Joint Commission journal on quality and patient safety最新文献

{"title":"Using Implementation Science-Informed Strategies to Improve Transitions of Care for Patients with Venous Thromboembolism","authors":"Elizabeth L. Ciemins PhD, MPH, MA (is Senior Vice President, Research and Analytics, American Medical Group Association (AMGA), Alexandria, Virginia),&nbsp;Cori C. Grant PhD, MBA, MS (is Research Assistant Professor, College of Liberal Arts and Social Sciences and Department of Health Systems and Population Health, University of Houston),&nbsp;Meghana Tallam MPH (is Population Health Research Analyst, AMGA),&nbsp;Cori Rattelman MS (is Senior Research Analyst, AMGA),&nbsp;Curt Lindberg DMan, MHA (is Principal and Senior Consultant, Partners in Complexity, Waitsfield, Vermont),&nbsp;Rae Ann Williams MD, FACP (is Department Chair, Internal Medicine, and Regional Medical Director, Primary Care, HealthPartners Medical Group, Bloomington, Minnesota),&nbsp;Paige S. Christensen NP (is Associate Medical Director, Thrombosis and Anticoagulation, and Director, Clinical Pharmacy Anticoagulation Service, Intermountain Healthcare, Salt Lake City),&nbsp;N. Marcus Thygeson MD, MPH (is Executive Director, Adaptive Health, San Rafael, California. Please address correspondence to Elizabeth L. Ciemins)","doi":"10.1016/j.jcjq.2024.12.007","DOIUrl":"10.1016/j.jcjq.2024.12.007","url":null,"abstract":"<div><h3>Background</h3><div>Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, are common causes of preventable hospital death. Most VTEs diagnosed in the outpatient setting are directly linked to a recent hospitalization or surgery.</div></div><div><h3>Methods</h3><div>A type 2 effectiveness-implementation hybrid study was conducted to develop and implement targeted interventions to improve care for patients with VTE in six US health systems. Primary outcomes included (1) 7-day follow-up after VTE diagnosis (phone calls, office visits); (2) VTE–related hospitalizations or emergency department (ED) visits within 45 days of acute VTE diagnosis; and (3) anticoagulant-associated adverse drug events (ADEs). Qualitative comparative analysis (QCA) identified interventions associated with improved care for patients with VTE.</div></div><div><h3>Results</h3><div>Among 1,265 patients, follow-up within 7 days of an index VTE diagnosis improved from 25.2% to 33.6% (<em>p</em> &lt; 0.0001); among 2,002 patients, hospitalizations/ED visits within 45 days of VTE diagnosis decreased across settings from 7.8% to 6.3% (<em>p</em> = 0.033), and the rate of anticoagulant-associated ADEs remained low (3.1% to 3.4%, <em>p</em> = 0.528). Factors characteristic of improving 7-day follow-up included combinations of (1) safer prescribing and management of anticoagulants and standardized protocols with centralized care processes or (2) safer prescribing and management of anticoagulants with improved care team communication and expanded anticoagulation clinic access for patients prescribed direct oral anticoagulants. Factors associated with 45-day hospitalization/ED visits improvement included high baseline rates of 7-day follow-up, high rates of baseline 45-day hospitalization/ED visits (larger opportunity), improved care team communication, and improved standardization and centralization of protocols.</div></div><div><h3>Conclusion</h3><div>Combinations of interventions, tailored to local context and team dynamics, improved ambulatory follow-up rates and reduced VTE–related utilization. Health systems may benefit from considering novel, implementation science–informed strategies to foster improvement.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 241-251"},"PeriodicalIF":2.3,"publicationDate":"2024-12-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143382403","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":"The Invisible Work to Manage Drug Shortages","authors":"Erin R. Fox PharmD, MHA, BCPS, FASHP (is Associate Chief Pharmacy Officer, Shared Services, University of Utah Health, and Professor (adjunct), Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City. Please address correspondence to Erin R. Fox)","doi":"10.1016/j.jcjq.2024.12.008","DOIUrl":"10.1016/j.jcjq.2024.12.008","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 3","pages":"Pages 165-166"},"PeriodicalIF":2.3,"publicationDate":"2024-12-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005628","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":"Safety Interventions in Cardiac Anesthesia: A Systematic Review","authors":"Lauren O'Callaghan MB, MSc, FCAI, FJFICMI (Royal College of Surgeons in Ireland, Dublin, and Fellow in Intensive Care Medicine, Department of Anaesthesia and