A blueprint for cancer screening and early detection: Advancing screening's contribution to cancer control.

From the mid-20th century, accumulating evidence has supported the introduction of screening for cancers of the cervix, breast, colon and rectum, prostate (via shared decisions), and lung. The opportunity to detect and treat precursor lesions and invasive disease at a more favorable stage has contributed substantially to reduced incidence, morbidity, and mortality. However, as new discoveries portend advancements in technology and risk-based screening, we fail to fulfill the greatest potential of the existing technology, in terms of both full access among the target population and the delivery of state-of-the art care at each crucial step in the cascade of events that characterize successful cancer screening. There also is insufficient commitment to invest in the development of new technologies, incentivize the development of new ideas, and rapidly evaluate promising new technology. In this report, the authors summarize the status of cancer screening and propose a blueprint for the nation to further advance the contribution of screening to cancer control.

Equitably improving outcomes for cancer survivors and supporting caregivers: A blueprint for care delivery, research, education, and policy.

Cancer care delivery is being shaped by growing numbers of cancer survivors coupled with provider shortages, rising costs of primary treatment and follow-up care, significant survivorship health disparities, increased reliance on informal caregivers, and the transition to value-based care. These factors create a compelling need to provide coordinated, comprehensive, personalized care for cancer survivors in ways that meet survivors' and caregivers' unique needs while minimizing the impact of provider shortages and controlling costs for health care systems, survivors, and families. The authors reviewed research identifying and addressing the needs of cancer survivors and caregivers and used this synthesis to create a set of critical priorities for care delivery, research, education, and policy to equitably improve survivor outcomes and support caregivers. Efforts are needed in 3 priority areas: 1) implementing routine assessment of survivors' needs and functioning and caregivers' needs; 2) facilitating personalized, tailored, information and referrals from diagnosis onward for both survivors and caregivers, shifting services from point of care to point of need wherever possible; and 3) disseminating and supporting the implementation of new care methods and interventions.

Pragmatic Approach to In Situ Simulation to Identify Latent Safety Threats Before Moving to a Newly Built ICU.

OBJECTIVES: Transitions to new care environments may have unexpected consequences that threaten patient safety. We undertook a quality improvement project using in situ simulation to learn the new patient care environment and expose latent safety threats before transitioning patients to a newly built adult ICU. DESIGN: Descriptive review of a patient safety initiative. SETTING: A newly built 24-bed neurocritical care unit at a tertiary care academic medical center. SUBJECTS: Care providers working in neurocritical care unit. INTERVENTIONS: We implemented a pragmatic three-stage in situ simulation program to learn a new patient care environment, transitioning patients from an open bay unit to a newly built private room-based ICU. The project tested the safety and efficiency of new workflows created by new patient- and family-centric features of the unit. We used standardized patients and high-fidelity mannequins to simulate patient scenarios, with "test" patients created through all electronic databases. Relevant personnel from clinical and nonclinical services participated in simulations and/or observed scenarios. We held a debriefing after each stage and scenario to identify safety threats and other concerns. Additional feedback was obtained via a written survey sent to all participants. We prospectively surveyed for missed latent safety threats for 2 years following the simulation and fixed issues as they arose. MEASUREMENTS AND MAIN RESULTS: We identified and addressed 70 latent safety threats, including issues concerning physical environment, infection prevention, patient workflow, and informatics before the move into the new unit. We also developed an orientation manual that highlighted new physical and functional features of the ICU and best practices gleaned from the simulations. All participants agreed or strongly agreed that simulations were beneficial. Two-year follow-up revealed only two missed latent safety threats. CONCLUSIONS: In situ simulation effectively identifies latent safety threats surrounding the transition to new ICUs and should be considered before moving into new units.

A Quality Improvement Project to Reduce Rapid Response System Inequities for Patients with Limited English Proficiency at a Quaternary Academic Medical Center.

