Showing papers in "Journal for Healthcare Quality in 2016"

Ohio Children's Hospitals' Solutions for Patient Safety: A Framework for Pediatric Patient Safety Improvement.

Abstract: Objectives Building upon their previous collective success and a clinical imperative for rapid improvement, the eight tertiary pediatric referral centers in Ohio sought to dramatically decrease the most serious types of harm that occur to hospitalized children by collectively employing high reliability methods focused on safety culture. Methods With the support of the hospitals’ executives, the Ohio collaborative obtained legal protection and built will by clearly identifying types and frequency of harm events that occur in each participating hospital and across the state. The improvement efforts were divided among task forces designed to incorporate the principles of high reliability organizations into the work of all employees, focusing primarily on the consistent application of error prevention behaviors. Results Between January 2010 and October 2012, the serious safety event rate among the participating hospitals decreased by 55%, equating to 70 fewer children per year who experienced this most severe type of event in the participating hospitals. Between January 2011 and October 2012, all events of serious harm were decreased by 40%, meaning 18 fewer children per month suffered serious harm. Conclusion Rapid and significant improvement in pediatric patient safety is possible through collaboration of children's hospitals dedicated to the application of high reliability principles and the noncompetitive sharing of outcomes and best practices.

How Hospitals Reengineer Their Discharge Processes to Reduce Readmissions.

Abstract: Background The Re-Engineered Discharge (RED) program is a hospital-based initiative shown to decrease hospital reutilization. We implemented the RED in 10 hospitals to study the implementation process. Design We recruited 10 hospitals from different regions of the United States to implement the RED and provided training for participating hospital leaders and implementation staff using the RED Toolkit as the basis of the curriculum followed by monthly telephone-based technical assistance for up to 1 year. Methods Two team members interviewed key informants from each hospital before RED implementation and then 1 year later. Interview data were analyzed according to common and comparative themes identified across institutions. Readmission outcomes were collected on participating hospitals and compared pre- versus post-RED implementation. Results Key findings included (1) wide variability in the fidelity of the RED intervention; (2) engaged leadership and multidisciplinary implementation teams were keys to success; (3) common challenges included obtaining timely follow-up appointments, transmitting discharge summaries to outpatient clinicians, and leveraging information technology. Eight out of 10 hospitals reported improvement in 30-day readmission rates after RED implementation. Conclusions A supportive hospital culture is essential for successful RED implementation. A flexible implementation strategy can be used to implement RED and reduce readmissions.

Validation of a Predictive Model to Identify Patients at High Risk for Hospital Readmission.

Abstract: Background Hospital readmission is an adverse patient outcome that is serious, common, and costly. For hospitals, identifying patients at risk for hospital readmission is a priority to reduce costs and improve care. Purpose The purposes were to validate a predictive algorithm to identify patients at a high risk for preventable hospital readmission within 30 days after discharge and determine if additional risk factors enhance readmission predictability. Methods A retrospective study was conducted on a randomized sample of 598 patients discharged from a Southeast community hospital. Data were collected from the organization's database and manually abstracted from the electronic medical record using a structured tool. Two separate logistic regression models were fit for the probability of readmission within 30 days after discharge. The first model used the LACE index as the predictor variable, and the second model used the LACE index with additional risk factors. The two models were compared to determine if additional risk factors increased the model's predictive ability. Results The results indicate both models have reasonable prognostic capability. The LACE index with additional risk factors did little to improve prognostication, while adding to the model's complexity. Conclusion Findings support the use of the LACE index as a practical tool to identify patients at risk for readmission.

Lean Six Sigma to Reduce Intensive Care Unit Length of Stay and Costs in Prolonged Mechanical Ventilation.

Abstract: OBJECTIVE Patients with prolonged mechanical ventilation (PMV) represent important "outliers" of hospital length of stay (LOS) and costs (∼$26 billion annually in the United States). We tested the hypothesis that a Lean Six Sigma (LSS) approach for process improvement could reduce hospital LOS and the associated costs of care for patients with PMV. DESIGN Before-and-after cohort study. SETTING Multidisciplinary intensive care unit (ICU) in an academic medical center. PATIENTS Adult patients admitted to the ICU and treated with PMV, as defined by diagnosis-related group (DRG). METHODS We implemented a clinical redesign intervention based on LSS principles. We identified eight distinct processes in preparing patients with PMV for post-acute care. Our clinical redesign included reengineering daily patient care rounds ("Lean ICU rounds") to reduce variation and waste in these processes. We compared hospital LOS and direct cost per case in patients with PMV before (2013) and after (2014) our LSS intervention. RESULTS Among 259 patients with PMV (131 preintervention; 128 postintervention), median hospital LOS decreased by 24% during the intervention period (29 vs. 22 days, p < .001). Accordingly, median hospital direct cost per case decreased by 27% ($66,335 vs. $48,370, p < .001). CONCLUSION We found that a LSS-based clinical redesign reduced hospital LOS and the costs of care for patients with PMV.

