Joint Commission journal on quality and patient safety最新文献

{"title":"Large Language Models as Raters of Hospital Incident Reports: A Blinded Multi-Model Evaluation of Severity Under-Grading and Shared Errors.","authors":"Gianmarco Sirago, Susanna Sabato, Natalia Sebastiani, Fiorenza Zotti, Alessandro Dell'Erba, Davide Ferorelli","doi":"10.1016/j.jcjq.2026.09.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.09.002","url":null,"abstract":"<p><strong>Background: </strong>Large language models (LLMs) are increasingly proposed to classify hospital incident reports, but evidence is dominated by single-model studies reported as aggregate concordance. The authors evaluated whether frontier LLMs reliably classify incident reports and grade harm severity, whether independent models err in correlated ways, and which failure modes matter clinically.</p><p><strong>Methods: </strong>Five LLMs (ChatGPT, Gemini, Claude, DeepSeek, Mistral) classified 824 anonymized incident reports from free text alone, using an identical prompt through providers' standard commercial interfaces, blinded to the reference and one another. Outputs were compared with an expert-adjudicated reference for event type and severity, with the original reporter, and across models (agreement statistics, calibration, severe event detection, ensembling, and a sentinel code audit). A 150-report subset was readministered > 2 months later for test-retest reliability; criterion-based and few-shot prompts tested prompt dependence.</p><p><strong>Results: </strong>Models classified event type reliably (κ 0.82-0.84) but graded severity poorly (weighted κ 0.39-0.47). Of 140 severe events, sensitivity was 0.41-0.50, rising to 0.68-0.79 when harm was documented in the narrative; much apparent failure reflected information insufficiency and construct mismatch. Errors were correlated (mean model-model κ exceeded model-reference κ), majority voting did not help, and no model surpassed the reporter. Confidence was weakly informative and sentinel codes often inconsistent with official content. On readministration, exact severity agreement was 0.59-0.80, with severe-to-no/mild-harm transitions in four of five models; explicit definitions or few-shot examples did not remove it in four of five models.</p><p><strong>Conclusion: </strong>Aggregate agreement concealed failure concentrated in severe events and shared across models. In this one-shot, model-only setting, LLMs classified event type reliably but were not adequate for autonomous severity or sentinel event grading; these determinations should remain with expert adjudication under algorithmovigilance.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149206888","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":"Collaborative Multidisciplinary Assessment of Performance: A Development Guide for Pediatric Heart Centers.","authors":"Timothé E L'Heureux, Amanda M McGlinchey, Sasha M Torres, Camille L Hancock Friesen","doi":"10.1016/j.jcjq.2026.09.004","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.09.004","url":null,"abstract":"<p><p>In July 2023 the Criss Heart Center at Children's Nebraska launched weekly Collaborative Multidisciplinary Assessment of Performance Rounds (CMAP) as part of a structured, prospective Safety Management System framework. CMAP are designed to facilitate transparent, timely, and multidisciplinary evaluation of patient outcomes following pediatric heart surgery. This initiative uses real-time data from the Society of Thoracic Surgeons Congenital Heart Surgery Database to create plots of each surgical patient's journey of risk-versus-time, from surgery through discharge, which are presented at weekly one-hour rounds. The ultimate goal of CMAP is to improve team performance and enhance patient outcomes.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149194104","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":"Embedding Clinical Pharmacy in Transitional Care: A Telehealth Comprehensive Medication Management Intervention for Postdischarge Glycemic Optimization.","authors":"Michelle Elsener, Adeel Arif, Erin Hendrick, Dimple Patel, Erika Horstmann, Farrukh N Jafri","doi":"10.1016/j.jcjq.2026.08.009","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.08.009","url":null,"abstract":"<p><strong>Background: </strong>Hospital discharge is a high-risk period for patients with diabetes. Pharmacist-led comprehensive medication management (CMM) reduces hemoglobin A1c (HbA1c) in ambulatory settings, but structured telehealth CMM embedded within hospital-based transitional care platforms is rarely described. This article reports the implementation, fidelity, and observed outcomes of a telehealth CMM program for patients discharged with poorly controlled diabetes from a nonacademic hospital.