BACKGROUND: Recognition of clinically deteriorating hospitalized patients with activation of rapid response (RR) systems can prevent patient harm. Patients with limited English proficiency (LEP), however, experience less benefit from RR systems than do their English-speaking counterparts. OBJECTIVE: To improve outcomes among hospitalized LEP patients experiencing clinical deteriorations. DESIGN: Quasi-experimental pre-post design using quality improvement (QI) statistics. PARTICIPANTS: All adult hospitalized non-intensive care patients with LEP who were admitted to a large academic medical center from May 2021 through March 2023 and experienced RR system activation were included in the evaluation. All patients included after May 2022 were exposed to the intervention. INTERVENTIONS: Implementation of a modified RR system for LEP patients in May 2022 that included electronic dashboard monitoring of early warning scores (EWSs) based on electronic medical record data; RR nurse initiation of consults or full RR system activation; and systematic engagement of interpreters. MAIN MEASURES: Process of care measures included monthly rates of RR system activation, critical response nurse consultations, and disease severity scores prior to activation. Main outcomes included average post-RR system activation length of stay, escalation of care, and in-hospital mortality. Analyses used QI statistics to identify special cause variation in pre-post control charts based on monthly data aggregates. KEY RESULTS: In total, 222 patients experienced at least one RR system activation during the study period. We saw no special cause variation for process measures, or for length of hospitalization or escalation of care. There was, however, special cause variation in mortality rates with an overall pre-post decrease in average monthly mortality from 7.42% (n = 8/107) to 6.09% (n = 7/115). CONCLUSIONS: In this pilot study, prioritized tracking, utilization of EWS-triggered evaluations, and interpreter integration into the RR system for LEP patients were feasible to implement and showed promise for reducing post-RR system activation mortality.

Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs.

BACKGROUND: Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT). OBJECTIVE: We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout. DESIGN: We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons. PARTICIPANTS: We surveyed all clinicians/staff in general PC and WH clinics. INTERVENTION: EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts. MAIN MEASURES: WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout. KEY RESULTS: Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout. CONCLUSIONS: EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study. TRIAL REGISTRATION: The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Lessons Learned: Evaluation of Fracture Liaison Service Quality Improvement Efforts in a Large Academic Healthcare System.

BACKGROUND: The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist. OBJECTIVE: We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation, and describe circumstances surrounding continued care gaps. DESIGN: Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation. PATIENTS: Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 and 3/31/22. INTERVENTION: A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit. MAIN MEASURES: Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated. KEY RESULTS: Of 1204 new fractures between 7/1/16 and 3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1] (p<0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p<0.001 versus pre), and 163/187 (87%) POST2 (p< 0.001 versus PRE, p=0.59 versus POST1). Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61%, p=0.016). CONCLUSION: An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates.

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study.

BACKGROUND: Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes. METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the 'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory. RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing. CONCLUSION: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

Integrating a Community-Based Health Information System with a Patient-Centered Medical Home to improve care of patients with hypertension: a longitudinal observational study protocol.

BACKGROUND: The primary healthcare system in Pakistan focuses on providing episodic, disease-based care. Health care for low-middle income communities is largely through a fee-for-service model that ignores preventive and health-promotive services. The growing burden of cardiovascular illnesses requires restructuring of the primary health care system allowing a community-to-clinic model of care to improve patient- and community-level health indicators. METHODS: We propose a model that integrates a Patient-Centered Medical Home (PCMH) with a Community-Based Health Information System (CBHIS) using hypertension (HTN) as an example. This protocol describes the integration and evaluation of the PCMH-CBHIS infrastructure through a population-based, observational, longitudinal study in a low-middle income, urban community in Pakistan. Participants are being enrolled in CBHIS and will be followed longitudinally over two years for HTN outcomes. A mixed-methods approach is adopted to evaluate the process of integrating PCMH with CBHIS. This involves building partnerships with the community through formal and informal meetings, focus group discussions, and a household health assessment survey (HAS). Community members identified with HTN are linked to PCMH for disease management. A customized electronic medical record system links community-level data with patient-level data to track changes in disease burden. The RE-AIM evaluation framework will be used to monitor community and individual-level metrics to guide implementation assessment, the potential for generalization, and the effectiveness of the PCMH in improving HTN-related health outcomes. Ethical clearance has been obtained from the Ethics Review Committee at Aga Khan University (2022-6723-20985). DISCUSSION: This study will evaluate the value of restructuring the primary care health system by ensuring systematic community engagement and measurement of health indicators at the patient- and community-level. While HTN is being used as a prototype to generate evidence for the effectiveness of this model, findings from this initiative will be leveraged towards strengthening the management of other acute and chronic conditions in primary care settings. If effective, the model can be used in Pakistan and other LMICs and resource-limited settings.

Barriers and facilitators to health professionals' engagement in quality improvement initiatives: a mixed-methods systematic review.

