Joint Commission journal on quality and patient safety最新文献

{"title":"Effect of an Institution-Specific Guideline on Adherence to the 2021 American Academy of Pediatrics Guidelines for Febrile Infants at a Community Emergency Department: A Quality Improvement Initiative","authors":"Alisha Ching MD (is Clinical Assistant Professor, Department of Emergency Medicine and Department of Pediatrics, University of Michigan Medical School.),&nbsp;Allison Cator MD, PhD (is Clinical Assistant Professor, Department of Emergency Medicine and Department of Pediatrics, University of Michigan Medical School.),&nbsp;Michele Carney MD (is Clinical Professor, Department of Emergency Medicine and Department of Pediatrics, University of Michigan Medical School.),&nbsp;Ruoer Bei MS (is PhD student, George Washington University.),&nbsp;Yaseen Rafee MD (is Associate Professor, Department of Pediatrics, College of Human Medicine, Michigan State University.),&nbsp;Nesma Ghanim MD (is Pediatric Infectious Diseases Fellow, Texas Children’s Hospital.),&nbsp;Tim Tomy MD (is Pediatric Resident, Hurley Medical Center, Flint, Michigan.),&nbsp;Adenike Fatiregun MBBS (is Neonatology Fellow, Medical College of Georgia.),&nbsp;Mai Elhadi MBBS (is Child Neurology Resident, Department of Pediatrics, Duke University School of Medicine.),&nbsp;Courtney W. Mangus MD, MSc (is Assistant Professor, Department of Emergency Medicine and Department of Pediatrics, University of Michigan Medical School. Please address correspondence to Alisha Ching)","doi":"10.1016/j.jcjq.2026.04.007","DOIUrl":"10.1016/j.jcjq.2026.04.007","url":null,"abstract":"<div><h3>Background</h3><div>In a community hospital emergency department (ED), wide practice pattern variation in the management of febrile infants ≤60 days was noted following the release of the 2021 American Academy of Pediatrics (AAP) guidelines. The authors identified a need to standardize practice and improve adherence to AAP recommendations in the care of febrile infants. The aim of this study was to improve ED provider adherence to AAP febrile infant guidelines to &gt; 80% within 18 months.</div></div><div><h3>Methods</h3><div>In this quality improvement initiative, institution-specific febrile infant guidelines and corresponding order sets in the electronic health record based on the AAP recommendations were developed. Age-based, institution-specific algorithms for diagnosis and management of febrile infants were distributed to ED providers. The researchers engaged in multiple Plan-Do-Study-Act cycles of targeted interventions and tracked provider adherence to AAP recommendations over 18 months. ED length of stay (LOS) for all patients and rate of blood cultures for febrile infants &gt; 60 days were tracked as balancing measures.</div></div><div><h3>Results</h3><div>Despite an initial improvement in provider adherence to AAP recommendations from a baseline of 59.1% to 82.0% immediately following implementation of the institution-specific guidelines, there was a subsequent return to 64.3% over 18 months postimplementation. Adherence fluctuated with substantial variability over time. The small overall improvement in adherence postimplementation of the guideline was not statistically significant. There was no statistically significant change in ED LOS for all patients or rate of blood cultures in older infants as a result of the interventions.</div></div><div><h3>Conclusion</h3><div>This project’s interventions resulted in statistically nonsignificant improvements in adherence to AAP guidelines for febrile infants ≤ 60 days old. Ongoing, high-reliability interventions may be required to consistently improve adherence to AAP guidelines.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 8","pages":"Pages 400-405"},"PeriodicalIF":3.0,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148015380","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Statewide Collaborative to Improve Timely Mental Health Follow-up for Medicaid Patients After Hospitalization.","authors":"Daniel E Jonas, Hilja Ruegg, Christina Watson, Katherine Brownlowe, Amanda Gusovsky Chevalier, Brad Martin, Melissa Unger, Cady Cornell, Amy Seidel, Benjamin Rubin, Mary C Borovicka, David Cassavar, William D Hayes","doi":"10.1016/j.jcjq.2026.07.015","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.07.015","url":null,"abstract":"<p><strong>Background: </strong>Providing timely follow-up care after hospitalization reduces readmissions and improves patient outcomes, yet rates for follow-up within seven days of discharge are relatively low.