Patient Factors Predictive of Hospital Readmissions Within 30 Days.

Abstract: BACKGROUND Under the Affordable Care Act, the Congress has mandated that the Centers for Medicare and Medicaid Services reduce payments to hospitals subject to their Inpatient Prospective Payment System that exhibits excess readmissions. Using hospital-coded discharge abstracts, we constructed a readmission measure that accounts for cross-hospital variation that enables hospitals to monitor their entire inpatient populations and evaluate their readmission rates relative to national benchmarks. METHODS Multivariate logistic regressions are applied to determine which patient factors increase the odds of a readmission within 30 days and by how much. This study uses deidentified discharge abstract data from a database of approximately 15 million inpatient discharges representing 611 acute care hospitals from Premier healthcare alliance over a 2-year period (2008q4-2010q3). The hospitals are geographically diverse and represent large urban academic centers and small rural community hospitals. RESULTS This study demonstrates that meaningful risk-adjusted readmission rates can be tracked in a dynamic database. The clinical conditions responsible for the index admission were the strongest predictive factor of readmissions, but factors such as age and accompanying comorbid conditions were also important. Socioeconomic factors, such as race, income, and payer status, also showed strong statistical significance in predicting readmissions. CONCLUSIONS Payment models that are based on stratified comparisons might result in a more equitable payment system while at the same time providing transparency regarding disparities based on these factors. No model, yet available, discriminates potentially modifiable readmissions from those not subject to intervention highlighting the fact that the optimum readmission rate for any given condition is yet to be identified.

Improving Care Transitions Across Healthcare Settings Through a Human Factors Approach.

Abstract: After more than two decades of research focused on care transition improvement and intervention development, unfavorable outcome measures associated with care transitions across healthcare settings persist. Readmissions rates remain an important outcome to target for intervention, adverse events associated with care transitions continue to be an issue, and patients are often dissatisfied with the quality of their care. Currently, interventions to improve care transitions are disease specific, require substantial financial investments in training allied healthcare professionals, or focus primarily on hospital-based discharge planning with mixed results. This complex situation requires a method of evaluation that can provide a comprehensive, in-depth, and context-driven investigation of potential risks to safe care transitions across healthcare settings, which can lead to the creation of effective, usable, and sustainable interventions. A systems' approach known as Human Factors and Ergonomics (HFE) evaluates the factors in a system that affect human performance. This article describes how HFE can complement and further strengthen efforts to improve care transitions.

Prevalence and Data Transparency of National Clinical Registries in the United States.

Abstract: Objective To determine the prevalence and characteristics of national clinical registries. Methods Review of clinical registries through the following: (1) PubMed search using MeSH term "registries," (2) clinical trials database search using the term "registry," (3) review of the American Medical Association (AMA) recognized specialty societies for registry affiliation, and (4) consultation with a panel representing the American Board of Medical Specialties (ABMS). Main outcome measures Outcomes that characterize registries (type, participants, specialty affiliation, funding), reflect data quality (risk adjustment, auditing practices), and indicate transparency (public reporting). Results We identified 153 clinical registries of which 47.7% (73) were health services registries, 43.1% (66) were disease registries, and 9.2% (14) were combination registries. The mean number of hospitals per registry was 1,693 (interquartile range [IQR] = 45-230), and the mean number of patients per registry was 1,160,492 (IQR = 2,150-10,045). Among the 117 AMA specialty societies, 16.2% (19) were affiliated with a registry. Government funding was associated with 26.1% (40/153) of registries. Of the 153 registries, 23.5% (36) risk adjusted outcomes and 18.3% (23) audited data. Mandatory public reporting of hospital outcomes for all participating hospitals was associated with 2.0% (3/153) of registries. Conclusion There is substantial opportunity to develop more specialty-specific clinical registries with publicly available data.

Preventable Readmission Risk Factors for Patients With Chronic Conditions.

