The Volume and Cost of Quality Metric Reporting.

Importance: US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known. Objective: To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts. Design, Setting, and Participants: Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year. Main Outcomes and Measures: Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type. Results: A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year). Conclusions and Relevance: Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.

Association of Hospital Participation in Bundled Payments for Care Improvement Advanced With Medicare Spending and Hospital Incentive Payments.

Importance: Bundled Payments for Care Improvement Advanced (BPCI-A) is a Centers for Medicare & Medicaid Services (CMS) initiative that aims to produce financial savings by incentivizing decreases in clinical spending. Incentives consist of financial bonuses from CMS to hospitals or penalties paid by hospitals to CMS. Objective: To investigate the association of hospital participation in BPCI-A with spending, and to characterize hospitals receiving financial bonuses vs penalties. Design, Setting, and Participants: Difference-in-differences and cross-sectional analyses of 4 754 139 patient episodes using 2013-2019 US Medicare claims at 694 participating and 2852 nonparticipating hospitals merged with hospital and market characteristics. Exposures: BPCI-A model years 1 and 2 (October 1, 2018, through December 31, 2019). Main Outcomes and Measures: Hospitals' per-episode spending, CMS gross and net spending, and the incentive allocated to each hospital. Results: The study identified 694 participating hospitals. The analysis observed a -$175 change in mean per-episode spending (95% CI, -$378 to $28) and an aggregate spending change of -$75.1 million (95% CI, -$162.1 million to $12.0 million) across the 428 670 episodes in BPCI-A model years 1 and 2. However, CMS disbursed $354.3 million (95% CI, $212.0 million to $496.0 million) more in bonuses than it received in penalties. Hospital participation in BPCI-A was associated with a net loss to CMS of $279.2 million (95% CI, $135.0 million to $423.0 million). Hospitals in the lowest quartile of Medicaid days received a mean penalty of $0.41 million; (95% CI, $0.09 million to $0.72 million), while those in the highest quartile received a mean bonus of $1.57 million; (95% CI, $1.09 million to $2.08 million). Similar patterns were observed for hospitals across increasing quartiles of Disproportionate Share Hospital percentage and of patients from racial and ethnic minority groups. Conclusions and Relevance: Among US hospitals measured between 2013 and 2019, participation in BPCI-A was significantly associated with an increase in net CMS spending. Bonuses accrued disproportionately to hospitals providing care for marginalized communities.

Association of Costs and Days at Home With Transfer Hospital in Home.

Importance: New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home-that is, completing hospitalization at home-is unclear. Objective: To evaluate the outcomes of the transfer component of a Veterans Affairs (VA) Hospital in Home program (T-HIH), taking advantage of natural geographical limitations in a program's service area. Design, Setting, and Participants: In this quality improvement study, T-HIH was offered to veterans residing in Philadelphia, Pennsylvania, and their outcomes were compared with those of propensity-matched veterans residing in adjacent Camden, New Jersey, who were admitted to the VA hospital from 2012 to 2018. Data analysis was performed from October 2019 to May 2020. Intervention: Enrollment in the T-HIH program. Main Outcomes and Measures: The main outcomes were hospital length of stay, 30-day and 90-day readmissions, VA direct costs, combined VA and Medicare costs, mortality, 90-day nursing home use, and days at home after hospital discharge. An intent-to-treat analysis of cost and utilization was performed. Results: A total of 405 veterans (mean [SD] age, 66.7 [0.83] years; 399 men [98.5%]) with medically complex conditions, primarily congestive heart failure and chronic obstructive pulmonary disease exacerbations (mean [SD] hierarchical condition categories score, 3.54 [0.16]), were enrolled. Ten participants could not be matched, so analyses were performed for 395 veterans (all of whom were men), 98 in the T-HIH group and 297 in the control group. For patients in the T-HIH group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, -3.77 to 0.61 days), VA costs were 20% lower (-$5910; 95% CI, -$13 049 to $1229), combined VA and Medicare costs were 22% lower (-$7002; 95% CI, -$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, -6.5 days; 95% CI, -12.1 to -0.96 days; P = .02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P = .01). Conclusions and Relevance: In this study, T-HIH was significantly associated with increased days at home and less nursing home use but was not associated with increased health care system costs.

Program for Supporting Frontline Improvement Projects in an Academic Radiology Department.