</p><p><strong>Methods: </strong>The authors implemented and evaluated a statewide collaborative (formed in 2018) to improve health outcomes for Ohio's Medicaid population, including a focus on timely follow-up after hospitalization for mental illness within seven days. Interventions (initiated in 2019) included developing new clinical services, completing follow-up phone calls after discharge, reserving dedicated appointment slots for hospital follow-up visits, expanding staffing, initiating collaborative care, convening predischarge planning groups, promoting warm handoffs, and using telehealth. A longitudinal analysis using binomial regression was conducted to retrospectively evaluate quarterly Medicaid claims and eligibility data from 2019 through 2023 to assess for improvement in the percentage of persons discharged who had timely follow-up after hospitalization. To compare annual changes observed for the statewide collaborative with national trends, changes were compared with publicly available data from the National Committee for Quality Assurance (NCQA).</p><p><strong>Results: </strong>The number of eligible discharges totaled 9,041 across the statewide collaborative from 2019 through 2023. The available data demonstrated improvement in timely follow-up after hospitalization for mental illness, from 47.9% in 2019 to 57.0% in 2023 (quarterly median 51.8%, for 2019-2023). In binomial regression, there was a highly significant increase in the probability of follow-up over time (p < 0.001). Compared with publicly available national payer data from NCQA, the collaborative had higher rates of follow-up (by 7.5 percentage points across the study period, p = 0.015), and the difference in trends over time was statistically significant (difference in slope = 2.15 percentage points per year, p = 0.01).</p><p><strong>Conclusion: </strong>A statewide learning collaborative was associated with an increased percentage of Medicaid beneficiaries receiving timely follow-up after hospitalization for mental illness.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148887533","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":"Transparency as a Catalyst for High-Quality Healthcare in Brazil.","authors":"Sabrina Bernardez-Pereira, Paula Tuma, Daniel Tavares Malheiro, J Matthew Austin","doi":"10.1016/j.jcjq.2026.07.014","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.07.014","url":null,"abstract":"<p><p>Transparency has become a central governance strategy for strengthening accountability, quality, and patient safety in healthcare systems. In high-income countries, this principle is often operationalized through the public reporting of standardized healthcare performance indicators, enabling comparability, organizational learning, and continuous improvement. In Brazil, however, although the availability of health data has advanced substantially, standardized public reporting of healthcare performance remains fragmented and uneven. Although hospitals are subject to extensive regulatory reporting requirements and the country has developed a robust health information infrastructure, Brazil still lacks a unified national framework for risk-adjusted, validated, and publicly reported hospital performance indicators. National information systems primarily disseminate aggregated data, limiting hospital-level comparability and public accountability. Private-sector initiatives led by the National Supplementary Health Agency and the Brazilian National Association of Private Hospitals have advanced benchmarking and outcomes measurement; however, access to comprehensive and comparable performance data remains limited in scope, coverage, and public accessibility across the Brazilian healthcare system. This article analyzes transparency as a governance principle in Brazilian healthcare, with a specific focus on public reporting of hospital performance as an essential operational mechanism to strengthen accountability and quality improvement. It identifies critical policy gaps, including the lack of standardized national indicators, limited use of risk adjustment, insufficient independent data validation, the absence of an integrated national public reporting system encompassing both public and private hospitals, and the limited integration of public-sector hospitals into existing reporting frameworks. The authors argue that establishing a unified, methodologically robust, and publicly accessible national hospital performance platform is a critical step toward strengthening governance, improving accountability, and advancing patient safety and high-quality healthcare in Brazil.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148865137","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":"Assessing the Relationship Between Emergency Department Boarding and Inpatient Unit Occupancy in Psychiatry.","authors":"Jack J Huang, Nicole M Benson, Amin Yakubu, Boyu Ren, Alisa Busch","doi":"10.1016/j.jcjq.2026.07.013","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.07.013","url":null,"abstract":"<p><strong>Background: </strong>Emergency department (ED) boarding of patients awaiting inpatient admission is a widespread challenge. Patients presenting for psychiatric reasons face disproportionate rates and durations of boarding. Prior literature suggests higher occupancy levels on inpatient medical units increases ED boarding, but this relationship has not been examined in psychiatry. The goal of this study was to examine the association between inpatient psychiatry occupancy levels and psychiatric ED boarding.