Joint Commission journal on quality and patient safety最新文献

{"title":"A Community-Based Intervention to Address Social Determinants of Health: A Pilot Study.","authors":"Nathan L Delafield, Amogh Havanur, Timethia J Bonner, Robert Horsley, Carolyn Mead-Harvey, Sophie Bersoux, Kama White, Nyima Ali, Adam J Milam","doi":"10.1016/j.jcjq.2025.08.002","DOIUrl":"10.1016/j.jcjq.2025.08.002","url":null,"abstract":"<p><strong>Background: </strong>This Innovation Report describes the feasibility and impact of an intervention focused on community-based social support to address social determinants of health (SDoH).</p><p><strong>Methods: </strong>This study followed adult patients (N = 12) referred by primary care teams at a Federally Qualified Health Center (FQHC) due to unresolved SDoH needs. Over 12 months, community volunteers (the Open Table Network Table) were paired with patients to address their primary SDoH needs. Primary outcomes included the implementation of the Open Table Network Table and resolution of the patients' primary SDoH needs, measured by achieving patient-defined goals. Secondary outcomes evaluated intervention impact on patient resilience, healthcare utilization, and other SDoH metrics (for example, economic stability). Semistructured qualitative interviews were conducted with participants postintervention. Primary outcomes were assessed qualitatively; secondary outcomes were tested using paired analyses.</p><p><strong>Results: </strong>Twelve patients were enrolled over 12 months, and their SDoH needs ranged from healthcare access to social isolation. Community volunteers resolved 91.7% of these primary SDoH needs, with a median volunteer effort of 47.5 hours (interquartile range [IQR] 22.5-73.0) provided to each participant. No statistically significant differences were seen in patient resilience, other SDoH metrics, or healthcare utilization postintervention. The intervention was implemented (that is, the intervention was feasible), but there were challenges to implementation, including recruitment of patients, the need for multiple connections, and the time commitment required by volunteers.</p><p><strong>Conclusion: </strong>The Open Table Network Table was implemented at an FQHC but required considerable volunteer effort and creativity. Further research is needed to assess the scalability, sustainability, and long-term social and clinical impact of this intervention.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12413544/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145006185","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Multihospital Analysis of Clinician-Reported Safety Events in People Living with Dementia: Contributing Factors and System Recommendations.","authors":"Lauren Bangerter, Garrett Zabala, Nicole E Werner, Yijung K Kim, Katharine Adams, Allan Fong, Raj Ratwani","doi":"10.1016/j.jcjq.2025.07.010","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.07.010","url":null,"abstract":"<p><strong>Background: </strong>People living with dementia (PLWD) are hospitalized at higher rates than those without dementia and are particularly vulnerable to safety events in the hospital. This study aimed to characterize the scope of clinician-reported safety events in PLWD, identify contributing factors from the perspective of reporting clinicians, and categorize clinician recommendations for system improvement.</p><p><strong>Methods: </strong>The authors analyzed safety events reported by clinicians between January 2018 and July 2023 through a voluntary reporting system at a 10-hospital health system in the mid-Atlantic region, representing a broad spectrum of hospitals and patient populations. A total of 1,287 clinician-reported safety events in PLWD were identified using a keyword search. Two researchers coded the event reports using validated taxonomies to classify contributing factors and clinician recommendations for improvement.</p><p><strong>Results: </strong>The most common clinician-reported safety events among PLWD were skin/tissue injuries (59.4%), falls (17.2%), and safety/security issues (6.9%). The most frequently cited contributing factors were situational factors (70.0%) and active failures (11.2%). Most clinician reports (65.6%) did not include any recommendation for improvement; 30.0% included person-based recommendations, and only 4.4% included system-based recommendations.</p><p><strong>Conclusion: </strong>Health systems should prioritize the prevention of pressure injuries and falls-two of the most common and preventable safety events. Effective interventions should integrate both person-based (for example, staff training, patient/family education) and system-based (for example, policies, protocols) strategies to improve safety for PLWD in the hospital.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145053497","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":"Association of Age-Friendly Hospital Care and Patient Outcomes for Older Adults.","authors":"Kathleen Drago, Bryanna De Lima","doi":"10.1016/j.jcjq.2025.07.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.07.008","url":null,"abstract":"<p><strong>Background: </strong>Hospitalized older adults are at greater risk for hospital-acquired complications than their younger counterparts. The Age-Friendly Health Systems 4Ms care delivery framework-What Matters, Mentation, Mobility, and Medication-provides evidence-based practices to improve care for older adults. This study assessed if 4Ms care in the hospital was associated with better patient outcomes and lower costs.