Joint Commission journal on quality and patient safety最新文献

{"title":"Demographic Profile and Oversight Duties of Today's Health Care Quality Leaders","authors":"Kimiyoshi J. Kobayashi MD, MBA (is Chief Quality Officer, UMass Memorial Medical Center, and Associate Professor, Departments of Medicine and Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Masschusetts), Amy C. Lu MD, MHP (is Chief Quality Officer and Vice President, University of California, San Francisco (UCSF) Health, and Professor, Department of Anesthesia and Perioperative Care, UCSF School of Medicine), Christopher S. Kim MD, MBA (is Senior Vice President and Chief Quality Officer, Wellstar Health System, Atlanta), Bela Patel MD, FCCP, FCCM, ATSF (is Professor of Medicine and Vice Dean of Healthcare Quality, University of Texas Health Science Center and Memorial Hermann Hospital, Houston), Jennifer Wiler MD, MBA, FACEP (is Professor, Department of Emergency Medicine, University of Colorado School of Medicine), Mbonu Ikezuagu MD, MHSA, FACP, CPE (is Vice President and Chief Quality Officer, ThedaCare, Neenah, Wisconsin), Jodi L. Eisenberg MHA, CPHQ (is Associate Vice President, Member Networks–Quality Executive Network, Vizient, Chicago), David M. Safley MD, FACC (is Vice President of Medical Affairs, Quality, Saint Luke's Health System, University of Missouri–Kansas City. Please address correspondence to Jodi Eisenberg)","doi":"10.1016/j.jcjq.2025.01.009","DOIUrl":"10.1016/j.jcjq.2025.01.009","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 381-385"},"PeriodicalIF":2.3,"publicationDate":"2025-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143501453","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Utilizing Recorded Resuscitations for Neonatal Team Process Improvement","authors":"Audrey Moore NNP (is Neonatology Nurse Practitioner, Lucile Packard Children's Hospital Stanford, Palo Alto, California, and Center for Advanced Pediatric & Perinatal Education (CAPE), Stanford University),&nbsp;Louis P. Halamek MD (is Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University),&nbsp;Janene H. Fuerch MD (is Clinical Associate Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University),&nbsp;Rodrigo B. Galindo MSc, CHSOS (is CAPE Simulation Lab Manager and Operations Specialist, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University),&nbsp;Nicole K. Yamada MD, MS (is Clinical Professor, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University. Please address correspondence to Audrey Moore)","doi":"10.1016/j.jcjq.2025.01.008","DOIUrl":"10.1016/j.jcjq.2025.01.008","url":null,"abstract":"<div><div>Newborn resuscitation requires health care professionals to quickly assemble into a high-functioning integrated team. At the authors’ academic children's hospital, there are billions of permutations of team composition that could attend a complex newborn delivery at any given time. ResusOne, a resuscitation safety and performance improvement program, uses recorded neonatal resuscitations to identify areas for improvement. The authors identified the following key areas that would support better team performance: (1) need for role clarity and task allocation among delivery team members and (2) communication challenges when calling for neonatal delivery teams. This article describes two tools that were developed to address the issues that were identified in these two areas.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 368-377"},"PeriodicalIF":2.3,"publicationDate":"2025-01-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143476621","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":"Change in US Hospital Practice After the Joint Commission Requirement to Use Distinct Methods of Newborn Identification: A Cross-Sectional 10-Year Follow-Up Survey","authors":"Jason S. Adelman MD, MS (Associate Dean for Quality and Patient Safety; Director, Center for Patient Safety Science; Vice Chair for Quality & Patient Safety, Department of Medicine; and Associate Professor of Medicine (in Biomedical Informatics) at Columbia University Irving Medical Center, Vagelos College of Physicians & Surgeons),&nbsp;Jo R. Applebaum MPH (Research Advisor, Center for Patient Safety Science, Columbia University Irving Medical Center),&nbsp;Nicole