Mandatory employee vaccination as a strategy for early and comprehensive health care personnel immunization coverage: Experience from 10 influenza seasons.

BACKGROUND: Influenza is responsible for thousands of deaths in the United States and presents particular challenges in health care facilities with a greater prevalence of people at increased risk for adverse outcomes. Annual influenza vaccination has long been recommended, and employer policies influence the likelihood health care personnel are immunized. METHODS: This is a review of vaccination data maintained by a large health care organization to assess the effects of a mandatory health care personnel vaccination policy implemented during 2008-2009. Vaccination rates, timing of immunizations, and requests for medical or religious exemptions were assessed from 2006-2007 to 2017-2018. RESULTS: The health care personnel vaccination rate was 70% during the influenza season before the mandatory policy was implemented and increased to 98.4% immediately afterward. Vaccination rates exceeded 97% during the subsequent 9 years. Religious and medical exemptions decreased at academic medical centers and remained consistent at community hospitals. Among immunized employees, the peak date for vaccination shifted to late September or early October compared to late October or early November before the mandatory policy. CONCLUSIONS: Requiring vaccination led to sustained increases in staff vaccination coverage at academic medical centers and community hospitals. The mandatory policy also appeared to encourage earlier vaccination.

Medications and Patient Characteristics Associated With Falling in the Hospital.

OBJECTIVES: The aim of this study was to evaluate specific medications and patient characteristics as risk factors of falling in the hospital. METHODS: This is a case-control study comparing demographic, health, mobility, and medication data for 228 patients who fell between June 29, 2007, and November 14, 2007, at a large tertiary care hospital and 690 randomly selected control patients. Logistic regression was used to identify fall risk factors. RESULTS: Independent risk factors of falling included history of falls (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.8-4.2); needing an assistive device (OR, 3.2; 95% CI, 1.5-6.8) or person assistance (OR, 2.1; 95% CI, 1.3-3.3) to ambulate; being underweight (OR, 2.4; 95% CI, 1.2-4.7) or obese (OR, 1.6; 95% CI, 1.0-2.5); confusion (OR, 2.4; 95% CI, 1.5-4.0); dizziness (OR, 2.1; 95% CI, 1.1-4.3); incontinence (OR, 1.5; 95% CI, 1.0-2.3); and an order for a hydantoin (OR, 3.3; 95% CI, 1.3-8.0) or benzodiazepine anticonvulsant (OR, 2.2; 95% CI, 1.5-3.3), haloperidol (OR, 2.8; 95% CI, 1.2-6.8), tricyclic antidepressant (OR, 2.4; 95% CI, 1.2-4.9), or insulin (OR, 1.5; 95% CI, 1.0-2.1). Female sex (OR, 0.8; 95% CI, 0.6-1.0), proton pump inhibitors (OR, 0.6; 95% CI, 0.4-0.9), and muscle relaxants (OR, 0.4; 95% CI, 0.3-0.7) were associated with lower risk for falling. CONCLUSIONS: This study identified medications and patient characteristics associated with increased risk for falling in the hospital. High-risk medications identified in this study may serve as targets for medication review or adjustment, which have been recommended as a component of multifaceted fall prevention programs.

Increasing patient satisfaction: a new model development.

Most patient satisfaction studies put an emphasis on finding key drivers (attribute) to increase overall patient satisfaction. However, it is not clear how much health care managers need to improve certain attributes to attain the target overall patient satisfaction level. The study aims at finding not only what attributes, but also how much these attributes need to be improved to attain the target levels of patient satisfaction. The study uses an ordinal logistic regression model to analyze attribute reactions to salient drivers. This approach would significantly enhance health care managers' capabilities to develop a strategic plan to improve their patient satisfaction levels.

Adding socioeconomic data to hospital readmissions calculations may produce more useful results.