Intensive Care, St. Vincent's University Hospital, Dublin),&nbsp;Shane Ahern MB, MCh, MRCS (Specialist Registrar, Department of Cardiothoracic Surgery, Cork University Hospital, Wilton, Cork, Ireland),&nbsp;Andrea Doyle BSc, PhD (Senior Research Fellow and Honorary Lecturer, Royal College of Surgeons in Ireland.)","doi":"10.1016/j.jcjq.2024.12.004","DOIUrl":"10.1016/j.jcjq.2024.12.004","url":null,"abstract":"<div><h3>Background</h3><div>The cardiac operating room is a complex, high-risk, sociotechnical system. Risks in cardiac surgery and anesthesiology have been extensively categorized, but less is known about effective risk reduction strategies. A comprehensive understanding of effective, evidence-based risk reduction strategies is necessary to improve patient safety in cardiac anesthesia.</div></div><div><h3>Methods</h3><div>An advanced literature search of MEDLINE, CINAHL, Embase, and Web of Science databases was conducted to identify studies involving the introduction of a tool or intervention to improve patient safety and human factors in cardiac anesthesia. Studies were screened independently by two authors applying prespecified inclusion and exclusion criteria. Risk reduction strategies and safety initiatives identified were classified according to the Systems Engineering Initiative for Patient Safety model. Data were extracted using a standardized form and were narratively synthesized.</div></div><div><h3>Results</h3><div>A total of 18 studies were identified for inclusion using preoperative briefing tools, intraoperative checklists, and postoperative handover tools. Preoperative briefing tools were associated with a significant reduction in patient mortality and length of hospital stay and also led to adaptations to planned operation. Intraoperative checklists demonstrated decreased bleeding, mortality, and blood transfusion requirements. Postoperative handover tools were associated with improved information transfer and teamwork.</div></div><div><h3>Conclusion</h3><div>This review identified three categories of tools that may be used to improve patient and organizational outcomes. Many of these tools are simple to introduce and sustainable in the long term and can be readily adapted to different centers.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 293-304"},"PeriodicalIF":2.3,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143059089","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":"Adverse Events Involving Telehealth in the Veterans Health Administration.","authors":"Peter D Mills, Anne Tomolo, Edward E Yackel","doi":"10.1016/j.jcjq.2024.12.002","DOIUrl":"https://doi.org/10.1016/j.jcjq.2024.12.002","url":null,"abstract":"<p><strong>Background: </strong>Telehealth involves providing health care remotely using communication tools such as telephone, video, and remote patient monitoring. Research on telehealth has shown many benefits, including improved access to care and reduced costs, and drawbacks, including delays in care, breakdowns in communication, and missed diagnoses. The use of telehealth nationally, including in the Veterans Health Administration (VHA), expanded dramatically during the COVID-19 pandemic. Despite its increased use, few studies have described adverse events or the role of patient safety in the provision of telehealth.</p><p><strong>Methods: </strong>The authors looked at all reports of adverse events and close calls in the VHA involving the use of telehealth between October 1, 2022, and February 2, 2023, and coded each case for the location of the event, type of event, and causes.</p><p><strong>Results: </strong>A total of 145 reports met criteria for review. Most events occurred in primary care, outpatient behavioral health, and radiology, with delays in care, medication errors, and equipment problems being common types. Most reported events did not cause harm; 45 cases were identified as an unsafe condition, 37 as a close call, and 15 as causing some harm to the patient. There were 3,609,105 telehealth episodes of care during this time, resulting in a reporting rate of 4.02 per 100,000 episodes of care and 0.42 reports of harm per 100,000 episodes of care.</p><p><strong>Conclusion: </strong>The most frequent telehealth-related events were delays in care, medication errors, and equipment issues, and most events were not unique to this modality. Further research is needed to characterize safety events unique to telehealth to better define parameters for patient safety activities. Recommendations to reduce errors include ongoing provider training, human factors analysis of telehealth processes, simplifying processes and procedures for providers and patients to get help for technical or knowledge deficits in real time, and examining the business rules for telehealth care.