Evaluating the Prevalence of Four Recommended Practices for Suicide Prevention Following Hospital Discharge.

BACKGROUND: The Joint Commission's National Patient Safety Goal (NPSG) for suicide prevention (NPSG.15.01.01) requires that accredited hospitals maintain policies/procedures for follow-up care at discharge for patients identified as at risk for suicide. The proportion of hospitals meeting these requirements through use of recommended discharge practices is unknown. METHODS: This cross-sectional observational study explored the prevalence of suicide prevention activities among Joint Commission-accredited hospitals. A questionnaire was sent to 1,148 accredited hospitals. The authors calculated the percentage of hospitals reporting implementation of four recommended discharge practices for suicide prevention. RESULTS: Of 1,148 hospitals, 346 (30.1%) responded. The majority (n = 212 [61.3%]) of hospitals had implemented formal safety planning, but few of those (n = 41 [19.3%]) included all key components of safety planning. Approximately a third of hospitals provided a warm handoff to outpatient care (n = 128 [37.0%)] or made follow-up contact with patients (n = 105 [30.3%]), and approximately a quarter (n = 97 [28.0%]) developed a plan for lethal means safety. Very few (n = 14 [4.0%]) hospitals met full criteria for implementing recommended suicide prevention activities at time of discharge. CONCLUSION: The study revealed a significant gap in implementation of recommended practices related to prevention of suicide postdischarge. Additional research is needed to identify factors contributing to this implementation gap.

Home Health Agency Patient Experience Measures and Their Relationship to Joint Commission Accreditation.

BACKGROUND: Health care accreditation is a widely accepted mechanism for improving the quality of care and promoting patient safety. An integral dimension of health care quality is the patient experience of care. However, the influence of accreditation on the patient experience is unclear. The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey is the standard for collecting patient care experience data in the home health setting. The aim of this study was to examine the association of Joint Commission accreditation on patients' experience of care by comparing HHCAHPS ratings from Joint Commission-accredited and non-Joint Commission-accredited home health agencies (HHAs). METHODS: This multiyear observational study used 2015-2019 HHCAHPS data obtained from the Centers for Medicare & Medicaid Services (CMS) website and Joint Commission databases. The data set included 1,454 (23.8%) Joint Commission-accredited and 4,643 (76.2%) non-Joint Commission-accredited HHAs. Dependent variables included three composite measures of care (Care of Patients, Provider-Patient Communications, and Specific Care Issues) and two global rating measures. Data were analyzed using a series of longitudinal random effects logistic regression models. RESULTS: This study found no association between Joint Commission accreditation and the two global HHCAHPS measures, modest significant increases for Joint Commission-accredited HHAs in measure rates for the Care of Patients and Communication composite measures (p < 0.05), and a more significant increase for the Specific Care Issues composite measure related to medication safety and home safety (p < 0.001). CONCLUSIONS: These findings suggest that Joint Commission accreditation may be positively associated with some patient experience of care outcomes. This relationship was most pronounced when there was significant overlap between the focus of the accreditation standards and focus of the HHCAHPS items.

Tracer Methodology and the quality of care: integrative literature review. / Método Tracer e a qualidade do cuidado na enfermagem: revisão integrativa da literatura.

OBJECTIVE: To analyze the scientific literature about the Tracer Method in the area of nursing. METHOD: Integrative literature review with 22 articles from the following databases: Latin American and Caribbean Literature in Health Sciences (LILACS); Medical Literature Analysis and Retrieval System Online(Medline/PubMed); Scientific Electronic Library Online (SciELO); Cumulative Index to Nursing & Allied Health Literature (CINAHL) and Web of Science. The search strategy included descriptors and keywords, as follows: Método Tracer, Método Traçador, Método Rastreador, Método de Avaliação, Usuário Guia amd Enfermagem correlated and combined with Boolean operators. RESULTS: Data was organized according to the scenarios where the method was applied, namely: health condition as a tracer condition for assessing the quality of care, compliance and non-compliance regarding the institutional protocols, reflection and training for accreditation. CONCLUSION: The Tracer Methodology is used for evaluating and improving the quality of care.

Método Tracer e a qualidade do cuidado na enfermagem: revisão integrativa da literatura / Método Tracer y la calidad del cuidado: revisión integral de la literatura / Tracer Methodology and the quality of care: integrative literature review

Resumo OBJETIVO Analisar a produção científica sobre o Método Tracer na área da enfermagem. MÉTODO Revisão integrativa, realizada com 22 artigos localizados nas bases de dados: Literatura Latino-Americana e do Caribe em Ciências e Saúde (LILACS); Medical Literature Analysis and Retrieval System Online(Medline/PubMed); Scientific Eletronic Library Online (SciELO); Cumulative Index to Nursing & Allied Health Literature (CINAHL) eWeb of Science. As estratégias de busca incluíram descritores e palavras-chave: Método Tracer, Método traçador, Método rastreador, Método de avaliação, Usuário Guia e Enfermagem correlacionados e combinados com operadores booleanos. RESULTADOS Organizaram-se os dados segundo os cenários de aplicação do método, a saber: agravos à saúde como condição traçadora para avaliar a qualidade dos cuidados, conformidades e não conformidades em relação aos protocolos institucionais, reflexão e capacitação para a acreditação. CONCLUSÃO O Método Tracer é utilizado para avaliação e melhoria da qualidade da assistência.