To better understand the degree to which risk-standardized thirty-day readmission rates may be influenced by social factors, we compared results for hospitals in Missouri under two types of models. The first type of model is currently used by the Centers for Medicare and Medicaid Services for public reporting of condition-specific hospital readmission rates of Medicare patients. The second type of model is an "enriched" version of the first type of model with census tract-level socioeconomic data, such as poverty rate, educational attainment, and housing vacancy rate. We found that the inclusion of these factors had a pronounced effect on calculated hospital readmission rates for patients admitted with acute myocardial infarction, heart failure, and pneumonia. Specifically, the models including socioeconomic data narrowed the range of observed variation in readmission rates for the above conditions, in percentage points, from 6.5 to 1.8, 14.0 to 7.4, and 7.4 to 3.7, respectively. Interestingly, the average readmission rates for the three conditions did not change significantly between the two types of models. The results of our exploratory analysis suggest that further work to characterize and report the effects of socioeconomic factors on standardized readmission measures may assist efforts to improve care quality and deliver more equitable care on the part of hospitals, payers, and other stakeholders.

MEASUREMENT: ACCOUNTING FOR RELIABILITY IN PERFORMANCE ESTIMATES.

When evaluating physician performance measures, physician leaders are faced with the quandary of determining whether departures from expected physician performance measurements represent a true signal or random error. This uncertainty impedes the physician leader's ability and confidence to take appropriate performance improvement actions based on physician performance measurements. Incorporating reliability adjustment into physician performance measurement is a valuable way of reducing the impact of random error in the measurements, such as those caused by small sample sizes. Consequently, the physician executive has more confidence that the results represent true performance and is positioned to make better physician performance improvement decisions. Applying reliability adjustment to physician-level performance data is relatively new. As others have noted previously, it's important to keep in mind that reliability adjustment adds significant complexity to the production, interpretation and utilization of results. Furthermore, the methods explored in this case study only scratch the surface of the range of available Bayesian methods that can be used for reliability adjustment; further study is needed to test and compare these methods in practice and to examine important extensions for handling specialty-specific concerns (e.g., average case volumes, which have been shown to be important in cardiac surgery outcomes). Moreover, it's important to note that the provider group average as a basis for shrinkage is one of several possible choices that could be employed in practice and deserves further exploration in future research. With these caveats, our results demonstrate that incorporating reliability adjustment into physician performance measurements is feasible and can notably reduce the incidence of "real" signals relative to what one would expect to see using more traditional approaches. A physician leader who is interested in catalyzing performance improvement through focused, effective physician performance improvement is well advised to consider the value of incorporating reliability adjustments into their performance measurement system.

Patient satisfaction: how patient health conditions influence their satisfaction.

With increasing emphasis in healthcare on patient satisfaction, many patient satisfaction studies have been administered. Most assume that all patients combine their healthcare experiences (such as nursing care, physician care, etc.) in the same way to arrive at their satisfaction; however, no research has been conducted prior to the present study to investigate how patients' health conditions influence the way they combine their healthcare experiences. This study aims to determine how seriously ill patients differ from less seriously ill patients during their combining process. Data were collected from five large hospitals in the St. Louis area by administering a patient satisfaction questionnaire. Multiple linear regression analyses with a scatter term, a severity measure, and interaction effects of the severity measure were conducted while controlling for age, gender, and race. Two models (overall quality of care and willingness to recommend to others) were analyzed, and the severity of illness variable revealed interaction effects with physician care, staff care, food, and scatter term variables in the willingness to recommend model (six attributes were analyzed: admission process, nursing care, physician care, staff care, food, and room). With more seriously ill patients, physician care becomes more important and staff care becomes less important, and seriously ill patients are proportionately more likely to combine their attribute reactions only in the willingness to recommend model. All six attributes are not equally influential. Nursing care and staff care show consistent influence in both models. These findings show that if healthcare managers want to increase their patient satisfaction, they should enhance nursing care and staff care first to experience the most improvement.

Patient satisfaction and organizational impact: a hierarchical linear modeling approach.

This article presents the rationale for using multilevel analysis to address the broad environmental contexts in patient satisfaction research. This study utilized patient satisfaction data and the American Hospital Association Hospital Guide Book (2004). This study found significant contributions of individual patient attribute reactions (nursing care, physician care, etc.), and also clearly demonstrated hospital-level effects and cross-level interactions on patient satisfaction. Thus, it is clear that patient satisfaction is not solely explained by patients' attribute reactions and their demographic variables, but is also explained by patients' hospital levels. This approach would offer additional understanding in patient satisfaction research.