OBJECTIVE. The purpose of this study was to describe the results of an ongoing program implemented in an academic radiology department to support the execution of small- to medium-size improvement projects led by frontline staff and leaders. MATERIALS AND METHODS. Staff members were assigned a coach, were instructed in improvement methods, were given time to work on the project, and presented progress to department leaders in weekly 30-minute reports. Estimated costs and outcomes were calculated for each project and aggregated. An anonymous survey was administered to participants at the end of the first year. RESULTS. A total of 73 participants completed 102 projects in the first 2 years of the program. The project type mix included 25 quality improvement projects, 22 patient satisfaction projects, 14 staff engagement projects, 27 efficiency improvement projects, and 14 regulatory compliance and readiness projects. Estimated annualized outcomes included approximately 4500 labor hours saved, $315K in supply cost savings, $42.2M in potential increased revenues, 8- and 2-point increase in top-box patient experience scores at two clinics, and a 60-incident reduction in near-miss safety events. Participant time equated to approximately 0.35 full-time equivalent positions per year. Approximately 0.4 full-time equivalent was required to support the program. Survey results indicated that the participants generally viewed the program favorably. CONCLUSION. The program was successful in providing a platform for simultaneously solving a large number of organizational problems while also providing a positive experience to frontline personnel.

Excessive Health Care Spending Fails to Improve U.S. Population Health.

A recent analysis highlights waste and missed opportunities to improve outcomes.

A SBM-DEA based performance evaluation and optimization for social organizations participating in community and home-based elderly care services.

The community and home-based elderly care service system has been proved an effective pattern to mitigate the elderly care dilemma under the background of accelerating aging in China. In particular, the participation of social organizations in community and home-based elderly care service has powerfully fueled the multi-supply of elderly care. As the industry of the elderly care service is in the ascendant, the management lags behind, resulting in the waste of significant social resources. Therefore, performance evaluation is proposed to resolve this problem. However, a systematic framework for evaluating performance of community and home-based elderly care service centers (CECSCs) is absent. To overcome this limitation, the SBM-DEA model is introduced in this paper to evaluate the performance of CECSCs. 186 social organizations in Nanjing were employed as an empirical study to develop the systematic framework for performance evaluation. Through holistic analysis of previous studies and interviews with experts, a systematic framework with 33 indicators of six dimensions (i.e., financial management, hardware facilities, team building, service management, service object and organization construction) was developed. Then, Sensitivity Analysis is used to screen the direction of performance optimization and specific suggestions were put forward for government, industrial associations and CECSCs to implement. The empirical study shows the proposed framework using SBM-DEA and sensitivity analysis is viable for conducting performance evaluation and improvement of CECSCs, which is conducive to the sustainable development of CECSCs.

The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.

Epidemiology and clinical features of emergency department patients with suspected and confirmed COVID-19: A multisite report from the COVID-19 Emergency Department Quality Improvement Project for July 2020 (COVED-3).

OBJECTIVE: The aim of the present study was to describe the epidemiology and clinical features of patients presenting to the ED with suspected and confirmed COVID-19. METHODS: The COVID-19 ED (COVED) Project is an ongoing prospective cohort study in Australian EDs. This analysis presents data from eight sites across Victoria and Tasmania for July 2020 (during Australia's 'second wave'). All adult patients who met criteria for 'suspected COVID-19' and underwent testing for SARS-CoV-2 in the ED were eligible for inclusion. Study outcomes included a positive SARS-CoV-2 test result and mechanical ventilation. RESULTS: In the period 1 July to 31 July 2020, there were 30 378 presentations to the participating EDs and 2917 (9.6%; 95% confidence interval 9.3-9.9) underwent testing for SARS-CoV-2. Of these, 50 (2%) patients returned a positive result. Among positive cases, two (4%) received mechanical ventilation during their hospital admission compared to 45 (2%) of the SARS-CoV-2 negative patients (odds ratio 1.7, 95% confidence interval 0.4-7.3; P = 0.47). Two (4%) SARS-CoV-2 positive patients died in hospital compared to 46 (2%) of the SARS-CoV-2 negative patients (odds ratio 1.7, 95% confidence interval 0.4-7.1; P = 0.49). Strong clinical predictors of a positive SARS-CoV-2 result included self-reported fever, non-smoking status, bilateral infiltrates on chest X-ray and absence of a leucocytosis on first ED blood tests (P < 0.05). CONCLUSION: In this prospective multi-site study from July 2020, a substantial proportion of ED patients required SARS-CoV-2 testing, isolation and enhanced infection prevention and control precautions. Presence of SARS-CoV-2 on nasopharyngeal swab was not associated with death or mechanical ventilation.

Developing Leaders and Scholars in Health Care Improvement: The VA Quality Scholars Program Competencies.