</p><p><strong>Methods: </strong>The authors retrospectively analyzed adults aged 65 years and older hospitalized at an academic hospital from September 2020 through December 2023 based on age-friendly status. Primary outcomes were length of stay (LOS), total charges, and 30-day hospital and emergency department (ED) readmissions. Linear regression models were used for LOS and total charges. Survival analyses and Cox proportional hazards models analyzed the 30-day hospital and ED readmissions. All models used propensity score matching to minimize confounding. Subgroup analyses were based on high and low case mix index (CMI).</p><p><strong>Results: </strong>The sample included 20,202 admissions for patients aged 65 years and older. The hospitalized older adults receiving 4Ms care had 15.5% lower hospital charges (95% confidence interval [CI] 13.02-17.92), 5.2% shorter stays (95% CI 2.91-7.37), and had a 10.4% lower rate of hospital and ED readmissions (hazard ratio 0.90, 95% CI 0.84-0.95) than those not receiving 4Ms care. The 4Ms recipients with a higher CMI had lower charges, shorter lengths of stay, and a lower risk of readmission than recipients with a lower CMI.</p><p><strong>Conclusion: </strong>The 4Ms care delivery framework was associated with reduced inpatient utilization and overall cost of care. These results support reliable delivery of the 4Ms to benefit older hospitalized adults.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145006191","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":"Déjà Vu? How Might Lessons Learned from Electronic Health Record Implementation Apply to Artificial Intelligence?","authors":"Eric G Poon, Andrew L Rosenberg, Adam B Landman, Tejal K Gandhi","doi":"10.1016/j.jcjq.2025.07.007","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.07.007","url":null,"abstract":"<p><strong>Background: </strong>The US healthcare system is currently facing significant challenges in quality, affordability, and labor shortages. Artificial intelligence (AI) promises to transform healthcare delivery by making it safer, more effective, less wasteful, and more patient-centered. With more than $30 billion invested in healthcare AI companies in the past three years, the proliferation of AI solutions is expected to bring much-needed relief to the strained healthcare industry. To harness the current enthusiasm for AI in healthcare, we can draw parallels to the adoption of electronic health records (EHRs) under the HITECH Act of 2009. EHR adoption has been widespread and has contributed to significant health information technology spending, but it has also brought unintended consequences, such as clinician burnout, workarounds, and mixed impacts on patient safety and quality measures. THE EHR ERA VS.</p><p><strong>The ai era: </strong>DIFFERENCES: This article grounds the discussion by first reviewing the key differences between the EHR implementation era that followed the passage of HITECH and the current AI era. The authors identified three characteristics of the AI era that distinguish it from the EHR implementation era: different regulatory and legislative context, diminished capacity of the workforce to absorb new work, and an accelerated pace of change. LESSONS FROM EHR IMPLEMENTATION TO CARRY FORWARD TO AI IMPLEMENTATION: Based on the collective experience of the authorship team and published literature on EHR and AI implementation, the authors identified five critical lessons from the EHR implementation era that organizations deploying AI must consider: (1) respect the human element, (2) build strong organizational governance, (3) adapt leadership and culture, (4) ready the workforce, and (5) build for the long term.</p><p><strong>Conclusion: </strong>By applying these lessons, organizational leaders can realize the potential of AI to improve patient outcomes and transform healthcare delivery.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145006173","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":"Telehealth for Pediatric Patients: Facilitators, Barriers, and Impact on Disparities.","authors":"Courtney Sump, Hadley Sauers-Ford, Sinem Toraman Turk, Kylee Denker, Carlos Casillas, Joanna Thomson","doi":"10.1016/j.jcjq.2025.07.006","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.07.006","url":null,"abstract":"<p><strong>Background: </strong>Although telehealth has potential to improve access to care by eliminating barriers such as transportation and childcare, it also may result in disparate access for certain populations. The aim of this study was to gain an in-depth understanding of telehealth access at a large quaternary care children's hospital.</p><p><strong>Methods: </strong>This qualitative study employed purposive sampling and semistructured interviews of key personnel across our institution, including caregivers, clinical providers, and telehealth operational leads and staff. Interviews targeting access to telehealth were recorded and transcribed verbatim. Using an inductive, thematic approach, each interview was coded independently by two study team members. The authors identified preliminary themes and iteratively reviewed interviews and codes to finalize themes with illustrative quotes.