A prospective multi-center quality improvement initiative (NINJA) indicates a reduction in nephrotoxic acute kidney injury in hospitalized children.

Nephrotoxic medication (NTMx) exposure is a common cause of acute kidney injury (AKI) in hospitalized children. The Nephrotoxic Injury Negated by Just-in time Action (NINJA) program decreased NTMx associated AKI (NTMx-AKI) by 62% at one center. To further test the program, we incorporated NINJA across nine centers with the goal of reducing NTMx exposure and, consequently, AKI rates across these centers. NINJA screens all non-critically ill hospitalized patients for high NTMx exposure (over three medications on the same day or an intravenous aminoglycoside over three consecutive days), and then recommends obtaining a daily serum creatinine level in exposed patients for the duration of, and two days after, exposure ending. Additionally, substitution of equally efficacious but less nephrotoxic medications for exposed patients starting the day of exposure was recommended when possible. The main outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) serum creatinine criteria (increase of 50% or 0.3 mg/dl over baseline). The primary outcome measure was AKI episodes per 1000 patient-days. Improvement was defined by statistical process control methodology and confirmed by Autoregressive Integrated Moving Average (ARIMA) modeling. Eight consecutive bi-weekly measure rates in the same direction from the established baseline qualified as special cause change for special process control. We observed a significant and sustained 23.8% decrease in NTMx-AKI rates by statistical process control analysis and by ARIMA modeling; similar to those of the pilot single center. Thus, we have successfully applied the NINJA program to multiple pediatric institutions yielding decreased AKI rates.

We Will Not Compete on Safety: How Children's Hospitals Have Come Together to Hasten Harm Reduction.

BACKGROUND: Launched in 2012, the Children's Hospitals' Solutions for Patient Safety (SPS) Network is a collaborative of children's hospitals in the United States and Canada working together to eliminate patient and employee/staff harm across all children's hospitals. METHODS: The SPS Network, which has grown from 8 to 137 hospitals, has a foundation of leadership engagement, noncompetition, data-driven learning, attention to safety culture, family engagement, and transparency. The SPS Leadership Group, which consists of more than 150 leaders from participating hospitals, forms condition-specific teams to promote the reduction of hospital-acquired harm in a phased design that includes an ongoing focus on both process improvement and safety culture enhancements. Hospital leaders are engaged through monthly reports, executive webinars, in-person meetings, and biannual training opportunities for boards of trustees. SPS has developed extensive opportunities for learning collaboration, including in-person networkwide learning sessions, regional meetings, general and condition-specific webinars, communications, and a shared website. RESULTS: Over time, the portfolio has expanded as SPS has achieved harm reduction targets for some conditions and begun work to reduce harm in other, previously unaddressed areas. In 2017 SPS reported a 9%-71% reduction in eight harm conditions by an initial cohort of 33 hospitals. SPS estimates that more than 9,000 children have been spared harm since 2012, with $148.5 million in health care spending avoided. CONCLUSION: Participation in the SPS Network has been associated with improved safety in children's hospitals. Widespread participation in this or similar collaborations has the potential to dramatically decrease harm to patients, employees, and staff.

Quality of Health Care for Children in Australia, 2012-2013.

