Daren Zhao MSc (is PhD candidate, Faculty of Social Sciences and Humanities, Mahidol University, Salaya, Nakhon Pathom, Thailand, and is affiliated with the Quality Control Management Department, Sichuan Provincial Orthopedics Hospital, Chengdu, Sichuan, China. Please address correspondence to Daren Zhao)
{"title":"The PDSA Cycle in the ED: Application and Quality Culture","authors":"Daren Zhao MSc (is PhD candidate, Faculty of Social Sciences and Humanities, Mahidol University, Salaya, Nakhon Pathom, Thailand, and is affiliated with the Quality Control Management Department, Sichuan Provincial Orthopedics Hospital, Chengdu, Sichuan, China. Please address correspondence to Daren Zhao)","doi":"10.1016/j.jcjq.2026.01.007","DOIUrl":"10.1016/j.jcjq.2026.01.007","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Page 199"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147306083","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}
Milou Steenbergen RN, MSc (is Nurse Researcher, Department of General Practice & Nursing Science and Department of Internal Medicine & Dermatology, University Medical Center (UMC) Utrecht, Utrecht University), Sigrid Vervoort PhD (is Assistant Professor, Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, UMC Utrecht), Lisette Schoonhoven PhD (is Professor, Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, UMC Utrecht), Bas de Vries MEd (is Senior Quality and Patient Safety Staff Advisor, UMC Utrecht), Maarten ten Berg PhD (is Researcher, Department of Clinical Chemistry and Haematology, UMC Utrecht), Debbie Vermond PhD (is Postdoctoral Researcher, Julius Center for Health Sciences and Primary Care, UMC Utrecht), Dorien Zwart MD, PhD (is Professor and General Practitioner, Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, UMC Utrecht. Please address correspondence to Milou Steenbergen)
{"title":"FRAM Analysis of Successful Hospital Discharge: A Case Study on Putting Safety-II Principles into Practice","authors":"Milou Steenbergen RN, MSc (is Nurse Researcher, Department of General Practice & Nursing Science and Department of Internal Medicine & Dermatology, University Medical Center (UMC) Utrecht, Utrecht University), Sigrid Vervoort PhD (is Assistant Professor, Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, UMC Utrecht), Lisette Schoonhoven PhD (is Professor, Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, UMC Utrecht), Bas de Vries MEd (is Senior Quality and Patient Safety Staff Advisor, UMC Utrecht), Maarten ten Berg PhD (is Researcher, Department of Clinical Chemistry and Haematology, UMC Utrecht), Debbie Vermond PhD (is Postdoctoral Researcher, Julius Center for Health Sciences and Primary Care, UMC Utrecht), Dorien Zwart MD, PhD (is Professor and General Practitioner, Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, UMC Utrecht. Please address correspondence to Milou Steenbergen)","doi":"10.1016/j.jcjq.2026.01.006","DOIUrl":"10.1016/j.jcjq.2026.01.006","url":null,"abstract":"<div><h3>Background</h3><div>The Functional Resonance Analysis Method (FRAM) helps understand daily practice and improve healthcare through a Safety-II approach. However, little guidance is provided on how to translate the results of a FRAM model into practice.</div></div><div><h3>Methods</h3><div>We conducted a qualitative case study to explore how FRAM worked for putting the Safety-II principles into practice by applying it to the discharge process. For this, we created a FRAM model of current discharge practices based on observations, interviews, and group discussions. Through group discussions with healthcare professionals, we explored how FRAM works for putting the principles of Safety-II into practice.</div></div><div><h3>Results</h3><div>We identified three themes relating to how FRAM works putting Safety-II principles into practice. The first is <em>acknowledging the complexity of daily practice</em> as a FRAM model raises awareness of the complexity and interdependencies involved. The second theme is <em>learning from what works and strengthening adaptability</em>. Based on the FRAM model, healthcare professionals can identify what works and gain a better understanding of the reasons behind it. The third theme is <em>reverting to the “find and fix” approach</em>. Rather than developing an understanding of how things usually go right to reinforce what works, they primarily sought to narrow the gap between work-as-imagined and work-as-done, and emphasize limiting variability.