Joint Commission journal on quality and patient safety最新文献

{"title":"The Next 50 Years.","authors":"Elizabeth Mort","doi":"10.1016/j.jcjq.2025.07.001","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.07.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"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}

{"title":"Utilizing Quality Improvement Methodology to Decrease Surgical Delays","authors":"Marina E. Robson Chase MD (is a General Surgery Resident at University of Kentucky HealthCare and Lexington Veterans Affairs (VA) Medical Center.),&nbsp;Madeline J. Anderson DO (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.),&nbsp;Wesley A. Stephens MD (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.),&nbsp;Brittany E. Levy MD, MPH (is a General Surgery Resident at University of Kentucky HealthCare and Lexington VA Medical Center.),&nbsp;Sherry Lantz RN, MSN (is the Operating Room Nurse Manager at Lexington VA Medical Center.),&nbsp;Jennifer Goforth RN, MBA (is the Operating Room Assistant Nurse Manager at Lexington VA Medical Center.),&nbsp;Melissa R. Newcomb MD, FACS (is an Associate Professor of General Surgery at University of Kentucky HealthCare and Deputy Chief of Surgery at Lexington VA Medical Center.),&nbsp;Andrew M. Harris MD (is an Associate Professor of Urology at University of Kentucky HealthCare and Chief of Surgery at Lexington VA Medical Center. Please address correspondence to Marina E. Robson Chase)","doi":"10.1016/j.jcjq.2025.04.004","DOIUrl":"10.1016/j.jcjq.2025.04.004","url":null,"abstract":"<div><h3>Background</h3><div>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.</div></div><div><h3>Methods</h3><div>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.</div></div><div><h3>Results</h3><div>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.</div></div><div><h3>Conclusion</h3><div>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.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 474-485"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","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":"Using In Situ Simulation to Identify Latent Safety Threats Prior to the Opening of Novel Patient Care Spaces in the Emergency Department","authors":"Briana D Miller MD (is Assistant Professor, Department of Emergency Medicine, School of Medicine, Oregon Health & Science University.),&nbsp;Andrew D Bloom MD (is Assistant Professor, Department of Emergency Medicine, Heersink School of Medicine, University of Alabama at Birmingham.),&nbsp;Helena Kons MD (is Resident Physician, Department of Emergency Medicine, Heersink School of Medicine, University of Alabama at Birmingham.),&nbsp;Marjorie Lee White MD, MA, MPPM (is Professor, Division of Emergency Medicine, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham. Please addrees correspondence to Briana Miller)","doi":"10.1016/j.jcjq.2025.02.007","DOIUrl":"10.1016/j.jcjq.2025.02.007","url":null,"abstract":"<div><h3>Background</h3><div>In the era of extreme emergency department (ED) boarding, hospital systems are using novel patient care areas to provide ongoing acute care. In any new patient care environment, there is a high risk for latent safety threats (LSTs), which can negatively affect patient outcomes. A series of in situ systems-based simulations were conducted to identify potential LSTs prior to the opening of a novel mobile care unit (MCU) in a tertiary hospital.</div></div><div><h3>Methods</h3><div>After a needs assessment in conjunction with institutional leadership, a series of in situ interprofessional simulation sessions were developed to represent realistic scenarios in the MCUs. Simulations included low-frequency high-acuity patient care scenarios as well as high-frequency day-to-day encounters. Data were collected in structured systems-based debriefing sessions via trained observers, video recordings, and participant surveys, with a primary outcome of identifying potential LSTs. The LSTs were categorized and then stratified using the <em>Survey Analysis for Evaluating Risk</em> (<em>SAFER</em>) Matrix. One simulation was repeated after mitigation strategies were employed by institutional leadership.</div></div><div><h3>Results</h3><div>A total of 117 staff participated in five simulation sessions. In the first round of simulations, 37 LSTs were identified, primarily in the categories of Environment/Wayfinding (13/37, 35.1%) and Communication (6/37, 16.2%). LSTs risk stratified using the <em>SAFER</em> Matrix provided prioritized feedback for hospital leadership to guide mitigation strategies prior to the opening of the new units. One LST was initially classified as high likelihood to harm on the <em>SAFER</em> Matrix. The simulated scenario involving this LST was repeated two weeks later with no further high-risk LSTs identified.</div></div><div><h3>Conclusion</h3><div>In situ simulations can serve as an effective tool to identify potential LSTs prior to the opening of novel patient care spaces.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 458-465"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780124","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":"Adverse Events Involving Telehealth in the Veterans Health Administration","authors":"Peter D. Mills PhD, MS (is Director, US Department of Veterans Affairs (VA) National Center for Patient Safety Field Office, White River Junction, Vermont, and Clinical Professor of Psychiatry, Geisel School of Medicine at Dartmouth.),&nbsp;Anne Tomolo MD, MPH (is Co-Director of the Chief Resident for Quality and Safety Program and Advanced Fellowship in Patient Safety Program, VA National Center for Patient Safety, and Associate Professor, Department of Medicine, Emory University School of Medicine.),&nbsp;Edward E. Yackel DNP, FNP-C, FAANP (is Executive Director, VA National Center for Patient Safety, and Adjunct Clinical Instructor, Department of Health Behavior and Biological Sciences, University of Michigan. Please address correspondence to Peter D. Mills)","doi":"10.1016/j.jcjq.2024.12.002","DOIUrl":"10.1016/j.jcjq.2024.12.002","url":null,"abstract":"<div><h3>Background</h3><div>Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.</div></div><div><h3>Methods</h3><div>The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.</div></div><div><h3>Results</h3><div>A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.