Joint Commission journal on quality and patient safety最新文献

{"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}

{"title":"Methodological Approaches for Analyzing Medication Error Reports in Patient Safety Reporting Systems: A Scoping Review","authors":"Olga Tchijevitch PhD, MSc (is a Researcher, Department of Clinical Research, Research Unit OPEN, University of Southern Denmark.),&nbsp;Sebrina Maj-Britt Hansen MSc (is PhD student, Department of Clinical Research, Research Unit OPEN, University of Southern Denmark.),&nbsp;Jesper Hallas MD, PhD (is Professor, Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark.),&nbsp;Søren Bie Bogh PhD, MSc (is Associate Professor, Department of Clinical Research, Research Unit OPEN, University of Southern Denmark.),&nbsp;Alma Mulac PhD, MPharm (is Senior Lecturer, Department of Pharmacy, University of Oslo, and Special Advisor, Pharmacist, Oslo University Hospital.),&nbsp;Sisse Walløe MSc (is a PhD student, Department of Clinical Research, Research Unit OPEN, University of Southern Denmark.),&nbsp;Mette Kring Clausen MSc (is Consultant, Clinical Development, Odense University Hospital, Region of Southern Denmark.),&nbsp;Søren Birkeland MD, PhD (is Professor in Psychiatry- and Health Law, Department of Regional Health Research, Faculty of Health Science, University of Southern Denmark and Forensic Mental Health Research Unit Middlefart (RFM) Please address correspondence to Olga Tchijevitch)","doi":"10.1016/j.jcjq.2024.10.005","DOIUrl":"10.1016/j.jcjq.2024.10.005","url":null,"abstract":"<div><h3>Background</h3><div>Medication errors (MEs) pose risks to patient safety, resulting in substantial economic costs. To enhance patient safety and learning from incidents, health care and pharmacovigilance organizations systematically collect ME data through reporting systems. Despite the growing literature on MEs in reporting systems, an overview of methods used to analyze them is lacking. The authors aimed to identify, explore, and map available literature on methods used to analyze MEs in reporting systems.</div></div><div><h3>Methods</h3><div>The review was based on Joanna Briggs Institute's methodology. The authors systematically searched electronic databases Embase, Medline, CINAHL, Cochrane Central, and other sources (Google Scholar, health care safety and pharmacovigilance centers’ websites). Literature published from January 2017 to December 2023 was screened and extracted by two independent researchers.</div></div><div><h3>Results</h3><div>Among the 59 extracted publications, analyses most often focused on MEs occurring in hospitals (57.6%), included both adult and pediatric patients (79.7%), and used national patent safety monitoring systems as a source (69.5%). We identified quantitative (39.0%), qualitative (11.9%), mixed methods (37.3%), and advanced computerized methods (11.9%). Descriptive quantitative analyses for categorized data were common; however, disproportionality analysis constituted a newer approach to address issues with reporting bias. Free-text data were commonly managed by content analysis, while mixed methods analyzed both categorized and free-text data. In addition, text mining, natural language processing, and artificial intelligence were used in more recent studies.</div></div><div><h3>Conclusion</h3><div>This scoping review uncovered a notable span and diversity in methodologies. Future research should assess the use, applicability, and effectiveness of newer methods such as disproportionality analysis and advanced computerized techniques.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"Pages 46-73"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142813078","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":"Health Care Workers’ Trust in Leadership: Why It Matters and How Leaders Can Build It","authors":"Jessica Greene PhD (is Professor and Luciano Chair of Health Care Policy, Marxe School of Public and International Affairs, Baruch College, City University of New York.),&nbsp;Diane Gibson PhD (Professor, Marxe School of Public and International Affairs, Baruch College, City University of New York.),&nbsp;Lauren A. Taylor PhD, MDiv, MPH (is Assistant Professor, Department of Population Health, NYU Grossman School of Medicine.),&nbsp;Daniel B. Wolfson MHSA (is Former Executive Vice President and Chief Operating Officer, American Board of Internal Medicine (ABIM) Foundation. Please address correspondence to Jessica Greene)","doi":"10.1016/j.jcjq.2024.09.002","DOIUrl":"10.1016/j.jcjq.2024.09.002","url":null,"abstract":"<div><h3>Background</h3><div>Rebuilding patient trust in the US health care system has received considerable attention recently, but there has been little focus on health care workers’ (HCWs) trust in the leaders of health care delivery organizations. This study explores (1) the professional impact on HCWs of trusting the leaders of the organizations where they work and (2) the leadership actions that build HCWs’ trust.</div></div><div><h3>Methods</h3><div>The authors examined these questions using a survey that was crowdsourced to 353 HCWs through social media posts and e-mails from national health organizations. For each open-ended question, qualitative codes were identified, iteratively finalized, and applied to each response. Descriptive statistics were used to analyze the closed-ended questions and examine how often each qualitative code was raised.