Importance: The quality of routine care for children is rarely assessed, and then usually in single settings or for single clinical conditions. Objective: To estimate the quality of health care for children in Australia in inpatient and ambulatory health care settings. Design, Setting, and Participants: Multistage stratified sample with medical record review to assess adherence with quality indicators extracted from clinical practice guidelines for 17 common, high-burden clinical conditions (noncommunicable [n = 5], mental health [n = 4], acute infection [n = 7], and injury [n = 1]), such as asthma, attention-deficit/hyperactivity disorder, tonsillitis, and head injury. For these 17 conditions, 479 quality indicators were identified, with the number varying by condition, ranging from 9 for eczema to 54 for head injury. Four hundred medical records were targeted for sampling for each of 15 conditions while 267 records were targeted for anxiety and 133 for depression. Within each selected medical record, all visits for the 17 targeted conditions were identified, and separate quality assessments made for each. Care was evaluated for 6689 children 15 years of age and younger who had 15 240 visits to emergency departments, for inpatient admissions, or to pediatricians and general practitioners in selected urban and rural locations in 3 Australian states. These visits generated 160 202 quality indicator assessments. Exposures: Quality indicators were identified through a systematic search of local and international guidelines. Individual indicators were extracted from guidelines and assessed using a 2-stage Delphi process. Main Outcomes and Measures: Quality of care for each clinical condition and overall. Results: Of 6689 children with surveyed medical records, 53.6% were aged 0 to 4 years and 55.5% were male. Adherence to quality of care indicators was estimated at 59.8% (95% CI, 57.5%-62.0%; n = 160 202) across the 17 conditions, ranging from a high of 88.8% (95% CI, 83.0%-93.1%; n = 2638) for autism to a low of 43.5% (95% CI, 36.8%-50.4%; n = 2354) for tonsillitis. The mean adherence by condition category was estimated as 60.5% (95% CI, 57.2%-63.8%; n = 41 265) for noncommunicable conditions (range, 52.8%-75.8%); 82.4% (95% CI, 79.0%-85.5%; n = 14 622) for mental health conditions (range, 71.5%-88.8%); 56.3% (95% CI, 53.2%-59.4%; n = 94 037) for acute infections (range, 43.5%-69.8%); and 78.3% (95% CI, 75.1%-81.2%; n = 10 278) for injury. Conclusions and Relevance: Among a sample of children receiving care in Australia in 2012-2013, the overall prevalence of adherence to quality of care indicators for important conditions was not high. For many of these conditions, the quality of care may be inadequate.

A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury.

Exposure to nephrotoxic medication is among the most common causes of acute kidney injury (AKI) in hospitalized patients. Here we conducted a prospective quality improvement project implementing a systematic Electronic Health Record screening and decision support process (trigger) in our quaternary pediatric inpatient hospital. Eligible patients were noncritically ill hospitalized children receiving an intravenous aminoglycoside for more than 3 days or more than 3 nephrotoxins simultaneously (exposure) from September 2011 through March 2015. Pharmacists recommended daily serum creatinine monitoring in exposed patients after appearance on the trigger report and AKI was defined by the Kidney Disease Improving Global Outcomes AKI criteria. A total of 1749 patients accounted for 2358 separate hospital admissions during which a total of 3243 episodes of nephrotoxin exposure were identified with 170 patients (9.7%) experiencing 2 or more exposures. A total of 575 individual AKI episodes occurred over the 43-month study period. Overall, the exposure rate decreased by 38% (11.63-7.24 exposures/1000 patient days), and the AKI rate decreased by 64% (2.96-1.06 episodes/1000 patient days). Assuming initial baseline exposure rates would have persisted without our project implementation, we estimate 633 exposures and 398 AKI episodes were avoided. Thus, systematic surveillance for nephrotoxic medication exposure and near real-time AKI risk can lead to sustained reductions in avoidable harm. These interventions and outcomes are translatable to other pediatric and nonpediatric hospitalized settings.

The application of the Global Trigger Tool: a systematic review.

PURPOSE: This study describes the use of, and modifications and additions made to, the Global Trigger Tool (GTT) since its first release in 2003, and summarizes its findings with respect to counting and characterizing adverse events (AEs). DATA SOURCES: Peer-reviewed literature up to 31st December 2014. STUDY SELECTION: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA EXTRACTION: Two authors extracted and compiled the demographics, methodologies and results of the selected studies. RESULTS OF DATA SYNTHESIS: Of the 48 studies meeting the eligibility criteria, 44 collected data from inpatient medical records and four from general practice records. Studies were undertaken in 16 countries. Over half did not follow the standard GTT protocol regarding the number of reviewers used. 'Acts of omission' were included in one quarter of studies. Incident reporting detected between 2% and 8% of AEs that were detected with the GTT. Rates of AEs varied in general inpatient studies between 7% and 40%. Infections, problems with surgical procedures and medication were the most common incident types. CONCLUSION: The GTT is a flexible tool used in a range of settings with varied applications. Substantial differences in AE rates were evident across studies, most likely associated with methodological differences and disparate reviewer interpretations. AE rates should not be compared between institutions or studies. Recommendations include adding 'omission' AEs, using preventability scores for priority setting, and re-framing the GTT's purpose to understand and characterize AEs rather than just counting them.