How trainees would disclose medical errors: educational implications for training programmes.

OBJECTIVES: The disclosure of harmful errors to patients is recommended, but appears to be uncommon. Understanding how trainees disclose errors and how their practices evolve during training could help educators design programmes to address this gap. This study was conducted to determine how trainees would disclose medical errors. METHODS: We surveyed 758 trainees (488 students and 270 residents) in internal medicine at two academic medical centres. Surveys depicted one of two harmful error scenarios that varied by how apparent the error would be to the patient. We measured attitudes and disclosure content using scripted responses. RESULTS: Trainees reported their intent to disclose the error as 'definitely' (43%), 'probably' (47%), 'only if asked by patient' (9%), and 'definitely not' (1%). Trainees were more likely to disclose obvious errors than errors that patients were unlikely to recognise (55% versus 30%; p < 0.01). Respondents varied widely in the type of information they would disclose. Overall, 50% of trainees chose to use statements that explicitly stated that an error rather than only an adverse event had occurred. Regarding apologies, trainees were split between conveying a general expression of regret (52%) and making an explicit apology (46%). Respondents at higher levels of training were less likely to use explicit apologies (trend p < 0.01). Prior disclosure training was associated with increased willingness to disclose errors (odds ratio 1.40, p = 0.03). CONCLUSIONS: Trainees may not be prepared to disclose medical errors to patients and worrisome trends in trainee apology practices were observed across levels of training. Medical educators should intensify efforts to enhance trainees' skills in meeting patients' expectations for the open disclosure of harmful medical errors.

How patient reactions to hospital care attributes affect the evaluation of overall quality of care, willingness to recommend, and willingness to return.

Patient satisfaction is a critical part of the quality outcomes of healthcare. Every industry is interested in customer satisfaction because satisfied customers are loyal customers. Healthcare is no exception. Many research studies assume that satisfied patients are more likely to recommend their providers to their friends and to return when they need care again. Although this assumption sounds logical, we argue that three dependent variables-the Evaluation of Overall Quality of Care, Willingness to Recommend, and Willingness to Return-are unique constructs. Thus, we examine how patient reactions (experiences) to different hospital care attributes (factors or dimensions) influence these dependent variables. Our study analyzed a comprehensive patient satisfaction data set collected by BJC HealthCare. We used a multiple linear regression model with a scatter term to analyze 14,432 cases. In Evaluation of Overall Quality of Care model, we found that the nursing care attribute showed the strongest influence, followed by staff care. In assessing the other two models-Willingness to Recommend and Willingness to Return-we found that staff care showed the strongest influence, followed by nursing care. Patients put a different emphasis or a different priority on their reactions to hospital care attributes, depending on which outcome they arrive at. In addition, we found that patients are disproportionately influenced by a weak or poor attribute reaction, which is a conjunctive strategy (risk averse). In general, nursing care and staff care should be the first priority for improvement. This may be good news because these areas are under the control of hospital managers.

Risk managers, physicians, and disclosure of harmful medical errors.

BACKGROUND: Physicians are encouraged to disclose medical errors to patients, which often requires close collaboration between physicians and risk managers. METHODS: An anonymous national survey of 2,988 healthcare facility-based risk managers was conducted between November 2004 and March 2005, and results were compared with those of a previous survey (conducted between July 2003 and March 2004) of 1,311 medical physicians in Washington and Missouri. Both surveys included an error-disclosure scenario for an obvious and a less obvious error with scripted response options. RESULTS: More risk managers than physicians were aware that an error-reporting system was present at their hospital (81% versus 39%, p < .001) and believed that mechanisms to inform physicians about errors in their hospital were adequate (51% versus 17%, p < .001). More risk managers than physicians strongly agreed that serious errors should be disclosed to patients (70% versus 49%, p < .001). Across both error scenario, risk managers were more likely than physicians to definitely recommend that the error be disclosed (76% versus 50%, p < .001) and to provide full details about how the error would be prevented in the future (62% versus 51%, p < .001). However, physicians were more likely than risk managers to provide a full apology recognizing the harm caused by the error (39% versus 21%, p < .001). CONCLUSIONS: Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology. These differences may create conflicts between risk managers and physicians regarding disclosure. Health care institutions should promote greater collaboration between these two key participants in disclosure conversations.