Abstract: Evidence indicates that the largest volume of hospital readmissions occurs among patients with preexisting chronic conditions Identifying these patients can improve the way hospital care is delivered and prioritize the allocation of interventions In this retrospective study, we identify factors associated with readmission within 30 days based on claims and administrative data of nine hospitals from 2005 to 2012 We present a data inclusion and exclusion criteria to identify potentially preventable readmissions Multivariate logistic regression models and a Cox proportional hazards extension are used to estimate the readmission risk for 4 chronic conditions (congestive heart failure [CHF], chronic obstructive pulmonary disease [COPD], acute myocardial infarction, and type 2 diabetes) and pneumonia, known to be related to high readmission rates Accumulated number of admissions and discharge disposition were identified to be significant factors across most disease groups Larger odds of readmission were associated with higher severity index for CHF and COPD patients Different chronic conditions are associated with different patient and case severity factors, suggesting that further studies in readmission should consider studying conditions separately

Catastrophic Medical Malpractice Payouts in Spain.

Abstract: Patient safety and professional liability are major con- cerns worldwide. Despite the pervasive influence of catastrophic malpractice payouts, little is known about the specific character- istics and the overall relevance and characteristics of these pay- outs, especially outside U.S. borders. Five hundred fifty claims led to a payout among 2,236 claims from January 1, 2004 to December 31, 2010, in Catalonia (Spain). We analyzed data on patient, provider, and claim characteristics. Accordingly to our sample, Spanish catastrophic payouts (SCP) were defined as pay- outs over€200,000, which was found in 32 cases (5.8%). Diagnos- tic errors and patient death were not as relevant as previously reported. However, it is remarkable that the literature emanating from different countries shows similar trends besides contextual differences: patients suffering minor injuries are not likely to re- ceive a catastrophic payout, catastrophic payouts are associated with patient age less than one; SCP are most associated with anes- thesiology and resuscitation, general surgery, and obstetrics and gynecology; and SCP were more likely to occur when a case went to trial compared to when a case was settled out of court. Stud- ies, such as this, provide a wider picture of the medical liability worldwide reality and helps avoiding isolated discourses.

Hospital Characteristics and the Agency for Healthcare Research and Quality Inpatient Quality Indicators: A Systematic Review.

Abstract: Background The Agency for Healthcare Research and Quality Inpatient Quality Indicators (IQIs) include inpatient mortality for selected procedures and medical conditions. They have assumed an increasingly prominent role in hospital comparisons. Healthcare delivery and policy-related decisions need to be driven by reliable research that shows associations between hospital characteristics and quality of inpatient care delivered. Objectives To systematically review the literature on associations between hospital characteristics and IQIs. Methods We systematically searched PubMed and gray literature (2000-2012) for studies relevant to 14 hospital characteristics and 17 IQIs. We extracted data for study characteristics, IQIs analyzed, and hospital characteristics (e.g., teaching status, bed size, patient volume, rural vs. urban location, and nurse staffing). Results We included 16 studies, which showed few significant associations. Four hospital characteristics (higher hospital volume, higher nurse staffing, urban vs. rural status, and higher hospital financial resources) had statistically significant associations with lower mortality and selected IQIs in approximately half of the studies. For example, there were no associations between nurse staffing and four IQIs; however, approximately 50% of studies showed a statistically significant relationship between nurse staffing and lower mortality for six IQIs. For two hospital characteristics-higher bed size and disproportionate share percentage-all statistically significant associations had higher mortality. Five hospital characteristics (teaching status, system affiliation, ownership, minority-serving hospitals, and electronic health record status) had some studies with significantly positive and some with significantly negative associations, and many studies with no association. Conclusions We found few associations between hospital characteristics and mortality IQIs. Differences in study methodology, coding across hospitals, and hospital case-mix adjustment may partly explain these results. Ongoing research will evaluate potential mechanisms for the identified associations.

Family Physicians' Quality Interventions and Performance Improvement for Hypertension through Maintenance of Certification.

