Asfandyar Khan, Tara Cohen, Scott A Shappell, Albert J Boquet
{"title":"Uncovering Latent Failures Using Human Factors Approach as a Diagnostic Tool for Quality Improvement in Orthopedic Surgery.","authors":"Asfandyar Khan, Tara Cohen, Scott A Shappell, Albert J Boquet","doi":"10.1097/JMQ.0000000000000265","DOIUrl":"https://doi.org/10.1097/JMQ.0000000000000265","url":null,"abstract":"<p><strong>Conclusions: </strong>The HFACS framework demonstrated strong reliability in identifying systemic weaknesses within orthopedic surgical workflows. These findings emphasize the urgent need for structured interventions that reduce distractions, improve team communication, and regulate vendor interactions in the operating room, all essential steps toward advancing safety and enhancing overall patient care quality.</p>","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144700885","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Morris Kharasch, Lindsay T Fazio, Tabitha Rosca, Nancy Schindler, Susan G Fisher, Lakshmi K Halasyamani
{"title":"A Physician Conduct Improvement Program to Address Disruptive Behavior in a Health Care Setting.","authors":"Morris Kharasch, Lindsay T Fazio, Tabitha Rosca, Nancy Schindler, Susan G Fisher, Lakshmi K Halasyamani","doi":"10.1097/JMQ.0000000000000262","DOIUrl":"https://doi.org/10.1097/JMQ.0000000000000262","url":null,"abstract":"<p><p>In an effort to provide comprehensive and consistently high-quality health care, the need to address professional behavior is rising. The physician conduct program was designed to reduce physician conduct concerns while providing an organizational culture in which physicians would thrive. This program includes a trained team, an event-reporting system, and a physician advisory council. Root causes, perspectives, and corrective strategies for each reported incident are explored with identified individuals in each incident. Over the 4 past years, complaints (n = 583) have included: rude or disrespectful comments to colleagues (52%), lack of physician communication with colleagues (15%), disrespectful interactions (23%) and inadequate communication with patients (5%), and violation of organizational policies (5%). The professional conduct program has provided a cohesive, systematic resource aligned with the health system's focus on teamwork, collegiality, and excellence in patient care.</p>","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144556372","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Junichi Ishigami, Ivy Simmons, Lucille Fields, Sumeska Thavarajah, Bernard G Jaar
{"title":"Pilot-Testing an Influenza Vaccination Program Tailored for Nephrology Care.","authors":"Junichi Ishigami, Ivy Simmons, Lucille Fields, Sumeska Thavarajah, Bernard G Jaar","doi":"10.1097/JMQ.0000000000000242","DOIUrl":"10.1097/JMQ.0000000000000242","url":null,"abstract":"","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":" ","pages":"137-139"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144045661","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Richard H Savel, Payam Benson, Carmen Collins, Srinivas Gongireddy, Christina Oquendo, Kwaku Gyekye, Eva Villar-Trinidad, Jill Fennimore, Ije Akunyili
{"title":"Independent Risk Factors for Less Than \"Top Box\" Doctor Communication Patient Experience Survey Scores in an Urban Teaching Hospital.","authors":"Richard H Savel, Payam Benson, Carmen Collins, Srinivas Gongireddy, Christina Oquendo, Kwaku Gyekye, Eva Villar-Trinidad, Jill Fennimore, Ije Akunyili","doi":"10.1097/JMQ.0000000000000238","DOIUrl":"10.1097/JMQ.0000000000000238","url":null,"abstract":"<p><p>This study explored the independent risk factors for patients giving a less than \"top box\" score on their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys in the \"doctor communication\" domain (DCD). After adjusting for age, gender, length of stay, receiving a postdischarge phone call (PC), new medication during hospitalization, highest education level, language spoken at home, and zip code, results from 803 HCAHPS surveys (from January 1 to December 31, 2023) revealed that not receiving a PC was associated with a more than doubling of the odds that a patient would give less than a \"top box\" score for the DCD (overall adjusted odds ratio of 2.22; 95% confidence interval: 1.77-2.78) and a nearly doubling the actual probability of doing so (34.3% less than \"top box\" score if no PC, 17.9% less than \"top box\" score if PC). These findings support the potential value of a post-discharge patient PC.</p>","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":" ","pages":"140-145"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143607673","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Adrianne Smiley, Joan M Griffin, Lynne M Vitagliano, Angela K Wold, Tish Mailloux, Beverly B Hansen, Kelli D Strader, Sherry Chesak, Nandita Khera, Michelle R Burns
