Joint Commission journal on quality and patient safety最新文献

{"title":"Understanding Psychological Safety in Health Care: A Qualitative Investigation and Practical Guidance.","authors":"Stephanie A Zajac, Kimberly N Williams, Sabina M Patel, Elizabeth H Lazzara, Joe R Keebler, Mark W Clemens, Courtney L Holladay","doi":"10.1016/j.jcjq.2025.04.009","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.009","url":null,"abstract":"<p><strong>Background: </strong>Psychological safety is a critical teamwork competency that promotes effective communication, teamwork, patient safety, and the well-being of health care professionals. However, previous research on barriers and facilitators to promotion of psychological safety has focused mainly on clinical staff, omitting other health care disciplines that contribute to patient safety and high-quality care.</p><p><strong>Methods: </strong>The authors conducted a qualitative study in one health system to identify barriers and facilitators to psychological safety in the workplace. Participants in a quality improvement (QI) initiative were invited through automated e-mails sent via the Qualtrics platform to participate in this survey. Employees self-selected whether to respond, as participation was not required as part of the QI initiative engagement.</p><p><strong>Results: </strong>A total of 429 participants across 19 departments spanning administration, education, research, and clinical areas were invited. The average survey response rate across departments was 52.2%. Participants answered two open-ended questions: (1) \"What are situations where it can be difficult to take an interpersonal risk and speak up [on this team]?\" and (2) \"What are the challenges to creating psychological safety within your current team?\" Three psychological safety subject matter experts coded the data to extract factors and subthemes. Thematic factors at the individual, team, and organization level were uncovered. Sixteen subcategories of factors that affect psychological safety emerged, uncovering two implications.</p><p><strong>Conclusion: </strong>Psychological safety as defined here includes not just team level but the individual and organization levels. Interventions must align with the factors at all three levels for a personalized and comprehensive approach.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-06-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144284386","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":"Patient Safety Metrics Monitoring Across Harvard-Affiliated Hospitals: A Mixed Methods Study.","authors":"Hojjat Salmasian, Astrid Van Wilder, Michelle Frits, Christine Iannaccone, Merranda Logan, Jonathan P Zebrowski, David Shahian, Mitchell Rein, David Levine, David W Bates","doi":"10.1016/j.jcjq.2025.05.001","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.05.001","url":null,"abstract":"<p><strong>Background: </strong>The past two decades have seen a surge in available patient safety metrics. However, the variability in how health care organizations choose and monitor these metrics remains unknown.</p><p><strong>Methods: </strong>The authors cataloged the metrics organizations chose and how actively they monitored them. Factors influencing the monitoring of patient safety metrics were investigated using surveys and in-depth interviews with patient safety experts from 11 Harvard-affiliated organizations.</p><p><strong>Results: </strong>Eighty-four individuals across 11 sites helped complete the surveys, with a mean of 2.5 representatives from each site interviewed. Significant variability in active monitoring of safety metrics was observed across different sites. Overall, 108 measures were monitored by at least 1 site. Agreement between sites about the choice of measures was weak (κ = 0.40, 95% confidence interval [CI] 0.37-0.43), ranging from κ = 0.13 (95% CI 0.07-0.20) for maternal safety measures to κ = 0.86 (95% CI 0.69-1.00) for measures of hospital-acquired infections. Although not all 23 mandatory measures were monitored across all sites, these had the highest likelihood of active monitoring. A substantial overlap existed in measures targeting the same safety event but with slight differences in definitions, limiting the comparability of rates across institutions. Key considerations for active monitoring included the perceived measure usefulness and measurement burden, although external mandates or internal institutional commitments were stronger motivators overall. Other contributors included access to analytics teams and platforms, registry participation, vendor investments, and strategic or leadership interests.</p><p><strong>Conclusion: </strong>This study offers critical guidance to health policymakers on designing and mandating safety metrics. Despite high variability in metric selection, health care organizations share common themes when deciding what to actively measure.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144336595","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":"Effects of a Workplace Well-Being Program on Professional Quality of Life Among Health Care Personnel.","authors":"Nicholas A Giordano, Ingrid M Duva, Beth Ann Swan, Theodore M Johnson, Jeannie P Cimiotti, Dorian A Lamis, JoAnna Hillman, Janelle Gowgiel, Kristin Giordano, Nikki Rider, Lisa Muirhead, Michelle Wallace, Tim Cunningham, Maureen Shelton, Timothy Harrison, LaTanya Holland, Ammar A Rashied, Jennifer S Mascaro","doi":"10.1016/j.jcjq.2025.04.