Despite the need for leaders in health care improvement across health professions, there are no standards for the knowledge and skills that should be achieved through advanced interprofessional health care improvement training. Existing health care improvement training competencies focus on foundational knowledge expected of all trainees or for specific career pathways. Health care improvement leaders fill multiple roles within organizations and promote interprofessional improvement practice. The diverse skill set required of modern health care improvement leaders necessitates the development of training competencies specifically for fellowships in applied health care improvement. The authors describe the development of the revised national Veterans Affairs Quality Scholars (VAQS) Program competencies. The VAQS Program is an interprofessional, postdoctoral training program whose mission is to develop leaders and scholars to improve health care. An interprofessional committee of VAQS faculty reviewed and revised the competencies over 4 months beginning in fall 2018. The first draft was developed using 111 competencies submitted by 11 VAQS training sites and a review of published competencies. The final version included 22 competencies spanning 5 domains: interprofessional collaboration and teamwork, improvement and implementation science, organization and system leadership, methodological skills and analytic techniques for improvement and research, and teaching and coaching. Once attained, the VAQS competencies will guide the skill development that interprofessional health care improvement leaders need to participate in and lead health care improvement scholarship and implementation. These broad competencies are relevant to advanced training programs that develop health care improvement leaders and scholars and may be used by employers to understand the knowledge and skills expected of individuals who complete advanced fellowships in applied health care improvement.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis.

BACKGROUND: Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. METHODS: FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. RESULTS: During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. CONCLUSIONS: In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

The interprofessional Veterans Affairs Quality Scholars program pre- and postdoctoral nurse fellow outcomes.

BACKGROUND: The Department of Veterans Affairs (VA) Quality Scholars (VAQS) program, an interprofessional fellowship that includes pre- and postdoctoral nurses, aims to inspire practice change leaders. Fellows participate in a national curriculum, lead improvement/research teams, and establish professional development plans with expert mentor guidance. PURPOSE: To describe the distinctive elements of the VAQS program, nurse fellow outcomes, and accomplishments of nurse alumni as leaders, researchers, and educators. METHODS: Data were reviewed and aggregated from past and current fellow surveys. FINDINGS: Nurse fellows completed research and improvement projects that benefitted both the VA and the local health systems. Scholarly outcomes include publications, conference presentations, grant submissions, teaching/leading quality improvement, and research initiatives. Graduates transition to positions as nurse scientists, academic faculty, and operational leaders. DISCUSSION: Fellows contribute to the strategic priorities of local and national VA and external health care organizations providing a pipeline of health system expert leaders, educators, and researchers. CONCLUSION: Doctoral nursing fellowship experiences build human capital for enhancing the science of improvement and implementation, interprofessional collaboration, and leadership.

Quality Measure Public Reporting Is Associated with Improved Outcomes Following Hip and Knee Replacement.

BACKGROUND: Given the inclusion of orthopaedic quality measures in the Centers for Medicare & Medicaid Services national hospital payment programs, the present study sought to assess whether the public reporting of total hip arthroplasty (THA) and total knee arthroplasty (TKA) risk-standardized readmission rates (RSRRs) and complication rates (RSCRs) was temporally associated with a decrease in the rates of these outcomes among Medicare beneficiaries. METHODS: Annual trends in national observed and hospital-level RSRRs and RSCRs were evaluated for patients who underwent hospital-based inpatient hip and/or knee replacement procedures from fiscal year 2010 to fiscal year 2016. Hospital-level rates were calculated with use of the same measures and methodology that were utilized in public reporting. Annual trends in the distribution of hospital-level outcomes were then examined with use of density plots. RESULTS: Complication and readmission rates and variation declined steadily from fiscal year 2010 to fiscal year 2016. Reductions of 33% and 25% were noted in hospital-level RSCRs and RSRRs, respectively. The interquartile range decreased by 18% (relative reduction) for RSCRs and by 34% (relative reduction) for RSRRs. The frequency of risk variables in the complication and readmission models did not systematically change over time, suggesting no evidence of widespread bias or up-coding. CONCLUSIONS: This study showed that hospital-level complication and readmission rates following THA and TKA and the variation in hospital-level performance declined during a period coinciding with the start of public reporting and financial incentives associated with measurement. The consistently decreasing trend in rates of and variation in outcomes suggests steady improvements and greater consistency among hospitals in clinical outcomes for THA and TKA patients in the 2016 fiscal year compared with the 2010 fiscal year. The interactions between public reporting, payment, and hospital coding practices are complex and require further study. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patient and caregiver experiences at a Multidisciplinary Tracheostomy Clinic.