Abstract: Purpose Hypertension is a cause of considerable morbidity and mortality. Our objective was to describe the quality outcomes associated with physicians’ completion of hypertension Performance in Practice Modules (PPMs) as part of Maintenance of Certification (MOC). Methods Descriptive study of all hypertension PPMs completed by family physicians from July 2006 to 2013. Descriptive statistics characterized physician demographics and quality outcomes; linear regression determined characteristics associated with improvement. Results In total, 7,319 hypertension PPMs were completed by family physicians that had a mean age of 47.9 years and 14.2 years of practice experience. Most (52.4%) chose lipid control as their quality improvement (QI) focus. Performance on all quality measures improved except mean low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol values; however, percentage of patients with LDL < 130 mg/dl improved. Improvement was seen in blood pressure control (87.4% to 92.6%, p < .05), low sodium diet counseling (74.1% to 92.7%, p < .05), and exercise counseling (82.4% to 94.4%, p < .05). In regression models, no variable was consistently associated with improvement. Discussion Family physicians improved the quality of care for patients with hypertension through MOC. Leveraging MOC across all specialties may become an important support for improving management of conditions that cause considerable morbidity and mortality.

Facilitating Nurses' Engagement in Hospital Quality Improvement: The New Jersey Hospital Association's Implementation of Transforming Care at the Bedside.

Abstract: Transforming Care at the Bedside (TCAB) is a program designed by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement to engage frontline staff in change processes to improve the work environment and patient care on nursing units. Originally designed and piloted in a small number of hospitals, TCAB is being disseminated through large-scale quality improvement (QI) collaboratives facilitated by professional organizations, such the New Jersey Hospital Association's Institute for Quality and Patient Safety (NJHA). This article presents the results of an evaluation of the NJHA dissemination effort. The evaluation team used an observational mixed-method evaluation design and multiple data sources to assess implementation of TCAB by nursing units in these facilities. The results show that most of the participating units successfully implemented the TCAB improvement processes. Nursing teamwork and three nursing-sensitive outcomes improved significantly over the course of TCAB, and TCAB unit managers attributed important improvements to their unit's participation. These findings suggest that TCAB is a viable mechanism for engaging frontline nursing staff in valuable QI activities. Other hospitals interested in furthering the culture and capacity for QI among frontline nursing unit staff should consider a TCAB collaborative for achieving these goals.

Discharge Delays for Patients Requiring In-Hospital Guardianship: A Cohort Analysis.

Abstract: OBJECTIVE To assess nonclinical factors delaying hospital discharge of guardianship patients. DATA Utilization review data over 3 years. DESIGN Retrospective cohort study. ANALYSIS Mann-Whitney test was used to compare patients' medically unnecessary days (MUD) of hospitalization with additional subcategories of delays-defined as beyond clinicians' control. FINDINGS Overall median number of MUD was 19.5; 14 of 48 patients were additionally delayed while awaiting long-term care Medicaid approval (N = 7, 50%), pending insurance (N = 3, 21%), social or transportation difficulties (N = 3, 21%), or preadmission review (N = 1, 7%). The median number of MUD for the 14 delayed patients was 63, a difference of 53 days compared with the routine guardianship cohort (P < .0001) and $5.5M in net revenue opportunity. CONCLUSIONS Nonclinical discharge delays for guardianship patients are costly and potentially unavoidable. Further exploration into policy change is therefore recommended.

Reducing Racial Disparities in Breast Cancer Survivors' Ratings of Quality Cancer Care: The Enduring Impact of Trust.

Abstract: PURPOSE Patient satisfaction provides an important illumination of the quality of care that is delivered. Satisfaction with care is often lower in Black women compared with their non-Hispanic White counterparts. Data are lacking regarding quality ratings of breast cancer patients. We examined racial disparities in ratings of the quality of cancer care in newly diagnosed Black (n = 217) and White (n = 152) patients. METHODS This was a cross-sectional observational study. Patients were recruited through hospitals and community outreach. Women with primary invasive, nonmetastatic breast cancer were eligible. Trained interviewers administered a standardized survey through telephone; clinical data were abstracted from medical records. The primary outcome, healthcare quality, was assessed using the PSQ-18, which assessed patients' ratings regarding four healthcare domains: interpersonal care, financial issues, technical ratings of physicians, and access and convenience. Independent variables included healthcare factors (e.g., suspicion toward the healthcare system), psychosocial factors (e.g., physicians' solicitation behaviors), and socioeconomic factors (e.g., limited access to resources). Multiple linear regression was used to evaluate associations between each healthcare quality domain and independent variables. RESULTS In univariate analysis, Black women reported lower ratings for four domains: technical (Black m = 3.99; White m = 4.26; p < .001), interpersonal (Black m = 4.15, White m = 4.35; p < .01), financial (Black m = 3.81, White m = 4.0, p < .001), and access and convenience (Black m = 3.92, White m = 4.08, p < .01). After adjusting for healthcare characteristics and psychosocial factors, trust in providers was significantly associated with three domains (β = 0.085, p < .001, technical; β = 0.066, p < .0001, interpersonal; β = 0.043, p < .0001, financial). CONCLUSION Racial disparities in ratings of healthcare quality were diminished across several domains after controlling for psychosocial and healthcare factors. Strategies aimed at improving self-efficacy in women with higher levels of mistrust may improve patient satisfaction.

