Journal for Healthcare Quality最新文献

Background: Rectal bleeding is a common concern among primary care patients and a risk marker for colorectal cancer. Yet, primary care patients who present with rectal bleeding frequently do not complete timely colonoscopies. We sought to determine if a phone-based, scheduling intervention for patients presenting with rectal bleeding in primary care would improve the rate of scheduling and completion of ordered colonoscopies.

Methods: We conducted a nonrandomized pre-post intervention study at an urban, academic, hospital-based primary care clinic. We included patients with a colonoscopy order for rectal bleeding who had not scheduled a colonoscopy within 2 weeks of the order date. We created a baseline cohort from August to October 2022 and an intervention cohort from November 2022 to June 2023. The pilot intervention involved up-to-3 outreach phone calls by a primary care-based phone service representative to study participants.

Results: Compared to the baseline cohort, patients in the intervention cohort had a significantly higher rate of colonoscopy completion at 365 days (p = .04). Higher rates in loop closure were seen across demographic cohorts.

Discussion: Proactive, primary care-based, outreach phone calls increased rates of completion of colonoscopies ordered for rectal bleeding.

Background: Target-based care (TBC) uses institutional data to create a shared mental model of anticipated postoperative milestones. This study evaluated the impact of a clinical effectiveness strategy, combining TBC with a clinical pathway and decision support, on outcomes in patients undergoing pectus excavatum repair.

Methods: This was a prospective study at a quaternary children's hospital between 2022 and 2024. Patients undergoing repair from 2018 to 2021 were historical controls. Target-based care included displaying bedside targets for length of stay (LOS) (outcome metric), Foley catheter and patient-controlled analgesia (PCA) discontinuation (process metrics), and a multidisciplinary evidence-based clinical pathway with an electronic order set.

Results: Overall, 91 patients were included: 52 preintervention and 39 postintervention. Median LOS decreased from 3 to 1.8 days (95% confidence interval [CI] 0.8-1.6, p < .05). The proportion of patients who met the LOS target of 2 days increased from 44.2% to 91.8% ( p < .05). The mean time to PCA discontinuation decreased from 1.6 to 0.8 days (95% CI 34.8-118.7, p < .05). The time to Foley catheter removal diminished from 22.2 to 17.1 hour (95% CI 0.6-9.6, p < .05).

Conclusions: A data-driven TBC with a clinical pathway had an immediate and sustained impact on patient care. Length of stay, PCA discontinuation, and time to Foley discontinuation decreased after TBC.

Abstract: Medical appointment no shows cause a delay in a patient receiving the care that they need and cause a burden for the health care provider organization. The purpose of this project was to explore whether the use of empathic language in preappointment text message communications with a patient would affect appointment attendance rates. This project was conducted within a mental health treatment organization and included 419 patients scheduled for a virtual intake appointment during a 30-day period. The results indicated that adjusting the language used in preappointment text message communication with patients did not generate a statistically significant change in attendance rates. Additional findings point to possible gender differences, although sample size limitations affected the strength of these findings. The days of the scheduled appointments also seemed to affect attendance rates.

Background: Human papillomavirus (HPV) vaccination rates lag behind other recommended adolescent vaccines. Practice- and clinician-based interventions to improve HPV vaccination rates are known to be effective in improving completion rates.

Purpose: The aim is to determine whether implementing bundled interventions across an integrated health system would result in systemwide improvements in HPV vaccination rates.

Methods: We assessed the impact of multilevel interventions across an integrated health system to increase HPV vaccination rates between 2019 and 2024 in a large and predominantly rural state. We analyzed the effects of implementing sequential bundles of interventions over multiple years, including efforts focused on quality improvement, physician leadership, electronic medical record enhancements, clinical decision support tools, and communications.

Results: Human papillomavirus vaccination completion rates improved from 46.2% in December 2019 to 55.4% in December 2024 (+9.2 percentage points), comparing favorably with changes in national rates during the same interval. These findings demonstrate that the interventions had a statistically significant impact on HPV vaccination rates in 13 year olds.

Conclusions: By applying multilevel interventions, a system-wide implementation strategy can be successful in increasing HPV vaccination rates across an integrated health system.

Background: Surgical instrument inventory optimization leads to sizable cost savings through tray reduction. Yet, a commonly overlooked benefit is the increase in efficiency stemming from reduced task variety for health care workers resulting from this reduction in inventory variety. We hypothesized that reducing the variety of surgical instrument trays would lead to significant improvement in reprocessing time, labor cost savings, and staff satisfaction.

Methods: We conducted a 12-month observational study at an academic hospital's medical device reprocessing (MDR) department before and after inventory optimization. The evaluated outcome measures were MDR time saved, labor cost reduction, and worker satisfaction as measured by an anonymized survey.

Results: After standardization, the results revealed that the time savings of new MDR technicians (14 ± 6.2 minutes) were significantly higher than the time savings of experienced MDR technicians (4.6 ± 5.7 minutes) (p < .001). The total reprocessing cost savings equal $2,575.96 Canadian Dollars (CAD) annually. We found a higher satisfaction with the standardized tray among MDR technicians, with eight of nine new MDR technicians (89%) significantly preferring it, and 12 of 19 (63%) experienced MDR technicians "somewhat" preferring the standardized tray.

Conclusion: Standardizing surgical trays enhances efficiency, reduces costs, and improves staff satisfaction, making it a valuable strategy in inventory management.

Introduction: Length of stay (LOS) is a critical metric for the efficient utilization of limited resources. A multidisciplinary task force in an academic hospital was created to optimize discharge planning with expanded resources to support a structured discharge process.

