The Joint Commission's Ongoing Professional Practice Evaluation Process: Costly, Ineffective, and Potentially Harmful to Safety Culture.

OBJECTIVE: To evaluate the estimated labor costs and effectiveness of Ongoing Professional Practice Evaluation (OPPE) processes at identifying outlier performers in a large sample of providers across multiple health care systems and to extrapolate costs and effectiveness nationally. METHODS: Six hospital systems partnered to evaluate their labor expenses related to conducting OPPE. Estimates for mean labor hours and wages were created for the following: data analysts, medical staff office professionals, department physician leaders, and administrative assistants. The total number of outlier performers who were identified by OPPE metrics alone and that resulted in lack of renewal, limitation, or revoking of hospital privileges during the past annual OPPE cycle (2022) was recorded. National costs of OPPE were extrapolated. Literature review of the effect of OPPE on safety culture in radiology was performed. RESULTS: The evaluated systems had 12,854 privileged providers evaluated by OPPE. The total estimated annual recurring labor cost per provider was $50.20. Zero of 12,854 providers evaluated were identified as outlier performers solely through the OPPE process. The total estimated annual recurring cost of administering OPPE nationally was $78.54 million. In radiology over the past 15 years, the use of error rates based on score-based peer review as an OPPE metric has been perceived as punitive and had an adverse effect on safety culture. CONCLUSION: OPPE is expensive to administer, inefficient at identifying outlier performers, diverts human resources away from potentially more effective improvement work, and has been associated with an adverse impact on safety culture in radiology.

Press Ganey: Patient-Centered Communication Drives Provider and Hospital Revenue.

BACKGROUND: Spurred on in part by government policies that base a portion of reimbursement around patient satisfaction, in 2016, Texas Children's Hospital instituted a patient-focused communication course entitled Breakthrough Communication. The aim of this study is to examine the effect of this training on provider-specific Press Ganey scores within the Department of Surgery, and to assess whether changes in Press Ganey scores correlate to hospital volume and revenue. METHODS: The intervention period was defined as calendar year 2017. Full-time faculty between 2016 and 2018 who completed the course in 2017 and had at least 10 returned Press Ganey surveys before and after the course were included in this study. Patient volume and revenue were analyzed. A subgroup analysis was conducted to compare participant against nonparticipant plastic surgeons. RESULTS: For the 56 surgeons who met the inclusion criteria, mean provider Press Ganey ratings increased from 92.0 to 94.3 following participation (p = 0.003). When compared to before intervention, clinical encounters increased by 26.2 percent, the number of patients increased by 26.0 percent, payments increased by 25.2 percent, and charges increased by 21.2 percent. In our subgroup analysis, there was a relative increase of 11 percent in the number of patients and 10 percent in the number of encounters for participant plastic surgeons. Participants reported 113 percent increases in charges and 71 percent increases in payments, whereas nonparticipants had decreases of 10 percent in charges and 4 percent in payments. CONCLUSION: The authors' findings indicate that improving surgeons' patient-centered communication skills is associated with an increase in patient satisfaction and an accompanying increase in both volume and reimbursements.

Pediatric Medication Safety in the Emergency Department.

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

The Daily Operational Brief: Fostering Daily Readiness, Care Coordination, and Problem-Solving Accountability in a Large Pediatric Health Care System.

At a pediatric health system, the Daily Operational Brief (DOB) was updated in 2015 after three years of operation. Quality and safety metrics, the patient volume and staffing assessment, and the readiness assessment are all presented. In addition, in the problem-solving accountability system, problematic issues are categorized as Quick Hits or Complex Issues. Walk-the-Wall, a biweekly meeting attended by hospital senior administrative leadership and quality and safety leaders, is conducted to chart current progress on Complex Issues. The DOB provides a daily standardized approach to evaluate readiness to provide care to current patients and improvement in the care to be provided for future patients.

A Novel Approach to Combining Pediatric Emergency Medicine and Global Health Fellowships.

OBJECTIVES: To describe the creation of the first known combined Pediatric Emergency Medicine-Global Health (PEM-GH) fellowship for graduates of pediatric or emergency medicine residency programs. METHODS: We detail the necessary infrastructure for a successfully combined PEM-GH fellowship including goals, objectives, curriculum, timeline, and funding. The fellowship is jointly supported by the department of pediatrics, section of pediatric emergency medicine (PEM), and the hospital. Fellows complete all requirements for the PEM fellowship and Global Health, the latter requiring an additional 12 months of training. Components of the Global Health fellowship include international fieldwork, scholarly activity abroad, advanced degree coursework, disaster training, and didactic curricula. RESULTS: Since 2005, 9 fellows (8 pediatric-trained and 1 emergency medicine-trained) have completed or are enrolled in the PEM-GH fellowship; 3 have graduated. All fellows have completed or are working toward advanced degrees and have or will participate in the disaster management course. Fellows have had 7 presentations at national or international meetings and have published 6 articles in peer-reviewed journals. Of the three graduates, all are working in academic PEM-GH programs and work internationally in Africa and/or Latin America. CONCLUSIONS: Our response to a global trend toward improvement in PEM care was the development of the first combined PEM-GH fellowship program. Recognizing the value of this program within our own institution, we now offer it as a model for building such programs in the future. This fellowship program promises to be a paradigm that can be used nationally and internationally, and it establishes a foundation for a full-fledged accredited and certified subspecialty.

Outside the box and into thick air: implementation of an exterior mobile pediatric emergency response team for North American H1N1 (swine) influenza virus in Houston, Texas.