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.008","url":null,"abstract":"<p><strong>Background: </strong>A healthy, competent, and compassionate health care workforce is critical to ensure that health systems can deliver high-quality, safe patient care. Therefore, health care personnel need access to scalable, recurring, evidence-based training opportunities to bolster compassion, mitigate burnout, and enhance resiliency, ultimately improving their professional quality of life. This evaluation examined the reach, effectiveness, adoption, implementation, and maintenance of workplace-based well-being training opportunities offered by Atlanta's Resiliency Resource for frontline Workers (ARROW) program across two health systems.</p><p><strong>Methods: </strong>ARROW formed through an academic practice partnership designed to introduce health care personnel to evidence-based mindfulness and compassion-based training opportunities: the Community Resiliency Model (CRM) and Cognitively-Based Compassion Training (CBCT). Trainees provided evaluation feedback immediately before, two weeks after, and three months after attending a CRM or CBCT event. The Short Professional Quality of Life Scale assessed compassion fatigue, burnout, and compassion satisfaction; the Connor-Davidson Resilience Scale assessed resiliency.</p><p><strong>Results: </strong>ARROW hosted 59 training events that directly trained 761 health care personnel. Trainees' compassion fatigue scores, a key component of professional quality of life, decreased up to three months after engaging in programming by 0.32 points (p = 0.005, d = -0.14). Trainees who attended CBCT events were observed to have additional declines in compassion fatigue scores, by 0.45 points (p = 0.016, d = -0.215). No differences in burnout, compassion satisfaction, or resiliency were observed. ARROW mentored 68 health care personnel to become either CRM- or CBCT-certified instructors using a train-the-trainer approach. New trainers continued to offer well-being training opportunities and reached an additional 772 colleagues.</p><p><strong>Conclusion: </strong>The findings from this evaluation indicate the broad reach and sustained impact ARROW had across health systems, engaging health care personnel in workplace well-being programming to bolster professional quality of life. Specifically, improvements in compassion fatigue scores following program participation corresponded to a small effect size; however, no changes in burnout, compassion satisfaction, or resiliency were seen after engaging in ARROW programming.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144284385","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":"The Frequency of Multiple Central Line-Associated Bloodstream Infections (CLABSIs) Occurring in the Same Child: A Five-Year Experience.","authors":"Tara P Sotak, Heidi B Troxler, Amber M Kirkley, Benny L Joyner, Michael J Steiner, Lane F Donnelly","doi":"10.1016/j.jcjq.2025.04.006","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.006","url":null,"abstract":"<p><strong>Background: </strong>The aim of this study was to evaluate one institution's five-year experience with the frequency of multiple central line-associated bloodstream infections (CLABSIs) occurring in the same child and to discuss the importance of previous CLABSI as a risk factor for future CLABSI and the implications for CLABSI rate calculation.</p><p><strong>Methods: </strong>The infection surveillance system includes data on central line days, CLABSI rate, and CLABSI count, including mucosal barrier injury (MBI) and non-MBI CLABSIs. Using this data, the authors determined the number of children who had more than one inpatient CLABSI during a five-year period. The team then calculated the percentage of total CLABSIs that are represented by patients with more than one CLABSI and the percentage of patients with CLABSI who had multiple CLABSIs.</p><p><strong>Results: </strong>During the five-year study period, there were 138 CLABSIs in 119 patients. Of the 138 CLABSIs, 36 (26.1%) occurred in children who had more than one CLABSI and 19 (13.8%) of those were repeat. Seventeen patients had more than 1 inpatient CLABSI (15 patients with 2 CLABSIs, and 2 patients with 3 CLABSIs). The CLABSI rate for this period was 1.83 per 1,000 central line days. With exclusion of repeat CLABSIs, the CLABSI rate would be 1.58 per 1,000 central line days, representing a 13.7% difference.</p><p><strong>Conclusion: </strong>Repeat CLABSI in the same patient is not uncommon and can contribute significantly to overall inpatient CLABSI rates. Prior CLABSI should be considered a risk factor for future CLABSI.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144181843","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":"Emergency Department Crowding: A Patient Safety Crisis Hidden in Plain Sight.","authors":"Timothy M Loftus, Emily G Wessling Tofovic","doi":"10.1016/j.jcjq.2025.04.007","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.007","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144132324","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":"A Systems-Based Framework for Integrating Health Equity and Patient Safety.","authors":"Jeannette Tsuei, Julia I Bandini, Angela D Thomas, Kortney Floyd James, Jason Michel Etchegaray, Lucy Schulson","doi":"10.1016/j.jcjq.2025.04.005","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.005","url":null,"abstract":"<p><p>Research is needed to better understand inequities in patient safety, to develop interventions to