INTRODUCTION: Children with tracheostomy are a heterogeneous population requiring care from multiple specialties. Multidisciplinary approaches to treating such patients helps to improve the quality of care they receive. Our institution established a Multidisciplinary Tracheostomy Clinics (MDTC) to address outpatient care coordination for tracheostomy patients by providing care from multiple disciplines at a single visit. We report patient/caregivers' experiences of our MDTC. METHODS: Patients with tracheostomy or their caregivers were prospectively recruited between Dec 2017-Oct 2019 to complete surveys assessing their experience at the MDTC. Demographic and satisfaction questionnaires were sent electronically by a REDCap survey distribution tool. Demographic data were collected, such as patient's residence and education level. Medical care variables assessed included history of MDTC attendance, commute time, medical specialties seen, tracheostomy "Go-Bag" use, home-care nursing, and MDTC satisfaction ratings. RESULTS: Twenty-nine patients/caregivers completed the satisfaction survey and 22 completed both the satisfaction survey and demographics questionnaire. Patient ages ranged from 11 months to 36 years. Twenty-three (79%) participants commuted for up to 2 h to the MDTC, and 6 (21%) commuted for more than 2 h. The median number of medical specialties seen at the MDTC was 3. All participants were satisfied that they saw all requested specialties. Tracheostomy supplies were checked for 25 of 28 patients. Twenty-three of 28 subjects rated staff teamwork as "excellent." Twenty-four of 28 patients were "highly likely" to recommend the MDTC. Twenty-three of 28 participants were "highly likely" to return, and 4 were "somewhat likely" to return. CONCLUSION: This study demonstrates that patients with tracheostomy and caregivers were satisfied with the improved coordination and facilitation of care through a Multidisciplinary Tracheostomy Clinic.

Case-mix adjusted postanaesthesia care unit length of stay and business intelligence dashboards for feedback to anaesthetists.

BACKGROUND: Despite advances in business intelligence software and evidence that feedback to doctors can improve outcomes, objective feedback regarding patient outcomes for individual anaesthetists is hampered by lack of useful benchmarks. We aimed to address this issue by producing case-mix and risk-adjusted postanaesthesia care unit (PACU) length of stay (LOS) benchmarks for integration into modern reporting tools. METHODS: We extended existing hospital information systems to calculate predicted PACU LOS using a neural network trained on patient age, surgery duration, sex, operating specialty, urgency, weekday, and insurance status (n=100 511). We then calculated the difference between observed mean and predicted PACU LOS for individual doctors, and compared the results with and without case-mix adjustment. We report practical implications of using visual analytics dashboards displaying the difference between observed and predicted PACU LOS to provide feedback to anaesthetic doctors. RESULTS: The neural network accounted for over half of observed variation in individual doctors' mean PACU LOS (mean predicted and mean actual LOS Spearman's r2=0.57). Account for case-mix reduced apparent spread, with 80% of individual doctors falling in a band of 4.3 min after case-mix adjusting, compared with a range of 24 min without adjustment. Case-mix adjusting also identified different individual doctors as outliers (Weighted Cohen's kappa [κ]=0.27). Finally, we demonstrated that we were able to integrate the adjusted metrics into routine reporting tools. CONCLUSION: With caution, case-mix adjustment of anaesthetic outcome measures such as PACU LOS potentially provides a useful continuous quality improvement tool. Unadjusted outcome measures are imprecise at best and misleading at worst.

Expanding Data Reporting Capacity of Free and Charitable Clinics: A Quality Improvement Project.

BACKGROUND: In 2018, member clinics of the Virginia Association of Free and Charitable Clinics (VAFCC) provided over 235,500 visits to un/underinsured patients. A survey of VAFCC members found that only 67% report on clinical outcome measures and 56% do not collect social determinant of health (SDOH) data. OBJECTIVE: The purpose of this project was to determine if the provision of web-based technical assistance toolkits and peer mentoring improve quality and data reporting capacity of VAFCC member clinics. METHODS: Clinics that self-selected were provided with 16 weeks of customized interventions including SDOH Data Reporting Toolkit, CMS Quality Data Reporting Toolkit, Electronic Health Record Implementation Toolkit, and peer mentoring. RESULTS: Post-implementation, 100% of participating clinics reported that the resources provided benefited their organizations and increased their capacity to report. CONCLUSIONS: The provision of technical assistance, tangible resources, and customized peer mentoring can better equip Free and Charitable Clinics (FCCs) to tell the story of their patients' social barriers and clinical outcomes. IMPLICATIONS FOR NURSING: DNP prepared nurses working with vulnerable populations are positioned to assist FCCs in documenting their relevance in the safety net system. Enhancing the ability of FCCs to collect and report data will allow them to demonstrate the provision of high-quality care, despite limited resources.