Quality improvement (QI) initiatives in healthcare are crucial for enhancing service quality and healthcare outcomes. The success of these initiatives depends on the active engagement of healthcare professionals, which can be influenced by several factors within the healthcare system. This systematic review synthesized the factors influencing healthcare professionals' engagement in QI projects, focusing on identifying both barriers and facilitators. A mixed methods systematic review (MMSR) was conducted using the JBI methodology for MMSR. Databases such as MEDLINE, CINAHL, Scopus, and Embase were searched for studies that explored barriers and facilitators to QI engagement of health professionals in the clinical setting. Methodological quality was assessed using the Mixed-Methods Appraisal Tool (MMAT). The extracted data were synthesized using the JBI convergent integrated approach to MMSR. Eighteen studies (seven qualitative, nine quantitative, and two mixed-methods) published between 2007 and 2023 were included in the review. The analysis revealed barriers and facilitators to engagement in QI initiatives at different levels of the health system. At the QI program level, the engagement of health professionals to QI was influenced by the approach to QI, evidence underpinning the QI initiative, QI knowledge and training, and access to QI specialists. At the health professional level, barriers and facilitators were related to their organizational role, motivation, perceptions about QI, and collaborations with individuals and groups. At the organizational level, factors related to culture and climate, leadership, available resources (including human resource and workload, infrastructure, and incentives), and institutional priorities influenced health professionals' participation in QI. This review highlights the complex interplay of organizational, individual, and QI program level factors that influence the engagement of healthcare professionals in QI. Overcoming these complex barriers and leveraging facilitators is crucial for enhancing participation in QI efforts. The findings underscore the need for a multi-level strategy that focuses on creating a conducive organizational culture, providing robust leadership, and ensuring adequate resources and training for healthcare professionals. Such strategies hold the potential to enhance the effectiveness and sustainability of QI initiatives in healthcare settings.

A multiphase, multicentre development and validation of two maturity tools assessing the implementation of the FlaQuM co-creation roadmap.

As part of the new Flanders Quality Model (FlaQuM) towards sustainable quality management systems, a co-creation roadmap with 6 primary drivers and 19 building blocks that guides healthcare organizations has been developed. Currently, no assessment tool is available to monitor hospitals' quality management systems implementation according to this co-creation roadmap. Therefore, we aimed to measure the maturity of the implementation of the FlaQuM co-creation roadmap in hospitals. A three-phase approach in co-design with 19 hospitals started with defining the scope, followed by establishing content validity through a literature review, involvement of content experts (n = 47), 20 focus groups with content experts (n = 79), and a Delphi round with healthcare quality managers (n = 19) to test the content validity index. Construct validity was assessed by confirmatory factor analyses and convergent validity by Spearman's ρ correlation coefficients. Based on 17 included existing maturity instruments and subcomponents of content experts, two maturity tools were developed according to the implementation of the FlaQuM co-creation roadmap: (i) a maturity matrix with 52 subcomponents and (ii) a co-creation scan with 19 statements. The overall scale-content validity index varied between 93.3% and 90.0% in terms of relevance and clarity, respectively. In a sample of 119 healthcare professionals, factor analyses revealed a six-factor structure and 16 (84.2%) of the 19 hypothesis for testing convergent validity between both maturity tools were statistically significant. Measuring the implementation of the FlaQuM co-creation roadmap and monitoring its maturity over time should be feasible by using these comprehensive maturity tools in hospitals. Results of both tools should be able to describe the current state of hospitals' implementation of the co-creation roadmap as basis for strategic improvement plans and next steps.

Organizational learning in surgery in Tanzania's health system: a descriptive cross-sectional study.

