Establishing best practices for structured NSQIP review.

INTRODUCTION: We describe an institutional program (INR- Interval NSQIP Review), to augment NSQIP utility through structured, multidisciplinary review of surgical outcomes in order to create near 'real-time' adverse event (AE) monitoring and improve surgeon awareness. METHODS: INR is a monthly meeting of quality analysts, surgeons and nursing leadership initiated to validate AE with NSQIP criteria, review data in real-time, and perform in-depth case analyses. Occurrence classification concerns were referred for national NSQIP review. Monthly reports were distributed to surgeons with AE rates and case-specific details. RESULTS: Since implementation, 377/3,026 AE underwent in-depth review. Of those, 7 occurrences were referred for clarification by central NSQIP review. Overall 37 (1.2%) were not consistent with NSQIP-defined AE after INR. Time from occurrence to surgeon review decreased by 223 days (296 vs. 73 days, p = 0.006). DISCUSSION: Structured monthly institutional review of AE prior to submission can create greater transparency and confidence of NSQIP data, reduce time from occurrence to surgeon recognition, and improve stakeholder understanding of AE definitions. This approach can be tailored to institutional needs and should be evaluated for downstream improvement in patient outcomes.

Optimizing Glycemic Control in Adults With Type 1 or Type 2 Diabetes Attending a Multidisciplinary Foot Clinic.

OBJECTIVES: To determine the impact of a diabetes nurse educator (DNE) on glycemic control in a multidisciplinary diabetes foot (MDF) clinic. METHODS: A prospective cohort trial to measure the impact of a DNE on glycemic control was conducted in an MDF clinic. Change in glycated hemoglobin (A1C) levels over time was measured against the percentage of patient visits (PPVs) accompanied by a glucose meter and/or diary. RESULTS: Increasing PPVs were significantly associated with decline in A1C levels in females. Every 10% increase in PPVs resulted in a 0.18% decrease in A1C levels (p<0.0001). To achieve a clinically important decrease of 1% in A1C levels, a 56% increase in PPVs was required. Increased A1C levels were significantly associated with higher baseline A1C levels (p<0.001) and increased hospital days for foot complications (p<0.0052). CONCLUSIONS: Regular, face-to-face contact with a DNE in an MDF clinic has a positive impact on glycemic control in females.

Utilizing technology to improve intraoperative family communication.

PURPOSE: To create and assess satisfaction with an electronic-medical-record (EMR) integrated communication system designed to optimize perioperative communication with families. METHODS: We built a tool in the EMR's intraoperative nursing navigation screen for sending customized or standardized text pages to families in English or Spanish. Preoperatively, families were given text pagers with instructions and a hospital map to facilitate leaving the waiting area. After 6 months, Press-Ganey™ data and internal surveys from randomly selected families, and all nurses and surgeons were analyzed for satisfaction and effectiveness. RESULTS: Press-Ganey™ data demonstrated 30% improvement in patient satisfaction (p < 0.05). Among families, > 90% indicated pagers were easy to use and provided the desired information during surgery. Of nurses, >90% found the system easy to use and believed it improved families' experience. All surgeons reported improved intraoperative communication and ease of finding families postoperatively. CONCLUSION: Perioperative family communication via EMR-integrated text improves efficiency and family, nurse, and surgeon satisfaction.

Successful turnaround of a university-owned, community-based, multidisciplinary practice network.

PURPOSE: The University of Utah purchased a 100-clinician, 9-practice multi-specialty primary care network in 1998. The university projected the network to earn a profit the first year of its ownership in a market with growing capitation; however, capitation declined and the network incurred up to a 21 million dollars operating loss per year. This case study describes the financial turnaround of the network. METHODS: In 2001, the university reconfigured the practices for a fee-for-service environment while preserving the group's multidisciplinary clinical and ancillary services. Changes included reorganization under the existing University of Utah Hospitals and Clinics system, new governance and leadership, closure of practices, creation of a billing office, new financial reporting, implementation of electronic health records, revision of physician compensation, capture of referrals, leadership and staff training, and practice reengineering. RESULTS: The network as a whole became profitable in 2004-2005. Its primary care component is projected to become profitable in 2 to 3 years. The network is opening new sites strategically important to the health system. CONCLUSIONS: This turnaround required commitment from senior university leaders, management with knowledge of primary care practice, retention of ancillary revenues, and management and business services specific to the network with support from other units within the university. Culture change within the group was essential. Our experience suggests that an academic health center can successfully operate a primary care network by attending to the unique needs of this challenging business. Doing so can strengthen the institution's overall financial and clinical performance and provide an important setting for teaching and research.

Improving the effectiveness of the medical visit: a brief visit-structuring workshop changes patients' perceptions of primary care visits.

OBJECTIVE: To teach visit-structuring strategies to primary care clinicians with a 1.5-h experiential workshop and assess its effect on patient perceptions of their medical visits. METHODS: We developed and conducted a 90 min workshop for 75 clinicians from seven primary care clinics, and evaluated the effectiveness of the workshop by assessing changes in patients' ratings of visit qualities from 1 week prior (n=301) to 1 week after (n=322) the workshop. Patients rated their physicians' visit-structuring skills as well as satisfaction with their medical visits. RESULTS: Patients were highly satisfied with their visits both before and after the workshop. Post-workshop ratings of medical visits were more likely to indicate that all problems were addressed during the visit. CONCLUSIONS: A brief workshop had a positive measurable effect on patients' perception of their medical visits. Future research should address the utility of patient rated assessments of visit characteristics. PRACTICE IMPLICATIONS: Physicians' ability to establish and maintain a productive structure in primary care office visit is an important skill that can improve the quality of care, and some changes in physician visit-structuring behavior can be measured using patient perceptions.