Mandatory influenza vaccination of health care workers: translating policy to practice.

BACKGROUND: Influenza vaccination of health care workers has been recommended since 1984. Multiple strategies to enhance vaccination rates have been suggested, but national rates have remained low. METHODS: BJC HealthCare is a large Midwestern health care organization with approximately 26,000 employees. Because organizational vaccination rates remained below target levels, influenza vaccination was made a condition of employment for all employees in 2008. Medical or religious exemptions could be requested. Predetermined medical contraindications include hypersensitivity to eggs, prior hypersensitivity reaction to influenza vaccine, and history of Guillan-Barré syndrome. Medical exemption requests were reviewed by occupational health nurses and their medical directors. Employees who were neither vaccinated nor exempted by 15 December 2008 were not scheduled for work. Employees still not vaccinated or exempt by 15 January 2009 were terminated. RESULTS: Overall, 25,561 (98.4%) of 25,980 active employees were vaccinated. Ninety employees (0.3%) received religious exemptions, and 321 (1.2%) received medical exemptions. Eight employees (0.03%) were not vaccinated or exempted. Reasons for medical exemption included allergy to eggs (107 [33%]), prior allergic reaction or allergy to other vaccine component (83 [26%]), history of Guillan-Barré syndrome (15 [5%]), and other (116 [36%]), including 14 because of pregnancy. Many requests reflected misinformation about the vaccine. CONCLUSIONS: A mandatory influenza vaccination campaign successfully increased vaccination rates. Fewer employees sought medical or religious exemptions than had signed declination statements during the previous year. A standardized medical exemption request form would simplify the request and review process for employees, their physicians, and occupational health and will be used next year.

Patient satisfaction: focusing on "excellent".

In an emerging competitive market such as healthcare, managers should focus on achieving excellent ratings to distinguish their organization from others. When it comes to customer loyalty, "excellent" has a different meaning. Customers who are merely satisfied often do not come back. The purpose of this study was to find out what influences adult patients to rate their overall experience as "excellent." The study used patient satisfaction data collected from one major academic hospital and four community hospitals. After conducting a multiple logistic regression analysis, certain attributes were shown to be more likely than others to influence patients to rate their experiences as excellent. The study revealed that staff care is the most influential attribute, followed by nursing care. These two attributes are distinctively stronger drivers of overall satisfaction than are the other attributes studied (i.e., physician care, admission process, room, and food). Staff care and nursing care are under the control of healthcare managers. If improvements are needed, they can be accomplished through training programs such as total quality management or continuous quality improvement, through which staff employees and nurses learn to be sensitive to patients' needs. Satisfying patients' needs is the first step toward having loyal patients, so hospitals that strive to ensure their patients are completely satisfied are more likely to prosper.

Natural language processing to identify adverse drug events.

We tested and adapted Cancer Text Information Extraction System (caTIES), a publicly available natural language processing tool (NLP), as a method for identifying terms suggestive of adverse drug events (ADEs). Although caTIES was intended to extract concepts from surgical pathology reports, we report that it can successfully be used to search for ADEs on a much broader range of documents.

Medical error disclosure among pediatricians: choosing carefully what we might say to parents.