Republished: developing capable quality improvement leaders.

BACKGROUND/OBJECTIVE: Cincinnati Children's Hospital Medical Center created the Intermediate Improvement Science Series (I(2)S(2)) training course to develop organisational leaders to do improvement, lead improvement and get results on specific projects. DESIGN METHODS: Each multidisciplinary class consists of 25-30 participants and 12 in-class training days over 6 months. Instructional methods include lectures, case studies, interactive application exercises and dialogue, participant reports and assigned readings. Participants demonstrate competence in improvement science by completing a project with improvement in outcome and/or process measures. They present on their projects and receive feedback during each session and one-on-one coaching between sessions. RESULTS: Since 2006, 279 participants in 11 classes have completed the I(2)S(2) course. Participant evaluations have consistently rated satisfaction, learning, application, impact and value very high. Large and statistically significant changes were observed in pre-course to post-course self-assessment of knowledge of five quality improvement topics. Approximately 85% of the projects demonstrated measurable improvement. At follow-up, 72% of improvement projects were completed and made a part of everyday operations in the participant's unit or were the focus of continuing improvement work. Many changes were spread to other units or programmes. Most (88%) responding graduates continued to participate in formal quality improvement efforts and many led other improvement projects. Nearly half of the respondents presented their results at one or more professional conference. CONCLUSIONS: Through the I(2)S(2) course, the authors are developing improvement leaders, accelerating the shift in the culture from a traditional academic medical centre to an improvement-focused culture, and building cross-silo relationships by developing leaders who understand the organisation as a large system of interdependent subsystems focused on improving health.

Association Between Hospital-Acquired Harm Outcomes and Membership in a National Patient Safety Collaborative.

Importance: Hospital engagement networks supported by the US Centers for Medicare & Medicaid Services Partnership for Patients program have reported significant reductions in hospital-acquired harm, but methodological limitations and lack of peer review have led to persistent questions about the effectiveness of this approach. Objective: To evaluate associations between membership in Children's Hospitals' Solutions for Patient Safety (SPS), a federally funded hospital engagement network, and hospital-acquired harm using standardized definitions and secular trend adjustment. Design, Setting, and Participants: This prospective hospital cohort study included 99 children's hospitals. Using interrupted time series analyses with staggered intervention introduction, immediate and postimplementation changes in hospital-acquired harm rates were analyzed, with adjustment for preexisting secular trends. Outcomes were further evaluated by early-adopting (n = 73) and late-adopting (n = 26) cohorts. Exposures: Hospitals implemented harm prevention bundles, reported outcomes and bundle compliance using standard definitions to the network monthly, participated in learning events, and implemented a broad safety culture program. Hospitals received regular reports on their comparative performance. Main Outcomes and Measures: Outcomes for 8 hospital-acquired conditions were evaluated over 1 year before and 3 years after intervention. Results: In total, 99 hospitals met the inclusion criteria and were included in the analysis. A total of 73 were considered part of the early-adopting cohort (joined between 2012-2013) and 26 were considered part of the late-adopting cohort (joined between 2014-2016). A total of 42 hospitals were freestanding children's hospitals, and 57 were children's hospitals within hospital or health systems. The implementation of SPS was associated with an improvement in hospital-acquired condition rates in 3 of the 8 conditions after accounting for secular trends. Membership in the SPS was associated with an immediate reduction in central catheter-associated bloodstream infections (coefficient = -0.152; 95% CI, -0.213 to -0.019) and falls of moderate or greater severity (coefficient = -0.331; 95% CI, -0.594 to -0.069). The implementation of the SPS was associated with a reduction in the monthly rate of adverse drug events (coefficient = -0.021; 95% CI, -0.034 to -0.008) in the post-SPS period. The study team observed larger decreases for the early-adopting cohort compared with the late-adopting cohort. Conclusions and Relevance: Through the application of rigorous methods (standard definitions and longitudinal time series analysis with adjustment for secular trends), this study provides a more thorough analysis of the association between the Partnership for Patients hospital engagement network model and reductions in hospital-acquired conditions. These findings strengthen previous claims of an association between this model and improvement. However, inconsistent observations across hospital-acquired conditions when adjusted for secular trends suggests that some caution regarding attributing all effects observed to this model is warranted.