Patient Safety Errors: Leveraging Health Information Technology to Facilitate Patient Reporting.

Abstract: Patient safety continues to be a national challenge not only for providers but for patients and families as well. In an attempt to standardize processes and systems, we have lost opportunities for improvement. For instance, current patient safety reporting systems tend to favor capturing details around events that are classified as highly clinically significant (i.e., sentinel-level and never events); yet little to no effort is spent on capturing information about less evident errors or near misses, nor simply about concerns that are more experiential in nature. As a result, patients' experiences and observations are relegated to the notion of satisfaction, real-time reporting remains illusive, and the ability to learn across incidents remains anecdotal rather than systematic. Herein we propose an alternative, real-time, innovative model that merges syndromic surveillance and patient engagement to embrace patient-initiated reporting of patient safety events and concerns. The result would be a patient safety system where patients are partners, in both the conduct of their care, and in the quality of the healthcare delivered.

Measuring Hospital‐Wide Mortality—Pitfalls and Potential

Abstract: Risk-adjusted hospital-wide mortality has been proposed as a key indicator of system-level quality. Several risk-adjusted measures are available, and one—the hospital standardized mortality ratio (HSMR)—is publicly reported in a number of countries, but not in the United States. This paper reviews potential uses of such measures. We conclude that available methods are not suitable for interhospital comparisons or rankings and should not be used for pay-for-performance or value-based purchasing/payment. Hospital-wide mortality is a relatively imprecise, crude measure of quality, but disaggregation into condition- and service-line–specific mortality can facilitate targeted improvement efforts. If tracked over time, both observed and expected mortality rates should be monitored to ensure that apparent improvement is not due to increasing expected mortality, which could reflect changes in case mix or coding. Risk-adjusted mortality can be used as an initial signal that a hospital's mortality rate is significantly higher than statistically expected, prompting further inquiry.

Innovation Practice Using Pervasive Mobile Technology Solutions to Improve Population Health Management: A Pilot Study of Gestational Diabetes Patient Care in Australia.

Abstract: Healthcare service delivery is moving forward from individual care to population health management, because of the fast growth of health records. However, to improve population health performance, it is necessary to leverage relevant data and information using new technology solutions, such as pervasive diabetes mobile technology solution of Inet International Inc., which offers the potential to facilitate patient empowerment with gestational diabetic care. Hence, this article examines the pilot study outcomes of a small clinical trial focusing on pregnant patients affected by gestational diabetes mellitus, in an Australian not for profit healthcare context. The aims include establishing proof of concept and also assessing the usability, acceptability, and functionality of this mobile solution and thereby generate hypotheses to be tested in a large-scale confirmatory clinical trial.

A Multidisciplinary Self-Directed Learning Module Improves Knowledge of a Quality Improvement Instrument: The HEART Pathway.

Abstract: We created and tested an educational intervention to support implementation of an institution wide QI project (the HEART Pathway) designed to improve care for patients with acute chest pain. Although online learning modules have been shown effective in imparting knowledge regarding QI projects, it is unknown whether these modules are effective across specialties and healthcare professions. Participants, including nurses, advanced practice clinicians, house staff and attending physicians (N = 486), were enrolled into an online, self-directed learning course exploring the key concepts of the HEART Pathway. The module was completed by 97% of enrollees (469/486) and 90% passed on the first attempt (422/469). Out of 469 learners, 323 completed the pretest, learning module and posttest in the correct order. Mean test scores across learners improved significantly from 74% to 89% from the pretest to the posttest. Following the intervention, the HEART Pathway was used for 88% of patients presenting to our institution with acute chest pain. Our data demonstrate that this online, self-directed learning module can improve knowledge of the HEART Pathway across specialties-paving the way for more efficient and informed care for acute chest pain patients.

Clostridium difficile Infection in Inflammatory Bowel Disease: A Nursing-Based Quality Improvement Strategy.

