Joint Commission journal on quality and patient safety最新文献

{"title":"The DRIP Criteria: Reducing the Frequency of Peripheral Intravenous Catheter Insertion in Hospitalized Patients.","authors":"Nicholas May, Lucia Gillman","doi":"10.1016/j.jcjq.2025.06.012","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.012","url":null,"abstract":"<p><strong>Background: </strong>Patient harm attributed to invasive devices is a global concern. Around 18% to 54% of all catheter-related hospital-acquired bloodstream infections (HABSIs) are attributable to peripheral intravenous cannulas (PIVCs). Between 4% and 28% of PIVCs placed in hospitalized patients and up to 50% of emergency department (ED) PIVCs are not used. Avoiding insertion of the \"just in case\" PIVC where safe to do so has potential to reduce patient risk.</p><p><strong>Tool development: </strong>The DRIP mnemonic (Deterioration, Rehydration, Intravenous medications, Procedure) was designed around four simple questions to guide clinicians' decision-making relating to PIVC insertion. DRIP can also be used to support the daily review of existing cannulas to confirm ongoing need. Both applications align to daily workflows to promote a culture of safety.</p><p><strong>Results: </strong>DRIP has assisted in reducing the number of idle PIVCs reported in monthly quality and safety audits from 8.3% to 1.8%. Removal of these PIVCs was possible after confirmation with treating teams that the device was not clinically indicated. This has reduced patient exposure to HABSI. During a 15-month period, independent assessment of PIVC insertion requests by the Vascular Access Team found that 3,103 PIVC requests (10.1%) were deemed not clinically indicated and were not inserted. None met DRIP criteria, which suggests independent expert clinician assessment aligns well to the DRIP criteria in practice.</p><p><strong>Conclusion: </strong>DRIP has shown that elimination of cannulation where not clinically indicated is achievable. Use of the DRIP tool can support safe organizational culture by encouraging staff to question the need for a PIVC to reduce or eliminate the \"just in case\" or idle cannula. Formal validation of DRIP across multiple settings would strengthen the evidence base underpinning PIVC decision-making.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144731051","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":"Improving the Treatment of Preoperative Anemia in Colorectal and Hepato-Pancreato-Biliary Patients: A Quality Improvement Initiative.","authors":"Helen Jingshu Jin, Tsan-Hua Tung, Sydney Selznick, Christine Cotton, Madeline Lemke, Lily J Park, Christopher C Harle, Bradley Moffat, Patrick Colquhoun, Terry Murray Zwiep","doi":"10.1016/j.jcjq.2025.06.007","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.007","url":null,"abstract":"<p><strong>Introduction: </strong>Preoperative anemia for patients undergoing major surgery is associated with increased postoperative morbidity and mortality, including increased requirement for perioperative blood transfusion, length of hospital stay, in-hospital mortality, and ICU admissions. In this quality improvement initiative, the authors describe measures implemented to promote preoperative anemia screening rates and increase uptake in hemoglobin optimizing interventions, with the goal of decreasing perioperative blood transfusion rates.</p><p><strong>Methods: </strong>Change ideas implemented included establishing a new relationship between the Division of General Surgery and the center's established Patient Blood Management (PBM) program; amending the center's electronic health record to include prebuilt order sets for anemia screening bloodwork, PBM referrals, and oral iron prescriptions; modifying surgical consent packages to include anemia screening questions; and providing education to relevant care team members.</p><p><strong>Results: </strong>A total of 1,444 patients were included. PBM referrals for anemic patients were increased to 24.6% from 0%. In patients with anemia (n = 754), preoperative treatment was independently associated with a decrease in perioperative blood transfusion (odds ratio 0.42, p = 0.007). Patients connected with the PBM program had decreased lengths of hospital stay (6.6 vs 9.7 days, p = 0.01), admissions to the ICU (1.1% vs 6.7%, p = 0.03), and in-hospital mortality (0% vs 4.3%, p = 0.04) compared to unreferred anemic patients.</p><p><strong>Conclusion: </strong>The interventions described were successful in decreasing the perioperative blood transfusion rates and improving postoperative outcomes for anemic patients undergoing major surgery. The initiatives were easily incorporated into the existing surgical workflow and can be expanded into other centers and surgical fields.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144731050","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}