</p><p><strong>Methods: </strong>Using the Institute for Healthcare Improvement Model for Improvement, eight Plan-Do-Study-Act (PDSA) cycles (July 2024-July 2025) refined referral, enrollment, documentation, and follow-up workflows. Adults discharged from internal medicine with HbA1c > 8% and a hospital-affiliated provider were offered pharmacist telehealth visits at discharge, 30, and 60 days via a nurse-led warm handoff, at no cost through an in-kind partnership. Fidelity was tracked with run charts; outcomes were evaluated descriptively, with adjusted analyses in the supplement.</p><p><strong>Results: </strong>Of 361 eligible patients, 209 were approached; 113 enrolled (54.1% of those approached). Non-enrollment reflected out-of-network providers (n = 152) or unreachability (n = 77). Visit attendance declined from 87% (30 days) to 66% (60 days); a median of 69% of routed notes received a provider response. Pharmacists generated 185 approved recommendations (58.4% diabetes-related). Among patients with follow-up values, mean HbA1c declined from 10.8% to 7.7% (enrolled, n = 81) and from 10.3% to 8.8% (not enrolled, n = 113; p < 0.001 at follow-up), while acute care utilization was unchanged. Enrollment and outcome gaps were observed for Black patients and Medicare enrollees.</p><p><strong>Conclusion: </strong>Embedding telehealth CMM within existing transitional care infrastructure was feasible without new inpatient staffing. Key lessons include the value of warm handoffs, the difficulty of reaching the highest-risk patients, and the need for equity-informed outreach.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110012","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":"Leveraging Tacit Knowledge to Improve Healthcare Quality in Surgery: An Explorative Ethnographic Study.","authors":"Charlie A Steen, Eduard Schmidt, Ronald S L Liem, Roderick F Schmitz, Joris J Blok, Jaap F Hamming, Abbey Schepers","doi":"10.1016/j.jcjq.2026.09.001","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.09.001","url":null,"abstract":"<p><strong>Background: </strong>Tacit knowledge (TK) is based on experience, intuition, and know-how. Healthcare professionals use it for decision-making in complex situations; still, it is often overlooked as a factor contributing to healthcare quality. Organizational knowledge creation theory explains how knowledge converts between tacit and explicit knowledge. Certain leadership behaviors help create supporting contexts that enhance leveraging TK for quality improvement. Therefore this study explores how healthcare professionals leverage TK for healthcare quality (improvement), and what role leadership plays in facilitating this process.</p><p><strong>Methods: </strong>An exploratory ethnographic single-case study was conducted in a surgical department of a Dutch teaching hospital, consisting of 55 hours of nonparticipant observations and informal conversations.</p><p><strong>Results: </strong>Leveraging TK was empirically observed in practices such as treatment choices and reflections on patient care. This occurred in planned settings, such as handovers and multidisciplinary meetings, and in spontaneous interactions. Leadership emerged as an important facilitator in these TK sharing processes by creating supporting contexts, with different leadership behaviors in planned and spontaneous interactions.</p><p><strong>Conclusion: </strong>TK is an integral part of both planned and spontaneous discussions in clinical care. It therefore is an important factor in quality of care and should be fostered explicitly by leadership. The developed taxonomy of leadership behaviors provides practical insight into how leaders can create supportive contexts for using TK in daily practice.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149216265","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":"Workplace Violence Prevention Program Targeting Patients at Risk of Violence in Nonpsychiatric Inpatient Units: A Prospective Interventional Study.","authors":"Son Chae Kim, Christina Vejnovich, Lyndsi Hall, Shelley Hultman","doi":"10.1016/j.jcjq.2026.08.010","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.08.010","url":null,"abstract":"<p><strong>Background: </strong>Healthcare workers across the world are subjected to increasing workplace violence, mostly arising from patient interactions. Effective workplace violence prevention programs are urgently needed, but there is limited evidence supporting such programs in nonpsychiatric inpatient units.