Abstract: Objectives Patients with inflammatory bowel disease (IBD) have a higher prevalence of Clostridium difficile infection (CDI) and worse outcomes. Research has highlighted the inconsistent care that is provided to patients with IBD, and at our institution, the CDI testing rate was 41%. The present quality improvement intervention sought to increase CDI testing for inpatients with IBD with a flare. Methods Eighty-nine patients admitted to our gastrointestinal unit over a 9-month period with IBD flare were eligible for the study. If a patient did not have a test for CDI ordered, the floor nurse collected stool and alerted the provider to order the test. The primary outcome was percent of eligible patients receiving a test. Secondary outcomes included rate of CDI, length of hospital stay, and readmission rate within 6 months. Results There was a significant increase in testing for CDI to 75% (p = .0151). Patients who received a test were more likely to have CDI (p = .0316), shorter hospital stays (p = .0095), and fewer readmissions (p = .0366). Conclusion This study used the nursing admission workflow to increase the rate of CDI testing. Future studies should further characterize inconsistencies in IBD care and implement quality improvements.

Blood Glucose Control in Noncritically Ill Patients Is Associated With a Decreased Length of Stay, Readmission Rate, and Hospital Mortality.

Abstract: PURPOSE Multiple studies have shown that hyperglycemia correlates with mortality and morbidity in critically ill patients This has not been demonstrated in noncritically hospitalized patients The primary objective of this study was to determine whether glycemic control shortens the length of stay (LOS) Secondary objectives included assessing readmissions, in-hospital mortality, and rates of hypoglycemia METHODS A retrospective review of hospitalized patients admitted between 2008 and 2012 with fingerstick blood sugar (FSBS) was performed Patients were divided into two groups: "controlled" FSBS (≥80% of FSBS were <180 mg/dL) and "uncontrolled" FSBS (<80% of FSBS were <180 mg/dL) The average LOS (ALOS) in days, in-hospital mortality, readmission rates, and rates of hypoglycemia was compared RESULTS A total of 32,851 patient records were reviewed ALOS for patients with controlled and uncontrolled FSBS was 586 and 617 days, respectively (p < 0001) Readmission within 30 days and hospital mortality were significantly lower in patients with controlled FSBS (p = 0000, 00001), whereas rates of hypoglycemia were significantly higher in the uncontrolled group (p = 00000) CONCLUSIONS Glycemic control was associated with decreased LOS, hospital mortality, and 30-day readmission rate in noncritically ill patients regardless of the presence or absence of diabetes

Reducing Depressive Symptoms in Nursing Home Residents: Evaluation of the Pennsylvania Depression Collaborative Quality Improvement Program.

Abstract: Depression reduces quality of life for nursing home (NH) residents and places them at greater risk for disability, medical morbidity, and mortality. However, accumulating evidence suggests that interventions for early detection and treatment can mitigate symptoms of clinical and subclinical levels of depression. The Promoting Positive Well-Being (PPW) program is a quality improvement (QI) intervention that features tools and strategies to assist NHs in early identification, assessment, treatment, and monitoring of residents with depressive symptoms. The PPW was evaluated in 40 NHs through an 8-month QI collaborative that provided participants with tools, webinar training, and technical support. Results showed a significant group by time interaction effect with facility quality rating as a covariate; the active group (n = 18 NHs) outperformed the waitlist control group (n = 19 NHs). In all, there was a 58% relative reduction in the percentage of residents with self-reported moderate-to-severe depressive symptoms. Most NHs reported that they were satisfied with the collaborative (97%) and would recommend it to others (86%); only 15% reported significant challenges. The rate of webinar attendance and data submission compliance was 92%. Results suggest that PPW is a promising approach that should be further evaluated in larger NH initiatives and other settings.

The Use of the Whole Primary-Care Team, Including Community Health Workers, to Achieve Success in Increasing Colon Cancer Screening Rate.

Abstract: The National Colorectal Cancer Roundtable, an organization cofounded by the American Cancer Society and the Centers for Disease Control and Prevention, has set an aggressive goal to achieve an 80% colon cancer screening rate by the year 2018 to reduce the burden of colon cancer in the United States. This goal is in alignment with the primary care movement to focus on prevention and population health. However, colon cancer screening has been proven as an especially challenging preventive measure to get traction on with patients. Oakland Family Medicine, a medium primary care practice in Maine, has engaged in a quality improvement project to increase the colon cancer screening rates from 28%, when the project started, to 80.3%. To achieve these results, it required a redesign of the primary care team, including the use of team extenders like community health workers. In addition, it requires understanding the data and its flaws, knowing the workflow and working to simplify it, and finally, to be clear what problem you are trying to solve. The Oakland Family Medicine project shows that closing the gaps in care for colon cancer screening is not only possible but that the new national goal is attainable also.