Organizational learning is critical for delivering safe, high-quality surgical care, especially in low- and middle-income countries (LMICs) where perioperative outcomes remain poor. While current investments in LMICs prioritize physical infrastructure, equipment, and staffing, investments in organizational learning are equally important to support innovation, creativity, and continuous improvement of surgical quality. This study aims to assess the extent to which health facilities in Tanzania's Lake Zone perform as learning organizations from the perspectives of surgical providers. The insights gained from this study can motivate future quality improvement initiatives and investments to improve surgical outcomes. We conducted a cross-sectional analysis using data from an adapted survey to explore the key components of organizational learning, including a supportive learning environment, effective learning processes, and encouraging leadership. Our sample included surgical team members and leaders at 20 facilities (health centers, district hospitals, and regional hospitals). We calculated the average of the responses at individual facilities. Responses that were 5+ on a 7-point scale or 4+ on a 5-point scale were considered positive. We examined the variation in responses by facility characteristics using a one-way ANOVA or Student's t-test. We used univariate and multiple regression to assess relationships between facility characteristics and perceptions of organizational learning. Ninety-eight surgical providers and leaders participated in the survey. The mean facility positive response rate was 95.1% (SD 6.1%). Time for reflection was the least favorable domain with a score of 62.5% (SD 35.8%). There was variation by facility characteristics including differences in time for reflection when comparing by level of care (P = .02) and location (P = .01), and differences in trying new approaches (P = .008), capacity building (P = .008), and information transfer (P = .01) when comparing public versus faith-based facilities. In multivariable analysis, suburban centers had less time for reflection than urban facilities (adjusted difference = -0.48; 95% CI: -0.95, -0.01; P = .046). Surgical team members reported more positive responses compared to surgical team leaders. We found a high overall positive response rate in characterizing organizational learning in surgery in 20 health facilities in Tanzania's Lake Zone. Our findings identify areas for improvement and provide a baseline for assessing the effectiveness of change initiatives. Future research should focus on validating the adapted survey and exploring the impact of strong learning environments on surgical outcomes in LMICs. Organizational learning is crucial in surgery and further research, funding, and policy work should be dedicated to improving learning cultures in health facilities.

Process management program to prevent falls in hospitalized patients with neuropsychiatric disorders: a quality improvement program.

BACKGROUND: Falls were among the most common adverse nursing events. The incidence of falls in patients with neuropsychiatric disorders was high, and the occurrence of falls not only caused physical and psychological harm to patients but also led to medical disputes. Therefore, interventions for falls prevention were essential, but evaluations of the intervention process were lacking. METHODS: In this study, a process management program to prevent falls based on the "structure-process-outcome" quality evaluation model was designed and applied to the clinical practice of falls prevention in hospitalized patients with neuropsychiatric disorders. The process quality evaluation checklist to prevent falls was used to supervise the implementation effect of intervention measures to prevent falls, identify the problems in the intervention measures, and make continuous improvements, to reduce the incidence of falls in such hospitalized patients as the final index. RESULTS: The incidence of inpatient falls decreased from 0.199‰ (0.199 per 1000 patient-days) to 0.101‰ (0.101 per 1000 patient-days) before and after the implementation of the process management program for 12 months, 24 months, and 36 months, respectively, and the difference was statistically significant (P < .05). The probability of falls was reduced by 49% after 36 months of monitoring. Furthermore, the proportion of patients at high risk of falls exhibited a downward trend. CONCLUSION: This quality improvement program was feasible and effective at reducing falls in hospitalized patients with neuropsychiatric disorders. Therefore, attention should be given to monitoring process quality in the management of falls.

Programmatic evaluation of interprofessional education: a quality improvement tool.

Robust demonstration of high-quality, fit-for-purpose interprofessional education (IPE) is essential for today's health professional students, staff, curricula, and regulatory bodies. As IPE moves from discrete "events" to fully embedded spirals of learning across degree programme curricula, effective mechanisms for monitoring continuous quality improvement are paramount. An accreditation tool was therefore developed for all learning activities contributing to the IPE curriculum of a university in Aotearoa New Zealand. We worked over 15 months, introducing a user-friendly tool to collect data, managing accreditation processes, and integrating with wider systems. We identified key levers to monitor, adjust, and continuously improve quality in IPE teaching and learning at individual-activity and programmatic levels.

Development of a Web-Based Oxygenation Dashboard for Preterm Neonates: A Quality Improvement Initiative.

BACKGROUND: Preterm neonates are extensively monitored to require strict oxygen target attainment for optimal outcomes. In daily practice, detailed oxygenation data are hardly used and crucial patterns may be missed due to the snapshot presentations and subjective observations. This study aimed to develop a web-based dashboard with both detailed and summarized oxygenation data in real-time and to test its feasibility to support clinical decision making. METHODS: Data from pulse oximeters and ventilators were synchronized and stored to enable real-time and retrospective trend visualizations in a web-based viewer. The dashboard was designed based on interviews with clinicians. A preliminary version was evaluated during daily clinical rounds. The routine evaluation of the respiratory condition of neonates (gestational age < 32 weeks) with respiratory support at the NICU was compared to an assessment with the assistance of the dashboard. RESULTS: The web-based dashboard included data on the oxygen saturation (SpO2), fraction of inspired oxygen (FiO2), SpO2/FiO2 ratio, and area < 80% and > 95% SpO2 curve during time intervals that could be varied. The distribution of SpO2 values was visualized as histograms. In 65% of the patient evaluations (n = 86) the level of hypoxia was assessed differently with the use of the dashboard. In 75% of the patients the dashboard was judged to provide added value for the clinicians in supporting clinical decisions. CONCLUSIONS: A web-based customized oxygenation dashboard for preterm neonates at the NICU was developed and found feasible during evaluation. More clear and objective information was found supportive for clinicians during the daily rounds in tailoring treatment strategies.