Resumen OBJETIVO Analizar la literatura científica sobre el Método Tracer en el área de enfermería. MÉTODO Revisión integrativa de la literatura, conducida con 22 artículos en las bases de datos: Literatura Latinoamericana y Caribe en Ciencias de la Salud (LILACS); Medical Literature Analysis and Retrieval System Online(Medline/PubMed); Scientific Electronic Library Online (SciELO); Cumulative Index to Nursing & Allied Health Literature (CINAHL) y Web of Science. La búsqueda incluyeron las palabras clave: trazador, método de evaluación, guía del usuario y enfermería relacionados y combinados con operadores booleanos. RESULTADOS Los datos se organizaron según los escenarios de aplicación del método: condición de salud estampados plotter para evaluar la calidad de atención, cumplimiento y no cumplimiento de protocolos, reflexión y formación para la acreditación. CONCLUSIÓN El Método Tracer se utiliza para mejorar la calidad de la atención.

Abstract OBJECTIVE To analyze the scientific literature about the Tracer Method in the area of nursing. METHOD Integrative literature review with 22 articles from the following databases: Latin American and Caribbean Literature in Health Sciences (LILACS); Medical Literature Analysis and Retrieval System Online(Medline/PubMed); Scientific Electronic Library Online (SciELO); Cumulative Index to Nursing & Allied Health Literature (CINAHL) and Web of Science. The search strategy included descriptors and keywords, as follows: Método Tracer, Método Traçador, Método Rastreador, Método de Avaliação, Usuário Guia amd Enfermagem correlated and combined with Boolean operators. RESULTS Data was organized according to the scenarios where the method was applied, namely: health condition as a tracer condition for assessing the quality of care, compliance and non-compliance regarding the institutional protocols, reflection and training for accreditation. CONCLUSION The Tracer Methodology is used for evaluating and improving the quality of care.

Civil Litigation and the Opioid Epidemic: The Role of Courts in a National Health Crisis.

The devastating impact of the national opioid epidemic has given rise to hundreds of lawsuits. This article details the extremely broad range of legal claims, compares the opioid cases to other public health litigation efforts, including tobacco, and describes the special mechanism - a multidistrict litigation - through which more than 700 opioid-related cases have been consolidated thus far, with settlement almost certain to follow.

Avoiding MRI-Related Accidents: A Practical Approach to Implementing MR Safety.

MRI is a ubiquitous medical imaging technology typically using superconductivity to generate a strong, homogeneous, and generally ceaseless magnetic field. MRI and its magnetic field pose many safety hazards, including magnetic forces on metals, tissue heating and burns, nerve stimulation, bioeffects, acoustic noise, and contrast agent complications. The primary concern is that a wide variety of patients, staff members, technologists, and physicians can approach the incessant magnetic field, creating great potential for accidents that could occur if metals from the environment, adornments, implants, and other unintended sources are also present in or near the field. Many accidents have occurred and are occasionally reported in the United States and countries all over the world. Through carefully structured oversight and the establishment of strict guidelines regarding access, responsibilities, and training, these risks can be mitigated, and accidents can be prevented. Fortunately, there is currently a wide variety of resources available to facilitate the successful implementation of an effective MRI safety program. This article presents a general overview of and the authors' experience with an MRI safety program in terms of risk management and training. The MR safety program requirements and regulations in the United States devised by The Joint Commission and the ACR are also discussed. With these resources and a carefully selected team, the risk for MRI-related accidents can be vastly reduced if not completely eliminated.

The Hidden Cost of Regulation: The Administrative Cost of Reporting Serious Reportable Events.