</div></div><div><h3>Conclusion</h3><div>We illustrate that FRAM is a useful tool for raising awareness and enhancing mutual understanding. However, FRAM requires moderated discussions on the model to maintain Safety-II principles for supporting healthcare professionals’ ability to succeed under varying conditions.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Pages 162-168"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147389863","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}
Abigail Evans PhD (is Senior Social Scientist, Health Research and Analytics, Battelle Memorial Institute, Columbus, Ohio.), Meridith Eastman PhD, MSPH (is Senior Research Scientist, Health Research and Analytics, Battelle Memorial Institute.), Patricia C. Dykes PhD, MA, RN (is Research Program Director, Center for Patient Safety Research and Practice, Brigham and Women’s Hospital, Boston, and Professor of Medicine, Harvard Medical School.), Barbara E. Jones MD, MSCI (is Associate Professor and Pulmonologist, Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine.), John Sather MD (is Associate Professor and Director of Patient Safety and Quality, Department of Emergency Medicine, Yale University School of Medicine.), Jeffrey Geppert EdM, JD (is Senior Research Leader, Health Research and Analytics, Battelle Memorial Institute. Please address correspondence to Abigail Evans)
{"title":"Natural Language Processing in Clinical Quality Measures of Diagnostic Performance: Learnings from Three Case Reports","authors":"Abigail Evans PhD (is Senior Social Scientist, Health Research and Analytics, Battelle Memorial Institute, Columbus, Ohio.), Meridith Eastman PhD, MSPH (is Senior Research Scientist, Health Research and Analytics, Battelle Memorial Institute.), Patricia C. Dykes PhD, MA, RN (is Research Program Director, Center for Patient Safety Research and Practice, Brigham and Women’s Hospital, Boston, and Professor of Medicine, Harvard Medical School.), Barbara E. Jones MD, MSCI (is Associate Professor and Pulmonologist, Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine.), John Sather MD (is Associate Professor and Director of Patient Safety and Quality, Department of Emergency Medicine, Yale University School of Medicine.), Jeffrey Geppert EdM, JD (is Senior Research Leader, Health Research and Analytics, Battelle Memorial Institute. Please address correspondence to Abigail Evans)","doi":"10.1016/j.jcjq.2026.01.005","DOIUrl":"10.1016/j.jcjq.2026.01.005","url":null,"abstract":"<div><h3>Background</h3><div>Clinical quality measures (CQMs) have historically relied on structured data elements in electronic health records; however, unstructured fields more reliably capture information needed to assess quality of care. Unstructured fields such as clinical notes and imaging results are particularly important for assessing diagnostic performance. Natural language processing (NLP) can efficiently capture nuanced information from unstructured fields to assess healthcare quality. This article describes three CQM projects that incorporated NLP in ways that are scalable for healthcare systemwide implementation.</div></div><div><h3>Methods</h3><div>The projects leveraged NLP to measure diagnostic performance related to venous thromboembolism, pneumonia, and pulmonary embolism, each of which is characterized by nonspecific symptoms and patient safety risk.</div></div><div><h3>Results</h3><div>NLP was used to extract patient symptoms, procedures, and findings from clinical notes in outpatient settings, emergency department visits, radiology reports, and discharge summaries. One NLP algorithm developed in the US Department of Veterans Affairs system performed comparably in an academic medical system. Other measures were successfully implemented in a data registry. Two of these CQMs were endorsed by the Centers for Medicare & Medicaid Services consensus-based entity. The third CQM set will be available as registry measures.</div></div><div><h3>Conclusion</h3><div>These projects demonstrate that CQMs leveraging NLP can achieve the high levels of reliability and validity necessary for national-level implementation. This will support efforts to assess diagnostic performance, which is often challenging to assess using structured data.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Pages 154-161"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147348354","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}