Applying the New Institute for Healthcare Improvement Inpatient Waste Tool to Identify "Waste" in the Intensive Care Unit.

Abstract: Healthcare waste-the inappropriate use of healthcare resources that provides no benefit to patients yet contributes to cost and even harm-is a potentially significant contributor to high healthcare costs. This project aimed to apply a new locally modified Institute for Healthcare Improvement (IHI)-developed waste identification tool to measure the prevalence of and reason for the inappropriate use of intensive care unit (ICU) beds, one type of potential waste. Unnecessary days (i.e., waste) and their causes in a 16-bed "closed" medical ICU (MICU) and a 10-bed "semi-closed" transplant surgical ICU (TSICU) were identified by physicians over a 3-month period. Data on 513 patients admitted to both ICUs for a total of 1,631 patient-days demonstrated that 15% of MICU days and 25.8% of TSICU days were unnecessary. Although causes of waste in each ICU differed, delays in transfer of patients out of the ICU, end-of-life decision-making, and delays in procedures were among the commonest. Determination of waste also varied among physicians, ranging from 4.5% to 27.7% in the MICU and 0%-37.5% in the TSICU. This study found that the IHI waste tool can be effectively used to identify waste in the ICU, which is common and varies based on the ICU type and physician perceptions.

Adolescents Are Less Satisfied with Inpatient Psychiatric Care than Their Parents: Does It Matter?

Abstract: Objective Patient satisfaction is a commonly used measure of healthcare quality. Limited research exists among psychiatric inpatients, especially adolescents, who pose unique challenges. This study sought to (1) concurrently assess adolescents’ and parents’ satisfaction with treatment and (2) compare their perspectives’ association with treatment outcomes. Methods This exploratory study assessed discharged adolescents from a specialty psychiatric hospital. Adolescent patients and parents completed the Perceptions of Care survey (POC), a measure of patient satisfaction. Patients also completed the Youth Self-Report measure, while parents also completed the Child Behavior Checklist—both are used as measures of mental health treatment outcomes. Results Adolescents and parents gave favorable overall ratings of care. Adolescents were more critical than their parents, and there was little agreement between them. Adolescents’ ratings on the POC frequently related to outcomes, whereas parents’ ratings rarely did. Conclusions Ratings of satisfaction with adolescent healthcare can vary depending on whether patients or caregivers are assessed. The discrepancy between them contains value: adolescents’ perception may be a better gauge of treatment outcomes and may affect treatment adherence. Future research should examine adolescent-specific concerns in the context of satisfaction with care and relate them to longer term treatment outcomes.

Comparative Effectiveness of Risk-Stratified Care Management in Reducing Readmissions in Medicaid Adults With Chronic Disease.

Abstract: Hospitalized adult Medicaid recipients with chronic disease are at risk for rehospitalization within 90 days of discharge, but most research has focused on the Medicare population. The purpose of this study is to examine the impact of population-based care management intensity on inpatient readmissions in Medicaid adults with pre-existing chronic disease. Retrospective analyses of 2,868 index hospital admissions from 2012 New York State Medicaid Data Warehouse claims compared 90-day post-discharge utilization in populations with and without transitional care management interventions. High intensity managed care organization interventions were associated with higher outpatient and lower emergency department post-discharge utilization than low intensity fee-for-service management. However, readmission rates were higher for the managed care cases. Shorter time to readmission was associated with managed care, diagnoses that include heart and kidney failure, shorter length of stay for index hospitalization, and male sex; with no relationship to age. This unexpected result flags the need to re-evaluate readmission as a quality indicator in the complex Medicaid population. Quality improvement efforts should focus on care continuity during transitions and consider population-specific factors that influence readmission. Optimum post-discharge utilization in the Medicaid population requires a balance between outpatient, emergency and inpatient services to improve access and continuity.

Enabling Quality: Electronic Health Record Adoption and Meaningful Use Readiness in Federally Funded Health Centers.