</p><p><strong>Methods: </strong>This prospective interventional study evaluated the effectiveness of a workplace violence prevention program. All patients admitted or transferred to four nonpsychiatric inpatient units from November 2024 to August 2025 were included. Following a baseline observational period, Phase 1 interventions were implemented, consisting of screening patients with the six-item Aggressive Behavior Risk Assessment Tool for Hospitalized Patients (ABRAT-H) and posting signage for patients with ABRAT-H scores ≥ 2. During the subsequent Phase 2 period, proactive rounding by a behavioral health response nurse was added to the Phase 1 interventions for patients with ABRAT-H scores ≥ 3.</p><p><strong>Results: </strong>Of 7,625 evaluable patients, 340 had ≥ 1 violent event (overall rate = 4.46%), while 106 patients committed physical assaults (1.39%). Compared to the baseline observational period, the violent event rate declined significantly during the Phase 2 period (5.30% vs. 3.71%, relative risk [RR] 0.69, 95% confidence interval [CI] 0.53-0.90, p = 0.007). Likewise, the physical assault rate decreased significantly between baseline and Phase 2 (1.89% vs. 0.82%, RR 0.43, 95% CI 0.26-0.73, p = 0.001). However, the decreases in violent events and physical assaults were not statistically significant between baseline and Phase 1.</p><p><strong>Conclusion: </strong>A workplace violence prevention program of screening patients with the ABRAT-H combined with signage posting and proactive nurse rounding for high-risk patients achieved a 31% relative reduction in violent events and a 57% relative reduction in physical assaults.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149061393","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":"Impact of a Centralized Quality Improvement Initiative on Repeat Blood Pressure Measurement at an Academic Medical Center.","authors":"Kayla Murphy, Caleb J Hood, Karunakara Dirisala, Jessica Voit, Rebecca Vigen, Michael E Bowen, Puneet Bajaj","doi":"10.1016/j.jcjq.2026.08.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.08.008","url":null,"abstract":"<p><strong>Background: </strong>Repeat blood pressure (BP) measurements help ensure accurate identification of controlled vs. uncontrolled BP. Within the Department of Medicine (DOM), the authors aimed to improve the rate of repeat BP measurement when the initial reading was ≥ 140/90 mmHg from the baseline of 40% to 50% between September 2022 and August 2023.</p><p><strong>Methods: </strong>A DOM Quality, Process Improvement and Outcomes Committee, with representatives from each division, led a centralized improvement effort to create a common data infrastructure, electronic dashboard for local use, feedback of data to clinical leaders, and educational materials for clinic use. Control and run charts were used to analyze the impact of repeat BP measurements on the process and outcome measures.</p><p><strong>Results: </strong>The 61 DOM clinics completed a total of 273,704 patient encounters between September 2022 and August 2023. A total of 74,614 encounters had an initial high BP reading ≥ 140/90 mmHg. In these encounters, the rate of repeat BP measurement increased from a mean 41% to 61%, and the BP control (< 140/90 mmHg) rate increased from a mean 74% to 78%. Similar improvements were seen in the subgroup with a known diagnosis of hypertension. In addition, the percentage of encounters reclassified from uncontrolled to controlled BP (< 140/90 mmHg) upon repeating the BP remained relatively stable with a median reclassification rate of 38%.</p><p><strong>Conclusion: </strong>This centralized, department-level intervention increased rates of repeat BP measurement. Improvement in BP control was observed prior to the implementation of interventions and continued to improve after. Using a system-level approach to quality improvement with centralized infrastructure, the study team facilitated changes in diverse clinics to improve clinical care.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149024981","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":"Decreasing Length of Stay in Elective Neurosurgery: Success of a Quality Improvement Initiative.","authors":"Stavros Matsoukas, Teleale F Gebeyehu, Jessica Canosa, Elizabeth Chiodi, Hekmat Zarzour, James S Harrop, Richard F Schmidt","doi":"10.1016/j.jcjq.2026.08.006","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.08.006","url":null,"abstract":"<p><strong>Background: </strong>This article describes the design, implementation, and results of a longitudinal multidisciplinary quality improvement (QI) initiative to improve length of stay (LOS) in elective neurosurgical patients at an academic satellite hospital.