{"title":"Improving Awareness and Communication of Do Not Resuscitate Orders During Transitions of Care.","authors":"Hanne Irene Jensen, Hanne Andersen, Helen Bruun","doi":"10.1016/j.jcjq.2025.06.003","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.003","url":null,"abstract":"<p><strong>Background: </strong>Do not resuscitate (DNR) orders are not always documented at transitions of care, which may lead to inappropriate resuscitation attempts. The objectives of this study were (1) to investigate the challenges in ensuring that all staff are aware of patients' DNR orders, (2) to examine documentation of DNR orders at transitions of care, and (3) to improve knowledge about DNR orders in institutions and at transitions of care.</p><p><strong>Methods: </strong>This intervention initiative with pre- and post-measurements (2020 and 2023) involved hospital departments and nursing homes in Denmark. The intervention consisted of a practical instruction brochure and an end-of-life presentation. The measurements included audits of resuscitation attempts and of DNR order documentation at transitions of care. Furthermore, the participating institutions completed an electronic survey on perceived challenges.</p><p><strong>Results: </strong>Thirty nursing homes and eight hospital departments participated in pre-measurement, 20 nursing homes and seven hospital departments participated in post-measurement, and 17 to 20 sites were included in paired analyses. The number of inappropriate resuscitation attempts was identical at pre- and post-measurements (none in nursing homes and five at the hospital). Correct documentation in nursing reports at hospital discharge increased from 32% to 53% (p = 0.003). Participating units that did not perceive challenges in ensuring knowledge of DNR orders increased from 10% to 48% (p < 0.001). At post-measurement, more than 80% of participating units had worked with models to ensure awareness of DNR orders and inclusion of DNR orders at transitions of care.</p><p><strong>Conclusion: </strong>Participants experienced a significant increased focus on DNR orders in their own departments. Likewise, a significant increase in communication of DNR orders at transitions of care was found.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144649498","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":"Language-Concordant Health Care: Implementation of a Bilingual Competency Program.","authors":"Nkiru Ogbuefi, Alexandra Forauer, Maryana Kovalchuk, Javier Gonzalez, Catalina Gomez Luna, Yunshan Niu, Francesca Gany, Lisa C Diamond","doi":"10.1016/j.jcjq.2025.06.004","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.06.004","url":null,"abstract":"<p><strong>Background: </strong>Language proficiency among health care professionals is essential for delivering equitable, high-quality care to patients with a non-English language preference (NELP). This study examines how implementing a Bilingual Competency Program (BCP) for diverse clinical staff enhances patient-centered care and improves the health care experience for NELP patients.</p><p><strong>Methods: </strong>This quality improvement initiative describes implementation of the BCP at an urban cancer center. Staff self-assessed their language skills using the adapted Interagency Language Roundtable Scale for Healthcare (ILR-H) and recorded this in the organization's human resources platform. Those self-rating as excellent attested to their proficiency and enrolled by signing an electronic statement. Those rating themselves as very good or good took an oral proficiency test. Those who passed joined the BCP, while those self-assessing as fair or poor were not included.</p><p><strong>Results: </strong>A total of 935 employees joined the program, representing 1,087 unique language entries across 67 languages, with Spanish, Mandarin, Russian, and Hindi being most common. Out of 1,087 unique entries, 641 (59.0%) self-assessed as excellent, 269 (24.7%) as very good (75.0% of whom [60/80] passed the proficiency test), and 130 (12.0%) as good (58.8% of whom [20/34] passed). Most participants (71.8%) were in patient-facing roles, and 68.7% held clinical positions. Of 1,087 unique entries, 721 (66.3%) were verified for language proficiency, 641 through self-assessment and 80 through formal testing.</p><p><strong>Conclusion: </strong>The BCP enhances linguistic competency by integrating validated assessments and evidence-based methods, addressing prior program limitations, and setting a new standard for improving health equity, care quality, and outcomes for NELP patients.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144649499","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}