Commentary: Engagement for Research and Quality Improvement - More Than Just Words.

We reflect on the paper from Hahn-Goldberg et al. (2024) who shared key learnings from a pan-Canadian quality improvement (QI) and patient engagement care transition initiative called Bridge-to-Home. In considering the approach and outcomes presented in their paper, we have generated reflections and practical suggestions on how to amplify engagement work even further: (1) patient engagement and QI are about relationships; (2) seamlessly implementing complex interventions across siloed organizations continues to be a challenge, which engagement alone cannot solve; (3) it is time for a paradigm shift; (4) QI is about human behaviour change and is inherently messy; and (5) embedding fulsome evaluation of engagement is essential.

Improving Timeliness of Antibiotic Administration Using a Provider and Pharmacist Facing Sepsis Early Warning System in the Emergency Department Setting: A Randomized Controlled Quality Improvement Initiative.

OBJECTIVES: Results of pre-post intervention studies of sepsis early warning systems have been mixed, and randomized clinical trials showing efficacy in the emergency department setting are lacking. Additionally, early warning systems can be resource-intensive and may cause unintended consequences such as antibiotic or IV fluid overuse. We assessed the impact of a pharmacist and provider facing sepsis early warning systems on timeliness of antibiotic administration and sepsis-related clinical outcomes in our setting. DESIGN: A randomized, controlled quality improvement initiative. SETTING: The main emergency department of an academic, safety-net healthcare system from August to December 2019. PATIENTS: Adults presenting to the emergency department. INTERVENTION: Patients were randomized to standard sepsis care or standard care augmented by the display of a sepsis early warning system-triggered flag in the electronic health record combined with electronic health record-based emergency department pharmacist notification. MEASUREMENTS AND MAIN RESULTS: The primary process measure was time to antibiotic administration from arrival. A total of 598 patients were included in the study over a 5-month period (285 in the intervention group and 313 in the standard care group). Time to antibiotic administration from emergency department arrival was shorter in the augmented care group than that in the standard care group (median, 2.3 hr [interquartile range, 1.4-4.7 hr] vs 3.0 hr [interquartile range, 1.6-5.5 hr]; p = 0.039). The hierarchical composite clinical outcome measure of days alive and out of hospital at 28 days was greater in the augmented care group than that in the standard care group (median, 24.1 vs 22.5 d; p = 0.011). Rates of fluid resuscitation and antibiotic utilization did not differ. CONCLUSIONS: In this single-center randomized quality improvement initiative, the display of an electronic health record-based sepsis early warning system-triggered flag combined with electronic health record-based pharmacist notification was associated with shorter time to antibiotic administration without an increase in undesirable or potentially harmful clinical interventions.

Correlation of Colorectal Surgical Skill With Patient Outcomes: A Cautionary Tale.

BACKGROUND: Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement. OBJECTIVE: Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons. DESIGN: Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates. SETTINGS: The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals. PATIENTS: Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons. MAIN OUTCOME MEASURES: Main outcome measures included 30-day risk-adjusted postoperative complications. RESULTS: The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41). LIMITATIONS: Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms. CONCLUSIONS: Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).

Sustained Implementation of a Multicomponent Strategy to Increase Emergency Department-Initiated Interventions for Opioid Use Disorder.

