Journal for Healthcare Quality最新文献

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.

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.

Background: Miscommunication is the leading cause of hospital medical error, most occurring during patient care handoffs. Even with successful implementation of a standardized handoff methodology, our hospital experienced continued handoff problems in the perioperative space. No studies have yet examined barriers to effective perioperative handoff communication.

Purpose: This study aims to identify and understand the barriers to effective perioperative handoffs that persist despite quality improvement efforts to improve handoff communication.

Methods: We initiated a qualitative study using thematic analysis of semistructured face-to-face interviews with nurses and physicians from perioperative units. Interviews were coded into themes and then categories.

Results: The barriers were categorized into administration, communication, and personnel. Administration involves knowledge and interpretation of administrative processes. Communication refers to forms and components of handoff communication and the environment where handoffs occur. Personnel refers to individual roles and responsibilities, and also as a quantitative resource. Specific quality improvement initiatives were proposed based on our study results.

Conclusions: Our findings suggest that successful handoff communication between perioperative areas requires identification of critical administrative, communication, and personnel barriers.

Implications: Hospitals can conduct similar interview-based studies to discover barriers to effective handoffs, and implement policies and procedures to improve safety in the perioperative space.

Introduction: Laboratory test utilization initiatives are well-studied in academic centers but less so in rural and community hospitals. We applied the EPIDEM model ( e xploration, p romotion, i mplementation, d ocumentation, e valuation, m odification) across a nine-hospital, predominantly rural health system to reduce unnecessary daily laboratory tests.

Methods: At the medical center, we began engaging key partners in October 2020 through targeted in-person meetings. Electronic health record (EHR) interventions (removing daily ×3 ordering, Choosing Wisely reminders, interval-based ordering restrictions) started system-wide in April 2021. Regional hospitals received EHR interventions and educational materials only.

Results: After clinical leadership approval in December 2020, our initiative's popularity accelerated, as groups requested inclusion. Across the health system, there was a 6%-20% reduction in tests per inpatient day. At the medical center, ordering decreased in December 2020 and dropped further with each EHR intervention. Unlike the sustained improvement observed at the medical center, ordering initially increased in the regional hospitals, decreased with each EHR intervention, but ultimately returned near baseline levels.

Conclusions: Social and behavioral strategies are essential for sustaining daily laboratory test reduction efforts. Lasting cultural change may require local champions at each hospital. The EPIDEM model prioritizes relational and contextual factors, enabling quality improvement even in resource-limited settings.