Krenitsky MD, MBA (Fellow in Patient Safety Research and Clinical Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center),&nbsp;Dena Goffman MD (Vice Chair for Quality and Patient Safety and Professor, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center),&nbsp;Saud Khan MBBS, MHA, MS (Data Scientist, Center for Patient Safety Science, Columbia University/NewYork-Presbyterian Hospital),&nbsp;Baruch S. Fertel MD (Associate Clinical Professor, Department of Emergency Medicine, Columbia University Irving Medical Center),&nbsp;Judy L. Aschner MD (Professor, Center for Discovery and Innovation, Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey)","doi":"10.1016/j.jcjq.2025.01.006","DOIUrl":"10.1016/j.jcjq.2025.01.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 378-380"},"PeriodicalIF":2.3,"publicationDate":"2025-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143433150","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":"Use of the Model for Improvement to Reduce Hyperglycemia in Adult Patients Admitted to a Public Tertiary Care Hospital","authors":"Gabriela Berlanda Ph.D. (Pharmacist, Hospital de Clínicas de Porto Alegre (HCPA) and Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil),&nbsp;Luiza Daniel de Souza (RN, HCPA and UFRGS),&nbsp;Juliana da Silva Lima MSc. (RN, HCPA),&nbsp;Caroline Tortato (Pharmacist, HCPA),&nbsp;Simone Silveira Pasin MSc. (RN, HCPA),&nbsp;Eloni Rotta MSc. (Pharmacist, HCPA),&nbsp;Melissa Hemesath MSc. (RN, HCPA),&nbsp;Thais Ortiz Hammes PhD. (RD, HCPA),&nbsp;Fernanda Rosa Indriunas Perdomini MSc. (RN, HCPA),&nbsp;Claudia Carolina Schnorr (MD, HCPA),&nbsp;Helena Barreto dos Santos PhD. (MD, HCPA),&nbsp;Cristiane Bauermann Leitao PhD. (MD, HCPA and Associate Professor, UFRGS),&nbsp;Beatriz D. Schaan PhD. (MD, HCPA and Full Professor, UFRGS. Please address correspondence to Gabriela Berlanda)","doi":"10.1016/j.jcjq.2025.01.004","DOIUrl":"10.1016/j.jcjq.2025.01.004","url":null,"abstract":"<div><h3>Background</h3><div>The objective of this study was to reduce by 50% the occurrence of average daily blood glucose (ADBG) &gt; 180 mg/dL among noncritical patients admitted to a surgical ward at a public tertiary care hospital.</div></div><div><h3>Methods</h3><div>This project ran from April 2022 to June 2023 and used the Model for Improvement (MFI) method. Health care Failure Modes and Effects Analysis was used to identify and analyze failure modes in hyperglycemia management, and a driver diagram (DD) was used to prioritize and structure changes. The Plan-Do-Study-Act (PDSA) tool facilitated the change process. Data were collected using standardized forms and monitored with run charts, considering process, outcome, and balance indicators. The DD included 12 changes focusing on protocol implementation, adequate medical prescription, correct insulin administration, proper blood glucose monitoring, appropriate diet prescription, safe care transitions between units, routine of publication and discussion of indicators, leadership engagement with frontline workers on hyperglycemia management, educational actions, and defining roles and responsibilities.</div></div><div><h3>Results</h3><div>A 69.0% reduction in ADBG &gt; 180 mg/dL and a 100% reduction in ADBG &gt; 300 mg/dL were achieved, though hypoglycemic events increased from 8 to 11 per 100 patient-days using insulin or oral antidiabetic medications. Reductions in nonconformities in medical prescription and insulin administration (50.0% and 71.4%, respectively) were also achieved.</div></div><div><h3>Conclusion</h3><div>In this pilot project, use of the MFI led to improved prescription practices, insulin administration, and blood glucose control, reducing the rate of hyperglycemia in hospitalized patients.