Perioperative Safety: Engage, Integrate, Empower, Sustain to Eliminate Patient Safety Events.

The perioperative environment is one of the most complex areas within a hospital with significant safety risks. Despite a long history of safety-focused work, a recent cluster of patient safety events prompted a renewed comprehensive approach to improve safety processes and transform culture. METHODS: Our team comprehensively approached perioperative safety through integration across traditional silos and a focus on institutional safety culture. This approach consisted of a careful review of all events, developing Perioperative Safety Coordinating and Education teams, testing and implementing new/revised safety processes, and an ongoing evaluation plan. RESULTS: Updates to our Perioperative Safety Mission and Tenets and the development of an empowered Safety Culture Champion team composed of a diverse group of frontline team members addressed our safety culture. In addition, key safety processes (time-outs, intraoperative huddles, and prevention of retained foreign bodies) were revised and implemented. Observation of key safety processes demonstrates a 90% compliance, which includes all steps and team engagement. After implementation, a span of 377 days between events was accomplished, which is significantly higher than the 33 days between events during our cluster. CONCLUSIONS: This work builds upon prior incremental improvements through a comprehensive investment in not only improving key processes but transforming the safety culture. Acceptable deviance from the standard process is no longer the norm. Instead, an approach that emphasizes understanding, integration, engagement, and accountability for safety by each team member for every patient, every time, every day, has been implemented.

Improving patient safety in radiology.

OBJECTIVE: Both horizontally oriented interventions (aimed at improving culture and environment in an effort to reduce the number of human errors potentially leading to patient harm) and vertically oriented (aimed at a specific area of errors) are needed to create a comprehensive safety program in radiology. Our objective is to describe horizontal interventions introduced to improve safety in radiology. CONCLUSION: Horizontal interventions--such as operational rounds with radiology leadership, safety coach programs, error prevention training, and a lessons-learned communication program--can successfully improve the safety culture and performance in radiology.

Improving patient safety in radiology: concepts for a comprehensive patient safety program.

A comprehensive safety program can have a positive influence on safety performance and safety culture within a department of radiology. The program should include both vertical interventions aimed at specific areas of potential safety errors as well as horizontal interventions aimed at improving safety culture and decreasing the baseline rate of human error. In our opinion, the key cultural transformations that must occur to improve safety culture include recognition that safety is an issue, emphasis that everyone is accountable for patient safety, and creating a culture where people are expected and encouraged to speak up in the face of uncertainty. The article describes the horizontal interventions to improve patient safety used in our department.

Improving patient safety: effects of a safety program on performance and culture in a department of radiology.

OBJECTIVE: Emphasis is being placed on improving the safety performance of the health care delivery system. The purpose of this study was to evaluate the effects of a program on safety performance and culture in a pediatric radiology department. MATERIALS AND METHODS: A comprehensive safety program implemented in a department of radiology included error prevention training for all employees, a safety coach program, safety awards, Crucial Conversations training, and operational rounds with radiology leaders. The number of serious safety events (events with deviation from best practice, patient harm, and causation) that in part involved radiology were compared for 2 years after implementation of the program and the previous 2 years (baseline). A U.S. Agency for Healthcare Research and Quality safety culture survey was distributed to radiology employees, and the responses were compared for periods early in the program and after full implementation of the program. Fisher's exact test was used to evaluate for statistically significant differences (p < 0.05) in the survey responses and the frequency of serious safety events. RESULTS: Before introduction of the safety program, radiology contributed to a serious safety event an average of once every 200 days as opposed to once in 780 days after implementation of the program (one event in more than two academic years) (p = 0.37). Improvement was found in all 12 dimensions of the culture survey after implementation of the program. Radiology scored higher than hospital averages in 10 of 12 dimensions of the survey. CONCLUSION: The safety program had a positive effect on safety culture. Although it is early in the process and proving statistical significance for rare events such as serious safety events is difficult, the mean number of days between serious safety events has increased from 200 to 780. We conclude that the program is having a positive effect on safety performance.