</p><p><strong>Results: </strong>The authors interviewed 25 participants and identified four themes: (1) Telehealth may perpetuate health disparities, including provider reluctance to offer telehealth to patients with a preferred language other than English; (2) Telehealth can help patients receive the right care, at the right place and time; (3) There are numerous facilitators to telehealth's uptake, including provider and caregiver buy-in and optimal physical workspace; and (4) There are challenges in its execution that lead to decreased uptake.</p><p><strong>Conclusion: </strong>Telehealth has many challenges to successful execution but is an integral component to providing the right care at the right place and time. This study was unique in capturing perspectives of multidisciplinary members of the healthcare team in addition to patient caregivers to provide a wide variety of perspectives on access to telehealth. The findings in this single-site, qualitative study identify that real and perceived assumptions about who is best suited for telehealth care may perpetuate health disparities and exacerbate gaps in access to care.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-07-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144955012","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":"Remembering Lucian Leape","authors":"Elizabeth Mort MD, MPH (is Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety, and Vice President and Chief Medical Officer, Joint Commission, Oakbrook Terrace, Illinois. Please address correspondence to Dr. Elizabeth Mort)","doi":"10.1016/j.jcjq.2025.07.004","DOIUrl":"10.1016/j.jcjq.2025.07.004","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 9","pages":"Page 514"},"PeriodicalIF":2.4,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144768663","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":"An Interview with Lucian Leape","authors":"","doi":"10.1016/j.jcjq.2025.07.003","DOIUrl":"10.1016/j.jcjq.2025.07.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 9","pages":"Pages 515-519"},"PeriodicalIF":2.4,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144896604","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 Joint Commission Journal on Quality and Patient Safety Welcomes New Editors","authors":"Dojna Shearer (Dojna Shearer is Senior Managing Editor for The Joint Commission Journal on Quality and Patient Safety, Joint Commission Resources, Oakbrook Terrace, IL. Please address correspondence to Dojna Shearer)","doi":"10.1016/j.jcjq.2025.07.005","DOIUrl":"10.1016/j.jcjq.2025.07.005","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 9","pages":"Pages 520-522"},"PeriodicalIF":2.4,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144896605","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":"Improving Screening for Alpha-1 Antitrypsin Deficiency in Adults with COPD.","authors":"Margery Dell Smith, Kimberly A Couch","doi":"10.1016/j.jcjq.2025.07.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.07.002","url":null,"abstract":"<p><strong>Background: </strong>Alpha-1 antitrypsin deficiency (AATD) is an underrecognized hereditary condition affecting approximately 2% of patients with chronic obstructive pulmonary disease (COPD) in the United States. Studies show a correlation between AATD and COPD progression, with a five-year mortality rate of 19% in severe AATD. National costs attributed to COPD were approximately $32.1 billion in 2010 and an estimated $49 billion in 2020. Chart audits at Onvida Health revealed that only 2.0% of patients diagnosed with COPD were tested for AATD. The authors aimed to improve effective care through AATD testing in adult patients with COPD in the primary care setting to 75% in an eight-week time frame.</p><p><strong>Methods: </strong>Baseline data were obtained from chart audits for patients with COPD and patient/staff surveys. The implementation spanned eight weeks using a Plan-Do-Study-Act (PDSA) process consisting of four cycles and two core interventions analyzed every two weeks. A shared decision-making checklist was developed for AATD screening and testing. A standard of care log constructed from current evidence was implemented for all patients with COPD.</p><p><strong>Results: </strong>Testing rates improved to 38.1% from a baseline of 2.0%. Although there was a 0.0% positivity rate for the diagnosis of AATD (two abnormal alleles), 19.7% (n = 12 of 61) of patients were identified as AATD carriers (one abnormal and one normal allele).</p><p><strong>Conclusion: </strong>Utilizing standard of care can aid in disease prevention and prevent progression with early identification of patients with AATD. Suggested next steps include lengthier studies to evaluate the carriers and their offspring.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144804109","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 Next 50 Years","authors":"Elizabeth Mort MD, MPH (is Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety, and Vice President and Chief Medical Officer, Joint Commission, Oakbrook Terrace, Illinois)","doi":"10.1016/j.jcjq.2025.07.001","DOIUrl":"10.1016/j.jcjq.2025.07.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 9","pages":"Page 513"},"PeriodicalIF":2.4,"publicationDate":"2025-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144717868","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}