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 313-320"},"PeriodicalIF":2.3,"publicationDate":"2025-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143537010","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":"Patient Safety Culture Among Nurses in Hospital Settings Worldwide: A Systematic Review and Meta-Analysis","authors":"Georgia Kyriakeli MBA, RN (is Deputy Director of Nursing Service, Department of Nursing Service, General Hospital Papageorgiou, Thessaloniki, Greece),&nbsp;Anastasia Georgiadou RM (is Registered Midwife, B’ Neonatal Intensive Care Unit, General Hospital Papageorgiou),&nbsp;Agapi Symeonidou MBA, RN (is Deputy Nurse Manager, 3rd Department of Internal Medicine, General Hospital Papageorgiou),&nbsp;Zoi Tsimtsiou PhD, MD (is Associate Professor, Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece),&nbsp;Theodoros Dardavesis PhD, MD (is Professor, Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, and Dean, School of Health Sciences, Aristotle University of Thessaloniki),&nbsp;Vasilios Kotsis PhD, MD (is Professor, 3rd Department of Internal Medicine, School of Medicine, Aristotle University of Thessaloniki. Please address correspondence to Georgia Kyriakeli)","doi":"10.1016/j.jcjq.2025.01.007","DOIUrl":"10.1016/j.jcjq.2025.01.007","url":null,"abstract":"<div><h3>Background</h3><div>Assessment of patient safety culture (PSC) is critical for health care organizations worldwide to recognize areas that require urgent attention, promote patient safety, and improve quality of care. The aim of this systematic review was to determine the overall PSC score among nurses worldwide and identify the dimensions of PSC that score the highest and the lowest, as well as any geographical differentiations.</div></div><div><h3>Methods</h3><div>Literature research was conducted in PubMed and Scopus search engines and the Agency for Healthcare Research and Quality (AHRQ) Research Reference List to identify studies published in English between January 2004 and May 2023 that used the Hospital Survey on Patient Safety Culture, version 1, to measure hospital nurses’ assessment of PSC. This review followed the PRISMA 2020 guidelines and was registered in PROSPERO.</div></div><div><h3>Results</h3><div>From 1,507 records, 21 studies were included with 10,951 participants. The overall PSC score was 3.341 (95% confidence interval [CI] 3.221–3.460). The dimension scored highest was Teamwork Within Units, with a mean score of 3.719 (95% CI 3.594–3.844). Staffing, with a mean score of 3.096 (95% CI 2.980–3.212) was scored lowest. Statistically significant differences related to geographical distribution were found for overall PSC score and five of the PSC dimensions.</div></div><div><h3>Conclusion</h3><div>Nurses throughout the world rated the PSC at their organizations moderate to good. Certain dimensions of PSC were reported to need reinforcement to create a strong overall safety culture in health care. Participants rated European hospitals as having a stronger PSC than South American or Middle Eastern hospitals. Differentiations need to be further studied and analyzed for effective and targeted global interventions.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 350-360"},"PeriodicalIF":2.3,"publicationDate":"2025-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143515649","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":"Developing a Standardized Process to Visualize, Analyze, and Communicate NSQIP Data Using an Advanced Visual Data Analytics Tool","authors":"Linda C. Alongi MSN (is Surgical Quality Improvement Coordinator, Park Nicollet Methodist Hospital, St. Louis Park, Minnesota),&nbsp;Brady Alsaker MSN (formerly Clinical Analyst, Park Nicollet Methodist Hospital, is Registered Nurse, Minnesota Department of Veterans Affairs, St. Paul, Minnesota),&nbsp;David J. Willis MD (is Surgeon, Park Nicollet Methodist Hospital, and System Medical Director of Quality Improvement, Surgical Services, HealthPartners, Minneapolis),&nbsp;William A. Burns (is Primary Research Assistant, HealthPartners Institute, Bloomington, Minnesota),&nbsp;Charles R. Watts MD, PhD (is Neurosurgeon and Chair of Neurosurgery, Park Nicollet Methodist Hospital. Please address correspondence to Charles R. Watts)","doi":"10.1016/j.jcjq.2025.01.003","DOIUrl":"10.1016/j.jcjq.2025.01.003","url":null,"abstract":"<div><h3>Background</h3><div>To help surgeons improve quality, the American College of Surgeons National Quality Improvement Program (ACS NSQIP) Semiannual Reports and Interim Semiannual Reports provide high-level views of 30-day morbidity and mortality rates. Surgeons at one hospital requested the ability to visualize data with interactive navigation and analysis of comorbidities monthly. Using advanced visual data analytics, the authors constructed a surgical scorecard to provide the desired feedback.