</p><p><strong>Methods: </strong>This was a retrospective operational data analysis in an integrated healthcare delivery system. The study population included patients presenting to EDs requiring inpatient psychiatry placement. Separate analyses were conducted for adult, child/adolescent, and geriatric populations. Data were obtained from operational dashboards created from electronic health record data. Generalized additive models were used to assess the relationship between inpatient psychiatry unit occupancy and ED boarding volume.</p><p><strong>Results: </strong>Among the adult population, higher inpatient psychiatry unit occupancy was associated with higher psychiatric ED boarding volume (for example, daily predicted boarding volume was 31.6 (95% confidence interval [CI] 27.6-35.6) at < 80% occupancy and 41.0 (95% CI 37.3-44.8) at ≥ 90% occupancy. For the child/adolescent population, higher occupancy was also associated with higher boarding volume, but at a lower occupancy threshold (≥ 60%). There was not a significant association between boarding and occupancy for the geriatric population.</p><p><strong>Conclusion: </strong>Higher inpatient psychiatry occupancy levels were associated with greater ED boarding, with the relationship best explained by boarding volume rather than duration. This possibly reflects dynamics in boarding and placement specific to psychiatry, including challenges of finding appropriate units for complex patients. In addition, health system factors that block beds (for example, staffing or infection status) likely influence the relationship between occupancy and boarding and should be incorporated into operational analyses aimed at reducing ED boarding.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148840168","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":"Implementation of Virtual Clinical Emergency Response Team Model: Impact on Response Timeliness and Reliability.","authors":"Carl Daniel, Aline Kalaydjian, Jannika V Machnik, Farhan Ishaq, Jada A Malveaux, Sarah Homer Dnp, Laura Griffin, Sarah Pletcher, Ngoc-Anh Anh Nguyen","doi":"10.1016/j.jcjq.2026.07.006","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.07.006","url":null,"abstract":"<p><strong>Background: </strong>Delays in Clinical Emergency Response Team (CERT) workflows and variability in post-event practices contribute to impaired response timeliness and documentation practices. Hybrid virtual-in-person response models may offer a feasible approach to improve response timeliness and reliability of post-event practices.</p><p><strong>Methods: </strong>The authors conducted a retrospective, single-center, pre-post quasi-experimental study evaluating a virtual CERT (vCERT) program that leveraged in-room audiovisual technology to enable immediate virtual response by a nurse practitioner (NP). Implementation occurred through a phased rollout-phase 1 (August 4, 2025; weekday day shifts) and phase 2 (September 29, 2025; expansion to 24/7 coverage). The study included 2,854 CERT activations between January 1 and December 31, 2025. The primary outcome was time to first NP contact, either in-person or virtual. Secondary outcomes included documentation compliance for post-event debriefs (structured team discussions immediately following an event) and four-hour follow-ups (scheduled reassessments four hours after an event). Outcomes were compared pre- and postimplementation.</p><p><strong>Results: </strong>In the postimplementation period, 80.4% (952/1,184) of all activations used the vCERT program. Median time to first NP contact decreased by 90.3%, from 3.50 minutes (IQR 2.86-4.22) preimplementation to 0.34 minutes (IQR 0.28-0.41) postimplementation (p < 0.001). Post-event debrief documentation compliance increased from 43.3% to 70.6% (p < 0.001), and four-hour follow-up documentation compliance increased from 10.1% to 26.6% (p < 0.001).</p><p><strong>Conclusion: </strong>This pre-post evaluation of a hybrid virtual-in-person emergency response model was associated with significant improvements in response timeliness and reliability of post-event activities. Collectively, these findings suggest that the vCERT model is feasible and may serve as an augmentation, rather than a replacement, of bedside care. Future studies should investigate the impact of such models on patient outcomes.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148761018","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 SMS Texting for Adverse Drug Reaction Surveillance: Evaluation of New Medication Prescriptions in Primary Care.","authors":"Tewodros Eguale, Alejandra Salazar, Maria Mirica, Pamela Garabedian, Lynn A Volk, Heather M Hussey, Sonam Shah, Adam B Landman, Aneesha Fathima Syed Mohamed, Renuka Kandikatla, Adam Wright, Gordon D Schiff","doi":"10.1016/j.jcjq.2026.07.