</p><p><strong>Methods: </strong>LOS was measured on a per-patient basis using an individualized LOS index (LOSI), defined as an observed-to-expected LOS ratio. Interventions were identified and implemented using QI methodology, and results were tracked in real time using Shewhart control charts over a 12-month period. Bimonthly meetings with a multidisciplinary working group enabled continuous and iterative development, review, and implementation of effective interventions. Notable interventions include standardizing electronic health record (EHR) order sets to include Enhanced Recovery After Surgery (ERAS) components; standardizing physical therapy, social work, and case management processes; streamlining radiology workflows; and standardizing interdisciplinary communication.</p><p><strong>Results: </strong>The initiative led to a sustained reduction in LOSI, with several consecutive months surpassing the institutional target of < 1, accomplishing the project's primary aim. Furthermore, at the completion of the project there was a statistically significant improvement in LOSI from the pre- to postintervention groups (1.13 vs. 0.93, p = 0.033).</p><p><strong>Conclusion: </strong>This initiative demonstrates that longitudinal, multidisciplinary QI efforts based on real-time analysis and data-driven adjustments can lead to impactful, sustained reductions in LOS for elective neurosurgical patients. The initiative provides a sustainable and adaptable framework that may serve as a model for other institutions seeking to improve perioperative efficiency and patient care outcomes.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149025076","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":"Penicillin Allergy Evaluation Pathway in a Community-Based Obstetric Setting: A Quality Improvement Study.","authors":"Fadi B Yahya, Mansi J Kanuga, Dayne H Voelker, Stacy L Judd, Candice R Stier","doi":"10.1016/j.jcjq.2026.08.005","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.08.005","url":null,"abstract":"<p><strong>Background: </strong>The objective of this study was to increase completion of penicillin allergy evaluation among pregnant patients and assess its impact on antibiotic utilization and safety.</p><p><strong>Methods: </strong>This quality improvement initiative was conducted across Mayo Clinic Health System obstetric departments in southeast Minnesota from September 12, 2023, through February 15, 2025. Pregnant patients with a reported penicillin allergy presenting for prenatal care were included. The intervention consisted of standardized screening, referral, and Allergy and Immunology-led evaluation, including skin testing and oral challenge. The primary outcome was completion of penicillin allergy evaluation. Secondary outcomes included antibiotic utilization and adverse events. Statistical comparisons were performed using χ² or Fisher's exact tests, with significance defined as p < 0.05.</p><p><strong>Results: </strong>Among 120 eligible patients, 56 (46.7%) completed evaluation, 24 (20.0%) had incomplete evaluation, and 40 (33.3%) declined. Of those completing evaluation, 49 (87.5%) were delabeled. β-lactam antibiotic use was significantly higher in the evaluation-complete group compared with the noncompleted group (96.6% vs 77.5%; p = 0.037). Among patients with group B Streptococcus positivity undergoing vaginal delivery, penicillin use was 90.9% in the evaluation-complete group compared with 0.0% in the noncompleted group (p < 0.001). Adverse reactions occurred in 4 patients and were mild and self-limited.</p><p><strong>Conclusion: </strong>Implementation of a structured penicillin allergy evaluation pathway in a community-based obstetric setting was feasible, safe, and associated with significant improvements in guideline-concordant antibiotic use.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149008604","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":"Prospective Failure Mode and Effects Analysis to Support Implementation Readiness for a New Hyperbaric Oxygen Therapy Service.","authors":"Loay Zaknoun, Moshe Kulikovsky, Einav Atzmona Rosh, Mazal Ben Hayoun, Salman Zarka","doi":"10.1016/j.jcjq.2026.08.003","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.08.003","url":null,"abstract":"<p><strong>Background: </strong>Launching a clinical service is a vulnerable phase in which latent risks may emerge before care processes stabilize. Hyperbaric oxygen therapy (HBOT) is a high-risk, technology-intensive service requiring infrastructure, equipment control, procedures, emergency preparedness, and cross-departmental coordination. The role of failure mode and effects analysis (FMEA) in supporting pre-launch implementation readiness has been less clearly described.