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2024-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143023579","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":"Complying with Joint Commission Health Equity Requirements: Medical-Legal Partnership Data and Health-Related Social Needs","authors":"Ashley B. Tartarilla MPH (formerly Senior Manager, Clinical Research, Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, is Director, Research and Scientific Affairs, GE HealthCare, Boston.) ,&nbsp;Leah Porter JD (formerly Medical-Legal Partnership Fellow, Office of General Counsel, Boston Children's Hospital.) ,&nbsp;James J. Horgan JD (is Senior Vice President and Deputy General Counsel, Office of General Counsel, Boston Children's Hospital.),&nbsp;Phillip D. Hahn MPH, CPH (is Biostatistician and Senior Safety and Quality Consultant, Program for Patient Safety and Quality, Boston Children's Hospital.),&nbsp;Grace Drost (formerly Research Assistant, Program for Patient Safety and Quality, Boston Children's Hospital, is JD Candidate, Suffolk University Law School.),&nbsp;Dionne A. Graham PhD (is Director, Evaluation and Analytics, Program for Patient Safety and Quality, Boston Children's Hospital, and Assistant Professor of Pediatrics, Harvard Medical School.),&nbsp;Michele M. Garvin JD, PhD (is Executive Vice President and Chief of Staff, Boston Children's Hospital.) ,&nbsp;Valerie L. Ward MD, MPH (is Senior Vice President, Pediatric Health Equity Strategies and Chief Health Equity Officer, Boston Children's Hospital, and Assistant Professor of Radiology, Harvard Medical School. Please address correspondence to Valerie L. Ward, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115.)","doi":"10.1016/j.jcjq.2024.12.003","DOIUrl":"10.1016/j.jcjq.2024.12.003","url":null,"abstract":"<div><h3>Background</h3><div>Medical-legal partnerships (MLPs) are a hospital-based resource for patients and families to address health-related legal needs, which often align closely with health-related social needs (HRSNs). For instance, patients and their families with housing insecurity or education, immigration, family law, or other legal needs, or who are having trouble accessing government benefits programs are referred by their health care provider to the MLP. Next, an intake process determines eligibility for MLP services that will result in connecting the patients and their families with resources or legal assistance to address the HRSNs. The Joint Commission's health equity requirements were established as a quality and safety imperative and focus on obtaining patient-specific data for HRSNs in the populations a hospital serves to address the root causes of disparities in patients’ health outcomes. The authors examined data for pediatric patients referred to the hospital's MLP as an example of using legal referral data to obtain HRSNs data to comply with these requirements.</div></div><div><h3>Methods</h3><div>The researchers collected and analyzed data on sociodemographic factors, clinical characteristics, and reason for referral of pediatric patients to a hospital-based MLP. Data were collected from January 1, 2019, to December 31, 2021, spanning the duration of the COVID-19 pandemic. The legal matters from January 1, 2019, to March 9, 2020, were classified as pre-COVID-19 pandemic legal matters, and the legal matters from March 10, 2020, to December 31, 2021, were classified as having occurred during the COVID-19 pandemic. These two time periods were analyzed to account for any pandemic-related effects.</div></div><div><h3>Results</h3><div>A total of 628 patients (median age 9.0 years; male 48.2%) were referred for 611 legal matters (referrals including more than 1 patient from a single household were counted once). Patients were more likely to be Hispanic/Latino, Black/African American, English-speaking, and publicly insured. Many had at least one complex chronic condition (44.4%). More than half of referrals were for housing insecurity (52.1%). This was consistent in the pre-COVID-19 pandemic period and during the COVID-19 period (52.0% vs. 52.2%, <em>p</em> = 0.95).</div></div><div><h3>Conclusion</h3><div>Most MLP referrals were for housing insecurity in children from medically underserved or marginalized populations. Aligning The Joint Commission's health equity requirements with legal referral data is a generalizable approach to improve the collection of HRSNs data for addressing disparities in health outcomes in the populations the hospital serves.