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.07.008","url":null,"abstract":"<p><strong>Background: </strong>Adverse drug reactions (ADRs) and their timely recognition are major patient safety concerns. Earlier detection of ADRs can improve outcomes through more timely medication management thereby minimizing harm. The research team has conducted studies to proactively monitor patients prescribed medications to identify potential ADRs, through pharmacist phone calls, interactive voice response (IVR) calls, and patient portal messaging. Because many patients regularly use SMS texting, the authors sought to leverage this technology to improve convenience and response rates.</p><p><strong>Methods: </strong>The team designed and deployed SMS text-based pharmacosurveillance coupled with live pharmacist support at three primary care clinics to identify potential ADRs among patients newly prescribed medication(s). Descriptive data were collected on response rates, medications prescribed, medication initiation, reasons for non-initiation, and types of potential ADR symptoms.</p><p><strong>Results: </strong>More than 42% of patients opted-in to receive text messages related to their new medication(s). A total of 884 unique patients prescribed 1,369 new medications were contacted. Most prescriptions were filled and started (52.2%), while 11.0% were not started-primarily due to insurance coverage issues and drug unavailability-and 36.9% did not respond to text/phone call. Overall, 110 patients (20.0%, 95% confidence interval [CI] 16.7%-23.3%) reported new potential ADR symptoms. Most patients reported that the text messaging service was helpful and easy to use.</p><p><strong>Conclusion: </strong>An automated SMS texting platform for ADR surveillance achieved higher response rates than prior outreach efforts using phone IVR and patient portal messaging. One in five respondents report potential ADRs to newly prescribed medications.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149001924","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association Between CMS Hospital Star Ratings and Medicare Payment Adjustments Across Value-Based Programs.","authors":"Samuel J Flanders","doi":"10.1016/j.jcjq.2026.07.012","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.07.012","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148764743","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":"Multicenter Standardized Mortality Review for Quality-of-Care Improvement: Implementing an Automated Workflow.","authors":"Rachel Aubuchon, Abin Sajan, Xenia Frisby, Andrea Adderley, Kelly Duvall, Baruch S Fertel","doi":"10.1016/j.jcjq.2026.07.010","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.07.010","url":null,"abstract":"<p><strong>Background: </strong>Mortality review is a key mechanism for identifying preventable harm and improving hospital-based quality and safety. Traditional review processes are manual, often delayed, and inconsistent across services, resulting in variable completion rates and limited ability to generate improvement strategies. Structured, multidisciplinary review models have shown benefits, but many institutions continue to rely on decentralized, retrospective approaches that lack electronic integration or automation. Traditional approaches often fail to identify systemwide patterns, yielding insights with limited utility for driving meaningful, organization-level improvements. To overcome these limitations, a redesigned tiered mortality review workflow and supporting Web-based system were implemented across a multicampus academic health system.</p><p><strong>Methods: </strong>A retrospective analysis was conducted comparing two six-month periods: the manual review process (January-June 2023) and the Web-based system (January-June 2025). The Web-based platform integrates automated case identification; structured Tier 1 reviews performed by frontline physicians, fellows, residents, advance practice providers (APPs), and nurses; and escalation to Tier 2 multidisciplinary committee review when indicated. Primary study outcomes included review completion rate, time to completion, and the number and nature of identified improvement opportunities.</p><p><strong>Results: </strong>During the manual review period (January-June 2023), 1,481 inpatient deaths occurred, of which 1,286 reviews were completed (86.8%). The mean time to completion was 78.4 days. Potential opportunities for improvement were identified in 63 cases (4.3%), with 3 cases (0.2%) resulting in implemented risk-reduction strategies. In the Web-based review period (January-June 2025), 1,440 inpatient deaths occurred, with 1,413 reviews completed (98.1%). The mean time to completion decreased markedly to 35.8 days. Potential improvement opportunities were identified in 165 cases (11.5%), with 72 cases (5.0%) leading to actionable risk-reduction strategies.</p><p><strong>Conclusion: </strong>A redesigned tiered mortality review working and supporting Web-based system improved completion rates and capture of actionable opportunities compared with manual review, providing a scalable framework to strengthen patient safety and institutional learning.