Utilizing Clinical Microsystems to Improve Mislabeled Specimen Occurrences in the Emergency Department.

INTRODUCTION: Mislabeled specimen collection in the emergency department has the potential to significantly harm patients. Studies suggest that improvement efforts can reduce specimen rejection from the laboratory and reduce mislabeled specimens in emergency departments and hospital-wide. METHODS: The clinical microsystems approach was used to understand the problem of mislabeled specimens in an emergency department that is part of a 133-bed community hospital in Pennsylvania. Plan-Do-Study-Act cycles were implemented with the help of a clinical microsystems coach. RESULTS: Significant reductions in mislabeled specimen collection were observed over the study period (P < .05). Sustainable improvements were achieved over the >3 years since the improvement initiative began in September 2019. DISCUSSION: Improving patient safety in complex clinical settings requires a systems approach. Using the established framework of clinical microsystems, along with a tenacious and persistent interdisciplinary team, helped create a reliable process for minimizing mislabeled specimens in the emergency department.

Teamwork Essentials for Hospitalists.

Teamwork is essential to providing high-quality patient care. Hospital settings pose important challenges to teamwork. Measurement is key to understanding baseline performance and assessing whether teamwork is improving. The authors recommend a multifaceted approach, using a combination of complementary interventions with an ultimate goal that improved teamwork translates into improved patient outcomes.

Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems.

BACKGROUND: A number of challenges impede our ability to consistently provide high quality care to patients hospitalized with medical conditions. Teams are large, team membership continually evolves, and physicians are often spread across multiple units and floors. Moreover, patients and family members are generally poorly informed and lack opportunities to partner in decision making. Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of a single intervention. We believe these interventions represent complementary and mutually reinforcing components of a redesigned clinical microsystem. Our specific objective for this study is to implement a set of evidence-based complementary interventions across a range of clinical microsystems, identify factors and strategies associated with successful implementation, and evaluate the impact on quality. METHODS: The RESET project uses the Advanced and Integrated MicroSystems (AIMS) interventions. The AIMS interventions consist of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities. Four hospital sites were chosen to receive guidance and resources as they implement the AIMS interventions. Each study site has assembled a local leadership team, consisting of a physician and nurse, and receives mentorship from a physician and nurse with experience in leading similar interventions. Primary outcomes include teamwork climate, assessed using the Safety Attitudes Questionnaire, and adverse events using the Medicare Patient Safety Monitoring System (MPSMS). RESET uses a parallel group study design and two group pretest-posttest analyses for primary outcomes. We use a multi-method approach to collect and triangulate qualitative data collected during 3 visits to study sites. We will use cross-case comparisons to consider how site-specific contextual factors interact with the variation in the intensity and fidelity of implementation to affect teamwork and patient outcomes. DISCUSSION: The RESET study provides mentorship and resources to assist hospitals as they implement complementary and mutually reinforcing components to redesign the clinical microsystems caring for medical patients. Our findings will be of interest and directly applicable to all hospitals providing care to patients with medical conditions. TRIAL REGISTRATION: NCT03745677 . Retrospectively registered on November 19, 2018.

Learning from a clinical microsystems quality improvement initiative to promote integrated care across a falls care pathway.

AIM: To identify learning from a clinical microsystems (CMS) quality improvement initiative to develop a more integrated service across a falls care pathway spanning community and hospital services. BACKGROUND: Falls present a major challenge to healthcare providers internationally as populations age. A review of the falls care pathway in Sheffield, United Kingdom, identified that pathway implementation was constrained by inconsistent co-ordination and integration at the hospital-community interface. APPROACH: The initiative utilised the CMS quality improvement approach and comprised three phases. Phase 1 focussed on developing a climate for change through engaging stakeholders across the existing pathway and coaching frontline teams operating as microsystems in quality improvement. Phase 2 involved initiating change by working at the mesosystem level to identify priorities for improvement and undertake tests of change. Phase 3 engaged decision makers at the macrosystem level from across the wider pathway in achieving change identified in earlier phases of the initiative. FINDINGS: The initiative was successful in delivering change in relation to key aspects of the pathway, engaging frontline staff and decision makers from different services within the pathway, and in building quality improvement capability within the workforce. Viewing the pathway as a series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change. Particular challenges encountered arose from organisational reconfiguration and cross-boundary working. CONCLUSION: CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.

