Joint Commission journal on quality and patient safety最新文献

{"title":"The Urgent Need for the Age-Friendly Health Systems Movement","authors":"Kedar S. Mate MD (is President and Chief Executive Officer, Institute for Healthcare Improvement, Boston.), Leslie Pelton MPA (is Vice President, Institute for Healthcare Improvement. Please address correspondence to Kedar S. Mate)","doi":"10.1016/j.jcjq.2024.02.003","DOIUrl":"10.1016/j.jcjq.2024.02.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 463-466"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139829414","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 50th Anniversary Article Collections: Clinician Well-Being and Burnout","authors":"","doi":"10.1016/j.jcjq.2024.04.011","DOIUrl":"https://doi.org/10.1016/j.jcjq.2024.04.011","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 472-473"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725024001405/pdfft?md5=b6388e2b0693e4545b4c03621ba2a08f&pid=1-s2.0-S1553725024001405-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141264125","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":"Infection Control Measure Performance in Long-Term Care Hospitals and Their Relationship to Joint Commission Accreditation","authors":"Stephen P. Schmaltz PhD, MPH, MS (is Senior Biostatistician, Department of Research, The Joint Commission, Oakbrook Terrace, Illinois.),&nbsp;Beth A. Longo DrPH, MSN, RN (is Associate Director, Department of Research, The Joint Commission.),&nbsp;Scott C. Williams PsyD (is Director, Department of Research, The Joint Commission. Please address correspondence to Beth A. Longo)","doi":"10.1016/j.jcjq.2024.02.005","DOIUrl":"10.1016/j.jcjq.2024.02.005","url":null,"abstract":"<div><h3>Background</h3><p>This study evaluated the relationship between Joint Commission accreditation and health care–associated infections (HAIs) in long-term care hospitals (LTCHs).</p></div><div><h3>Methods</h3><p>This observational study used Centers for Medicare &amp; Medicaid Services (CMS) LTCH data for the period 2017 to June 2021. The standardized infection ratio (SIR) of three measures used by the Centers for Disease Control and Prevention's National Healthcare Safety Network were used as dependent variables in a random coefficient Poisson regression model (adjusting for CMS region, owner type, and bed size quartile): catheter-associated urinary tract infections (CAUTIs), <em>Clostridioides difficile</em> infections (CDIs), and central line–associated bloodstream infections (CLABSIs) for the periods 2017 to 2019 and July 1, 2020, to June 30, 2021. Data from January 1 to June 30, 2020, were excluded due to the COVID-19 pandemic.</p></div><div><h3>Results</h3><p>The data set included 244 (73.3%) Joint Commission–accredited and 89 (26.7%) non–Joint Commission–accredited LTCHs. Compared to non–Joint Commission–accredited LTCHs, accredited LTCHs had significantly better (lower) SIRs for CLABSI and CAUTI measures, although no differences were observed for CDI SIRs. There were no significant differences in year trends for any of the HAI measures. For each year of the study period, a greater proportion of Joint Commission–accredited LTCHs performed significantly better than the national benchmark for all three measures (<em>p</em> = 0.04 for CAUTI, <em>p</em> = 0.02 for CDI, <em>p</em> = 0.01 for CLABSI).</p></div><div><h3>Conclusion</h3><p>Although this study was not designed to establish causality, positive associations were observed between Joint Commission accreditation and CLABSI and CAUTI measures, and Joint Commission–accredited LTCHs attained more consistent high performance over the four-year study period for all three measures. Influencing factors may include the focus of Joint Commission standards on infection control and prevention (ICP), including the hierarchical approach to selecting ICP–related standards as inputs into LTCH policy.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 425-434"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139965528","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":"Reusing Single-Use Intermittent Pneumatic Compression Devices to Promote Greenhouse Gas Reduction in Hospitals: A Pilot Study","authors":"Imane Hammana MSc, PhD (is Researcher, Health Technology Assessment Unit, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal.),&nbsp;Marie-Claude Bernier (is Senior Advisor, Respiratory Therapy and Anesthesiology, CHUM.),&nbsp;Sabrine Sahmi (is Senior Advisor, Material Resources Management, CHUM.),&nbsp;Alfons Pomp MD, FRCSC, FACS. (is Professor of Surgery and Director, Health Technology Assessment Unit, CHUM. Please address correspondence to Alfons Pomp)","doi":"10.1016/j.jcjq.2024.01.012","DOIUrl":"10.1016/j.jcjq.2024.01.012","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 456-457"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140068371","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":"Clinician Well-Being and Burnout: Panel Interview with Tait Shanafelt, Lisa Rotenstein, and Christine Sinsky","authors":"David W. Baker MD, MPH, FACP (at the time of this interview recording, was Editor-in-Chief, The Joint Commission Journal on Quality and Patient Safety, Oakbrook Terrace, Illinois. Please address correspondence to Scott Williams)","doi":"10.1016/j.jcjq.2024.04.005","DOIUrl":"10.1016/j.jcjq.2024.04.005","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 6","pages":"Pages 467-471"},"PeriodicalIF":2.3,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140777170","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 Review of Modifiable Health Care Factors Contributing to Inpatient Suicide: An Analysis of Coroners’ Reports Using the Human Factors Analysis and Classification System for Healthcare","authors":"","doi":"10.1016/j.jcjq.2024.05.008","DOIUrl":"10.1016/j.jcjq.2024.05.008","url":null,"abstract":"<div><h3>Background</h3><div>Inpatient suicides have devastating and long-lasting consequences for patients, families, and health care organizations<span>, posing a major challenge for hospitals. Although many studies have identified patient risk factors for inpatient suicide, the modifiable health care factors are less understood. Failure to understand these modifiable factors weakens organizations’ ability to design and implement effective prevention strategies.