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149136768","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":"Priorities, Approaches, and Performance for Outpatient Antithrombotic Stewardship: The ADAPT Project.","authors":"Cassiopeia Frank, Tara Lech, Arthur Allen, Darren Triller","doi":"10.1016/j.jcjq.2026.07.009","DOIUrl":"https://doi.org/10.1016/j.jcjq.2026.07.009","url":null,"abstract":"<p><strong>Background: </strong>Antithrombotic (AT) agents are widely used and highly effective but are frequently implicated in preventable adverse events. Despite growing interest in AT stewardship, the outpatient care environment lacks a standardized measurement infrastructure analogous to what has been achieved in antimicrobial stewardship. The authors sought to characterize current outpatient practices across five care process priorities (CPPs) and examine gaps between clinical monitoring and system-level tracking to support future quality measurement and benchmarking.</p><p><strong>Methods: </strong>The researchers conducted a sequential explanatory mixed methods evaluation of established anticoagulation management clinics. A national cross-sectional survey was followed by semistructured interviews. The survey assessed the presence of clinical monitoring and capacity for system-level tracking for each CPP; interviews explored operational approaches, reach, facilitators, and barriers.</p><p><strong>Results: </strong>Among 45 responding sites, monitoring of CPPs was common in some or all clinics, but system-level tracking was substantially less prevalent, with marked heterogeneity by CPP and setting. Sites frequently reported having protocols in place, yet few described routine tracking of adherence to them. US Department of Veterans Affairs (VA) clinics consistently demonstrated systemwide tracking-notably higher performance for warfarin time in therapeutic range (TTR) and broader reach-whereas non-VA sites more often relied on manual, labor-intensive audits or case-by-case review. Interview narratives revealed that survey-reported monitoring often reflected informal checks without automated data capture, standardized feedback loops, or population-level reporting.</p><p><strong>Conclusion: </strong>Outpatient AT stewardship practices show high variability and a pervasive gap between clinical monitoring and population-level tracking. Advancing from monitoring to tracking is a prerequisite for specification and implementation of quality measures and benchmarking. Priorities include governance, data automation, and operational support aligned with core stewardship elements to enable reliable, scalable measurement of AT safety and effectiveness.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148759556","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 Visual Management to Improve Compliance with Chlorhexidine Gluconate Bathing and Nasal Decolonization.","authors":"Abigail Ruby, Eman Chami, Hannah Musgrove, Xuan Ma, Jennifer McLenon, Gwen Gnam","doi":"10.1016/j.jcjq.2026.07.007","DOIUrl":"10.1016/j.jcjq.2026.07.007","url":null,"abstract":"<p><strong>Background: </strong>Visual management tools are designed to drive desired behaviors and support consistent performance. When tailored to specific practice areas, these tools become more relevant for staff.</p><p><strong>Methods: </strong>Visual management tools were designed and implemented for this project to standardize nursing handoff communication and improve administration of 2% chlorhexidine gluconate (CHG)-impregnated wipe bathing and prophylactic alcohol-based nasal decolonization swabs. Supply locations were standardized across the hospital, and a wipeable sticker was added to patient whiteboards, which served as a visual reminder, prompting discussion of CHG bathing and nasal decolonization administration status during nursing handoff.</p><p><strong>Results: </strong>Compliance with nursing documentation of chlorhexidine gluconate bathing (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.57-1.76, p < 0.001) and nasal decolonization (OR 1.86, 95% CI 1.81-1.93, p < 0.001) improved postimplementation (October 2023-April 2024 vs. October 2024-April 2025). Improvements were also noted in central line-associated bloodstream infection (rate ratio [RR] 0.47, 95% CI 0.28-0.76, p = 0.003) and methicillin-resistant Staphylococcus aureus bacteremia (RR 0.80, 95% CI 0.20-3.01, p = 0.74) rates when comparing preimplementation and postimplementation data.</p><p><strong>Conclusion: </strong>This project demonstrates that visual management tools may help to improve nursing handoff communication, and CHG bathing and nasal decolonization administration and documentation.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":3.0,"publicationDate":"2026-07-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148721671","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}