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 279-285"},"PeriodicalIF":2.3,"publicationDate":"2024-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143425243","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":"Frailty Screening Using the Risk Analysis Index: A User Guide","authors":"Daniel E. Hall MD, MDiv, MHSc, FACS (is Professor of Surgery and Anesthesiology & Perioperative Medicine, University of Pittsburgh, and Core Investigator, Center for Health Equity Research and Promotion, US Department of Veterans Affairs (VA) Pittsburgh Healthcare System.),&nbsp;Carly A. Jacobs MPH (is Health Science Specialist, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System.),&nbsp;Katherine M. Reitz MD, MSc (is Assistant Professor of Surgery, University of Pittsburgh, and Vascular Surgeon, University of Pittsburgh Medical Center.),&nbsp;Shipra Arya MD, SM, FACS (is Professor, Department of Surgery, Stanford University School of Medicine, and Section Chief, Vascular Surgery, VA Palo Alto Healthcare System, Palo Alto, California.),&nbsp;Michael A. Jacobs MS (is Research Health Science Specialist, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System.),&nbsp;John Cashy PhD (is Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System.),&nbsp;Jason M. Johanning MD, MS, FACS (is Professor, University of Nebraska Medical Center, and Chief Surgical Consultant, Nebraska-Western Iowa VA Medical Center. Please address correspondence to Daniel E. Hall.)","doi":"10.1016/j.jcjq.2024.12.005","DOIUrl":"10.1016/j.jcjq.2024.12.005","url":null,"abstract":"<div><div>The Risk Analysis Index (RAI) has emerged as the most thoroughly validated and flexible assessment of surgical frailty, proven feasible for at-scale bedside screening and available in a suite of tools, that effectively risk stratifies patients across a wide variety of clinical contexts and data sources. This user guide provides a definitive summary of the RAI's theoretical model, historical development, validation, statistical performance, and clinical interpretation, placing the RAI in context with other frailty assessments and emphasizing some of its advantages. Detailed instructions are provided for each RAI variant, along with a systematic review of existing RAI–related literature.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 3","pages":"Pages 178-191"},"PeriodicalIF":2.3,"publicationDate":"2024-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143038980","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving Time to Diagnosis and Management of Pediatric Patients with Acute Neurologic Dysfunction","authors":"Sandra P. Spencer MD (is Associate Professor, Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado.),&nbsp;Nathaniel H. Forman MD (formerly Pediatric Emergency Medicine Fellow, Nationwide Children's Hospital, Columbus, Ohio, is Attending Physician, Pediatric Emergency Medicine, Joe DiMaggio Children's Hospital, Hollywood, Florida.),&nbsp;Melissa G. Chung MD (is Attending Pediatric Neurologist and Critical Care Physician, Nationwide Children's Hospital, and Associate Professor of Clinical Pediatrics, Ohio State University College of Medicine.),&nbsp;Terri Dachenhaus RN, BSN, CPEN (is Nurse Supervisor, Division of Emergency Medicine, Nationwide Children's Hospital.),&nbsp;Annie I. Drapeau MD, MSc, FRCSC (formerly Pediatric Neurosurgeon, Nationwide Children's Hospital, is Pediatric Neurosurgeon and Assistant Professor, Section of Neurosurgery, University of Manitoba.),&nbsp;Christopher Gerity MPH, RT, MRSO (is Clinical Manager of MRI, Nationwide Children's Hospital.),&nbsp;Rodrigo Iglesias MS (is Quality Improvement Specialist, Center for Clinical Excellence, Nationwide Children's Hospital.),&nbsp;Jeremy Y. Jones MD (is Neuroradiology Section Chief, Department of Pediatric Radiology, Nationwide Children's Hospital.),&nbsp;Marlina E. Lovett MD (is Attending Physician, Division of Critical Care Medicine, Nationwide Children's Hospital, and Assistant Professor, Ohio State University College of Medicine.),&nbsp;Julie C. Leonard MD, MPH (is Associate Division Chief for Research in Emergency Medicine, Nationwide Children's Hospital, and Professor, Department of Pediatrics, Ohio State University College of Medicine. Please address correspondence to Sandra P. Spencer)","doi":"10.1016/j.jcjq.2024.12.001","DOIUrl":"10.1016/j.jcjq.2024.12.001","url":null,"abstract":"<div><h3>Background</h3><div>Children presenting to the pediatric emergency department (PED) with neurologic dysfunction require prompt evaluation. Many PEDs successfully implement stroke alerts. However, most pediatric patients presenting with neurologic dysfunction have a non-stroke diagnosis better evaluated using magnetic resonance imaging (MRI). Therefore, we created a Neuro Deterioration clinical pathway using fast MRI to reduce time from PED arrival to completion of radiologic report by 25% in all PED patients presenting with new neurologic dysfunction.