Journal for Healthcare Quality最新文献

Background: Percutaneous ultrasound-guided core needle biopsies (CNB) and fine needle aspirations (FNA) provide high yield and minimal risk for neck pathology diagnosis. Organizational shifts led to the planned closing of a long-standing pathology FNA clinic and a potential doubling in biopsy volume for our neuroradiology neck biopsy service.

Purpose: We formulated a quality improvement (QI) initiative with three goals for our service: (1) maintain or decrease mean days to biopsy, (2) maintain or decrease variation in days to biopsy, and (3) maintain diagnostic yield.

Methods: We added physician assistants to the biopsy team and opened a community hospital biopsy clinic. Weekly neuroradiology neck CNB and FNA were tracked from September 4, 2023, to June 23, 2024.

Results: As anticipated, biopsy volume nearly doubled (6.1 ± 2.4 to 12.1 ± 1.2 per week between the first and last 8 weeks, p = .006). Statistical process control methods showed special cause shorter mean times-to-biopsy (8.6 days from 9.6 days) and special cause reduced week-to-week variation (0.8 days from 2.0 days) attributable to our process changes without special cause change in diagnostic rate (90.1% across the project period).

Conclusions: These results highlight the successful application of QI methodology to modify and monitor volume-driven adaptations in a medical procedure clinic.

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: 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.

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.

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.

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.