Journal for Healthcare Quality最新文献

Abstract: In this article, we describe our experience developing and implementing a multipronged approach to improve performance across a strategic subset of quality measures within primary care. Detailed techniques include data visualization and analytics, process reengineering, team engagement, visual project management, continuous improvement methods and training, and incentives and recognition. We achieved positive change across 12 high priority measures which we deemed the "High Value Framework (HVF)" by fostering a collaborative, nonpunitive, problem-solving culture. We focused on measures that had the greatest potential for impact from a clinical, reimbursement, and reputational perspective. More importantly, we sustained gains despite the challenges posed by the COVID-19 pandemic, thereby demonstrating programmatic resilience and high process reliability. This systematic approach serves as a practical blueprint for other healthcare entities seeking to navigate the complexities of quality improvement in a dynamic environment. The model provides a strategic framework for prioritizing and standardizing quality measures, effectively engaging stakeholders, and managing organizational change. Our model emerged from a need to address real-world operational challenges, rather than as an academic or theoretical exercise, and was developed independently of existing literature on measure prioritization and standardization at the time of its inception.

Abstract: Gender and sexual minority individuals experience higher rates of mistreatment and discrimination in healthcare compared with their non-lesbian, gay, bisexual, transgender, queer, and other nonheterosexual (LGBTQ+) peers. The Healthcare Equality Index (HEI) aims to create more inclusive environments and to provide metrics for quality improvement. Currently, only one adult hospital in the District of Columbia has earned the highest recognition from the HEI. Our institution is part of the same regional health system as this hospital, yet has never been evaluated by the HEI. This study explores the knowledge, attitudes, and perceptions surrounding the HEI at our institution to assess the feasibility of its participation. During the study period of July 2021 to June 2022, a total of 12 physicians, administrators, and educators from both hospitals and our affiliated school of medicine were interviewed. All participants expressed support after HEI requirements and improving inclusivity for LGBTQ+ patients. Participants at the other hospital cited unanimous support amongst hospital administrators as key for successful HEI implementation. Participants also mentioned cost, staff shortages, and the school of medicine's religious affiliation as potential barriers to this goal. Ultimately, hospital implementation of HEI guidelines is feasible despite shifting institutional priorities and resource limitations through greater stakeholder buy-in and streamlining a systemwide approach.

Background/purpose: Documentation of resuscitation preferences is crucial for patients undergoing surgery. Unfortunately, this remains an area for improvement at many institutions. We conducted a quality improvement initiative to enhance documentation percentages by integrating perioperative resuscitation checks into the surgical workflow. Specifically, we aimed to increase the percentage of general surgery patients with documented resuscitation statuses from 82% to 90% within a 1-year period.

Methods: Three key change ideas were developed. First, surgical consent forms were modified to include the patient's resuscitation status. Second, the resuscitation status was added to the routinely used perioperative surgical checklist. Finally, patient resources on resuscitation processes and options were updated with support from patient partners. An audit survey was distributed mid-way through the interventions to evaluate process measures.

Results: The initiatives were successful in reaching our study aim of 90% documentation rate for all general surgery patients. The audit revealed a high uptake of the new consent forms, moderate use of the surgical checklist, and only a few patients for whom additional resuscitation details were added to their clinical note.

Conclusions: We successfully increased the documentation percentage of resuscitation statuses within our large tertiary care center by incorporating checks into routine forms to prompt the conversation with patients early.

Introduction: Healthcare disparities may be exacerbated by upstream incapacity to collect high-quality and accurate race, ethnicity, and language (REaL) data. There are opportunities to remedy these data barriers. We present the Denver Health (DH) REaL initiative, which was implemented in 2021.

Methods: Denver Health is a large safety net health system. After assessing the state of REaL data at DH, we developed a standard script, implemented training, and adapted our electronic health record to collect this information starting with an individual's ethnic background followed by questions on race, ethnicity, and preferred language. We analyzed the data for completeness after REaL implementation.

Results: A total of 207,490 patients who had at least one in-person registration encounter before and after the DH REaL implementation were included in our analysis. There was a significant decline in missing values for race (7.9%-0.5%, p < .001) and for ethnicity (7.6%-0.3%, p < .001) after implementation. Completely of language data also improved (3%-1.6%, p < .001). A year after our implementation, we knew over 99% of our cohort's self-identified race and ethnicity.

Conclusions: Our initiative significantly reduced missing data by successfully leveraging ethnic background as the starting point of our REaL data collection.

Abstract: Code status (CS) is often overlooked while admitting patients to the hospital. This is important for patients with end-stage disease. This quality improvement project investigated whether a CS pop-up alert in the electronic medical record, combined with provider education, improved addressing CS. The project consisted of a baseline chart review, implementation of the alert and physician education, and a postintervention chart review. We reviewed 1828 charts at baseline and 1,775 at postintervention. From univariable analysis, there were improvements in addressing CS, being full code, cardiopulmonary resuscitation, intubation, use of vasopressors, and cardioversion technique categories (all p < .001). Documentation of do not resuscitate did not change. From logistic regression, after controlling for age, race, end-stage liver disease, stroke, cancer, hospital unit, and sepsis, patients in the postintervention period were two times more likely to have CS addressed (odds ratio [OR] = 2.04, p < .001). There was a significant improvement in CS documentation from our interventions.