</div></div><div><h3>Methods</h3><div>The authors undertook a proof-of-concept project tracking surgical site infections (SSIs) and associated medical comorbidities. An anonymized training dataset of 3,438 patients was sampled between January 1, 2021, and October 31, 2022, from the hospital's NSQIP data. For proof-of-concept interface/system testing and to maintain data privacy, a synthetic 5,000-patient NSQIP database was generated using the Synthetic Data Vault, Python 3.7. Comorbidity variables were: diabetes mellitus, HgbA1c, immunosuppressive therapy, hypertension requiring medication, body mass index, and smoking within one year. The primary outcome was SSI. The research team generated scorecards for SSIs as a function of time, surgical department, and medical comorbidity. Odds ratios with confidence intervals and chi-square tests were used to analyze the relationships between SSI and comorbidities.</div></div><div><h3>Results</h3><div>Advanced visual data analytics improved the timeliness of NSQIP Semiannual Reports and Interim Semiannual Reports from 6 months to 45 days. The scorecard allowed for visualization of data trends as a function of time, specialty, and procedural group. Statistical testing allowed for the identification of surgeons who were statistical outliers with regard to SSIs.</div></div><div><h3>Conclusion</h3><div>Implementation of an on-demand scorecard for data visualization and analysis allowed for up-to-date analysis of the relationship between medical comorbidities and SSI and identification of performance outliers.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 361-367"},"PeriodicalIF":2.3,"publicationDate":"2025-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143531398","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":"Mixed Methods Study of the Interfacility Transfer System Utilizing Both Patient-Reported Experiences and Direct Observation of the Transfer Consent Process","authors":"Lauren K. Stewart MD, MS (is Assistant Professor of Emergency Medicine, Indiana University School of Medicine.),&nbsp;Dillon Bille (is Medical Student, Indiana University School of Medicine.),&nbsp;Beth Fields PhD, MS (is Associate Professor, School of Education, University of Wisconsin.),&nbsp;Leah Kemper (formerly Microbiology Student, Indiana University, is APHL-CDC Fellow, Wadsworth Center, New York State Department of Health, Albany, New York.),&nbsp;Connor Pappa (is Student, Indiana University.),&nbsp;Eric S. Orman MD, MSCR (is Associate Professor of Medicine, Indiana University School of Medicine.),&nbsp;Malaz A. Boustani MD, MPH (is Professor of Medicine and Aging Research, Indiana University School of Medicine.),&nbsp;Edmond Ramly PhD, MS (is Associate Professor and Program Director, Department of Health & Wellness Design, Indiana University School of Public Health.),&nbsp;Andrew Hybarger DO (is Emergency Medical Services Fellow, Indiana University School of Medicine, and Deputy Medical Director, Indianapolis Emergency Medical Services.),&nbsp;Andrew K. Watters MD (is Associate Professor of Emergency Medicine Practice, Indiana University School of Medicine.),&nbsp;Nancy K. Glober MD (is Assistant Professor of Emergency Medicine, Indiana University School of Medicine. Please address correspondence to Lauren K. Stewart)","doi":"10.1016/j.jcjq.2025.01.005","DOIUrl":"10.1016/j.jcjq.2025.01.005","url":null,"abstract":"<div><h3>Background</h3><div>Interfacility transfer is an integral component of the modern health care system. However, there are no commonly agreed-upon standards for interfacility processes or for patient engagement and shared decision-making in transfer, and little is known about their experience. This study used qualitative methods to better understand the patient and care partner experience with interfacility emergency department (ED)-to-ED transfer.</div></div><div><h3>Methods</h3><div>This mixed methods study used two distinct data sources: (1) semistructured interviews of older adult patients and their care partners, performed at bedside in a large, tertiary care hospital (receiving facility) following interfacility transfer, and (2) direct observation of the transfer consent process at two community EDs (referring facilities) in the same health system.