Peter J. Pronovost MD, PhD (is Chief Quality & Clinical Transformation Officer and Veale Distinguished Chair in Leadership and Clinical Transformation, University Hospitals Health System, Cleveland, and Professor, Department of Anesthesia and Critical Care Medicine, School of Medicine, Case Western Reserve University), Nancy E. Kass ScD (is Phoebe R. Berman Professor, Johns Hopkins Berman Institute of Bioethics and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health), Ruth R. Faden MD, MPH (is Philip Franklin Wagley Professor, Johns Hopkins Berman Institute of Bioethics (Berman Institute Founder) and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health. Please address correspondence to Peter J. Pronovost)
{"title":"The Current Framework to Distinguish Research from Quality Improvement Is Stalling Improvement of Care","authors":"Peter J. Pronovost MD, PhD (is Chief Quality & Clinical Transformation Officer and Veale Distinguished Chair in Leadership and Clinical Transformation, University Hospitals Health System, Cleveland, and Professor, Department of Anesthesia and Critical Care Medicine, School of Medicine, Case Western Reserve University), Nancy E. Kass ScD (is Phoebe R. Berman Professor, Johns Hopkins Berman Institute of Bioethics and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health), Ruth R. Faden MD, MPH (is Philip Franklin Wagley Professor, Johns Hopkins Berman Institute of Bioethics (Berman Institute Founder) and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health. Please address correspondence to Peter J. Pronovost)","doi":"10.1016/j.jcjq.2026.01.002","DOIUrl":"10.1016/j.jcjq.2026.01.002","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Pages 194-198"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146258121","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}
Michael Stocker MD, J. Christopher Champion MD, MBA, Jonathan W. Andereck MD, MBA, William B. Stubblefield MD, MPH
{"title":"Response to “The PDSA Cycle in the ED: Application and Quality Culture”","authors":"Michael Stocker MD, J. Christopher Champion MD, MBA, Jonathan W. Andereck MD, MBA, William B. Stubblefield MD, MPH","doi":"10.1016/j.jcjq.2026.01.010","DOIUrl":"10.1016/j.jcjq.2026.01.010","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Page 200"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147355148","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}
Neil E. Rens MD, MBA, MSc (is Chief Resident Physician and Clinical Fellow, Department of Anesthesiology, Massachusetts General Hospital (MGH), Mass General Brigham (MGB), Boston.) , Johanna J. Rajotte (is Doctoral Candidate, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.) , Hao Deng MD, MPH, MBA, DrPH(c) (is Assistant Investigator and Statistical Consultant, Department of Anesthesiology, MGH, MGB.), Jiawei Meng MPH (former Biostatistician, MGH, is Senior Business Analytics Manager, Privia Health.), Ariel L. Mueller MA (is Administrative Director for Research, Department of Anesthesiology, MGH, MGB.), Timothy T. Houle PhD (is Associate Professor, Department of Anesthesiology, MGH, MGB.), Jeanine P. Wiener-Kronish MD (is Emeritus Chief of Anesthesiology, MGH.), Kyan C. Safavi MD, MBA (is Attending Physician and Associate Chief Medical Officer, MGH.), Katarina J. Ruscic MD, PhD (is Attending Physician, Assistant Professor, Senior Division Director for Multispecialty Anesthesia, Department of Anesthesiology, MGH, MGB. Please address correspondence to Katarina J. Ruscic)