Team-Based Care: The Changing Face of Cardiothoracic Surgery.

Cardiothoracic surgical care is a team sport. The increased complexity and sophistication of this field have resulted in the development of highly functioning multidisciplinary and interprofessional teams to optimize clinical outcomes. This article provides an overview of a team-based, patient-centric "systems" approach to the care of cardiothoracic surgery patients.

Improving Nursing Home Care through Feedback On PerfoRMance Data (INFORM): Protocol for a cluster-randomized trial.

BACKGROUND: Audit and feedback is effective in improving the quality of care. However, methods and results of international studies are heterogeneous, and studies have been criticized for a lack of systematic use of theory. In TREC (Translating Research in Elder Care), a longitudinal health services research program, we collect comprehensive data from care providers and residents in Canadian nursing homes to improve quality of care and life of residents, and quality of worklife of caregivers. The study aims are to a) systematically feed back TREC research data to nursing home care units, and b) compare the effectiveness of three different theory-based feedback strategies in improving performance within care units. METHODS: INFORM (Improving Nursing Home Care through Feedback On PerfoRMance Data) is a 3.5-year pragmatic, three-arm, parallel, cluster-randomized trial. We will randomize 67 Western Canadian nursing homes with 203 care units to the three study arms, a standard feedback strategy and two assisted and goal-directed feedback strategies. Interventions will target care unit managerial teams. They are based on theory and evidence related to audit and feedback, goal setting, complex adaptive systems, and empirical work on feeding back research results. The primary outcome is the increased number of formal interactions (e.g., resident rounds or family conferences) involving care aides - non-registered caregivers providing up to 80% of direct care. Secondary outcomes are a) other modifiable features of care unit context (improved feedback, social capital, slack time) b) care aides' quality of worklife (improved psychological empowerment, job satisfaction), c) more use of best practices, and d) resident outcomes based on the Resident Assessment Instrument - Minimum Data Set 2.0. Outcomes will be assessed at baseline, immediately after the 12-month intervention period, and 18 months post intervention. DISCUSSION: INFORM is the first study to systematically assess the effectiveness of different strategies to feed back research data to nursing home care units in order to improve their performance. Results of this study will enable development of a practical, sustainable, effective, and cost-effective feedback strategy for routine use by managers, policy makers and researchers. The results may also be generalizable to care settings other than nursing homes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02695836 . Date of registration: 24 February 2016.

A quality improvement project to decrease emergency department and medical intensive care unit transfer times.

OBJECTIVE: To reduce transfer time of critically ill patients from the emergency department (ED) to the medical intensive care unit (MICU). DESIGN: A prospective, observational study assessing preimplementation and postimplementation of quality improvement interventions in a tertiary academic medical center. INTERVENTIONS: A team of frontline health care professional including ED, MICU, and supporting services using the clinical microsystems approach mapped out existing practice patterns, determined causes for delays, and used the Plan-Do-Study-Act to test changes. Measurements and Main Results The team identified multiple issues that contributed to delays. These included poor coordination between transport services, respiratory therapy, and nursing in transferring patients from the ED as well delays in identification and transfer of stable MICU patients. These interventions reduced transfer time from 4.2 (3.4-5.7) hours to 2.2 (1.4-3.1) hours (median [interquartile range]; P<.001). Hospital length of stay decreased from 9.9±9 to 8.3±7 days (P<.03). CONCLUSION: A team made up of frontline health care professionals using a structured quality improvement process and implementing multifaceted, multistage interventions, reduced transfer delays, and length of stay. Added benefits included engagement among members of the 2 microsystems and a more cohesive approach to patient care.