American Journal of Medical Quality最新文献

Although lung cancer claims more lives than any other cancer in the United States, screening is severely underutilized, with <6% of eligible patients screened nationally in 2021 versus 76% for breast cancer and 67% for colorectal cancer. This article describes an effort to identify key reasons for the underutilization of lung cancer screening in a rural population and to develop interventions to address these barriers suitable for both a large health system and local community clinics. Data were generated from 26 stakeholder interviews (clinicians, clinical staff, and eligible patients), a review of key systems (Electronic Health Record and billing records), and feedback on the feasibility of several potential interventions by health care system staff. These data informed a human-centered design approach to identify possible interventions within a complex health care system by exposing gaps in care processes and electronic health record platforms that can lead patients to be overlooked for potentially life-saving screening. Deployed interventions included communication efforts focused on (1) increasing patient awareness, (2) improving physician patient identification, and (3) supporting patient management. Preliminary outcomes are discussed.

Despite the widespread adoption of early warning systems (EWSs), it is uncertain if their implementation improves patient outcomes. The authors report a pre-post quasi-experimental evaluation of a commercially available EWS on patient outcomes at a 700-bed academic medical center. The EWS risk scores were visible in the electronic medical record by bedside clinicians. The EWS risk scores were also monitored remotely 24/7 by critical care trained nurses who actively contacted bedside nurses when a patient's risk levels increased. The primary outcome was inpatient mortality. Secondary outcomes were rapid response team calls and activation of cardiopulmonary arrest (code-4) response teams. The study team conducted a regression discontinuity analysis adjusting for age, gender, insurance, severity of illness, risk of mortality, and hospital occupancy at admission. The analysis included 53,229 hospitalizations. Adjusted analysis showed no significant change in inpatient mortality, rapid response team call, or code-4 activations after implementing the EWS. This study confirms the continued uncertainty in the effectiveness of EWSs and the need for further rigorous examinations of EWSs.

The need for a method to examine complex, multidisciplinary processes involving many diverse organizations initially led multiple US federal agencies to adopt the traditional Kaizen, a Lean process improvement method typically used within a single organization, to encompass multiple organizations each with its own leadership and priorities. First, the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology adapted Kaizen to federal agency processes for the development of electronic clinical quality measures. Later, the Centers for Disease Control and Prevention (CDC) further modified this adapted Kaizen during its Adapting Clinical Guidelines for the Digital Age (ACG) initiative, which aimed to improve the broader scope of guideline development and implementation. This is a methods article to document the adapted Kaizen method for future use in similar complex processes, illustrating how to apply the adapted Kaizen through CDC's ACG initiative and showing the reach achieved by using the adapted Kaizen method. The adapted Kaizen includes pre-Kaizen planning, a Kaizen event, and post-Kaizen implementation that accommodate multidisciplinary and multi-organizational participation. ACG included 5 workgroups that each developed products to support their respective scope: Guideline Creation, Informatics Framework, Translation and Implementation, Communication and Dissemination, and Evaluation. Despite challenges gathering diverse perspectives and balancing the competing priorities of multiple organizations, the ACG participants produced interrelated standards, processes, and tools-further described in separate publications-that programs and partners have leveraged. Use of a siloed approach may not have supported the development and dissemination of these products.

Existing literature supports the view that adverse outcomes from surgical interventions are more likely to be the result of degraded nontechnical skills (NTS) rather than the technical skills of surgeons. In the present context, NTS comprise the behaviors and cognitions deployed by surgeons to make decisions, maintain awareness of the operating environment, communicate with and lead supporting personnel. A contemporary safety thesis suggests that focusing on what makes things go right (eg, NTS) is far more productive than retrospective analysis (learning from mistakes). The present qualitative research explored how surgeons deploy NTS to facilitate safe and effective outcomes from surgical interventions. The thematic analysis revealed that this surgical cohort engaged specific self-regulated NTS along an intervention construct consisting of planning, implementation, monitoring progress, and deliberate learning through reflection during the preoperative, operative, and postoperative phases of care. Behaviors supporting these contentions were identified in the data and used to amplify use of the construct.

Clinical practice guidelines (CPGs) support individual and population health by translating new, evidence-based knowledge into recommendations for health practice. CPGs can be provided as computable, machine-readable guidelines that support the translation of recommendations into shareable, interoperable clinical decision support and other digital tools (eg, quality measures, case reports, care plans). Interdisciplinary collaboration among guideline developers and health information technology experts can facilitate the translation of written guidelines into computable ones. The benefits of interdisciplinary work include a focus on the needs of end-users who apply guidelines in practice through clinic decision support systems as part of the Centers for Disease Control and Prevention's (CDC's) Adapting Clinical Guidelines for the Digital Age (ACG) initiative, a group of interdisciplinary experts proposed a process to facilitate the codevelopment of written and computable CPGs, referred to as the "integrated process (IP)."1 This paper presents a framework for evaluating the IP based on a combination of vetted evaluation models and expert opinions. This framework combines 3 types of evaluations: process, product, and outcomes. These evaluations assess the value of interdisciplinary expert collaboration in carrying out the IP, the quality, usefulness, timeliness, and acceptance of the guideline, and the guideline's health impact, respectively. A case study is presented that illustrates application of the framework.

The Centers for Disease Control and Prevention's Adapting Clinical Guidelines for the Digital Age initiative aims to redesign and improve guideline development, implementation, and standardization. Historically, aspects of guideline development and implementation have been siloed. This leads to long lag times for guidelines to reach patient care, unnecessary redundancy, and potential for misinterpretation, leading to inconsistencies in how the recommendations are applied. A multidisciplinary, multiorganizational holistic approach brought together experts in guideline development, informatics, communication, implementation, and evaluation to understand and identify problems in guideline development and implementation, define an ideal state with no constraints, and then design a future state that advances the process close to the ideal state. The Adapting Clinical Guidelines for the Digital Age workgroups each worked on one focus area and included experts from the other areas to help analyze the current state and develop holistic solutions for the future state. Each workgroup produced interrelated standards, processes, and tools that can be used across the continuum of guideline development and implementation.

The goal of this article is to describe an integrated parallel process for the co-development of written and computable clinical practice guidelines (CPGs) to accelerate adoption and increase the impact of guideline recommendations in clinical practice. From February 2018 through December 2021, interdisciplinary work groups were formed after an initial Kaizen event and using expert consensus and available literature, produced a 12-phase integrated process (IP). The IP includes activities, resources, and iterative feedback loops for developing, implementing, disseminating, communicating, and evaluating CPGs. The IP incorporates guideline standards and informatics practices and clarifies how informaticians, implementers, health communicators, evaluators, and clinicians can help guideline developers throughout the development and implementation cycle to effectively co-develop written and computable guidelines. More efficient processes are essential to create actionable CPGs, disseminate and communicate recommendations to clinical end users, and evaluate CPG performance. Pilot testing is underway to determine how this IP expedites the implementation of CPGs into clinical practice and improves guideline uptake and health outcomes.