{"title":"Association of Vital Sign and Laboratory Abnormalities Detected via Remote Monitoring with ICU Readmission and Mortality: An Observational Cohort Study","authors":"Neil E. Rens MD, MBA, MSc (is Chief Resident Physician and Clinical Fellow, Department of Anesthesiology, Massachusetts General Hospital (MGH), Mass General Brigham (MGB), Boston.) , Johanna J. Rajotte (is Doctoral Candidate, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.) , Hao Deng MD, MPH, MBA, DrPH(c) (is Assistant Investigator and Statistical Consultant, Department of Anesthesiology, MGH, MGB.), Jiawei Meng MPH (former Biostatistician, MGH, is Senior Business Analytics Manager, Privia Health.), Ariel L. Mueller MA (is Administrative Director for Research, Department of Anesthesiology, MGH, MGB.), Timothy T. Houle PhD (is Associate Professor, Department of Anesthesiology, MGH, MGB.), Jeanine P. Wiener-Kronish MD (is Emeritus Chief of Anesthesiology, MGH.), Kyan C. Safavi MD, MBA (is Attending Physician and Associate Chief Medical Officer, MGH.), Katarina J. Ruscic MD, PhD (is Attending Physician, Assistant Professor, Senior Division Director for Multispecialty Anesthesia, Department of Anesthesiology, MGH, MGB. Please address correspondence to Katarina J. Ruscic)","doi":"10.1016/j.jcjq.2026.02.001","DOIUrl":"10.1016/j.jcjq.2026.02.001","url":null,"abstract":"<div><h3>Background</h3><div>Post-intensive care unit (ICU) patients remain at high risk for adverse outcomes, and early identification of instability may improve outcomes and reduce costs. This study measures the association between eight vital sign and laboratory abnormalities (“flags”) on surgical wards and the odds of ICU readmission or death in surgical patients after ICU transfer. Flags captured intuitive indications for ICU admission, including tachycardia, hypotension, hypoxemia, hyperkalemia, hyperglycemia, hypoglycemia, and anemia, which may be missed with infrequent ward evaluation.</div></div><div><h3>Methods</h3><div>This single-center, observational cohort study included all adult surgical patients transferred from the ICU to a general care ward between May 2017 and March 2019 pre-COVID-19 pandemic. A mixed effects model evaluated the relationship between virtual flags and adverse discharge within six hours, adjusted for demographics and confounders. Modeling was inferential and not intended for diagnostic or screening prediction.</div></div><div><h3>Results</h3><div>A total of 391 surgical ICU admissions were enrolled, comprising 138,623 rolling one-hour observation windows. After ICU discharge, 73 (18.7%) transfers died or were readmitted to the ICU. A flag on the wards was associated with 11.44-fold increased odds of ICU readmission or death within six hours of the flag (95% CI: 7.49-17.49) and 3.36-fold increased odds within 48 hours (95% CI: 2.23-5.05). A tachycardia flag raised the odds by 25.25 (95% CI: 13.34-47.82). Flags occurred on average every 2.6 hours per hundred ward patients monitored.</div></div><div><h3>Conclusions</h3><div>The presence of eight actionable vital sign and laboratory abnormalities which were detected in an automated system was strongly associated with ICU readmission or death after ICU transfer. Incorporating such monitoring on surgical wards could enable timely interventions, improve patient safety, and reduce mortality without alarm fatigue.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Pages 177-186"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147486132","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":"Process Variation as Friend and Foe: Rethinking Safety in Complex Adaptive Systems","authors":"Anthony P. Weiss MD, MBA, MSc, CPE, FAPA","doi":"10.1016/j.jcjq.2026.02.006","DOIUrl":"10.1016/j.jcjq.2026.02.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Page 143"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147578542","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}
Eric T. Roberts PhD, MPH (is Epidemiologist and Research Specialist, Department of Medicine, University of California, San Francisco (UCSF)), Gabriela Schmajuk MD, MSc (is Professor, Department of Medicine, UCSF, and Chief of Rheumatology, San Francisco Veterans Affairs Medical Center), Jessica Fitzpatrick PhD, MPH (is Research Data Analyst, UCSF), Jing Li MPH (is Senior Research Data Analyst, UCSF), Jinoos Yazdany MD, MPH (is Professor, Department of Medicine, UCSF, and Chief, Division of Rheumatology, Zuckerberg San Francisco General Hospital. Please address correspondence to Eric T. Roberts)