</div></div><div><h3>Conclusion</h3><div>The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 7","pages":"Pages 486-492"},"PeriodicalIF":2.4,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143023579","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":"True Dialogue Across Language Difference Is Essential to Health Care Quality.","authors":"Leonor Fernández, Rose L Molina","doi":"10.1016/j.jcjq.2025.06.010","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.010","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144649501","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":"Mediating Clinical Conflict: An Expanded Role for Patient Relations Offices.","authors":"Autumn Fiester","doi":"10.1016/j.jcjq.2025.06.009","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.009","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144717926","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 Morbidity, Mortality, and Improvement Conference: An Innovative, Action-Oriented Learning Space.","authors":"Julie Dickinson, Sebastian Placide, Samantha Magier, Naseema B Merchant","doi":"10.1016/j.jcjq.2025.06.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.008","url":null,"abstract":"<p><strong>Background: </strong>While providing learning from adverse events, traditional morbidity and mortality conferences may not consistently discuss systems, action items, and execution plans, or engage interprofessional audiences to address adverse events. The aim of this study was to design a space to learn from adverse events and, through engaging diverse staff, develop systems-oriented action items, establish mechanisms to follow through on these items, and close the loop with staff on system improvements.</p><p><strong>Methods: </strong>A planning group designed a quarterly conference in which involved staff review an adverse event with an interdisciplinary, interdepartmental audience. Through interactive discussion, attendees identify root causes and potential system-level solutions. Actionable solutions are implemented and communicated at the next conference. Attendee surveys were conducted to gauge the perceived impact of the conference series on safety culture. The monthly average of submitted safety reports was evaluated as a surrogate safety culture marker.</p><p><strong>Results: </strong>Conference attendance grew by 157.5%. Participants reported increased comfort in raising concerns (from 84.0% to 100.0%), improved interprofessional teamwork (from 84.0% to 100.0%), unit-based shifts to a learning culture (from 64.0% to 93.4%), positive clinical area changes (from 52.0% to 90.0%), and positive health system changes (from 84.0% to 96.7%). The average number of monthly safety reports increased by 17.0%.</p><p><strong>Conclusion: </strong>The morbidity, mortality, and improvement conference demonstrated improvements in reported safety attitudes, interdisciplinary collaboration, system design, learning culture, psychological safety, and safety reporting. This interdisciplinary, interdepartmental, system-focused, interactive conference with closed-loop communication is an effective tool for cultivating trust in safety culture and transforming staff into safety ambassadors and change agents.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144717867","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":"Simulation for Targeted Education, Process Improvement, and Systems Integration (STEPS): A Novel Approach to Health Care Quality Improvement Using In Situ Simulation.","authors":"Jessica C Schoen, Janee M Klipfel, Shelley M Wolfe, Valerie D Willis, Vanessa E Torbenson, Jason J DeWitt, Jennifer L Fang, Regan N Theiler","doi":"10.1016/j.jcjq.2025.06.005","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.005","url":null,"abstract":"<p><strong>Background: </strong>To meet Joint Commission maternal safety standards and facilitate the implementation of acute care obstetrics telemedicine (TeleOB) consultation services throughout one health system, the authors developed a novel in situ simulation framework called STEPS: Simulation for Targeted Education, Process improvement, and Systems integration. STEPS addresses education, process improvement, and systems integration objectives within each simulation scenario, a three-in-one approach to in situ simulation that has not been previously described.</p><p><strong>Methods: </strong>The STEPS framework was used to design and implement multidisciplinary in situ simulations in six emergency departments and four labor and delivery units in two states. Simulations and debriefs were facilitated by simulation education-trained faculty. Opportunities for improvement (OFIs) were addressed by appropriate leadership teams. Participants provided feedback via a voluntary survey after each simulation session.</p><p><strong>Results: </strong>A total of 136 OFIs were identified. Many OFIs were observed in more than one simulation session or across multiple sites, but 33 were distinct (9 distinct educational OFIs, 16 distinct process improvement OFIs, and 8 distinct systems integration OFIs). OFIs were assigned to appropriate personnel to design and implement mitigation strategies. Simulation faculty followed up with site leadership about two weeks after each simulation session to provide feedback and review the status of mitigation efforts. Of 162 participants, 91 (56.2%) completed the post-session survey. Of those who responded, 96.7% reported increased confidence in managing similar cases in their own practice. Many also noted improved familiarity with telemedicine resources and workflows.</p><p><strong>Conclusion: </strong>The STEPS approach is a novel and effective way to simultaneously meet education, process improvement, and systems integration objectives in each simulation scenario and across a large health system.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144717866","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":"Generating Value Through Structural Investment: Rebalancing Value-Based Payment, Pay for Transformation, and Fee-for-Service.","authors":"Jeffrey J Geppert, Peta M A Alexander, Nicole Brennan, Kedar S Mate, Kathy J Jenkins","doi":"10.1016/j.jcjq.2025.06.006","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-06-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144707512","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":"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}