Methods: Between January and June 2023, multiple interventions were implemented in Hospital Medicine group. Inpatient LOS and other process, outcome, and balancing measures in the post-intervention period (July to December 2023) were compared to those in the pre-intervention period (July to December 2022). The patient demographics and clinical characteristics were adjusted for confounding factors.

Results: The mean inpatient LOS was 5.8 days post-intervention compared with 6.5 days in the pre-intervention cohort. After adjusting for potential confounding factors, we found a significant reduction in inpatient LOS by 0.56 days (p = .019), while it did not affect all-cause readmissions or emergency department (ED) visits within 30 days after discharge.

Conclusions: Our multidisciplinary discharge bundle, appropriate case management support level and documentation enhancement seem to be a promising approach for coordinating discharge communication and subsequently reducing the LOS. Our plan is to scale this approach to other clinical areas, address identified care progression delays, and better manage the ED throughput to improve the care delivery system.

Introduction: Less than 1/5th of eligible patients are prescribed statins for primary prevention in the United States.

Methods: We conducted a quality improvement program augmented by contextually responsive implementation strategies (IS), Plan-Do-Study-Act cycles, and Lean Six Sigma Principles to optimize statin therapy among 40-75-year-old patients without atherosclerotic cardiovascular diseases (ASCVD) in primary prevention in resident internal medicine clinic. We conducted needs assessment; identified process measures, barriers to statin optimization using discussions; and rank ordered these barriers. We mapped multiple IS to the barriers using discussions/consensus over 2 years. We retrofitted the IS to the Expert Recommendations for Implementing Change (ERIC) taxonomy to facilitate IS reporting.

Results: We noted significant improvement in process measures such as lipid panel orders (64.6% vs. 95.5%), its completion (78.6% vs. 95.3%), ASCVD risk score completion (3% vs. 91%), and statin therapy optimization (34.5% vs. 90%) over 2 years among eligible patients (baseline vs. final cohort, respectively; all p ≤ .001).

Conclusions: Using improvement and implementation science to identify needs assessment, process measures, and barriers in statin optimization and mapping IS to the barriers can help improve statin optimization in primary prevention. Our reporting of IS using the ERIC taxonomy should further help operationalize IS in other contexts.

Purpose: To evaluate whether acquisition of independent dialysis facilities by large chains is associated with changes in clinical quality metrics and patient-reported experiences of care.

Methods: We conducted a longitudinal cohort study using 2016-2020 data from Medicare Dialysis Facility Care Compare (DFC) and In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS). Facility acquisition was defined as the transition of a nonchain-owned facility to chain ownership. We estimated within-facility changes in clinical and patient-reported outcomes after acquisition using linear regression with facility and year fixed effects, adjusting for ownership type and facility size.

Results: Among 4,627 facilities in the DFC sample and 1,377 in the ICH-CAHPS sample, acquisition was associated with a 3.0% relative increase in hospitalization rates, a 9.4% increase in infection rates, and a 0.5% decline in dialysis adequacy. Patient-reported experiences showed a statistically significant 1.0% decline in reported information sharing while other experience metrics trended negatively but were not statistically significant.

Conclusions: Facility acquisition was associated with worsening clinical performance and small declines in patient experience. These findings suggest consolidation may negatively affect dialysis care quality, underscoring the need for closer oversight of industry mergers.

Background: Emergency department (ED) crowding is a crisis of an overstrained health care system that is associated with poor patient outcomes and dissatisfaction. We aimed to assess the effect of an interdisciplinary, provider-led triage team, "the Dugout," on ED length of stay (LOS), door-to-provider (DTP), and left without being seen (LWBS) rates.

Methods: We used a before-and-after design. The setting is an urban, teaching, adult and pediatric 63-bed emergency department with a total annual volume more than 90,000 and an admission rate of 35%. Data were collected on adult patients (18 years and older) who presented during a similar 6-month period before (October 2023-March 2024) and after (October 2024-March 2025) implementation of the Dugout.

Results: There were 34,106 and 31,704 adult encounters in the pre- and postimplementation periods, respectively. The Dugout was associated with a reduction in LWBS from 14.1% to 3.0% (p < .001). DTP decreased from a median of 59 to 38 minutes (p < .001). The median overall ED LOS decreased from 448 to 429 minutes (p < .001), and the LOS for discharged patients decreased from 407 to 344 minutes (p < .001).

Conclusions: The introduction of a dedicated, interdisciplinary team stationed in the triage area was associated with reduced LWBS, DTP, and ED LOS.

Objective: Low-value laboratories lead to healthcare inefficiencies, unnecessary interventions, and environmental waste. Maternal complete blood count (CBC) testing is routine after cesarean birth, but does not change clinical management in most cases. We aimed to decrease routine postpartum CBC testing at a tertiary-care hospital and replace it with targeted ordering for patients at increased risk of severe anemia.

Methods: After reviewing baseline practices, we implemented a quality improvement intervention with two plan-do-study-act (PDSA) cycles. The intervention involved modification of the CBC order in the electronic postpartum order set and creation of ordering criteria: hemoglobin ≤110g/L, above average blood loss, or operating time. The primary outcome was the postpartum CBC draw proportion. Short- and long-term data were collected and evaluated using a run chart.

Results: During PDSA2, we observed a reduction in CBC draws from 99% to 34% (n = 202). Nine patients met criteria for CBC but did not have a draw; none had signs or symptoms of anemia. Decrease in draws was stable at 1 year. Detection of severe anemia (≤70 g/L) was unchanged before and after intervention (2.4 vs. 2.3%, p = .88).

Conclusions: Our intervention resulted in a significant and sustained change in postpartum CBC ordering. Similar initiatives should consider modifying ordering criteria to suit local trends.