</span></div></div><div><h3>Methods</h3><div>The Human Factors Analysis and Classification System for Healthcare (HFACS–Healthcare) was used to classify and analyze modifiable health care factors that contributed directly or indirectly to inpatient suicides in Australian hospitals between 2009 and 2018. Comparisons were made between general and psychiatric hospital units to identify context-specific recommendations.</div></div><div><h3>Results</h3><div><span>Of the 367 cases, 216 (58.9%) had enough information to analyze the contributing factors, and 214 (58.3%) included unit location information. Multiple modifiable health care factors were identified in the cases as contributing to the patients’ suicides. Commonly, cases reported decision errors made by individuals (57.4%), problems with the physical environment (56.0%), and unit-level operational decision-making errors (that is, planned inappropriate operations) (48.6%). An association was found between unit type and problems with coordination, mental state, tasks, physical environment, planned inappropriate operations, and organizational culture (</span><em>p</em> &lt; 0.05).</div></div><div><h3>Conclusion</h3><div>General prevention initiatives may not be effective in addressing inpatient suicides across specialty units. HFACS–Healthcare enabled a deeper understanding of inpatient suicide and the identification of priority areas that, if addressed, could help reduce the number of preventable suicides in hospitals. Hospital suicide prevention initiatives need to be tailored to specific units and target individual and system vulnerabilities to improve safety and reduce inpatient suicide rates.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 711-718"},"PeriodicalIF":2.3,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141468102","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":"Partnership as a Pathway to Diagnostic Excellence: The Challenges and Successes of Implementing the Safer Dx Learning Lab","authors":"Jennifer Sloane PhD, MS (is Advanced Postdoctoral Fellow, Health Services Research and Development, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, and Baylor College of Medicine, Houston.),&nbsp;Hardeep Singh MD, MPH (is Research Scientist and Co-Chief, Health Policy, Quality and Informatics Program, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, and Professor, Baylor College of Medicine.),&nbsp;Divvy K. Upadhyay MD, MPH, CPHRM, CPPS (is Diagnostic Safety Program Leader, Division of Quality, Safety and Patient Experience, Geisinger, Danville, Pennsylvania and Assistant Professor, Health System Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania.),&nbsp;Saritha Korukonda MD, MS, CCRP (is Research Project Manager II, Geisinger.),&nbsp;Abigail Marinez MPH (is Research Coordinator II, Baylor College of Medicine.),&nbsp;Traber D. Giardina PhD, MSW (is Investigator, Implementation and Innovation Program, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, and Assistant Professor, Baylor College of Medicine. Please address correspondence to Traber D. Giardina)","doi":"10.1016/j.jcjq.2024.05.011","DOIUrl":"10.1016/j.jcjq.2024.05.011","url":null,"abstract":"<div><h3>Background</h3><div><span>Learning health system (LHS) approaches could potentially help </span>health care organizations<span> (HCOs) identify and address diagnostic errors. However, few such programs exist, and their implementation is poorly understood.</span></div></div><div><h3>Methods</h3><div>The authors conducted a qualitative evaluation of the Safer Dx Learning Lab, a partnership between a health system and a research team, to identify and learn from diagnostic errors and improve diagnostic safety at an organizational level. The research team conducted virtual interviews to solicit participant feedback regarding experiences with the lab, focusing specifically on implementation and sustainment issues.</div></div><div><h3>Results</h3><div>Interviews of 25 members associated with the lab identified the following successes: learning and professional growth, improved workflow related to streamlining the process of reporting error cases, and a psychologically safe culture for identifying and reporting diagnostic errors. However, multiple barriers also emerged: competing priorities between clinical responsibilities and research, time-management issues related to a lack of protected time, and inadequate guidance to disseminate findings. Lessons learned included understanding the importance of obtaining buy-in from leadership and interested stakeholders, creating a psychologically safe environment for reporting cases, and the need for more protected time for clinicians to review and learn from cases.