STUDY OBJECTIVE: We describe the implementation of a mobile pediatric emergency response team for mildly ill children with influenza-like illnesses during the H1N1 swine influenza outbreak. METHODS: This was a descriptive quality improvement study conducted in the Texas Children's Hospital (Houston, TX) pediatric emergency department (ED), covered, open-air parking lot from May 1, 2009, to May 7, 2009. Children aged 18 years or younger were screened for viral respiratory symptoms and sent to designated areas of the ED according to level of acuity, possibility of influenza-like illness, and the anticipated need for laboratory evaluation. RESULTS: The mobile pediatric emergency response team experienced 18% of the total ED volume, or a median of 48 patients daily, peaking at 83 patients treated on May 3, 2009. Although few children had positive rapid influenza assay results and the morbidity of disease in the community appeared to be minimal for the majority of children, anxiety about pandemic influenza drove a large number of ED visits, necessitating an increase in surge capacity. Surge capacity was augmented both through utilization of existing institutional resources and by creating a novel area in which to treat patients with potential airborne pathogens. Infection control procedures and patient safety were also maximized through patient cohorting and adaptation of social distancing measures to the ED setting. CONCLUSION: The mobile pediatric emergency response team and screening and triage algorithms were able to safely and effectively identify a group of low-acuity patients who could be rapidly evaluated and discharged, alleviating ED volume and potentially preventing transmission of H1N1 influenza.

Job market survey of recent pediatric emergency medicine fellowship graduates.

OBJECTIVES: The American Academy of Pediatrics Section of Emergency Medicine's Subcommittee on Administration developed a survey tool targeting recent pediatric emergency medicine (PEM) fellowship graduates to assess the current PEM job market in a variety of areas including (1) the new positions accepted, (2) perspectives of fellowship training, and (3) the relationship between PEM and general emergency medicine practice. METHODS: The 40-question internet-based survey was developed through www.surveymonkey.com. Solicitations to PEM fellowship graduates who completed training between the years 2000 and 2005 were sent via the Section of Emergency Medicine member e-mail list as well as the PEM LISTSERV. Data collection occurred from April to May 2005. RESULTS: Of 125 survey respondents, 89% completed a 3-year pediatrics residency plus a 3-year PEM fellowship. Offers to graduates of positions with research expectations outnumbered clinical positions, 3:2, with an average of 5 total positions offered per respondent. Thirty-four percent remained at the institution of fellowship graduation, and 71% accepted faculty appointments with medical school affiliation. Seventy percent of work time was spent on clinical duties and 10% on research. Most felt better prepared in the areas of clinical training and teaching than in the areas of research and administration. Additional general emergency medicine exposure was not desired. Half of the respondents felt that a 2-year fellowship program would have met their career goals. CONCLUSIONS: Recent PEM fellowship graduates felt that job availability was good and were satisfied with their new positions. Respondents perceived better fellowship training in clinical and teaching aspects than in research and administration. New positions were heavily clinical and matched career goals.

Pediatric restraint use is associated with reduced transports by emergency medical services providers after motor vehicle crashes.

OBJECTIVE: To determine the association between pediatric restraint use during motor vehicle crashes and patient transports by emergency medical services (EMS) providers. METHODS: Children under 16 years of age who were involved in motor vehicle crashes in Houston or Harris County, Texas, in 1997 were identified from Texas Department of Public Safety (DPS) crash data. DPS data were linked probabilistically to City of Houston Fire Department EMS data to identify whether the children were transported from the scene by EMS. Odds ratios were calculated to determine the association between restraint use and EMS transport. Logistic regression was used to control for age and injury severity in this relationship. RESULTS: From the linked data for 1997, 1,696 children were involved in reported automobile or truck crashes to which EMS responded. Of the 1,580 children about whom information concerning restraint use was available, 1,309 (83%) were wearing some type of safety restraint and 1,342 (85%) were transported by EMS. Adjusting for injury severity, children wearing safety restraints during motor vehicle crashes were 60% (95% confidence interval 34-75%) less likely to be transported by EMS than those not wearing safety restraints during such crashes. CONCLUSIONS: The use of safety restraints during motor vehicle crashes is associated with a reduction in the number of children transported from the scene by EMS providers. This effect is independent of age and injury severity.

Practice guidelines and performance measures in emergency medical services for children.

Practice guidelines and performance measures are critical elements of an effective quality improvement process for emergency medical services for children (EMSC). Practice guidelines address the clinical management of individual patients, and performance measures assess the quality of care delivered to a population. The public and private sectors have invested considerable resources in developing practice guidelines and performance measures to improve the quality of health care services. As organizations continue development efforts, health care professionals who are actively involved in emergency care must collaborate to develop guidelines that address the unique physiologic, psychologic, and cultural needs of children. The Emergency Medical Services for Children Managed Care Task Force recommended the development of a series of white papers to focus on issues related to practice guidelines and performance measures in EMSC. The Maternal and Child Health Bureau, Health Resources and Services Administration, the National Highway Traffic Safety Administration, and the Robert Wood Johnson Foundation jointly sponsored the project. The paper was developed by a panel selected from a pool of experts in managed care, quality improvement, and emergency medical services. After a review of the literature, the panelists met to discuss critical issues related to practice guidelines and performance measures in EMSC. The panelists developed recommendations that can serve as resources for managed care organizations, health care providers, professional associations, and governmental policy makers. The panel recognized the lack of nationally recognized pediatric emergency care guidelines and performance measures and called for immediate action in these areas.