</div></div><div><h3>Results</h3><div>A total of 21 patients and 14 care partners were interviewed. The authors identified several common themes related to perceptions and experiences with interfacility transfer: (1) communication (for example, perceived lack of agency), (2) logistics (for example, wait times), (3) impacts on family (for example, distance from home), (4) uncertainty about the bill (for example, transfer-associated costs), and (5) quality of care (for example, greater trust in tertiary care centers). Direct observations of the transfer consent process for 14 unique patient encounters were also conducted. The research team observed considerable variability in practice patterns among sending clinicians and identified frequent patient-reported issues related to transfer logistics and effective communication, including distractions, lack of privacy, absence of support system, physical pain and/or psychological stress, preferred language, and health literacy.</div></div><div><h3>Conclusion</h3><div>These data suggest several potential areas for improvement in the care of patients requiring interfacility transfer, to increase engagement and allow patients and their care partners to make better-informed decisions most consistent with their goals of care.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 5","pages":"Pages 331-341"},"PeriodicalIF":2.3,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143425320","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":"Training Hospital Nurses to Write Detailed Narratives and Describe Contributing Factors in Incident Reports: The SAFER Education Program","authors":"Tara N. Cohen PhD, MS (is Director of Surgical Safety and Human Factors Research, Department of Surgery, and Director of Simulation Research, Department of Simulation and Interprofessional Education, Cedars-Sinai Medical Center, Los Angeles.),&nbsp;Teryl K. Nuckols MD, MSHS (is Vice Chair of Clinical Research and Director of General Internal Medicine, Department of Internal Medicine, Cedars-Sinai Medical Center.),&nbsp;Carl T. Berdahl MD, MS (is Assistant Professor, Departments of Medicine and Emergency Medicine, Cedars-Sinai Medical Center.),&nbsp;Edward G. Seferian MD, MS (formerly Chief Patient Safety Officer, Department of Patient Safety, Cedars-Sinai Medical Center, is Vice President, Patient Safety and Quality, Johns Hopkins Hospital, Baltimore.),&nbsp;Sara G. McCleskey PhD, MS (is Associate Policy Researcher, Department of Behavioral Policy and Sciences, RAND, Los Angeles.),&nbsp;Andrew J. Henreid MPH (is Clinical Research Associate, Department of Internal Medicine, Cedars-Sinai Medical Center, and Graduate Assistant, Department of Psychological Sciences, University of Connecticut.),&nbsp;Donna W. Leang PharmD, MSHS (is Associate Director, Medication Safety/Regulatory Compliance, Transitions of Care, Department of Pharmacy, Cedars-Sinai Medical Center.),&nbsp;Maria Andrea Lupera RN, MS (formerly Critical Care Registered Nurse, Cedars-Sinai Medical Center, is Clinical Nurse, Kaiser Permanente, Los Angeles.),&nbsp;Bernice L. Coleman PhD, ACNP-BC, FAAN (is Director of Nursing Research, Department of Nursing, and Assistant Professor, Department of Biomedical Sciences, Cedars-Sinai Medical Center. Please address correspondence to Tara Cohen)","doi":"10.1016/j.jcjq.2025.01.002","DOIUrl":"10.1016/j.jcjq.2025.01.002","url":null,"abstract":"<div><h3>Background</h3><div>In high-risk industries, the primary purpose of incident reporting is to obtain insights into contributing factors. Incident reporting systems in hospitals receive numerous reports from nurses but often lack detailed, actionable information. Enriching the information captured by incident reports would facilitate local efforts to improve patient safety.</div></div><div><h3>Methods</h3><div>The authors developed the Systems Approach For Event Reporting (SAFER) educational program to train nurses to (1) write detailed narratives and (2) describe contributing factors. To achieve these objectives, the research team incorporated the Situation, Background, Assessment, Recommendation (SBAR) model and the Systems Engineering Initiative for Patient Safety (SEIPS) model. The authors conducted pilot tests with nurses, made iterative refinements, then deployed SAFER on eight nursing units at an academic medical center.