</div></div><div><h3>Conclusion</h3><div>Findings suggest that a learning health systems approach using partnerships between researchers and a health system affected organizational culture by prioritizing learning from diagnostic errors and encouraging clinicians to be more open to reporting. The study findings can help organizations overcome barriers to engage clinicians and inform future implementation and sustainment of similar initiatives.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 12","pages":"Pages 834-841"},"PeriodicalIF":2.3,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141468103","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":"Artificial Intelligence and the Practice of Patient Safety: GPT-4 Performance on a Standardized Test of Safety Knowledge","authors":"","doi":"10.1016/j.jcjq.2024.05.007","DOIUrl":"10.1016/j.jcjq.2024.05.007","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 745-747"},"PeriodicalIF":2.3,"publicationDate":"2024-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141317390","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":"BONE Break: A Hot Debrief Tool to Reduce Second Victim Syndrome for Nurses","authors":"","doi":"10.1016/j.jcjq.2024.05.005","DOIUrl":"10.1016/j.jcjq.2024.05.005","url":null,"abstract":"<div><p><span>The pandemic has intensified clinicians’ workloads, leading to an increased incidence of adverse events and subsequent second victim syndrome, with almost half of health care clinicians experiencing its symptoms. However, following a </span>literature review<span>, no tools were found that addressed second victim syndrome in nurses. To address these issues and the gap in the literature, the authors developed the BONE Break hot debriefing tool. BONE Break is designed to be facilitated by charge nurses or other unit leaders as a means of offering peer support to other nurses who went through an adverse event. During its initial implementation, BONE Break was employed in 43 of 46 events adverse events (93.5%), and 41 of 43 sessions (95.3%) were deemed helpful. The research team has continued to gain stakeholder buy-in and implement BONE Break across multiple sites. Future work will determine BONE Break's efficacy in enhancing long-term nursing retention and reducing second victim symptoms.</span></p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Pages 673-677"},"PeriodicalIF":2.3,"publicationDate":"2024-05-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141030638","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":"Divergent Trends in Postoperative Length of Stay and Postdischarge Complications over Time","authors":"","doi":"10.1016/j.jcjq.2024.05.006","DOIUrl":"10.1016/j.jcjq.2024.05.006","url":null,"abstract":"<div><h3>Background</h3><p>There is a push toward shorter length of stay (LOS) after surgery by hospitals, payers, and policymakers. However, the extent to which these changes have shifted the occurrence of complications to the postdischarge setting is unknown. The objectives of this study were to (1) evaluate changes in LOS and postdischarge complications over time and (2) assess factors associated with postdischarge complications.</p></div><div><h3>Study Design</h3><p><span>Patients who underwent surgery across five specialties (colorectal, esophageal, hepatopancreatobiliary [HPB], gynecology<span>, and urology) were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) procedure-targeted database (2014–2019). Trends in the proportion of postdischarge complications within 30 days of surgery and predictors of postdischarge complications were assessed using multivariable </span></span>logistic regression.</p></div><div><h3>Results</h3><p>Among 538,172 patients evaluated, median LOS decreased from 3 (2014) to 2 days (2019) (<em>p</em><span><span> &lt; 0.001). Overall, 12.2% of patients experienced a 30-day complication, with 50.4% occurring postdischarge. with the highest in hysterectomy<span><span> (80.9%), prostatectomy (74.6%), and </span>cystectomy (54.6%). The overall </span></span>postoperative complication decreased, but the proportion of postdischarge complications increased from 44.6% (2014) to 56.4% (2019) (</span><em>p</em><span><span> &lt; 0.001), including surgical site infection<span> (superficial/deep/organ space/wound dehiscence), other infection (pneumonia/urinary tract infection/sepsis), cardiovascular (myocardial infarction/cardiac arrest/stroke), and venous thromboembolism. Factors associated with an increased odds of postdischarge complications included Hispanic or other race, higher American Society of Anesthesiologists class, dependent functional status, increased </span></span>body mass index, higher wound class, inpatient complication, longer operation, and procedure type (HPB/colorectal/hysterectomy/esophagectomy, vs. prostatectomy) (all </span><em>p</em> &lt; 0.001).</p></div><div><h3>Conclusion</h3><p>This comprehensive retrospective analysis across five representative surgical specialties highlighted that although LOS has decreased over time, the proportion of postdischarge complications has increased over time. Focusing on the development of a comprehensive, proactive, postdischarge monitoring system to better identify and manage postdischarge complications is necessary.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Pages 630-637"},"PeriodicalIF":2.3,"publicationDate":"2024-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141025517","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}