</div></div><div><h3>Results</h3><div>One in five (20.2%) HCWs trusted leadership “very much,” more than a third (36.9%) trusted “somewhat,” and 42.9% had lower levels of trust. Almost all (97.7%) reported that the degree of trust they had in their organization's leadership affected them professionally. Among HCWs who trusted their organization's leadership, the most common impact was feeling professional satisfaction, followed by providing higher-quality work. HCWs described three main ways health care organization leaders earned their trust: communicating effectively (being transparent and soliciting HCWs’ input), treating HCWs well (with respect and kindness and providing good compensation), and prioritizing patient care.</div></div><div><h3>Conclusion</h3><div>The findings suggest health care organizations would benefit from leaders seeking to earn HCWs’ trust. With trust in leadership, HCWs report higher work quality and greater professional satisfaction.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"Pages 11-18"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142466008","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":"Housing Instability Screening and Referral Programs: A Scoping Review","authors":"Shravan Asthana (is Medical Student, Northwestern University Feinberg School of Medicine.),&nbsp;Luis Gago (is Medical Student, Northwestern University Feinberg School of Medicine.),&nbsp;Joshua Garcia (is Medical Student, Northwestern University Feinberg School of Medicine.),&nbsp;Molly Beestrum MLIS (is Head of Research and Information Services, Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine.),&nbsp;Teresa Pollack MS, CPHQ (is Director, Quality Operations, Northwestern Medicine, Chicago;),&nbsp;Lori Post PhD (is Professor, Departments of Emergency Medicine and Medical Social Sciences, and Director, Buehler Center for Health Policy and Economics, Northwestern University Feinberg School of Medicine.),&nbsp;Cynthia Barnard PhD, MBA (formerly Vice President, Quality, Northwestern Medicine, is Assistant Professor, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine.),&nbsp;Mita Sanghavi Goel MD, MPH, FACP (is Professor, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine. Please address correspondence to Mita Sanghavi Goel)","doi":"10.1016/j.jcjq.2024.08.007","DOIUrl":"10.1016/j.jcjq.2024.08.007","url":null,"abstract":"<div><h3>Background</h3><div>Housing instability in the United States is a critical social determinant of health, influencing health outcomes and health care utilization. This scoping review aimed to analyze literature on US health system screening and response programs addressing housing instability, highlighting methodologies, geographic and demographic variations, and policy implications.</div></div><div><h3>Methods</h3><div>Adhering to PRISMA-ScR guidelines, the review included studies focusing on US health systems that screen and refer for housing instability. Major scholarly databases, including PubMed and Scopus, were queried. Screening and response program characteristics, methodologies, and outcomes were characterized.</div></div><div><h3>Results</h3><div>Thirty studies published between 2003 and 2023 were included in this study. Included studies were primarily cross-sectional (26.7%) or quality improvement (20.0%), among 9 other designs. Screening programs were predominantly implemented in academic hospital systems (46.7%) and in the Northeast (63.3%). Of the 25 adult population studies, 68.0% were in outpatient settings, and of the 23 studies providing detailed information on their process, 52.2% used electronic health record entry. Of the 22 studies that describe their screening tool, 15 used institution-specific tools, and only 4 of the remaining 7 studies used identical tools. Of the 20 studies that described their response to positive screenings, 13 provided patients with a paper or electronic referral to a collaborating community partner, while only 6 aided the patient in connecting with community resources.</div></div><div><h3>Conclusion</h3><div>This study found significant variability in screening and response programs for housing instability among US health care providers. A lack of standardized definitions and methodologies hampers effective comparison and implementation of these programs. Future research should focus on standardizing screening methods and measurement of interventions and outcomes to address housing instability.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"Pages 1-10"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142400262","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":"Optimization of a Sterile Processing Department Using Lean Six Sigma Methodology, Staffing Enhancement, and Capital Investment","authors":"Michael E. Natarus DPT, MBA (is Manager, Improvement Consulting, Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital, Chicago.),&nbsp;Allison Shaw MPH, MS (is Senior Improvement Consultant, Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Abbey Studer MBA (is Senior Director, Quality and Safety, Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Charles Williams CSPDT (is Manager, Sterile Processing Department, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Cherie Dominguez CSPDT (is Lead Resource Coordinator, Sterile Processing Department, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Holdemar Mangual MSIHE, MBA (is Senior Director Strategy