Clinical microsystems, Part 3. Transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies.

BACKGROUND: Two hospitals-a large, urban academic medical center and a rural, community hospital-have each chosen a similar microsystem-based approach to improvement, customizing the engagement of the micro-, meso-, and macrosystems and the improvement targets on the basis of an understanding of the local context. CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER (CCHMC): Since 2004, strategic changes have been developed to support microsystems and their leaders through (1) ongoing improvement training for all macro-, meso-, and microsystem leaders; (2) financial support for physicians who are serving as co-leaders of clinical microsystems; (3) increased emphasis on aligning academic pursuits with improvement work at the clinical front lines; (4) microsystem leaders' continuous access to unit-level data through the organization's intranet; and (5) encouragement of unit leaders to share outcomes data with families. COOLEY DICKINSON HOSPITAL (CDH): CDH has moved from near closure to a survival-turnaround focus, significant engagement in quality and finally, a complete reframing of a quality focus in 2004. Since then, it has deployed the clinical microsystems approach in one pilot care unit (West 2, a medical surgery unit), broadened it to two, then six more, and is now spreading it organizationwide. In "2+2 Charters," interdisciplinary teams address two strategic goals set by senior leadership and two goals set by frontline microsystem leaders and staff DISCUSSION: CCHMC and CDH have had a clear focus on developing alignment, capability, and accountability to fuse together the work at all levels of the hospital, unifying the macrosystem with the mesosystem and microsystem. Their improvement experience suggests tips and actions at all levels of the organization that could be adapted with specific context knowledge by others.

Clinical microsystems, part 1. The building blocks of health systems.

BACKGROUND: Wherever, however, and whenever health care is delivered-no matter the setting or population of patients-the body of knowledge on clinical microsystems can guide and support innovation and peak performance. Many health care leaders and staff at all levels of their organizations in many countries have adapted microsystem knowledge to their local settings. CLINICAL MICROSYSTEMS: A PANORAMIC VIEW: HOW DO CLINICAL MICROSYSTEMS FIT TOGETHER? As the patient's journey of care seeking and care delivery takes place over time, he or she will move into and out of an assortment of clinical microsystems, such as a family practitioner's office, an emergency department, and an intensive care unit. This assortment of clinical microsystems-combined with the patient's own actions to improve or maintain health--can be viewed as the patient's unique health system. This patient-centric view of a health system is the foundation of second-generation development for clinical microsystems. LESSONS FROM THE FIELD: These lessons, which are not comprehensive, can be organized under the familiar commands that are used to start a race: On Your Mark, Get Set, Go! ... with a fourth category added-Reflect: Reviewing the Race. These insights are intended as guidance to organizations ready to strategically transform themselves. CONCLUSION: Beginning to master and make use of microsystem principles and methods to attain macrosystem peak performance can help us knit together care in a fragmented health system, eschew archipelago building in favor of nation-building strategies, achieve safe and efficient care with reliable handoffs, and provide the best possible care and attain the best possible health outcomes.

Using a network organisational architecture to support the development of Learning Healthcare Systems.

