursing assessment at admission for 3 months in 2021 at 2 Neurology wards at the University Hospital of Graz. These data were retrospectively compared to 2 previous time periods without BRASS. For the prospective part of this study, a paper-based survey was performed to analyze the satisfaction of the nurses at the 2 wards with the application of BRASS.

Results: The median LOS was significantly longer during the time of the assessment with BRASS as compared to the 2 years before [8 (4, 14) days in 2021, 6 (4, 10) days in 2020, 6 (4, 9) days in 2019; 2021 vs 2020: P = .002; 2021 vs 2019: P < .001]. Readmission rates did not differ significantly, but outpatient readmission decreased compared to 2019 (17% in 2021, 23% in 2019, P = .040).

Conclusion: The use of BRASS did not reduce the length of hospital stay compared to the 2 years before, but outpatient readmission rates decreased and discharge home was more frequent. Therefore, BRASS might be a helpful tool to improve discharge management and avoid readmissions.