Execution, Ann & Robert H. Lurie Children's Hospital.),&nbsp;John Olmstead MSN, MBA (is Senior Director, Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Krystal Westmoreland MPS, CSPDT (formerly SPD Educator, Ann & Robert H. Lurie Children's Hospital, is Regional Director, Sterile Processing, Ascension, Chicago.),&nbsp;Tasha Gill MPH (is Manager, Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital.),&nbsp;W. Zeh Wellington DNP, RN, NE-BC3 (is Director, Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital.),&nbsp;Derek S. Wheeler MD, MMM, MBA (is Executive Vice President and Chief Operating Officer, Ann & Robert H. Lurie Children's Hospital, and Professor of Pediatrics, Northwestern University Feinberg School of Medicine.),&nbsp;Jonathan B. Ida MD, MBA, FACS (is Attending Physician, Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital, and Associate Professor of Otolaryngology - Head & Neck Surgery, Northwestern University Feinberg School of Medicine. Please address correspondence to Michael E. Natarus)","doi":"10.1016/j.jcjq.2024.10.006","DOIUrl":"10.1016/j.jcjq.2024.10.006","url":null,"abstract":"<div><h3>Background</h3><div>Many hospitals and surgery centers have focused improvement efforts on operating room inefficiencies. A common inefficiency is missing and unusable surgical instrumentation, which can result in case delays and decreased effectiveness. Lean Six Sigma methodology, a set of process improvement tools focused on the reduction of waste and variation, has been used to identify and correct root causes of missing and unusable instrumentation.</div></div><div><h3>Methods</h3><div>An analysis of current operations was performed within the Sterile Processing Department (SPD). The team assessed physical workflows, including decontamination, assembly, sterilization, and sterile storage, as well as digital processes. The team identified five drivers of defects: (1) staffing and training, (2) inventory management, (3) equipment and SPD physical environment, (4) standard workflows and communication, and (5) governance structure. A root cause was established for each driver, and Lean Six Sigma principles were applied. Two metrics were established to assess accuracy and efficiency in the SPD. First pass yield was defined as the proportion of trays processed that were usable after the first cycle. Tray defect rate was defined as the proportion of requested instruments that were missing or unusable.</div></div><div><h3>Results</h3><div>After implementation, the SPD increased first pass yield from 81.0% to 97.4% (<em>p</em> &lt; 0.001) and reduced the defect rate from 2.2% to &lt; 0.10% (<em>p</em> &lt; 0.001) with sustainment for more than a year.</div></div><div><h3>Conclusion</h3><div>Application of Lean Six Sigma methodology improved tray accuracy in a hospital's SPD. It is feasible and beneficial to apply improvement methodology developed for manufacturing in the hospital setting to reduce missing and unusable instrumentation.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"Pages 33-45"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142824212","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":"Development of a Calculator to Determine Individualized Opioid Doses for Treatment of Vaso-Occlusive Episodes for Sickle Cell Disease in the Emergency Department","authors":"Patricia L. Kavanagh MD (is Associate Professor, Department of Pediatrics, Chobanian & Avedisian School of Medicine, Boston University, and Research Faculty, Center of Excellence in Sickle Cell Disease, Boston Medical Center.),&nbsp;John J Strouse MD, PhD (is Associate Professor, Departments of Medicine and Pediatrics, Duke University School of Medicine, and Hematologist, Duke University Comprehensive Sickle Cell Center.),&nbsp;Judith A. Paice PhD, RN (is Research Professor, Northwestern University Feinberg School of Medicine.),&nbsp;Stephanie O. Ibemere PhD, RN (is Assistant Professor, Duke University School of Nursing.),&nbsp;Paula Tanabe PhD, RN (is Professor, Duke University School of Nursing and Duke University School of Medicine. Please address correspondence to Patricia L. Kavanagh)","doi":"10.1016/j.jcjq.2024.10.002","DOIUrl":"10.1016/j.jcjq.2024.10.002","url":null,"abstract":"<div><div>Sickle cell disease (SCD) is a life-limiting multisystem disease primarily affecting individuals of African and Latinx descent. Its most common complication is painful vaso-occlusive episodes (VOEs), which is also the most common reason individuals with SCD seek care in the emergency department (ED). National guidelines recommend the use of standardized approaches to pain management in the ED, preferably using pain management plans tailored to each patient. However, no standard approach to developing these plans exists. This article describes the development of an opioid calculator to help SCD clinicians create individualized plans to better manage acute painful VOE in the ED setting.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"Pages 74-79"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710300","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":"Reviewer Acknowledgments","authors":"","doi":"10.1016/S1553-7250(24)00373-8","DOIUrl":"10.1016/S1553-7250(24)00373-8","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 1","pages":"Pages 80-81"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143142879","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}