Reducing time to complete neuropsychological assessments within a memory assessment service and evaluating the wider impact.

In 2016, the Older People's Mental Health Service (OPMHS) within Bedfordshire and Luton (provided by East London Foundation National Health Service Trust) faced considerable challenges in providing an accessible service for assessment of suspected dementia. Those referred to the Memory Assessment Service (MAS) encountered waiting times exceeding national recommendations. A quality improvement (QI) project was initiated by OPMHS Psychologists within all four multidisciplinary MAS clinics in Bedfordshire and Luton. The project aimed to reduce the time from the date of referral for within-team neuropsychological assessment to finalisation of the report to 6 weeks (42 days) by April 2017. In parallel to the initiative, the wider impact of the QI project was investigated. Through the combination of change ideas tested and implemented, all four MAS clinics were successful in meeting the primary project aim. The combined mean time between referral received by psychology and report finalised reduced by 28.76 days from 65.1 to 36.34 days, and with reduced variation across the clinics. These changes were sustained throughout the duration of the project and beyond, and successful change ideas were incorporated into routine practice with control methods developed. Exploring the wider impact, a focus group with six psychology staff members involved in the project was also completed. Thematic analysis identified three themes from the focus group: staff impact, service impact and service user impact. Further subthemes were identified regarding both desirable and undesirable impact across the system. The approaches used may be useful for other services embarking on reduced wait time initiatives for access to care. Additionally, understanding ongoing areas of impact on staff, the wider service and service users can help reduce or mitigate undesirable or unintended consequences and work towards sustainability of such changes.

Informed Clustering of Donation Service Areas for Improved Benchmarking.

The donation community continuously strives to collaborate and share effective practices to further the mission of saving and healing lives. Donation service areas in which the Organ Procurement Organizations (OPOs) work are multifaceted in their demographics, inciting the Organ Procurement and Transplantation Network to consider a more holistic and objective measure of similarity rather than the size of population alone or locational proximity alone. This would allow OPOs, as a part of their quality improvement efforts, to learn from and mentor other organizations that are dealing with similar challenges. By incorporating multiple informative characteristics together, we can distinguish those likenesses only revealed by taking into account multiple factors simultaneously. We used statistical approaches that take many characteristics of interest describing a donation service area and purposely excluded performance measures that an OPO may be able to influence by their own practices. Unsupervised learning methods combined the original characteristics into a smaller number of new variables, eliminating correlation and overlap in information from the original characteristics, and clustered donation service areas based on the general characteristics and population of the area. This analysis is a first step in providing a different perspective for OPOs to learn from other organizations that may face similar challenges, as well as to share best practices and open new lines of communication.

Studying Institutional Situational Awareness Through Anonymous Incident Reporting.

BACKGROUND AND OBJECTIVES: The efficacy of anonymous incident reporting (AIR) is critical to creating a culture of safety. Prior studies have sought to establish AIR in a similar manner as aviation, nuclear power, and other industries. However, health care presents unique challenges that differ greatly from these industries. We present a straightforward method using statistical process control to study the progression and efficacy of AIR. METHODS: This study represents a retrospective review of all anonymous incident reports and surgical critical events from 2012 to 2017 at a single-institution, 500-bed, university-based, metropolitan Veterans Affairs Administration Medical Center located in Texas. This work was approved by the Veterans Administration Quality Board and deemed to be an appropriate quality improvement project. This project did not require institutional review board approval. RESULTS: There was an exponential increase in AIRs in the first 15 months from 1 report per month to 168 reports in the ninth month (1425% increase). The results then plateaued over time (first year: 1017, second year: 1634, and third year: 1938-common-cause variation). A logarithmic regression was performed for progression of AIRs per month yielding the equation y = -7E-13ln(x) + 142.92, Pearson Correlation Coefficient = 0.55, where y represents number of reports and x time by month. The highest number of Critical Incident Tracking Notification System (CITNS) reports was observed early in the self-reporting process and decreased over time (first year: 5, second year: 2, third year: 1, fourth year: 1, and fifth year: 0). The numbers of AIR and CITNS reports were found to be inversely related with a Pearson correlation coefficient of -0.4. CONCLUSIONS: Statistical process control can be applied to an institution's AIR program to study progression and situational awareness.