improve safety and equity together, and to measure the efficacy of such interventions. Although measures of disparities in health outcomes, health care access, and quality of care are common, patient safety equity measurement remains underdeveloped. For example, disparities have often been documented in chronic diseases or access to preventive care but are less frequently studied for adverse drug events or postoperative complications. Patients of minority backgrounds experience higher rates of preventable harm-Black patients face increased risk of hospital-acquired infections and medication errors compared to white patients, yet most health systems lack specific tools to systematically measure and address these safety disparities. Based on a literature review and expert panel conducted between January 2023 and December 2023, the authors identified health system-level measures of equity in patient safety and present a preliminary maturity framework for health systems working toward equity in patient safety. This review found several tools for measuring health disparities and health equity more broadly, but few are specifically designed to evaluate equity in patient safety events and processes. To address this critical gap, the authors leveraged feedback from a panel of eight subject matter experts to develop a preliminary framework designed to support health systems in assessing their maturity levels and integrating equity in patient safety in a stepwise manner. The framework consists of three maturity levels (fundamental, intermediate, advanced) and six domains: (1) data collection and training, (2) data validation, (3) data stratification and analysis, (4) communicating findings, (5) addressing and resolving equity gaps in patient safety, and (6) organizational infrastructure and culture.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144284384","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":"Utilizing Quality Improvement Methodology to Decrease Surgical Delays.","authors":"Marina E Robson Chase, Madeline J Anderson, Wesley A Stephens, Brittany E Levy, Sherry Lantz, Jennifer Goforth, Melissa R Newcomb, Andrew M Harris","doi":"10.1016/j.jcjq.2025.04.004","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.004","url":null,"abstract":"<p><strong>Background: </strong>Surgical delays waste time and space and lead to patient safety concerns, staff and patient dissatisfaction, and increased operating room (OR) costs. Preventing delays is crucial to OR safety and efficiency. A quality improvement (QI) initiative was designed to identify common delay causes and implement targeted interventions to reduce overall case delays and first start case delays.</p><p><strong>Methods: </strong>At a facility with eight full-time ORs, up to 21.5% of cases were delayed per month. Through a preintervention audit, preoperative paperwork issues were determined to be the most common cause of delays. Examination of the current state revealed irregular processes for preoperative paperwork completion and unreliable communication between the provider and preoperative teams. The paperwork completion process and preoperative communication were standardized. Cases were audited for paperwork issues, and rates of delays were analyzed using data collected from the electronic health record and OR scheduling systems.</p><p><strong>Results: </strong>This project achieved a 39.2% relative reduction in overall delays and a 25.0% relative reduction in first start delays. The proportion of all cases delayed by paperwork was reduced by 60.1%, and the proportion of first start cases delayed due to paperwork was reduced by 49.6%. The rate of paperwork issues in all cases decreased by 43.3%. The project has matured to sustainability with lasting improvement in delay rates despite increasing surgical case volume.</p><p><strong>Conclusion: </strong>These interventions substantially decreased total and first start delays, as well as delays due to paperwork issues. Understanding current state, designing appropriate interventions, and securing frontline staff buy-in are critical to achieving a QI goal. Through these principles, simple interventions considerably reduced case delays without added cost.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144093702","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":"Achieving Safe Telehealth.","authors":"Jorge A Rodriguez, David W Bates","doi":"10.1016/j.jcjq.2025.04.003","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144019040","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":"Corrigendum to: ``Leveraging approaches and tools of implementation science and configurational comparative methods in quality improvement'' [The Joint Commission Journal on Quality and Patient Safety Volume 51, Issue 4 (2025) Pages 239-240].","authors":"Gabrielle Matias, Nandita R Nadig, Reiping Huang","doi":"10.1016/j.jcjq.2025.04.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143965985","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":"Navigating the Pathway to Quality Leadership: Perspectives from Contemporary Quality Executives.","authors":"Christopher S Kim, Kimiyoshi J Kobayashi, David M Safley, Bela Patel, Jennifer Wiler, Mbonu Ikezuagu, Jodi L Eisenberg, Amy C Lu","doi":"10.1016/j.jcjq.2025.04.001","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.04.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-04-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144019453","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}