Journal for Healthcare Quality最新文献

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.

Background: The Centers for Medicare and Medicaid Services (CMS) reimburse hospitals through the Hospital Value-Based Purchasing Program (HVBP) based on clinical outcomes, safety, efficiency, and patient satisfaction, currently weighted equally. The aim is to explore whether adjusting these weights could address reimbursement inequities for safety net hospitals (SNH).

Methods: We assessed 2,731 non-federal hospitals using CMS payment files. They were divided into SNH and non-SNH based on their DSH (Disproportionate Share Hospital) status in 2020. We compared both groups' 2020 HVBP scores to ensure data accuracy and account for COVID-19 impacts.

Results: SNHs had lower person and community engagement domain scores (6.9) compared to non-SNHs (8.87, p<0.001), resulting in lower HVBP total performance scores (TPS) (p<0.001) and lower 2020 HVBP adjustment factors (p<0.001). Changing the TPS weights to 35% for clinical outcomes and safety, 25% for efficiency, and 5% for patient and community engagement improved TPS for SNH.

Conclusions: Prioritizing clinical outcomes and safety measures can ease financial pressure on SNH.

Introduction: Heart failure (HF) is one of the most common diagnoses in the United States during hospitalization. The incidence of HF is expected to increase in the future, coinciding with the expected increase in the utilization of post-acute care facilities. Recent studies have demonstrated that the implementation of an original Heart Failure Disease Management Program (HFDMP) has a significant potential to decrease readmissions. The Department of Internal Medicine at two acute care hospitals coordinated with a post-acute facility for the implementation of an HFDMP quality improvement project.

Methods: The interdisciplinary team developed the HFDMP, which included formalized training for the entire resident care staff, redesigning the post-acute facility's dietary manual, strengthening the postdischarge appointments workflow, creating a dedicated HF unit, identifying additional patient care supplies needed to care for residents with HF, and identifying metrics to monitor after implementation to determine success.

Results: Before the implementation of the program, the 30-day readmission rate of the HF hospital was 20%. After implementation, only one resident was readmitted for non-HF-related conditions, corresponding to a 30-day readmission rate of 2.78%.

Conclusions: The implementation of similar HFDMPs at post-acute care facilities across the country represents a significant opportunity to decrease 30-day readmissions and improve resource utilization.

Introduction: To improve access to care, the Veterans Administration (VA) offers eligible veterans the choice to receive Community Care (CC). Local changes to CC scheduling coincided with a decrease in expected surgical volumes. This project aimed to increase the retention of CC eligible veterans from 66% to 76% by September 2024, while prioritizing veteran autonomy.

Methods: The quality improvement team learned CC eligible veterans were not offered a choice between community and VA care during scheduling. A decentralized and individualized scheduling process was developed to ensure veteran choice was respected and to increase consult retention. Consult retention rates were measured as the intervention was progressively scaled across surgical disciplines.

Results: With the new scheduling process, retention rate increased from 66.1% to 69.3% and veteran choice was respected for over 5,500 veterans.

Conclusions: As both private and VA networks explore strategies to retain patients within their health systems, a decentralized scheduling approach may not significantly affect retention rates. However, this project highlights how easily complex health care processes can lose sight of patient-centered care, which must remain the ultimate goal.

Background: Patient satisfaction is a key indicator of health care quality, yet the impact of primary diseases on outpatient satisfaction remains underexplored. This study examined whether the primary disease independently influences patient satisfaction.

Methods: We retrospectively analyzed 8,259 outpatient experience records from clinics (n = 6,347), hospitals (n = 1,374), and tertiary hospitals (n = 538) using data from the 2023 Medical Service Experience Survey in Korea. The primary diseases for outpatient visit were categorized into 50 specific conditions grouped under 9 disease categories. Multivariate analyses were conducted, adjusting for demographic and health care-related factors.

Results: The primary disease was identified as an independent factor affecting satisfaction. Patients with cancer, particularly those with thyroid and breast cancer, reported the highest satisfaction, whereas patients with depression or bipolar disorder had the lowest. In addition, different diseases independently influenced satisfaction to varying degrees. Factors such as medical provider's manner (especially nurses) and facility convenience were also significantly associated with satisfaction.

Conclusions: Although the precise mechanisms remain unclear, the primary disease should be considered an important determinant of patient satisfaction. Future research should take into account the impact of specific diseases on patient satisfaction when designing studies or interpreting results.