Abstract: The Health Resources and Services Administration has supported the adoption of electronic health records (EHRs) by federally funded health centers for over a decade; however, little is known about health centers' current EHR adoption rates, progress toward Meaningful Use, and factors related to adoption. We analyzed cross-sectional data from all 1,128 health centers in 2011, which served over 20 million patients during that year. As of 2011, 80% of health centers reported using an EHR, and high proportions reported using many advanced EHR functionalities. There were no indications of disparities in EHR adoption by census region, urban/rural location, patient sociodemographic composition, physician staffing, or health center funding; however, there were small variations in adoption by total patient cost and percent of revenue from grants. Findings revealed no evidence of a digital divide among health centers, indicating that health centers are implementing EHRs, in keeping with their mission to reduce health disparities.

Using Lean to Advance Quality Improvement Research.

Abstract: Introduction Quality improvement research skills are not commonplace among quality improvement practitioners, and research on the effectiveness of quality improvement has not always kept pace with improvement innovation. However, the Lean tools applied to quality improvement should be equally relevant to the advancement of quality improvement research. Methods We applied the Lean methods to develop a simplified quality improvement publication pathway enabling a small research methodology group to increase quality improvement research throughout the institution. The key innovations of the pathway are horizontal integration of the quality improvement research methods group across the institution, implementation of a Lean quality improvement research pathway, and application of a just-in-time quality improvement research toolkit. Results This work provides a road map and tools for the acceleration of quality improvement research. At our institution, the Lean quality improvement research approach was associated with statistically significant increases in the number (annual mean increase from 3.0 to 8.5, p = .03) and breadth of published quality improvement research articles, and in the number of quality improvement research projects currently in process. Discussion Application of Lean methods to the quality improvement research process can aid in increasing publication of quality improvement articles from across the institution.

Process Mapping and Time Study to Improve Efficiency of New Procedure Implementation for High-Dose Rate Prostate Brachytherapy.

Abstract: New technologies and procedures have the potential to improve outcomes; however, initial implementation is often associated with a steep learning curve, decreased efficiency, and patient safety implications. Implementation of a real-time, ultrasound-based prostate high-dose rate brachytherapy procedure involved a multidisciplinary team composed of approximately 6-8 team members and numerous complex tasks. To characterize time spent on various aspects of the procedure and improve efficiency, the team developed a detailed process map, time study, and team debriefings. A benchmark was created based on an experienced institution which has performed >100 procedures annually. The process map was analyzed based on clinical tasks and treatment planning tasks. Over the course of 17 cases at a single institution, total procedure time ranged from 222 to 107 minutes. Implementation of the process map resulted in a reduction of total time by 52%. The implementation of a new procedure benefits from the integration and utilization of a process map. We were able to reduce procedure time significantly, which resulted in decreased time under general anesthesia, reduced risk of deep vein thrombosis, improved overall patient safety, patient throughput, and decreases in staffing demands.

Attributing Responsibility: Hospitals Account for 20% of Variance in Acute Myocardial Infarction Patient Mortality.

Abstract: Applying a log-logistic accelerated failure time mixed effects model to a sample of 95,504 in-hospital patients with acute myocardial infarction (AMI) between 2005 and 2010 in the United States, we measured the relative contribution of hospitals (vs. patients) in explaining in-hospital AMI mortality. Before adjusting for age, race, income, 29 comorbidities of AMI patients, and primary payer, hospital characteristics explained 19.93% of the variance in AMI in-hospital mortality. After controlling for these, variance explained declined by 5.65%, to 14.28%. These findings have implications for policymakers in assessing hospitals' "responsibility" for AMI patient mortality, for hospitals in allocating resources toward improving AMI patient care, and for medical intermediaries in making liability judgments and payment allocations to hospitals.

How Quality Improvement Practice Evidence Can Advance the Knowledge Base.

Abstract: Recommendations for the evaluation of quality improvement interventions have been made in order to improve the evidence base of whether, to what extent, and why quality improvement interventions affect chosen outcomes. The purpose of this article is to articulate why these recommendations are appropriate to improve the rigor of quality improvement intervention evaluation as a research endeavor, but inappropriate for the purposes of everyday quality improvement practice. To support our claim, we describe the differences between quality improvement interventions that occur for the purpose of practice as compared to research. We then carefully consider how feasibility, ethics, and the aims of evaluation each impact how quality improvement interventions that occur in practice, as opposed to research, can or should be evaluated. Recommendations that fit the evaluative goals of practice-based quality improvement interventions are needed to support fair appraisal of the distinct evidence they produce. We describe a current debate on the nature of evidence to assist in reenvisioning how quality improvement evidence generated from practice might complement that generated from research, and contribute in a value-added way to the knowledge base.