</div></div><div><h3>Methods</h3><div>After creating an algorithm and allocating resources, the team used quality improvement methodology to implement a Neuro Deterioration clinical pathway. Interventions focused on patient identification, patient flow, and electronic decision support. Statistical process control charting assessed interventions. The primary outcome measure was time from PED arrival to completion of radiologic report. Additional measures included time from arrival to image finish and percentage of patients on pathway.</div></div><div><h3>Results</h3><div>From 2018 to 2021, time from PED arrival to completion of radiologic report reduced by 32.2%. The average time decrease from a baseline of 211 (<em>n</em> = 287, January 2018–August 2019) to 143 minutes (<em>n</em> = 162, October 2020–December 2021), as noted by a centerline shift on the statistical process control chart. Average time from PED arrival to image finish decreased from 179 to 131 minutes. Percentage of patients on pathway increased. The average age of patients on pathway was 11.5 years, 63.8% were admitted, and 87.5% had a fast MRI for initial imaging. Of the 30.4% of patients with abnormal findings on initial imaging, 85.8% had non-stroke etiologies.</div></div><div><h3>Conclusion</h3><div>The authors created a sustainable Neuro Deterioration clinical pathway to improve time to diagnosis of all pediatric patients with neurologic findings in the PED.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 252-260"},"PeriodicalIF":2.3,"publicationDate":"2024-12-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005623","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":"Voices of Frontline Leaders: Challenges and Opportunities from Frontline Primary Care Clinic Leaders in a Safety-Net Health Care System","authors":"Jessica Wallace DrPH, MPH, MSHS, PA-C (is Lead Advanced Practice Provider for Family Medicine, Denver Health and Hospital Authority, Denver),&nbsp;Read Pierce MD (is Chief Quality, Safety, and Transformation Officer, Denver Health and Hospital Authority),&nbsp;Thomas J Staff MD, MPH (is Chief Medical Officer, STRIDE Community Health Center, Denver),&nbsp;Rebecca Allyn MD (is Internist, Denver Health and Hospital Authority. Please address correspondence to Rebecca Allyn)","doi":"10.1016/j.jcjq.2024.11.012","DOIUrl":"10.1016/j.jcjq.2024.11.012","url":null,"abstract":"<div><h3>Background</h3><div>Burnout, disengagement, and turnover among clinicians is a major challenge for the US health care industry. Research has shown that higher direct supervisor leadership scores correlate with decreased provider burnout and increased professional fulfillment. Safety-net health systems such as Federally Qualified Health Centers (FQHCs) face increased challenges due to limited financial resources, more complex social determinants of health among patients, and often fewer physician leaders who can serve as mentors compared to large, integrated health systems.</div></div><div><h3>Methods</h3><div>The authors interviewed frontline physician leaders of primary care clinics in a large, urban FQHC network regarding their approach to leadership, prior training and support, opinions related to provider burnout, and ideas for improvement. Qualitative data analysis was completed using the Immersion–Crystallization method, reaching theme saturation.</div></div><div><h3>Results</h3><div>Key themes were structure of leaders’ roles, challenges in daily leadership that outstripped time set aside for leadership activities, and the nature of and response to team members’ burnout. Leaders found their roles meaningful and viewed themselves as a bridge between institutional decisions and frontline providers. Longer duration in leadership roles, formal and informal mentoring, and networks of support were related to increased confidence. Variation existed in the amount and perceived value of leadership training, development, and support. Physician leaders emphasized the importance of a high-functioning clinic leadership team and expressed frustration with a lack of connection to institutional decision-making. Leaders were empathetic to the drivers of burnout among their teams and strove to assist individual providers while facing challenges from structural causes of burnout.