Introduction: Hurricane Helene's disruption of Baxter's North Carolina manufacturing facility in September 2024 created significant supply disruptions and an urgent need to reduce intravenous fluid (IVF) usage across our 12 acute care hospital health system.

Methods: Our approach combined an integrated informatics and operational response that included real-time electronic health record monitoring, clinical decision support tools, and hospital-level operational interventions.

Results: We achieved and sustained a peak 44% reduction in IVF usage while maintaining quality metrics.

Conclusions: Analysis of 68,430 patient encounters demonstrated no significant changes in acute kidney injury or mortality rate, although demonstrating a reduction in length of stay. This study describes the rationale and impact of our approach and provides a framework for healthcare systems facing similar supply chain disruptions.

Background: Discharge to home is an increasingly used hospital metric unlikely to be met by all patients after hip fracture surgery. There has never been a study using a badge buddy system in patients with hip fracture to improve rates of discharge to home.

Methods: This was a retrospective review of patients who underwent hip fracture surgery between October 2022 and September 2024. The badge buddy was a tag placed on the ID badges of the hip fracture care team, containing information regarding fracture type and talking points for staff members. Primary outcome variables included discharge disposition and readmissions.

Results: A total of 172 patients were included in the control group and 163 patients in the badge buddy group. Discharge to home improved by 14.4% after project implementation (33.1% vs. 47.5%; p = .0038) without any differences in total readmissions (24 control vs. 22 badge buddy).

Conclusion: Use of the badge buddy is associated with an improved rate of discharge home in patients admitted to an orthopedic service without any difference in absolute number of readmissions after badge buddy initiation. The badge buddy system is a useful adjunct to create cohesive messaging across hospital staff to improve home discharge rates in our patients with hip fracture.

Introduction: Patient-centered care is paramount for optimal outcomes. To address this, at Meritus Health, we asked a simple, yet profound question: "What matters most to you? (WMM)" This question, integrated into the patients' electronic health records (EHRs), facilitates meaningful conversations and helps tailor care to align with patient goals. This initiative, grounded in the principles of Age-Friendly Healthcare from the John A. Hartford Foundation, underscores the power of information by enabling clinicians to gain a comprehensive understanding of their patients. Our implementation required significant teamwork and provider engagement. Over 3 years, we have recorded more than 65,000 responses, creating a strategic priority for the health system to personalize care, guide clinical decision making, and drive continuous improvement. This strategic priority is health system wide. Patient-facing units and departments all across the health system track and report monthly metrics on the number of WMM responses captured. In addition, many departments across the system lead quality-improvement projects to improve and refine the process of asking this question.

Methods: We assessed the patient responses to the WMM question to identify the frequency of common answers and also sought to review the implementation of the question process for learning.

Results: In our analysis of more than 65,000 patient responses, we categorized the answers into the top distinct groups with the top five categories identified being family and relationships (noted 38% of the time), well-being (22%), health concerns (15%), lifestyle (6%), and religion and faith (3%).

Conclusions: Asking and knowing WMM to patients offers more than just insight; it builds a meaningful conversation and relationship between the provider and patient in knowing the whole person. The top responses from patients are intuitively not surprising. The key to our questioning of the patients and the integration in the EHR are not the responses themselves, but the process of asking, knowing, and acting on WMM to patients. Ultimately, asking WMM can be a powerful tool in advancing patient-centric care and building population health.

Abstract: Unplanned return emergency department (ED) visits (RV) and return ED visits leading to admission (RVA) are common. A comprehensive assessment of prognostic factors associated with RVs and RVAs is required to guide further inquiry into how they might be mitigated. We conducted a prognostic indicator systematic review of factors associated with an emergency department (ED) return visit (RV) and RV with admission (RVA) within 30 days of the index ED visit using PRIMSA guidelines (PROSPERO #CRD42023483802). After searching Medline, EMBASE, CINAHL, and Cochrane Library, two investigators independently screened titles/abstracts, extracted data, and assessed risks of bias using the QUIPS template. In total, six studies were included. Most studies were hampered by risks of bias from study participation and study attrition. We found wide variation in the inclusion or exclusion of patient phenotypes associated with frequent ED utilization in the denominator of patients at risk for RV and RVA. Ultimately, heterogeneity and risk of bias precluded meta-analyses. We tabulated ranges of odds ratios for multiple subject-level, ED-level, and hospital-level prognostic factors. Male patient sex, Medicaid or Medicare insurance, and lower acuity emergency severity index scores were most consistently associated with higher risks of RV and RVA within 30 days.