</div></div><div><h3>Results</h3><div>An online learning module provides background information, a detailed curriculum leveraging SBAR and SEIPS models, interactive exercises, real-world examples of enhanced reports, and concluding information on how enhanced reporting benefits both nursing practice and patient safety. Nurses received a badge buddy—a laminated, double-sided reminder card to hang behind identification badges that reinforces key elements of SBAR and SEIPS models. In pilot testing, nurses reported that completing the module took 10 to 20 minutes, the material was clear and easy to understand, and they understood its purpose and objectives. The completion rate for implementation of SAFER online training was 88.7% (809/912 eligible nurses).</div></div><div><h3>Conclusion</h3><div>SAFER is an innovative program that introduces human factors principles to nurses and trains them to incorporate SBAR and SEIPS into incident reporting. SAFER is acceptable and feasible. Ongoing work includes testing the impact of SAFER on improving the utility of incident reports.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 305-311"},"PeriodicalIF":2.3,"publicationDate":"2025-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143079829","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":"Increasing Utilization of an In-Home Remote Exam Device in a Complex Care Center","authors":"Marie Pfarr MD (is Assistant Professor, Division of Pediatric Hospital Medicine, Department of Pediatrics, and Director of Complex Care (Teal Team), Heersink School of Medicine, University of Alabama at Birmingham.),&nbsp;Scott Callahan MD, FAAP (is Staff Physician, Division of General and Community Medicine, Department of Pediatrics, Cincinnati Children's Hospital, and Assistant Professor, Department of Pediatrics, University of Cincinnati College of Medicine.),&nbsp;Calise Curry (is Clinical Research Coordinator, Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center.),&nbsp;Karen Jerardi MD, MEd (is Co-Director, Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and Professor, Department of Pediatrics, University of Cincinnati College of Medicine.),&nbsp;Kathleen Pulda (is Senior Telehealth Consultant, Center for Telehealth, Cincinnati Children's Hospital Medical Center.),&nbsp;Michelle Rummel (is Senior Telehealth Consultant, Center for Telehealth, Cincinnati Children's Hospital Medical Center.),&nbsp;Della Smith-Sokol (is Program Management Specialist, Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center.),&nbsp;Julie Stalf MSN, RN, CPN (is RN Clinical Manager, Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center.),&nbsp;Joanna Thomson MD, MPH (is Attending Physician, Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, and Associate Professor, Department of Pediatrics, University of Cincinnati College of Medicine.),&nbsp;Hadley Sauers-Ford MPH (is Senior Clinical Research Coordinator, Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center. Please address correspondence to Marie A. Pfarr)","doi":"10.1016/j.jcjq.2025.01.001","DOIUrl":"10.1016/j.jcjq.2025.01.001","url":null,"abstract":"<div><h3>Background</h3><div>The use of telehealth and remote exam devices for children with medical complexity (CMC) allows providers to engage with CMC in their home environment and alleviate caregiver burdens with in-person visits. The authors’ objective was to increase the percentage of telehealth visits in which a remote exam device was used in a complex care center from 0% to 50% over a six-month period.</div></div><div><h3>Methods</h3><div>This improvement work targeted a pediatric complex care center. The multidisciplinary quality improvement team developed key drivers to design Plan-Do-Study-Act cycles. Key drivers included access to device, timely identification of patients with devices, ease of connection, strong provider coaching, and caregivers and providers who were knowledgeable and motivated in using the device. Interventions focused on increasing distribution of devices, streamlining the scheduling process, establishing a device registry, education for caregivers and providers on using the device successfully, translating materials into common languages, and providing remote Internet connections. The primary outcome measure was the percentage of telehealth visits completed using the remote exam device. The researchers also tracked the number of devices distributed. The active intervention period was June 2021 to December 2021, with continued data collection through April 2022.