OBJECTIVE: To determine whether and how pediatricians would disclose serious medical errors to parents. DESIGN: Cross-sectional survey. SETTING: St Louis, Missouri, and Seattle, Washington. PARTICIPANTS: University-affiliated hospital and community pediatricians and pediatric residents. Main Exposure Anonymous 11-item survey administered between July 1, 2003, and March 31, 2004, containing 1 of 2 scenarios (less or more apparent to the child's parent) in which the respondent had caused a serious medical error. MAIN OUTCOME MEASURES: Physician's intention to disclose the error to a parent and what information the physician would disclose to the parent about the error. RESULTS: The response rate was 56% (205/369). Overall, 53% of all respondents (109) reported that they would definitely disclose the error, and 58% (108) would offer full details about how the error occurred. Twenty-six percent of all respondents (53) would offer an explicit apology, and 50% (103) would discuss detailed plans for preventing future recurrences of the error. Twice as many pediatricians who received the apparent error scenario would disclose the error to a parent (73% [75] vs 33% [34]; P < .001), and significantly more would offer an explicit apology (33% [34] vs 20% [20]; P = .04) compared with the less apparent error scenario. CONCLUSIONS: This study found marked variation in how pediatricians would disclose a serious medical error and revealed that they may be more willing to do so when the error is more apparent to the family. Further research on the impact of professional guidelines and innovative educational interventions is warranted to help improve the quality of error disclosure communication in pediatric settings.

Reducing medication prescribing errors in a teaching hospital.

BACKGROUND: Medication errors occur frequently, result in significant morbidity and mortality, and are often preventable. A multifaceted intervention was conducted to reduce prescribing errors in handwritten medication orders written by house staff. METHODS: A before-and-after design was used to evaluate the intervention--which included grand rounds, an interactive presentation for house staff, and reminders (a checklist, chart inserts, and requests for clarification)--and targeted 20 safe prescribing behaviors. RESULTS: At baseline, prescribing errors were more common among surgical house staff than medical house staff (1.08 errors/order versus 0.76 errors/order, p < .001). Only 1% of orders contained an overt error, but 49% were incomplete, 27% contained dangerous dose and frequency abbreviations, and 17% were illegible. Postintervention, the mean number of prescribing errors per order decreased for surgical house staff from 1.08 (standard deviation [SD], 0.23) to 0.85 (SD, 0.11; p < .001), with a more marked effect for house staff who attended the didactic portion of the intervention. In addition, the mean number of the more significant errors per order decreased from 0.65 (SD, 0.19) to 0.45 (SD, 0.13; p < .001), and significant decreases occurred in the proportion of orders that were incomplete, were illegible, and contained an overt error. However, prescribing errors per order increased in orders written by medical house staff from 0.76 (SD, 0.14) to 0.98 (SD, 0.11; p < .001). DISCUSSION: The intervention was associated with a modest improvement in the quality of medication orders written by surgical house staff. To reduce prescribing errors, multilevel interventions are needed, including training in safe prescribing for all physicians. Such training may need to be started in medical school and augmented and reinforced throughout residency.

The attitudes and experiences of trainees regarding disclosing medical errors to patients.

PURPOSE: To measure trainees' attitudes and experiences regarding medical error and error disclosure. METHOD: In 2003, the authors carried out a cross-sectional survey of 629 medical students (320 in their second year, 309 in their fourth year), 226 interns (159 in medicine, 67 in surgery), and 283 residents (211 in medicine, 72 in surgery), a total 1,138 trainees at two U.S. academic health centers. RESULTS: The response rate was 78% (889/1,138). Most trainees (74%; 652/881) agreed that medical error is among the most serious health care problems. Nearly all (99%; 875/884) agreed serious errors should be disclosed to patients, but 87% (774/889) acknowledged at least one possible barrier, including thinking that the patient would not understand the disclosure (59%; 525/889), the patient would not want to know about the error (42%; 376/889), and the patient might sue (33%; 297/889). Personal involvement with medical errors was common among the fourth-year students (78%; 164/209) and the residents (98%; 182/185). Among residents, 45% (83/185) reported involvement in a serious error, 34% (62/183) reported experience disclosing a serious error, and 63% (115/183) had disclosed a minor error. Whereas only 33% (289/880) of trainees had received training in error disclosure, 92% (808/881) expressed interest in such training, particularly at the time of disclosure. CONCLUSIONS: Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so. Formal disclosure curricula, coupled with supervised practice, are necessary to prepare trainees to independently disclose errors to patients by the end of their training.

