Quality Management in Health Care最新文献

Background and objectives: Spine surgery is associated with a high incidence of postoperative medical adverse events (AEs). Many of these events are considered "minor" though their cost and effect on outcome may be underestimated. We sought to examine the clinical and cost-effectiveness of a postoperative quality improvement (QI) care bundle in mitigating postoperative medical AEs in adult surgical spine patients.

Methods: We collected 14-year prospective observational interrupted time series (ITS) with two historical cohorts: 2006 to 2008, pre-implementation of the postoperative QI care bundle; and 2009 to 2019, post-implementation of the postoperative QI care bundle. Adverse Events were identified and graded (Minor I and II) using the previously validated Spine AdVerse Events Severity (SAVES) system. Pearson Correlation tested for changes across patient and surgical variables. Adjusted segmented regression estimated the effect of the postoperative QI care bundle on the annual and absolute incidences of medical AEs between the two periods. A cost model estimated the annual cumulative cost savings through preventing these "minor" medical AEs.

Results: We included 13,493 patients over the study period with a mean of 964 per year (SD ± 73). Mean age, mean Charlson Comorbidity Index (CCI), and mean spine surgical invasiveness index (SSII) increased from 48.4 to 58.1 years; 1.7 to 2.6; and 15.4 to 20.5, respectively (p < 0.001). Unadjusted analysis confirmed a significant decrease in the annual number of all medical AEs (p < 0.01). When adjusting for age, CCI and SSII, segmented regression demonstrated a significant absolute reduction in the annual incidence of cardiac, pulmonary, nausea and medication-related AEs by 9.58%, 7.82%, 11.25% and 15.01%, respectively (p < 0.01). The postoperative QI care bundle was not associated with reducing the annual incidence of delirium, electrolyte levels or GI AEs. Annual projected cost savings for preventing Grade I and II medical AEs were $1,808,300 CAD and $11,961,500 CAD.

Conclusion: Postoperative QI care bundles are effective for improving patient care and preventing medical care-related AEs, with significant cost savings. Postoperative QI care bundles should be tailored to the specific vulnerability of the surgical population for experiencing AEs.

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: 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.

Methods: 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).

Conclusion: 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.

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: Bundled interventions and auditing have been recommended to reduce central line-associated bloodstream infection (CLABSI) events at acute care hospitals. We review the outcomes of a bundle audit program at an adult and pediatric academic medical center from April 1, 2021, to May 31, 2022. To analyze the impact on CLABSI rates following the introduction of a central line maintenance bundle audit process.

Methods: All audit survey data, CLABSI event rates, and line days were collected. Statistical relationships were evaluated for CLABSI bundle performance with CLABSI rates and audit volume with CLABSI rates. Analyses were conducted at the hospital and unit level.

Results: No correlation is found between CLABSI rates and audit performance at the hospital level (adult units, P = .619, r-sq = 2.13%; peds/NICU, P = .825, r-sq = 0.43%) or at the unit level (n = 7; P = .8-.896, r-sq = 0.15%-18.2%). There was no correlation in CLABSI rates when reviewing performance by audit volume at the hospital level (adult, P = .65, r-sq = 1.7%; peds/NICU, P = .677, r-sq = 1.5%) or at the unit level (n = 7; P = .25-.8, r-sq = 1.2%-8.5%). By contrast, a single unit that did not participate in the audit program during the sample period reported a lower CLABSI rate than comparable participating units ( P = .008).

Conclusion: During the sample period, there was no relationship found between this CLABSI bundle audit program and improvement in CLABSI performance.

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: Histopathology has been increasingly playing a vital role in patient diagnosis. Histopathology laboratories have been riddled with multiple problems such as inefficiency, errors, and rising costs. Lean management, a concept derived from the Toyota production systems, helps in improving the operational efficiency by removing waste or errors. The lean concept has been demonstrated to reduce waiting times, improve patient safety and satisfaction, and reduce costs in health care. We aimed to assess the impact of lean management on the frequency of errors in the histopathology laboratory of a tertiary level hospital.

Methods: This was a before-and-after study where the lean process was implemented in a phased manner beginning with an assessment of its need by the senior specialists, data collection, training of staff, post-training data collection and analysis. The various errors that were possible in the workflow of the laboratory were identified. The frequency of errors in 2018 (pre-intervention) and 2021 (post-intervention) was noted and compared.

Results: Data collection from the pre-intervention period revealed that delay in microtomy, incorrect patient identification details on the requisition form, and sample received without appropriate fixative had the highest frequency of events leading to errors in histopathology. After the implementation of lean principles in the laboratory, the error frequency reduced by 30.79%. The highest decline was noted in the delay caused by grossing being performed in the morning hours (64.5% reduction), while the smallest reduction (16.67%) was noted for samples arriving from the clinical departments at erratic times.

Conclusion: The present study emphasizes that the implementation of simple measures of lean management in a histopathology laboratory can be effective in reducing errors and improving efficiency without adding to the cost to the laboratory.

Background and objectives: Assessment of acute coronary syndrome (ACS) has pressured rapid diagnostic evaluation through point of care troponins (POCT-Tns). However, POCT-Tns have demonstrated inconsistent accuracy compared to laboratory (LABT)-Tn. A POCT-Tn used inappropriately to "rule-out" ACS can lead to premature diagnostic closure. We aimed to minimize indiscriminate POCT-Tn testing, while balancing test turnaround time (TAT), institutional cost, and impact on patient time to disposition (TTD).

Methods: A quality improvement (QI) initiative from 2018 to 2022 included educational interventions and electronic health record (EHR) adaptations. We evaluated test characteristics, trended test frequency, TATs, cost, and TTD. We used statistical process control charts to evaluate changes in test frequency over time. We used the Mann-Whitney U and Wilcoxon Signed-Rank Sum test to analyze changes in TAT, TTD, and cost.

Results: POCT-Tn had high discordance with LAB-Tn (9.7%) and low sensitivity (52.5%). SPCs showed a significant decrease in POCT-Tn tests performed over time. LABT-Tn TATs were longer than POCT-Tn (54 vs 21 min; P < .001). Total Tn testing costs decreased by $668 827.83 annually. Compared to pre-initiative, arrival to disposition was 20 min longer for patients receiving a LABT-Tn (P < .001) and 37 min shorter for patients receiving a POCT with reflex to LABT-Tn (P < .001).

Conclusion: POCT-Tn test characteristics may place patients at risk for missed ACS. A combined approach using education and EHR adaptations decreased use of indiscriminate POCT-Tn tests, decreased health care costs, and resulted in clinically appropriate changes in disposition times for this large cohort of ED patients.