</div></div><div><h3>Results</h3><div>The median percentage of telehealth visits using the remote exam device increased from 0% to 43% over the intervention period with non–special cause variation in device utilization in the subsequent four months. The most impactful intervention focused on increasing device distribution.</div></div><div><h3>Conclusion</h3><div>Quality improvement methods were used to increase the utilization of an in-home remote exam device for CMC.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 286-292"},"PeriodicalIF":2.3,"publicationDate":"2025-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143425260","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":"PROPEL Discharge: An Interdisciplinary Throughput Initiative","authors":"Jessica DeMaio MSN, RN, CNML, CMSRN (is Medicine Performance Improvement Coordinator, Yale New Haven Hospital, New Haven, Connecticut.),&nbsp;Olivia Purdy MSN, RN (is Assistant Patient Service Manager, Verdi 5 West, Yale New Haven Hospital.),&nbsp;Jennifer Ghidini DNP, MSN, APRN, CNML (is Executive Nursing Director, Medicine and Medical Intensive Care Services, Yale New Haven Hospital.),&nbsp;Jennifer Menillo MSHA, BSN, RN, CNML (is Nursing Director, Medicine and Medical Intensive Care Services, Yale New Haven Hospital.),&nbsp;Rebecca Viney MSN, RN (is Medicine Performance Manager, Yale New Haven Hospital.),&nbsp;Chelsea Hogan MSN, RN (is Patient Service Manager, Verdi 5 West, Yale New Haven Hospital. Please address correspondence to Jessica DeMaio)","doi":"10.1016/j.jcjq.2024.10.003","DOIUrl":"10.1016/j.jcjq.2024.10.003","url":null,"abstract":"<div><h3>Background</h3><div>Increased care demands at a health care institution led to strained resources, emergency department (ED) congestion, safety events, and patient and employee dissatisfaction. Moreover, high volumes of afternoon discharges contributed to limited early morning bed availability and admission bottlenecks.</div></div><div><h3>Methods</h3><div>A 29-month pre-post design quality improvement project on 19 acute care, adult medicine units across two campuses at a large academic medical center was implemented to improve discharge timeliness, length of stay (LOS), and ED throughput by increasing pre-11:00 <span>a.m.</span> discharges. Based on Lean Six Sigma methodology, interventions included standardized interdisciplinary discharge processes and roles, processes to ensure performance data transparency and access, a recognition program, and a barrier tracking and mitigation process for continued improvements.</div></div><div><h3>Results</h3><div>During the intervention period, pre-11:00 <span>a.m.</span> discharges increased from 5.1% to 21.8% (<em>p</em> &lt; 0.001), discharge orders were entered 42 minutes earlier (<em>p</em> &lt; 0.001), patients were discharged 56 minutes earlier (<em>p</em> &lt; 0.001), the percentage of discharges completed within 90 minutes from discharge order improved from 26.2% to 38.1% (<em>p</em> &lt; 0.001), the percentage of discharges by 3:00 <span>p.m.</span> improved from 44.7% to 55.9% (<em>p</em> &lt; 0.001), ED admissions arrived to units 44 minutes earlier (<em>p</em> &lt; 0.001), median LOS decreased by 0.46 days (<em>p</em> &lt; 0.001), median observed-to-expected (O:E) LOS decreased by 0.05 (<em>p</em> &lt; 0.001), and opportunity day reductions contributed to increased bed capacity of 18.84 beds per day.</div></div><div><h3>Conclusion</h3><div>Early morning discharges are associated with improved patient throughput and are safe, achievable, and sustainable via interventions focused on frontline engagement, interdisciplinary collaboration, standardization, barrier mitigation, data accessibility, and accountability.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"Pages 19-32"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142785691","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}