The US National Academy of Sciences has called for the development of a Learning Healthcare System in which patients and clinicians work together to choose care, based on best evidence, and to drive discovery as a natural outgrowth of every clinical encounter to ensure innovation, quality and value at the point of care. However, the vision of a Learning Healthcare System has remained largely aspirational. Over the last 13 years, researchers, clinicians and families, with support from our paediatric medical centre, have designed, developed and implemented a network organisational model to achieve the Learning Healthcare System vision. The network framework aligns participants around a common goal of improving health outcomes, transparency of outcome measures and a flexible and adaptive collaborative learning system. Team collaboration is promoted by using standardised processes, protocols and policies, including communication policies, data sharing, privacy protection and regulatory compliance. Learning methods include collaborative quality improvement using a modified Breakthrough Series approach and statistical process control methods. Participants observe their own results and learn from the experience of others. A common repository (a 'commons') is used to share resources that are created by participants. Standardised technology approaches reduce the burden of data entry, facilitate care and result in data useful for research and learning. We describe how this organisational framework has been replicated in four conditions, resulting in substantial improvements in outcomes, at scale across a variety of conditions.

Putting evidence-based clinical practice guidelines into practice: an academic pediatric center's experience.

BACKGROUND: Clinical practice guidelines can provide a much-needed interface between research and practice, pointing the way to higher quality, evidence-based, and more cost-effective care. Cincinnati Children's Hospital Medical Center developed a formal process for the production of 29 evidence-based guidelines and companion tools. COMPONENTS OF DEVELOPMENT AND IMPLEMENTATION: Clinical practice guidelines and their companion documents are developed by interprofessional teams that are led by community physicians and that include hospital-based physicians, nurses, other allied health professionals, and patients or parents. An education coordinator develops an education plan that outlines specific clinical practice changes and expected outcomes to be monitored. Guideline evidence is embedded into companion documents and processes available at the point of care. Electronic order sets for treatments and medications have been developed using available guidelines as sources of evidence. All guideline-based order sets include an automatic order for use of the associated clinical pathway. It is important to create and maintain an evidence-based environment in an academic medical center. CONCLUSIONS: Keys to success include a rigorous methodology, tools that place the evidence in the hands of providers at the site of care, feedback on outcomes, and an environment that encourages evidence-based care.

Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm.

OBJECTIVES: To determine if an improvement collaborative of 33 children's hospitals focused on reliable best practice implementation and culture of safety improvements can reduce hospital-acquired conditions (HACs) and serious safety events (SSEs). METHODS: A 3-year prospective cohort study design with a 12-month historical control population was completed by the Children's Hospitals' Solutions for Patient Safety collaborative. Identification and dissemination of best practices related to 9 HACs and SSE reduction focused on key process and culture of safety improvements. Individual hospital improvement teams leveraged the resources of a large, structured children's hospital collaborative using electronic, virtual, and in-person interactions. RESULTS: Thirty-three children's hospitals from across the United States volunteered to be part of the Children's Hospitals' Solutions for Patient Safety collaborative. Thirty-two met all the data submission eligibility requirements for the HAC improvement objective of this study, and 21 participated in the high-reliability culture work aimed at reducing SSEs. Significant harm reduction occurred in 8 of 9 common HACs (range 9%-71%; P < .005 for all). The mean monthly SSE rate decreased 32% (from 0.77 to 0.52; P < .001). The 12-month rolling average SSE rate decreased 50% (from 0.82 to 0.41; P < .001). CONCLUSIONS: Participation in a structured collaborative dedicated to implementing HAC-related best-practice prevention bundles and culture of safety interventions designed to increase the use of high-reliability organization practices resulted in significant HAC and SSE reductions. Structured collaboration and rapid sharing of evidence-based practices and tools are effective approaches to decreasing hospital-acquired harm.

Reliability science and patient safety.

Reliability is failure-free operation over time--the measurable capability of a process, procedure, or service to perform its intended function. Reliability science has the potential to help health care organizations reduce defects in care, increase the consistency with which care is delivered, and improve patient outcomes. Based on its principles, the Institute for Health care Improvement has developed a three-step model to prevent failures, mitigate the failures that occur, and redesign systems to reduce failures. Lessons may also be learned from complex organizations that have already adopted the principles of reliability science and operate with high rates of reliability. They share a preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and underspecification of structures.