{"title":"Longitudinal Reliability of Rheumatology Patient Safety Measures and Implications for CMS Case Minimums","authors":"Eric T. Roberts PhD, MPH (is Epidemiologist and Research Specialist, Department of Medicine, University of California, San Francisco (UCSF)), Gabriela Schmajuk MD, MSc (is Professor, Department of Medicine, UCSF, and Chief of Rheumatology, San Francisco Veterans Affairs Medical Center), Jessica Fitzpatrick PhD, MPH (is Research Data Analyst, UCSF), Jing Li MPH (is Senior Research Data Analyst, UCSF), Jinoos Yazdany MD, MPH (is Professor, Department of Medicine, UCSF, and Chief, Division of Rheumatology, Zuckerberg San Francisco General Hospital. Please address correspondence to Eric T. Roberts)","doi":"10.1016/j.jcjq.2026.01.008","DOIUrl":"10.1016/j.jcjq.2026.01.008","url":null,"abstract":"<div><h3>Background</h3><div>Metrics with acceptable reliability are necessary to ensure that quality measures reward performance. Low metric reliability may result from a lack of differences between reporting entities or low numbers of eligible patients. The Merit-based Incentive Payment System (MIPS) incentivizes high-performing practices to report, which may lower practice-to-practice variation and lower reliability. This study evaluated the impact of voluntary participation in MIPS and measure denominator counts on practice-specific reliability estimates.</div></div><div><h3>Methods</h3><div>Data came from the Rheumatology Informatics System for Effectiveness (RISE) registry, which passively collects electronic health record (EHR) data. Practice-specific metric reliability was calculated on two safety measures—QPP176 (tuberculosis screening) and ACR10 (hepatitis B screening)—in two cohorts: the full sample of practices with data in RISE and the subset of practices that reported performance data on these measures to MIPS. The authors report longitudinal summary statistics on metric reliability, performance, and the number of eligible patients. The study team also examined estimates longitudinally stratified by patients counts.</div></div><div><h3>Results</h3><div>Both the RISE and MIPS samples had acceptable median reliability (> 0.85) but a wide range (0.04–1.0) despite differences in performance. Analyses showed that for both measures for all years, the practice-specific metric reliability remains ≥ 0.80 when the number of eligible patients was at least 20 and ≥ 0.70 when the number of eligible patients was at least 10.</div></div><div><h3>Conclusion</h3><div>Self-selection into the MIPS program did not reduce the reliability of the examined patient safety measures. In addition, we found acceptable metric reliability at denominator counts lower than currently required by CMS suggesting case minimums for certain measures could be lowered to further encourage quality improvement in a wider subset of practices.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Pages 169-176"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147348328","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}
Aarthi Vijaykumar MD, MSHQS, CPE, FASN (is Nephrologist, Advocate Sherman Hospital, and Nephrology Associates of Northern Illinois, Elgin, Illinois.), David Goodman MD, PhD (is Medical Director of Quality and Safety, Advocate Good Shepherd Hospital, Barrington, Illinois.), Robert Whitcomb MD (is Vice President and Chief Medical Information Officer – Perioperative Medical Informatics, Advocate Health.), Michelle Ruther MBA, MSN, RN (is RN Manager of Aligned Projects, Clinical Effectiveness, Advocate Health, Crest Hill, Illinois.), Alex Miloshov MBA (is Manager of Data Analytics, Managed Health, Specialty Engagement and Value Initiatives.), Matt Pallini MS (is Director, Data Science, Advocate Health, Downers Grove, Illinois.), Jamie Layton RN (is Senior Clinical Information Analyst, Advocate Health, Oak Brook, Illinois.), Debra O’Connor DO (is Vice President of Specialty Engagement and Value Initiatives, Enterprise Population Health, Advocate Health. Please address correspondence to Aarthi Vijaykumar)