</div></div><div><h3>Conclusion</h3><div>Frontline leaders in safety-net clinics play a powerful role in the well-being and resilience of their provider care teams and typically are highly engaged despite facing significant barriers to success. Investing in development and formal support for frontline physician leaders in primary care safety-net settings is important to ensure their longevity and a resilient provider workforce.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 261-269"},"PeriodicalIF":2.3,"publicationDate":"2024-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143005597","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Simulation-Based Clinical System Testing of Neonatal Resuscitation Readiness Across a Rural Health System Identifies Common Latent Safety Threats","authors":"Jeffrey Holmes MD (is Attending Physician, Department of Emergency Medicine, Maine Medical Center, Portland, Maine),&nbsp;Micheline Chipman RN (is Clinical Educator, Hannaford Center for Safety, Innovation and Simulation),&nbsp;Beth Gray (is Program Manager, Hannaford Center for Safety, Innovation and Simulation),&nbsp;Timothy Pollick (is Simulation Specialist, Hannaford Center for Safety, Innovation and Simulation),&nbsp;Samantha Piro MBA (is Program Manager, Department of Pediatrics, Barbara Bush Children's Hospital at MaineHealth),&nbsp;Leah Seften (is Children's Health Research Navigator, Department of Pediatrics, Barbara Bush Children's Hospital),&nbsp;Alexa Craig MD, MSc, MS (is Neonatal and Pediatric Neurologist, Department of Pediatrics, Barbara Bush Children's Hospital),&nbsp;Allison Zanno MD (is Neonatologist and Clinical Faculty, Department of Pediatrics, Barbara Bush Children's Hospital),&nbsp;Misty Melendi MD (is Neonatologist and Clinical Faculty, Department of Pediatrics, Barbara Bush Children's Hospital),&nbsp;Leah Mallory MD (is Medical Director, Hannaford Center for Safety, Innovation and Simulation, and Pediatric Hospitalist Department of Pediatrics, Barbara Bush Children's Hospital. Please address correspondence to Leah Mallory)","doi":"10.1016/j.jcjq.2024.11.009","DOIUrl":"10.1016/j.jcjq.2024.11.009","url":null,"abstract":"<div><h3>Background</h3><div>Simulation offers an opportunity to practice neonatal resuscitation and test clinical systems to improve safety. The authors used simulation-based clinical systems testing (SbCST) with a Healthcare Failure Mode and Effect Analysis (HFMEA) rubric to categorize and quantify latent safety threats (LSTs) during in situ training in eight rural delivery hospitals. The research team hypothesized that most LSTs would be common across hospitals. LST themes were identified across sites.</div></div><div><h3>Methods</h3><div>Between May 2019 and May 2023, the neonatal simulation team conducted half-day training sessions including a total of 177 interprofessional delivery room team members. Teams participated in skills stations, followed by in situ simulations with facilitated debriefs. Facilitators included neonatologists and simulation faculty trained in HFMEA. HFMEA rubrics were completed for each site with mitigation strategies captured on follow-up. LSTs were compared across sites.</div></div><div><h3>Results</h3><div>A total of 67 distinct LSTs were identified. Forty-one of 67 (61.2%) were shared by more than one hospital, and 26 (38.8%) were unique to individual hospitals. LSTs were distributed across five systems categories and three teams categories. The 4 LSTs detected at 75% or more of hospitals were lack of clear newborn blood transfusion protocols, inconsistent use of closed-loop communication, inconsistent processes for accessing additional resources, and inconsistent use of a recorder.</div></div><div><h3>Conclusion</h3><div>Use of SbCST across a health system allows for comparison of LSTs at each site and identification of common opportunities to mitigate safety threats. Systemwide analysis provides leaders with data needed to guide resource allocation to track and ensure effective implementation of solutions for prioritized LSTs. Identification of themes may allow other hospitals that have not participated in simulation testing to engage in prospective readiness efforts.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 3","pages":"Pages 199-210"},"PeriodicalIF":2.3,"publicationDate":"2024-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142970926","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Joint Commission Journal on Quality and Patient Safety 50th Anniversary Article Collections: Patient Communication","authors":"","doi":"10.1016/j.jcjq.2024.11.003","DOIUrl":"10.1016/j.jcjq.2024.11.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 12","pages":"Pages 897-898"},"PeriodicalIF":2.3,"publicationDate":"2024-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142701719","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}