BACKGROUND: More than half of the 50 states (27) and the District of Columbia require reporting of Serous Reportable Events (SREs). The goal is to hold providers accountable and improve patient safety, but there is little information about the administrative cost of this reporting requirement. This study was conducted to identify costs associated with investigating and reporting SREs. METHODS: This qualitative study used case study methods that included interviewing staff and review of data and documents to investigate each SRE occurring at one academic medical center during fiscal year 2013. A framework of tasks and a model to categorize costs was created. Time was summarized and costs were estimated for each SRE. RESULTS: The administrative cost to process 44 SREs was estimated at $353,291, an average cost of $8,029 per SRE, ranging $6,653 for an environmental-related SRE to $21,276 for a device-related SRE. Care management SREs occurred most frequently, costing an average $7,201 per SRE. Surgical SREs, the most expensive on average, cost $9,123 per SRE. Investigation of events accounted for 64.5% of total cost; public reporting, 17.2%; internal reporting, 10.2%; finance and administration, 6.0%; and 2.1%, other. Even with 26 states mandating reporting, the 17.2% incremental cost of public reporting is substantial. CONCLUSION: Policy makers should consider the opportunity costs of these resources, averaging $8,029 per SRE, when mandating reporting. The benefits of public reporting should be collectively reviewed to ensure that the incremental costs in this resource-constrained environment continue to improve patient safety and that trade-offs are acknowledged.

An Outpatient Performance Improvement Project: A Baseline Assessment of Adherence to Pain Reassessment Standards.

BACKGROUND: This performance improvement (PI) project was conducted to recommend improvements for pain reassessment workflow and policies at a large military primary care clinic. The Joint Commission survey identified inconsistent pain reassessment practices at the facility in 2012. A review of the literature reveals that pain reassessment procedures can be affected by unclear organizational policies, poorly designed documentation procedures, and redundant or inefficient workflow practices. This PI project was designed to assess pain reassessment compliance rates, associated documentation, and clinic workflow, and to identify opportunities for improvement. METHODS: Pain reassessment compliance was evaluated using an Electronic Medical Record (EMR) query for patients treated between February 1 and May 30, 2013, who received Toradol at a large military outpatient clinic (n = 151). In addition, observations of clinic workflow were conducted using tracer methodology as recommended by The Joint Commission to track a convenience sample of 12 patients moving through clinic care processes. Pain reassessment documentation and workflow procedures were then evaluated using the Situation Awareness (SA) framework, which is an approach used to evaluate operational implications of factors affecting staff decisions and performance (e.g., stress and workload, interface design, automation, complexity of workflow, staff abilities and training, goals and expectations). RESULTS: The EMR review revealed compliance rates greater than 90% for all pain reassessment requirements with the exception of the maximum 30-minute interval between initial and follow-up pain assessment required by clinic policy, which had a compliance rate of 38%. Pain reassessments were documented to occur at a mean time of 48.25 minutes after initial assessment. During the tracer, none of the 12 patient encounters was fully compliant with clinic policies. An analysis of clinic workflow using the SA framework revealed that the SA of clinic staff was impacted by a lack of standardized procedures and heavy reliance on staff memory. DISCUSSION: Recommendations for improvement included possible extension of the 30-minute time requirement, development of a template for pain reassessment documentation in the EMR, standardizing hand off and admission/discharge processes, and designing an electronic or manual dashboard to indicate pain reassessment times. Future PI projects in other military clinics would benefit from use of the SA perspective to review clinic policies, EMR documentation, and workflow analysis. Further analysis will be needed to evaluate the impact of these improvements.

Global trends in center accreditation by the Joint Commission International: growing patient implications for international medical and surgical care.

Millions of patients travel internationally for medical and surgical care. We found that the annual number of centers accredited by the Joint Commission International increased from one center in 1999 to 132 centers in 2016; there are currently 939 accredited centers across 66 countries. Public health and medicolegal implications related to medical travel deserve attention.

Health Quality Measures Addressing Disparities in Culturally and Linguistically Appropriate Services: What are Current Gaps?

PURPOSE: Disparities in health care persist among many at-risk groups. This study examines the current state of health quality measures addressing disparities and culturally and linguistically appropriate services (CLAS), and identifies important gaps in existing measures and their implementation. METHODS: We searched key quality reporting databases and websites to identify measures and structural program requirements addressing disparities or CLAS. We also conducted a dozen semi-structured interviews to obtain expert perspectives. RESULTS: Twenty-four measures and eight private or public-sector programs with relevant structural requirements were identified. Half the measures focused on language needs. Few measures were used in national reporting programs and adoption of requirements has been limited. Barriers to implementation included lack of data among health plans, lack of health workforce training, and challenges in defining cultural competence. CONCLUSIONS: Future efforts should seek to enhance implementation of existing quality measures addressing disparities and CLAS, and address barriers to their adoption.

Impact of Stroke Center Certification on Mortality After Ischemic Stroke: The Medicare Cohort From 2009 to 2013.