{"title":"Reducing Postoperative Acute Kidney Injury: A Regional Quality Improvement Initiative of 26 Community-Based Hospitals","authors":"Aarthi Vijaykumar MD, MSHQS, CPE, FASN (is Nephrologist, Advocate Sherman Hospital, and Nephrology Associates of Northern Illinois, Elgin, Illinois.), David Goodman MD, PhD (is Medical Director of Quality and Safety, Advocate Good Shepherd Hospital, Barrington, Illinois.), Robert Whitcomb MD (is Vice President and Chief Medical Information Officer – Perioperative Medical Informatics, Advocate Health.), Michelle Ruther MBA, MSN, RN (is RN Manager of Aligned Projects, Clinical Effectiveness, Advocate Health, Crest Hill, Illinois.), Alex Miloshov MBA (is Manager of Data Analytics, Managed Health, Specialty Engagement and Value Initiatives.), Matt Pallini MS (is Director, Data Science, Advocate Health, Downers Grove, Illinois.), Jamie Layton RN (is Senior Clinical Information Analyst, Advocate Health, Oak Brook, Illinois.), Debra O’Connor DO (is Vice President of Specialty Engagement and Value Initiatives, Enterprise Population Health, Advocate Health. Please address correspondence to Aarthi Vijaykumar)","doi":"10.1016/j.jcjq.2026.01.003","DOIUrl":"10.1016/j.jcjq.2026.01.003","url":null,"abstract":"<div><h3>Background</h3><div>Postoperative acute kidney injury (PO-AKI) is a leading surgical complication across multiple surgical service lines within Advocate Health’s Midwest Region. Analysis revealed significant intersite and temporal variability in PO-AKI incidence, reflecting the lack of a standardized prevention framework. In response, a multifaceted quality improvement initiative was launched to standardize prevention strategies for elective surgical admissions through the implementation of evidence-based clinical decision support (CDS) tools, including risk assessment models, practice alerts, and order sets with mitigation care bundles.</div></div><div><h3>Methods</h3><div>A multidisciplinary team collaboratively developed and implemented the PO-AKI reduction initiative. Using regional data analytics, the team created a risk stratification tool to identify at-risk patients. Evidence-based alerts and care bundles were embedded into the electronic health record (EHR) and deployed across 26 sites in Illinois and Wisconsin. Implementation was guided by improvement science methodologies to accelerate adoption of CDS tools.</div></div><div><h3>Results</h3><div>At baseline in April 2021, PO-AKI rates averaged 1,031 cases per month. Phase 1 of the intervention introduced intraoperative hypotension alerts for anesthesia teams, resulting in a 33% reduction in intraoperative hypotension episodes. With the full implementation of risk tools, alerts, and order sets in Phase 3, AKI incidence declined to 400 cases per month. Process control analysis showed sustained improvement from baseline. For those who developed PO-AKI, a reduction in length of stay from baseline was observed.</div></div><div><h3>Conclusion</h3><div>This initiative demonstrates that standardized, multidisciplinary approaches, particularly those leveraging EHR–integrated CDS and improvement science strategies, can meaningfully reduce PO-AKI and clinical variation across a regional healthcare system.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 4","pages":"Pages 144-153"},"PeriodicalIF":2.4,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147348378","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}
Melissa Peskin MD (is Clinical Associate Professor, Department of Obstetrics and Gynecology, New York University Long Island (NYULI), and Director, Obstetrics and Gynecology Simulation, NYU Langone Hospital–Long Island, Mineola, New York.), Brittany H. Sanford MD (is Clinical Assistant Professor, Department of Obstetrics and Gynecology, Westchester Medical Center, Valhalla, New York.), Celia A. Muoser MD, MPH (is Maternal Fetal Medicine Specialist, Maternal Fetal Medicine Associates, New York City.), Emma Chew Murphy MD (is Complex Family Planning Specialist, University of California, San Francisco.), Amoli Kulkarni MD (is Obstetrics and Gynecology Resident, Montefiore Medical Center, Einstein College of Medicine, Bronx, New York.), Beatrice Lynch MD (is Obstetrics and Gynecology Resident Resident, Rutgers-New Jersey Medical School, Newark, New Jersey.), Tess Nienaltowa (is Medical Student, Albert Einstein College of Medicine.), Marlena Gehret Plagianos (is Senior Biostatistician, Center for Biomedical Research, Population Council, New York City.), Peter Bernstein MD, MPH (is Maternal Fetal Medicine Specialist, and System Vice Chair of Obstetrics for Quality and Safety, Mount Sinai Hospital, New York City.), Pe’er Dar MD (is Director, Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women’s Health, Montefiore Medical Center, Einstein College of Medicine. Please address correspondence to Melissa Peskin, MD)