Abstract: Central line-associated blood stream infections (CLABSIs) are a quality marker for the critical care environment. They have become an area of particular interest because they cost the healthcare system close to a billion dollars per year and have a significant impact on patient safety. Through a preliminary analysis of our system's CLABSI rates, we found significantly higher rates than the national average, prompting further investigation. We decreased our CLABSI rate by over 40% from 2021 (1.6 per 1,000 line days) to the fourth quarter of 2022 (0.91) and kept the rate below or around the national rate (0.86) for the last three quarters of 2022. Through looking at current outcome data, identifying key stakeholders, developing dedicated committees, conducting root cause analyses, monitoring progress, adjusting procedures, scaling to the system, and continuously monitoring and reporting results, we have shown the efficacy of this kind of quality improvement structure and strive to reduce our hospital system's impact on avoidable healthcare-associated patient harm.

Introduction: Handoffs between the operating room (OR) and post-anesthesia care unit (PACU) require a high volume and quality of information to be transferred. This study aimed to improve perioperative communication with a handoff tool.

Methods: Perioperative staff at a quaternary care center was surveyed regarding perception of handoff quality, and OR to PACU handoffs were observed for structured criteria. A 25-item tool was implemented, and handoffs were similarly observed. Staff was then again surveyed. A multidisciplinary team led this initiative as a collaboration.

Results: After implementation, nursing reported improved perception of time spent (2.63-3.68, p = .02) and amount of information discussed (2.85-3.73, p = .05). Anesthesia also reported improved personal communication (3.69-4.43, p = .004), effectiveness of handoffs (3.43-3.82, p = .02), and amount of information discussed (4.26-4.76, p = .05). After implementation, observed patient information discussed during handoffs increased for both surgical and anesthesia team members. The frequency of complete and near-complete handoffs increased (40%-74%, p < .001).

Conclusions: A structured handoff tool increased the amount of essential information reported during handoffs between the OR and PACU and increased team members' perception of handoffs.

Introduction: To address healthcare spending growth and coordinated primary care, most states in the United States have adopted patient-centered medical homes (PCMHs). To evaluate urban rural difference on accessing PCMH among US children, particularly for children with developmental disabilities (DDs) and mental health disorders (MHDs).

Methods: This cross-sectional study used the 2016-2018 National Survey for Children's Health (NSCH). Multivariable adjusted logistic regression analyses were used to assess the association between accessing PCMHs and rurality and mental/developmental conditions/disorders.

Results: Children with both DDs and MHDs were statistically significantly higher in rural areas (10.9% rural vs. 8.3% urban, p ≤ .001). Children in rural areas reported higher odds of accessing PCMHs (14%) among all U.S. children, but no differences by subgroups for children with MHDs and/or DDs. Compared with children without DDs/MHDs, the reduction in access to PCMHs varies by children's health status (41% reduction for children both DDs and MHDs, 25% reduction for children with MHDs without DDs) effects. Children with MHDs/DDs were less likely to receive family-centered care, care coordination, and referrals.

Conclusions: Quality improvements through PCMHs could focus on family-centered care, care coordination, and referrals. Patient-centered medical home performance measurement could be improved to better measure mental health integration and geographical differences.

Abstract: The implementation of the National Health Insurance has transformed the medical care landscape in Taiwan, rendering perceived medical service quality (PMSQ) and patient satisfaction significant focal points in medical care management. Past studies mostly focused on the technical aspects of medical care services, while overlooking the patients' perception of services and the delivery process of PMSQ in the medical care experience. This study integrated the theoretical framework of the Donabedian SPO model and the SERVQUAL questionnaire. The survey was conducted among the outpatients of three types of medical institutions in northern Taiwan: academic medical centers, metropolitan hospitals, and local community hospitals. A total of 400 questionnaires were collected, and 315 valid questionnaires remained after eliminating the incomplete ones. This study established a PMSQ delivery model to explore patients' perceptions of medical service quality. It was found that the variable, Assurance, could deliver the PMSQ and enhance the Medical outcome (MO), while improving the variable, Tangible, in medical institutions could not significantly enhance the MO. These findings emphasize the importance of healthcare institutions prioritizing the professional background, demeanor of their healthcare staff, treatment methods, and processes over tangible elements.

Background: Veterans Affairs (VA) implemented the Veteran-centered Whole Health System initiative across VA sites with approaches to implementation varying by site.

Purpose: Using the Consolidated Framework for Implementation Research (CFIR), we aimed to synthesize systemic barriers and facilitators to Veteran use with the initiative. Relevance to healthcare quality, systematic comparison of implementation procedures across a national healthcare system provides a comprehensive portrait of strengths and opportunities for improvement.

Methods: Advanced fellows from 11 VA Quality Scholars sites performed the initial data collection, and the final report includes CFIR-organized results from six sites.

Results: Key innovation findings included cost, complexity, offerings, and accessibility. Inner setting barriers and facilitators included relational connections and communication, compatibility, structure and resources, learning centeredness, and information and knowledge access. Finally, results regarding individuals included innovation deliverers, implementation leaders and team, and individual capability, opportunity, and motivation to implement and deliver whole health care.

Discussion and implications: Examination of barriers and facilitators suggest that Whole Health coaches are key components of implementation and help to facilitate communication, relationship building, and knowledge access for Veterans and VA employees. Continuous evaluation and improvement of implementation procedures at each site is also recommended.