Improving colorectal cancer screening disparities among Somali-speaking patients in an Internal Medicine Residency Clinic.

Colorectal cancer (CRC) is the third-most lethal cancer in the USA, and early detection through screening is crucial for improving outcomes. However, significant disparities in access and utilisation of CRC screening exist among patients with limited English proficiency. Our Quality Improvement (QI) team developed and implemented a video, featuring a Somali-speaking physician, created with input from internal medicine (IM) residents, patient education experts and community leaders to increase the rate of CRC screening uptake within a Somali-speaking population receiving primary care within an IM Residency Clinic. The baseline proportion of average-risk Somali-speaking patients who had successfully been screened for CRC was 46.3% (63/134). The proportion of patients agreeable to undergo CRC screening was assessed monthly from the beginning of video implementation (June 2022 to December 2022). We found that this intervention corresponded with a significant increase in willingness to undergo CRC screening from 36.4% to 100% during the early stages of intervention. At the end of our measurement timeframe, the proportion of the original population fully screened for CRC was 50.7% (68/134). Implementation of the video intervention was also assessed and determined to be minimally disruptive to the clinic flow.

Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care.

PURPOSE: Primary care practices manage most patients with diabetes and face considerable operational, regulatory, and reimbursement pressures to improve the quality of this care. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team nurses and pharmacists to improve diabetes care. METHODS: Using a retrospective, interrupted-time series design, we evaluated the EPCD model's impact on D5, a publicly reported composite quality measure of diabetes care: glycemic control, blood pressure control, low-density lipoprotein control, tobacco abstinence, and aspirin use. We examined 32 primary care practices in an integrated health care system that cares for adults with diabetes; practices were categorized as staff clinician practices (having physicians and advanced practice providers) with access to EPCD (5,761 patients); resident physician practices with access to EPCD (1,887 patients); or staff clinician practices without access to EPCD (10,079 patients). The primary outcome was the percentage of patients meeting the D5 measure, compared between a 7-month preimplementation period and a 10-month postimplementation period. RESULTS: After EPCD implementation, staff clinician practices had a significant improvement in the percentage of patients meeting the D5 composite quality indicator (change in incident rate ratio from 0.995 to 1.005; P = .01). Trends in D5 attainment did not change significantly among the resident physician practices with access to EPCD (P = .14) and worsened among the staff clinician practices without access to EPCD (change in incident rate ratio from 1.001 to 0.994; P = .05). CONCLUSIONS: Implementation of the EPCD team model was associated with an improvement in diabetes care quality in the staff clinician group having access to this model. Further study of proactive, multidisciplinary chronic disease management led by care team nurses and integrating clinical pharmacists is warranted.

A survey of outpatient Internal Medicine clinician perceptions of diagnostic error.

Background Little is known about how practicing Internal Medicine (IM) clinicians perceive diagnostic error, and whether perceptions are in agreement with the published literature. Methods A 16-question survey was administered across two IM practices: one a referral practice providing care for patients traveling for a second opinion and the other a traditional community-based primary care practice. Our aim was to identify individual- and system-level factors contributing to diagnostic error (primary outcome) and conditions at greatest risk of diagnostic error (secondary outcome). Results Sixty-five of 125 clinicians surveyed (51%) responded. The most commonly perceived individual factors contributing to diagnostic error included atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). The most commonly cited system-level factors included cognitive burden created by the volume of data in the electronic health record (EHR) (68%), lack of time to think (64%) and systems that do not support collaboration (40%). Conditions felt to be at greatest risk of diagnostic error included cancer (46%), pulmonary embolism (43%) and infection (37%). Conclusions Inadequate clinician time and sub-optimal patient and test follow-up are perceived by IM clinicians to be persistent contributors to diagnostic error. Clinician perceptions of conditions at greatest risk of diagnostic error may differ from the published literature.

What Can Apologies in the Electronic Health Record Tell Us About Health Care Quality, Processes, and Safety?

INTRODUCTION: Apologizing to patients is an encouraged practice, yet little is known about how and why providers apologize and what insights apologies could provide in improving quality and safety. OBJECTIVE: The aim of the study was to determine whether provider apologies in the electronic health record could identify patient safety concerns and opportunities for improvement. METHODS: After performing a free-text search, we randomly selected 100 clinical notes from 1685 available containing terminology related to apology. We categorized the reason for apology, presence and classification of medical error, level of patient harm, and practice improvement opportunities. We compared patient events discovered from apologies in the medical record to standard patient incident report logs. RESULTS: Of 100 randomly selected apologies, 37 were related to a delay in care, 14 to misunderstanding, 11 to access to care, and 8 to information technology. For apologies related to delay, the median delay was 6 days (mean = 8.9, range = 0-41). Twenty-four (65%) of the 37 delays were related to diagnostic testing.Medical errors were associated with 46 (46%) of the 100 apologies. Sixty-four (64%) of the 100 apologies were associated with actionable opportunities for improvement. These opportunities were classified into 37 discrete issues across 8 broad categories. When apology review was compared with standard incident report logs, 27 (73%) of the 37 discrete issues identified by patient apology review were not found in incident reporting; both methods identified similar rates of patient harm. CONCLUSIONS: Review of apologies in the electronic health record can identify patient safety concerns and improvement opportunities not apparent through standard incident reporting.

Population health challenges in primary care: What are the unfinished tasks and who should do them?

BACKGROUND: There are numerous recommendations from expert sources that help guide primary care providers in cancer screening, infectious disease screening, metabolic screening, monitoring of drug levels, and chronic disease management. Little is known about the potential effort needed for a healthcare system to address these recommendations, or the patient effort needed to complete the recommendations. METHODS: For 73 recommended population healthcare items, we examined each of 28,742 patients in a primary care internal medicine practice to determine whether they were up-to-date on recommended screening, immunizations, counseling, and chronic disease management goals. We used a rule-based software tool that queries the medical record for diagnoses, dates, laboratory values, pathology reports, and other information used in creating the individualized recommendations. We counted the number of uncompleted recommendations by age groups and examined the healthcare staff needed to address the recommendations and the potential patient effort needed to complete the recommendations. RESULTS: For the 28,742 patients, there were 127,273 uncompleted recommendations identified for population health management (mean recommendations per patient 4.36, standard deviation of 2.65, range of 0-17 recommendations per patient). The age group with the most incomplete recommendations was age of 50-65 years with 5.5 recommendations per patient. The 18-35 years age group had the fewest incomplete recommendations with 2.6 per patient. Across all age groups, initiation of these recommendations required high-level input (physician, nurse practitioner, or physician's assistant) in 28%. To completely adhere to recommended services, a 1000-patient cross-section cohort would require a total of 464 procedures and 1956 lab tests. CONCLUSION: Providers and patients face a daunting number of tasks necessary to meet guideline-generated recommendations. We will need new approaches to address the burgeoning numbers of uncompleted recommendations.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature.

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.