</p><p><strong>Methods: </strong>The authors conducted a prospective, multidisciplinary patient safety improvement project during pre-implementation of a hospital-based HBOT service in northern Israel. FMEA linked risk identification with mitigation planning, accountability, operational controls, readiness activities, and early post-launch review.</p><p><strong>Results: </strong>The FMEA mapped 13 process stages and identified 114 failure modes. High-priority risks extended beyond in-chamber treatment to maintenance, patient preparation and transfer, discharge planning, equipment control, and fire and electrical safety. The highest risk priority number (RPN) was 504 for use of a non-approved external electrical device; RPNs were prioritization aids rather than precise risk estimates. Of the 10 highest-priority failure modes, mitigation actions for 7 were implemented before launch, while 3 underwent additional reinforcement during early follow-up. All core launch-facing staff completed preparation, and three operational checklists were deployed. By February 2026, 347 treatment sessions had been completed, with no patient harm events identified in the reviewed top-risk categories. This was treated as an early operational observation, not evidence of reduced harm.</p><p><strong>Conclusion: </strong>Prospective multidisciplinary FMEA helped structure implementation readiness by linking risk identification with mitigation ownership, operational controls, readiness review, and early post-launch learning. This single-center project did not evaluate whether FMEA reduced patient harm or improved clinical outcomes. FMEA or a comparable prospective hazard-assessment method may be considered in pre-launch planning for selected high-risk clinical services.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148944970","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":"Formative Perceptions on Structured Transfer Escalation: Proactive and Unified Process (STEP-UP) for Inter-ICU Transfers of Acute Respiratory Failure Patients in a Large Health System.","authors":"Chuanfen Ni, Sophie Yao, Kelli Scott, Jacqueline M Kruser, Reiping Huang, Jane L Holl, Meeta Prasad Kerlin, Sanjay Mehrotra, Susan Russell, Jeffrey P Huml, Laeeq Shamsuddin, Bassam Hashem, Cahren Cruz, Nandita R Nadig","doi":"10.1016/j.jcjq.2026.08.001","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.08.001","url":null,"abstract":"<p><strong>Background: </strong>Inter-ICU transfer of patients with acute respiratory failure occurs between hospitals to facilitate specialized care or treatment options. However, no uniform guidance exists to help clinicians decide why or when patients should be transferred. This lack of guidance contributes to inequities in transfers leading to negative impacts on quality of care and patient-centered outcomes. The objectives of this study were (1) to examine ICU clinicians' perception on the transfer processes within a large health system, (2) to develop a novel Structured Transfer Escalation: Proactive and Unified Process (STEP-UP) for inter-ICU transfer of acute respiratory failure (ARF) patients, and (3) to gather feedback on the relevance of STEP-UP for future work.</p><p><strong>Methods and results: </strong>The authors employed Consolidated Framework for Implementation Research (CFIR) 2.0 as a framework throughout this mixed-methods study. Eighty-six ICU clinicians from seven hospitals responded to a survey about perceptions on inter-ICU transfers. 72.1% of participants felt that it was feasible to identify patients who would benefit from transfer and 89.5% felt that an earlier decision would be ideal for patient outcomes. An expert panel used the survey data to develop STEP-UP with two components: (a) a time-based decision-making query regarding transfer and (b) a checklist of key tasks to facilitate shared decision-making, collaborative discussion, and standardized sign-out to accomplish a transfer. Qualitative interviews of 19 clinicians revealed the lack of structure during transfers as a recurring theme, and the majority of clinicians perceived STEP-UP as comprehensive and easy to apply.</p><p><strong>Conclusion: </strong>The authors identified facilitators (for example, health system with a network of hospitals, positive clinician attitudes, and hospital culture around transfers) and barriers (for example, limited bed availability, asymmetric communication) to be considered in future work around a structured system for transfers.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148989365","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}