BACKGROUND AND PURPOSE: An increasing number of hospitals have been certified as primary stroke centers (PSCs). It remains unknown whether the action toward PSC certification has improved the outcome of stroke care. This study aimed to understand whether PSC certification reduced stroke mortality. METHODS: We examined Medicare fee-for-service beneficiaries aged ≥65 years who were hospitalized between 2009 and 2013 for ischemic stroke. Hospitals were classified into 3 groups: new PSCs, the hospitals that received initial PSC certification between 2009 and 2013 (n=634); existing PSCs, the PSCs certified before 2009 (n=785); and non-SCs, the hospitals that have never been certified as PSCs (n=2640). Multivariate logistic regression and Cox proportional hazards model was used to compare the mortality among the 3 groups. RESULTS: Existing PSCs were significantly larger than new PSCs as reflected by total number of beds and annual stroke admission (P<0.0001). Compared with existing PSCs, new PSCs had lower in-hospital (odds ratio, 0.862; 95% confidence interval [CI], 0.817-0.910) and 30-day mortality (hazard ratio [HR], 0.981; 95% CI, 0.968-0.993), after adjusting for patient demographics and comorbidities. Compared with non-SCs, new PSCs had lower adjusted in-hospital (odds ratio, 0.894; 95% CI, 0.848-0.943), 30-day (HR, 0.904; 95% CI, 0.892-0.917), and 1-year mortality (HR, 0.907; 95% CI, 0.898-0.915). Existing PSCs had lower adjusted 30-day (HR, 0.922; 95% CI, 0.911-0.933) and 1-year mortality (HR, 0.900; 95% CI, 0.892-0.907) than non-SCs. CONCLUSIONS: Obtaining stroke certification may reduce stroke mortality and overcome the disadvantage of being smaller hospitals. Further study of other outcome measures will be useful to improve stroke system of care.

Patient Mortality During Unannounced Accreditation Surveys at US Hospitals.

Importance: In the United States, hospitals receive accreditation through unannounced on-site inspections (ie, surveys) by The Joint Commission (TJC), which are high-pressure periods to demonstrate compliance with best practices. No research has addressed whether the potential changes in behavior and heightened vigilance during a TJC survey are associated with changes in patient outcomes. Objective: To assess whether heightened vigilance during survey weeks is associated with improved patient outcomes compared with nonsurvey weeks, particularly in major teaching hospitals. Design, Setting, and Participants: Quasi-randomized analysis of Medicare admissions at 1984 surveyed hospitals from calendar year 2008 through 2012 in the period from 3 weeks before to 3 weeks after surveys. Outcomes between surveys and surrounding weeks were compared, adjusting for beneficiaries' sociodemographic and clinical characteristics, with subanalyses for major teaching hospitals. Data analysis was conducted from January 1 to September 1, 2016. Exposures: Hospitalization during a TJC survey week vs nonsurvey weeks. Main Outcomes and Measures: The primary outcome was 30-day mortality. Secondary outcomes were rates of Clostridium difficile infections, in-hospital cardiac arrest mortality, and Patient Safety Indicators (PSI) 90 and PSI 4 measure events. Results: The study sample included 244 787 and 1 462 339 admissions during survey and nonsurvey weeks with similar patient characteristics, reason for admission, and in-hospital procedures across both groups. There were 811 598 (55.5%) women in the nonsurvey weeks (mean [SD] age, 72.84 [14.5] years) and 135 857 (55.5%) in the survey weeks (age, 72.76 [14.5] years). Overall, there was a significant reversible decrease in 30-day mortality for admissions during survey (7.03%) vs nonsurvey weeks (7.21%) (adjusted difference, -0.12%; 95% CI, -0.22% to -0.01%). This observed decrease was larger than 99.5% of mortality changes among 1000 random permutations of hospital survey date combinations, suggesting that observed mortality changes were not attributable to chance alone. Observed mortality reductions were largest in major teaching hospitals, where mortality fell from 6.41% to 5.93% during survey weeks (adjusted difference, -0.38%; 95% CI, -0.74% to -0.03%), a 5.9% relative decrease. We observed no significant differences in admission volume, length of stay, or secondary outcomes. Conclusions and Relevance: Patients admitted to hospitals during TJC survey weeks have significantly lower mortality than during nonsurvey weeks, particularly in major teaching hospitals. These results suggest that changes in practice occurring during periods of surveyor observation may meaningfully affect patient mortality.

Meeting The Joint Commission's Dose Incident Identification and External Benchmarking Requirements Using the ACR's Dose Index Registry.

PURPOSE: The purpose of this investigation was to evaluate the potential of using the ACR's Dose Index Registry(®) to meet The Joint Commission's requirements to identify incidents in which the radiation dose index from diagnostic CT examinations exceeded the protocol's expected dose index range. METHODS: In total, 10,970 records in the Dose Index Registry were statistically analyzed to establish both an upper and lower expected dose index for each protocol. All 2015 studies to date were then retrospectively reviewed to identify examinations whose total examination dose index exceeded the protocol's defined upper threshold. Each dose incident was then logged and reviewed per the new Joint Commission requirements. CONCLUSIONS: Facilities may leverage their participation in the ACR's Dose Index Registry to fully meet The Joint Commission's dose incident identification review and external benchmarking requirements.