{"title":"Impact of a Multifaceted Quality Improvement Initiative Aimed at Reducing Primary Cesarean Delivery Rates","authors":"Melissa Peskin MD (is Clinical Associate Professor, Department of Obstetrics and Gynecology, New York University Long Island (NYULI), and Director, Obstetrics and Gynecology Simulation, NYU Langone Hospital–Long Island, Mineola, New York.), Brittany H. Sanford MD (is Clinical Assistant Professor, Department of Obstetrics and Gynecology, Westchester Medical Center, Valhalla, New York.), Celia A. Muoser MD, MPH (is Maternal Fetal Medicine Specialist, Maternal Fetal Medicine Associates, New York City.), Emma Chew Murphy MD (is Complex Family Planning Specialist, University of California, San Francisco.), Amoli Kulkarni MD (is Obstetrics and Gynecology Resident, Montefiore Medical Center, Einstein College of Medicine, Bronx, New York.), Beatrice Lynch MD (is Obstetrics and Gynecology Resident Resident, Rutgers-New Jersey Medical School, Newark, New Jersey.), Tess Nienaltowa (is Medical Student, Albert Einstein College of Medicine.), Marlena Gehret Plagianos (is Senior Biostatistician, Center for Biomedical Research, Population Council, New York City.), Peter Bernstein MD, MPH (is Maternal Fetal Medicine Specialist, and System Vice Chair of Obstetrics for Quality and Safety, Mount Sinai Hospital, New York City.), Pe’er Dar MD (is Director, Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women’s Health, Montefiore Medical Center, Einstein College of Medicine. Please address correspondence to Melissa Peskin, MD)","doi":"10.1016/j.jcjq.2025.12.001","DOIUrl":"10.1016/j.jcjq.2025.12.001","url":null,"abstract":"<div><h3>Introduction</h3><div>The ideal approach to safely reduce the rising rates of cesarean deliveries (CDs) is unknown. The authors evaluated the impact of a multifaceted quality improvement (QI) initiative aimed at curbing the rising trend in the institutional nulliparous term singleton vertex (NTSV) CD rate at an urban, academic, safety-net hospital.</div></div><div><h3>Methods</h3><div>The primary intervention was a biweekly interdisciplinary educational meeting, wherein NTSV CD cases were reviewed and audited. In addition, an educational bulletin, NTSV score cards, labor position training, and efforts to promote guideline adherence were introduced. The research team examined the institutional NTSV CD rates by quarters and evaluated the trend, modeling the probability of a CD for the pre- and postintervention periods using logistic regression, with time as an ordinal variable. The authors also examined cesarean indications as well as maternal and neonatal complications before and after the QI implementation.</div></div><div><h3>Results</h3><div>There was a trend toward a decrease in CDs during the postintervention period, falling from 32.9% to 26.3% in the 12 months following implementation. Using an interrupted time series analysis to assess differences in trends, the trend before intervention was +2.63% per quarter (95% confidence interval [CI] 2.30–3.03, p < 0.001), while the change in trend postintervention was -3.78% per quarter (95% CI -4.74 to -2.81, p < 0.001, R<sup>2</sup> = 0.973). This suggests an increasing trend prior to intervention that was effectively reversed. Both maternal and neonatal complications rates remained comparable between pre- and postintervention periods for those who had NTSV CDs.</div></div><div><h3>Conclusion</h3><div>Multifaceted strategies incorporating interactive case review meetings can lead to practice change and may be a feasible strategy to reduce an institutional NTSV CD rate.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"52 3","pages":"Pages 107-114"},"PeriodicalIF":2.4,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145989340","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}
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