STUDY OBJECTIVE: There is strong evidence supporting emergency department (ED)-initiated buprenorphine for opioid use disorder, but less is known about how to implement this practice. Our aim was to describe implementation, maintenance, and provider adoption of a multicomponent strategy for opioid use disorder treatment in 3 urban, academic EDs. METHODS: We conducted a retrospective analysis of electronic health record data for adult patients with opioid use disorder-related visits before (March 2017 to November 2018) and after (December 2018 to July 2020) implementation. We describe patient characteristics, clinical treatment, and process measures over time and conducted an interrupted time series analysis using a patient-level multivariable logistic regression model to assess the association of the interventions with buprenorphine use and other outcomes. Finally, we report provider-level variation in prescribing after implementation. RESULTS: There were 2,665 opioid use disorder-related visits during the study period: 28% for overdose, 8% for withdrawal, and 64% for other conditions. Thirteen percent of patients received medications for opioid use disorder during or after their ED visit overall. Following intervention implementation, there were sustained increases in treatment and process measures, with a net increase in total buprenorphine of 20% in the postperiod (95% confidence interval 16% to 23%). In the adjusted patient-level model, there was an immediate increase in the probability of buprenorphine treatment of 24.5% (95% confidence interval 12.1% to 37.0%) with intervention implementation. Seventy percent of providers wrote at least 1 buprenorphine prescription, but provider-level buprenorphine prescribing ranged from 0% to 61% of opioid use disorder-related encounters. CONCLUSION: A combination of strategies to increase ED-initiated opioid use disorder treatment was associated with sustained increases in treatment and process measures. However, adoption varied widely among providers, suggesting that additional strategies are needed for broader uptake.

SIGIS-SIAMS-SIE position statement of gender affirming hormonal treatment in transgender and non-binary people.

PURPOSE: Gender Incongruence (GI) is a marked and persistent incongruence between an individual's experienced and the assigned gender at birth. In the recent years, there has been a considerable evolution and change in attitude as regards to gender nonconforming people. METHODS: According to the Italian Society of Gender, Identity and Health (SIGIS), the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE) rules, a team of experts on the topic has been nominated by a SIGIS-SIAMS-SIE Guideline Board on the basis of their recognized clinical and research expertise in the field, and coordinated by a senior author, has prepared this Position statement. Later on, the present manuscript has been submitted to the Journal of Endocrinological Investigation for the normal process of international peer reviewing after a first internal revision process made by the SIGIS-SIAMS-SIE Guideline Board. RESULTS: In the present document by the SIGIS-SIAMS-SIE group, we propose experts opinions concerning the psychological functioning, gender affirming hormonal treatment, safety concerns, emerging issues in transgender healthcare (sexual health, fertility issues, elderly trans people), and an Italian law overview aimed to improve gender non-conforming people care. CONCLUSION: In this Position statement, we propose experts opinions concerning the psychological functioning of transgender people, the gender-affirming hormonal treatment (full/partial masculinization in assigned female at birth trans people, full/partial feminization and de-masculinization in assigned male at birth trans people), the emerging issues in transgender health care aimed to improve patient care. We have also included an overview of Italian law about gender affirming surgery and registry rectification.

Refining a capability development framework for building successful consumer and staff partnerships in healthcare quality improvement: A coproduced eDelphi study.

BACKGROUND: The capability of consumers and staff may be critical for authentic and effective partnerships in healthcare quality improvement (QI). Capability frameworks describe core knowledge, skills, values, attitudes, and behaviours and guide learning and development at individual and organizational levels. OBJECTIVE: To refine a capability framework for successful partnerships in healthcare QI which was coproduced from a scoping review. DESIGN: A two-round eDelphi design was used. The International Expert Panel rated the importance of framework items in supporting successful QI partnerships, and suggested improvements. They also rated implementation options and commented on the influence of context. PARTICIPANTS: Seven Research Advisory Group members were recruited to support the research team. The eDelphi panel included 53 people, with 44 (83%) and 42 (77. 8%) participating in rounds 1 and 2, respectively. They were from eight countries and had diverse backgrounds. RESULTS: The Research Advisory Group and panel endorsed the framework and summary diagram as valuable resources to support the growth of authentic and meaningful partnerships in QI across healthcare contexts, conditions, and countries. A consensus was established on content and structure. Substantial rewording included a stronger emphasis on growth, trust, respect, inclusivity, diversity, and challenging the status quo. The final capability development framework included three domains: Personal Attributes, Relationships and Communication, and Principles and Practices. The Equalizing Decision Making, Power, and Leadership capability was foundational and positioned across all domains. Ten capabilities with twenty-seven capability descriptions were also included. The Principles and Practices domain, Equalizing Decision Making, Power, and Leadership capability, and almost half (44.4%) of the capability descriptions were rated as more important for staff than consumers (p < .01). However, only the QI processes and practices capability description did not meet the inclusion threshold for consumers. Thus, the framework was applicable to staff and consumers. CONCLUSION: The refined capability development framework provides direction for planning and provision of learning and development regarding QI partnerships. PATIENT OR PUBLIC CONTRIBUTION: Two consumers were full members of the research team and are coauthors. A Research Advisory Group, inclusive of consumers, guided study execution and translation planning. More than half of the panel were consumers.