Cincinnati Children's Hospital Medical Center: transforming care for children and families.

BACKGROUND: Cincinnati Children's Hospital Medical Center pursues its vision to be the leader in improving child health through the creation of new knowledge, education of professionals and the community, and transformation of our health care delivery system. OVERALL APPROACH TO QUALITY AND SAFETY: The strategic plan focuses on achieving the best medical and quality of life outcomes, patient and family experience of care, and value through horizontal integration of research and delivery system design, thereby accelerating the transfer of new knowledge to the bedside. CREATING QUALITY FROM THE FAMILY PERSPECTIVE: Family members and patients participate at all levels of the organization, from the organizationwide family advisory council, to unit-based inpatient teams, to serving as family faculty who teach pediatric residents and orient new employees. Family members ensure that children's and parents' voices are heard. DISCUSSION: Key factors contributing to ongoing transformation include senior leaders' drive for change, focus on perfection or near-perfection goals, vertical alignment in measures, accountability, improvement capability, commitment to internal and external transparency, and focus on measurement and constancy of purpose.

Ohio Children's Hospitals' Solutions for Patient Safety: A Framework for Pediatric Patient Safety Improvement.

OBJECTIVES: Building upon their previous collective success and a clinical imperative for rapid improvement, the eight tertiary pediatric referral centers in Ohio sought to dramatically decrease the most serious types of harm that occur to hospitalized children by collectively employing high reliability methods focused on safety culture. METHODS: With the support of the hospitals' executives, the Ohio collaborative obtained legal protection and built will by clearly identifying types and frequency of harm events that occur in each participating hospital and across the state. The improvement efforts were divided among task forces designed to incorporate the principles of high reliability organizations into the work of all employees, focusing primarily on the consistent application of error prevention behaviors. RESULTS: Between January 2010 and October 2012, the serious safety event rate among the participating hospitals decreased by 55%, equating to 70 fewer children per year who experienced this most severe type of event in the participating hospitals. Between January 2011 and October 2012, all events of serious harm were decreased by 40%, meaning 18 fewer children per month suffered serious harm. CONCLUSION: Rapid and significant improvement in pediatric patient safety is possible through collaboration of children's hospitals dedicated to the application of high reliability principles and the noncompetitive sharing of outcomes and best practices.

Toward High-Value Care: A Quality Improvement Initiative to Reduce Unnecessary Repeat Complete Blood Counts and Basic Metabolic Panels on a Pediatric Hospitalist Service.

OBJECTIVE: Achieving high-value health care is a goal of health care providers who strive to increase quality and decrease cost. Decreasing laboratory tests is a potential method to increase value. We used quality improvement methodology to decrease the percentage of unnecessary complete blood counts (CBCs) and basic metabolic panels (BMPs) obtained on a pediatric hospital medicine service from 13.5% to <5%. METHODS: A pre- and postintervention design was conducted including all patients admitted to 2 hospital medicine teams between May 2013 and December 2014. Multiple interventions linked to key drivers were tested through rapid plan-do-study-act cycles. Primary and secondary outcome measures, percent reduction of unnecessary CBCs and BMPs, and consecutive day tests were analyzed using statistical process control. Total billed charges, laboratory charges, 7-day readmission rates, and length of stay were compared pre- and postintervention. RESULTS: Primary outcome of unnecessary CBCs and BMPs was reduced from a baseline of 13.5% to 4.5%. Secondary outcome measure of consecutive day testing was reduced from 20.9% to 8.5%. Median laboratory charges decreased significantly ($842 [$256-$1863] vs $800 [$222-$1616], P = .002), with no significant differences in total billed charges, 7-day readmission rates, or length of stay. CONCLUSIONS: Rapid cycle plan-do-study-act methodology, initially focusing on the inclusion of a daily laboratory plan in progress notes, was an effective means to improve laboratory utilization and decrease laboratory charges without adversely affecting other quality measures. Spreading these efforts to different patient populations and laboratory tests could have a demonstrable effect on the value of health care.