Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project.

OBJECTIVE: Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. STUDY SETTING: In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. STUDY DESIGN: Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools. DATA COLLECTION METHODS: Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites. PRINCIPAL FINDINGS: Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all P<0.001). Mean days between laboratory test date and evidence of completed action/treatment plan decreased by 19.4 days (P<0.001). Staff surveys showed modest but nonsignificant improvement for intervention practices relative to controls overall and for the 3 high-risk domains that were the focus of PROMISES. CONCLUSIONS: A consortium of stakeholders, quality improvement tools, coaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.

Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.

BACKGROUND: Ambulatory practices deliver most health care services and contribute to malpractice risk. Yet, policymakers and practitioners often lack information about safety and malpractice risk needed to guide improvement. OBJECTIVE: To assess staff and administrator perceptions of safety and malpractice risk in ambulatory settings. RESEARCH DESIGN: We administered surveys in small-sized to medium-sized primary care practices in Massachusetts as part of a randomized controlled trial to reduce ambulatory malpractice risk. SUBJECTS: Twenty-five office practice managers/administrators and 482 staff, including [physicians, physician assistants, and nurse practitioners (MD/PA/NPs)], nurses, other clinicians, managers, and administrators. MEASURES: Surveys included structured questions about 3 high-risk clinical domains: referral, test result, and medication management, plus communication with patients and among staff. The 30-item administrator survey evaluated the presence of organizational safety structures and processes; the 63-item staff survey queried safety and communication concerns. RESULTS: Twenty-two administrators (88%) and 292 staff (61%) responded. Administrators frequently reported important safety systems and processes were absent. Suboptimal or incomplete implementation of referral and test result management systems related to staff perceptions of their quality (P<0.05). Staff perceptions of suboptimal processes correlated with their concern about practice vulnerability to malpractice suits (P<0.05). Staff was least positive about referral management system safety, talking openly about safety problems, willingness to report mistakes, and feeling rushed. MD/PA/NPs viewed high-risk system reliability more negatively (P<0.0001) and teamwork more positively (P<0.03) than others. CONCLUSIONS: Results show opportunities for improvement in closing informational loops and establishing more reliable systems and environments where staff feels respected and safe speaking up. Initiatives to transform primary care should emphasize improving communication among facilities and practitioners.

A Statewide Program to Improve Management of Suspected Urinary Tract Infection in Long-Term Care.

BACKGROUND/OBJECTIVES: Suspected urinary tract infection (UTI) is the most common indication for antibiotic use in long-term care (LTC). Due to the high prevalence of asymptomatic bacteriuria, for which antibiotics are not warranted, these antibiotics are frequently unnecessary. We implemented a collaborative quality improvement program to improve the management of suspected UTI in LTC residents by increasing awareness of current guidelines, with a focus on decreasing treatment in the absence of symptoms. DESIGN/INTERVENTION: Two separate collaboratives included workshops, webinars, and coaching calls. PARTICIPANTS: A total of 31 facilities participated in the first collaborative, with 17 submitting sufficient data for analysis and 34 in the second, with data analyzed from 25. MEASUREMENTS: Facilities reported monthly numbers of urine cultures, UTI diagnoses, Clostridioides difficile infections (CDIs), and resident days. RESULTS: When comparing the baseline period to the first collaborative period, the intercollaborative period to the second collaborative period, and the first collaborative period to the second, the incident rate ratios (95% confidence intervals) were 0.74 (0.68-0.81), 0.83 (0.73-0.94), and 0.63 (0.57-0.69), respectively, for urine culturing rate; 0.73 (0.64-0.83), 0.86 (0.70-1.05), and 0.60 (0.51-0.69), respectively, for UTI diagnosis rate; and 0.56 (0.40-0.82), 1.61 (0.71-4.14), and 0.45 (0.27-0.74), respectively, for CDI rate. CONCLUSION: The program we implemented was associated with reductions in urine cultures, UTI diagnosis, and CDI; and it suggests that this type of intervention can promote appropriate management of UTI in the LTC setting. J Am Geriatr Soc 68:62-69, 2019.

Reconciling medications at admission: safe practice recommendations and implementation strategies.

BACKGROUND: Fifty hospitals collaborated in a patient safety initiative developed and implemented by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association. METHODS: A consensus group identified safe practices and suggested implementation strategies. Four collaborative learning sessions were offered, and teams monitored their progress and shared successful strategies and lessons learned. Reports from participating teams and an evaluation survey were then used to identify successful techniques for reconciling medications. RESULTS: For the 50 participating hospitals, implementation strategies most strongly correlated with success included active physician and nursing engagement, having an effective improvement team, using small tests of change, having an actively engaged senior administrator, and sending a team to multiple collaborative sessions. DISCUSSION: Adoption of the reconciling safe practices proved challenging. The process of writing medication orders at patient transfer points is complex. The hospitals' experiences demonstrated that implementing the proposed safe practices requires a team effort with leadership support and vigilant measurement.

Communicating critical test results: safe practice recommendations.

BACKGROUND: Massachusetts hospitals have collaborated in a patient safety initiative conducted by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association which is aimed at improving the ability to communicate critical test results in a timely and reliable way to the clinician who can take action. Solutions to this problem would address enhancing communication, teamwork, and information transfer, all fundamental system factors linked to patient safety. DEVELOPING THE SAFE PRACTICE RECOMMENDATIONS AND THE "STARTER SET": A Coalition-convened Consensus Group defined critical test results as values/interpretations for which reporting delays can result in serious adverse outcomes for patients. The scope included laboratory, cardiology, radiology, and other diagnostic tests in inpatient, emergency, and ambulatory settings. The Consensus Group developed Safe Practice Recommendations to promote successful communication of results, and a "starter set" of test results sufficiently abnormal to be widely agreed to be considered "critical." DISSEMINATION: The recommendations and the starter set of test results were disseminated in a statewide collaborative open to all Massachusetts hospitals. Hospitals' team members tested changes and shared successful strategies that improved the reliability of communicating critical test results. An evaluation of the results of this collaborative is underway.

An early look at a four-state initiative to reduce avoidable hospital readmissions.

Launched in 2009, the State Action on Avoidable Rehospitalizations initiative, known as STAAR, aims to reduce rates of avoidable rehospitalization in Massachusetts, Michigan, Ohio, and Washington by mobilizing state-level leadership to improve care transitions. With the program two years into its four-year cycle, 148 hospitals are working in partnership with more than 500 cross-continuum team partners. Although there are no publicly available data on whether the project is achieving its primary goal of reducing avoidable rehospitalizations, the effort has so far been successful in aligning numerous complementary initiatives within a state, developing statewide rehospitalization data reports, and mobilizing a sizable number of hospitals to work on reducing rehospitalizations. More than 90 percent of participating hospitals have formed teams to routinely review rehospitalizations with their community-based colleagues.