{"title":"Peer Support for Caregivers: An Acute Care Quality Improvement Initiative.","authors":"Adrianne Smiley, Joan M Griffin, Lynne M Vitagliano, Angela K Wold, Tish Mailloux, Beverly B Hansen, Kelli D Strader, Sherry Chesak, Nandita Khera, Michelle R Burns","doi":"10.1097/JMQ.0000000000000249","DOIUrl":"https://doi.org/10.1097/JMQ.0000000000000249","url":null,"abstract":"","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":"40 4","pages":"208-209"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144532521","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Peter J Pronovost, J Matthew Austin, Arnold Milstein
{"title":"To Err Is Human: Failing to Reduce Overall Harm Is Inhumane.","authors":"Peter J Pronovost, J Matthew Austin, Arnold Milstein","doi":"10.1097/JMQ.0000000000000250","DOIUrl":"10.1097/JMQ.0000000000000250","url":null,"abstract":"","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":" ","pages":"199-201"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144003489","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Susanna Betti, Harrison Bell, Jonathan Glatt, Erika J Yoo, David A Oxman
{"title":"An Analysis of Exposure Keratopathy Cases to Promote Changes in Eye Care Practice in Intensive Care Units.","authors":"Susanna Betti, Harrison Bell, Jonathan Glatt, Erika J Yoo, David A Oxman","doi":"10.1097/JMQ.0000000000000240","DOIUrl":"10.1097/JMQ.0000000000000240","url":null,"abstract":"<p><p>Exposure keratopathy (EK) is corneal damage from prolonged environmental exposure. If untreated, EK can lead to corneal scarring and/or blindness. Critically ill patients are at high risk. A case of EK in our intensive care unit led us to investigate the incidence of EK in our critical care units and understand the interventions needed to reduce its impact. We found 44 cases of EK over 3 years. 95% received mechanical ventilation and 32% received paralytic agents. Average time to diagnosis was 15.8 days from intensive care unit admission. More than a quarter (27%) of patients had severe EK at diagnosis, and 52% of patients had received prior eye care. EK occurred frequently in our critical care units. Many subjects did not receive prophylaxis and disease was diagnosed at a late stage. To address this, we plan a 3-pronged approach focusing on prevention, early recognition, and timely initiation of treatment.</p>","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":" ","pages":"173-176"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144049496","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Evaluating Bias in Substance Use Screening for Hospitalized Obstetric Patients.","authors":"Julia Liu, Makenzie Perdue, Rebecca Mercier","doi":"10.1097/JMQ.0000000000000253","DOIUrl":"https://doi.org/10.1097/JMQ.0000000000000253","url":null,"abstract":"","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":"40 4","pages":"210-211"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144532519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Still At It.","authors":"David B Nash","doi":"10.1097/JMQ.0000000000000237","DOIUrl":"https://doi.org/10.1097/JMQ.0000000000000237","url":null,"abstract":"","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":"40 4","pages":"135-136"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144532522","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Use of Inpatient Subspecialty Consults Among Hospitalists.","authors":"Nikhil Sood, Gagan Dhillon, Ritesh Kanotra, Farzana Hoque","doi":"10.1097/JMQ.0000000000000244","DOIUrl":"10.1097/JMQ.0000000000000244","url":null,"abstract":"","PeriodicalId":101338,"journal":{"name":"American journal of medical quality : the official journal of the American College of Medical Quality","volume":" ","pages":"202-205"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144063694","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}