Patient safety event reporting in critical care: a study of three intensive care units.

OBJECTIVE: To increase patient safety event reporting in three intensive care units (ICUs) using a new voluntary card-based event reporting system and to compare and evaluate observed differences in reporting among healthcare workers across ICUs. DESIGN: Prospective, single-center, interventional study. SETTING: A medical ICU (19 beds), surgical ICU (24 beds), and cardiothoracic ICU (17 beds) at a 1,371-bed urban teaching hospital. PATIENTS: Adult patients admitted to these three study ICUs. INTERVENTIONS: Use of a new, internally designed, card-based reporting program to solicit voluntary anonymous reporting of medical errors and patient safety concerns. MEASUREMENTS AND MAIN RESULTS: During a 14-month period, 714 patient safety events were reported using a new card-based reporting system, reflecting a significant increase in reporting compared with pre-intervention Web-based reporting (20.4 reported events/1,000 patient days pre-intervention to 41.7 reported events/1,000 patient days postintervention; rate ratio, 2.05; 95% confidence interval, 1.79-2.34). Nurses submitted the majority of reports (nurses, 67.1%; physicians, 23.1%; other reporters, 9.5%); however, physicians experienced the greatest increase in reporting among their group (physicians, 43-fold; nurses, 1.7-fold; other reporters, 4.3-fold) relative to pre-intervention rates. There were significant differences in the reporting of harm by job description: 31.1% of reports from nurses, 36.2% from other staff, and 17.0% from physicians described events that did not reach/affect the patient (p = .001); and 33.9% of reports from physicians, 27.2% from nurses, and 13.0% from other staff described events that caused harm (p = .005). Overall reported patient safety events per 1,000 patient days differed by ICU (medical ICU = 55.5, cardiothoracic ICU = 25.3, surgical ICU = 40.2; p < .001). CONCLUSIONS: This card-based reporting system increased reporting significantly compared with pre-intervention Web-based reporting and revealed significant differences in reporting by healthcare worker and ICU. These differences may reveal important preferences and priorities for reporting medical errors and patient safety events.

An intervention to improve secondary prevention of coronary heart disease.

BACKGROUND: Translating guidelines into clinical practice has proved to be quite difficult, even when the guidelines are well accepted and noncontroversial. Both computerized reminders and academic detailing have been effective in changing physician prescribing behavior. In this study, we sought to use these methods, mediated by clinical pharmacists, to improve adherence to the secondary prevention guidelines in hospitalized patients with myocardial infarction. METHODS: A randomized, prospective study was performed in which computerized alerts identifying hospitalized patients with elevated troponin I levels were routed to clinical pharmacists. The pharmacists then conducted academic detailing for physicians caring for patients with acute myocardial infarction who were randomized to the intervention group. Patients in the control group received standard care. The main outcome measure was the proportion of patients discharged on a regimen of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and statins. RESULTS: The intervention had a significant impact on the proportion of patients discharged on a regimen of angiotensin-converting enzyme inhibitors (328/365 [89.9%] vs 409/488 [83.8%], intervention vs control, respectively, P = .02), and statins (344/365 [94.2%] vs 436/488 [89.3%], P = .02). There was no statistical impact on beta-blocker (350/365 [95.9%] vs 448/488 [91.8%], P = .10) or aspirin use (352/365 [96.4%] vs 471/488 [96.5%], P = .87). When all 4 classes were considered together, 305 (83.6%) of 365 patients vs 343 (70.3%) of 488 patients were discharged on a regimen of all secondary prevention medications to which they did not have a contraindication (P<.001). CONCLUSION: A computerized alert with pharmacist-mediated academic detailing is an effective means to increase adherence to secondary prevention guidelines for coronary heart disease.

Using business intelligence to monitor clinical quality metrics.

BJC HealthCare (BJC) uses a number of industry standard indicators to monitor the quality of services provided by each of its hospitals. By establishing an enterprise data warehouse as a central repository of clinical quality information, BJC is able to monitor clinical quality performance in a timely manner and improve clinical outcomes.