Guiding Principles to Address the Impact of Algorithm Bias on Racial and Ethnic Disparities in Health and Health Care.

Importance: Health care algorithms are used for diagnosis, treatment, prognosis, risk stratification, and allocation of resources. Bias in the development and use of algorithms can lead to worse outcomes for racial and ethnic minoritized groups and other historically marginalized populations such as individuals with lower income. Objective: To provide a conceptual framework and guiding principles for mitigating and preventing bias in health care algorithms to promote health and health care equity. Evidence Review: The Agency for Healthcare Research and Quality and the National Institute for Minority Health and Health Disparities convened a diverse panel of experts to review evidence, hear from stakeholders, and receive community feedback. Findings: The panel developed a conceptual framework to apply guiding principles across an algorithm's life cycle, centering health and health care equity for patients and communities as the goal, within the wider context of structural racism and discrimination. Multiple stakeholders can mitigate and prevent bias at each phase of the algorithm life cycle, including problem formulation (phase 1); data selection, assessment, and management (phase 2); algorithm development, training, and validation (phase 3); deployment and integration of algorithms in intended settings (phase 4); and algorithm monitoring, maintenance, updating, or deimplementation (phase 5). Five principles should guide these efforts: (1) promote health and health care equity during all phases of the health care algorithm life cycle; (2) ensure health care algorithms and their use are transparent and explainable; (3) authentically engage patients and communities during all phases of the health care algorithm life cycle and earn trustworthiness; (4) explicitly identify health care algorithmic fairness issues and trade-offs; and (5) establish accountability for equity and fairness in outcomes from health care algorithms. Conclusions and Relevance: Multiple stakeholders must partner to create systems, processes, regulations, incentives, standards, and policies to mitigate and prevent algorithmic bias. Reforms should implement guiding principles that support promotion of health and health care equity in all phases of the algorithm life cycle as well as transparency and explainability, authentic community engagement and ethical partnerships, explicit identification of fairness issues and trade-offs, and accountability for equity and fairness.

Application of Behavioral Economics Principles Improves Participation in Mailed Outreach for Colorectal Cancer Screening.

INTRODUCTION: Colorectal cancer (CRC) is a major cause of cancer-related morbidity and mortality in the United States. Although various interventions have improved screening rates, they often require abundant resources and can be difficult to implement. Social psychology and behavioral economics principles offer an opportunity for low-cost and easy-to-implement strategies but are less common in clinical settings. METHODS: We randomized 2,000 patients aged 50-75 years eligible for CRC screening to one of the 2 mailed interventions: a previously used text-based letter describing and offering fecal immunochemical testing (FIT) and colonoscopy (usual care arm); or a letter leveraging social psychology and behavioral economics principles (e.g., implied scarcity and choice architecture), minimal text, and multiple images to offer FIT and colonoscopy (intervention arm). We compared total screening uptake, FIT uptake, and colonoscopy uptake at 1-month intervals in each group. RESULTS: There were 1,882 patients included in the final analysis. The mean age was 69.3 years, and baseline characteristics in the 2 groups were similar. Screening completion at 26 weeks was 19.5% in the usual care arm (16.3% FIT vs 3.2% colonoscopy, P < 0.01) and 24.1% in the intervention arm (22.1% FIT vs 2.0% colonoscopy, P < 0.01) (P = 0.02). DISCUSSION: Among primary care patients aged 50-75 years in an academic setting, mailed CRC outreach employing social psychology and behavioral economics principles led to a higher participation in CRC screening than usual care mailed outreach. TRANSLATIONAL IMPACT: Mailed interventions to increase CRC screening should incorporate social psychology and behavioral economics principles to improve participation.

ABCs of Hospitalized Patients: A Simple Before-After Study of a Communication Tool to Improve Quality of Inpatient Care.

OBJECTIVES: Within the past several years, innovative communication tools have been established as viable quality improvement mechanisms in health care. Meanwhile, the economic and societal burdens of hospital-acquired conditions (HACs) continue to rise. Various interventions have been attempted to reduce HACs. This study evaluated the effectiveness of a communication tool in reducing risk factors for HACs. METHODS: A communication tool aimed at reducing HAC risk factors was developed by an interdisciplinary team of physicians and nurses and tested in a simple before-after quality improvement study. It included 8 components: ambulation/fall risk, blood glucose greater than 200 mg/dL, central venous catheters, deep venous thrombosis prophylaxis, erosions of the skin/dermal ulcers, Foley/urinary catheters, got communication, and heart monitor/telemetry. This communication tool facilitated multidisciplinary communication. The nurses completed it nightly, and the physicians reviewed the communication tool each morning and, when appropriate, addressed components of care that were out of compliance with best practices. RESULTS: The use of the ABCs of Hospitalized Patients Communication Tool led to daily improvements with reduction in the percentage of patients with blood glucose greater than 200 mg/dL from 43.3% to 35.1%, reduction in the use of central venous catheters from 8.2% to 1.0% of patients, increase in the use of chemical deep venous thrombosis prophylaxis from 45.4% of patients to 56.7%, reduction in the use of urinary catheters from 27.6% to 13.2%, and decrease in use of telemetry from 67.5% to 55.1%. All of the results have P < 0.05. These improvements were sustained over time. CONCLUSIONS: Implementation of a multidisciplinary communication tool serves as a simple, resource-conscious, and customizable instrument to reduce the risk factors for developing HACs. This communication tool can be easily disseminated and used by other institutions.

Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California.

QUALITY ISSUE: Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas. INITIAL ASSESSMENT: Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required. CHOICE OF SOLUTION: An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions. IMPLEMENTATION: Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning. EVALUATION: Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition. LESSONS LEARNED: A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.

Leveraging lean principles in creating a comprehensive quality program: The UCLA health readmission reduction initiative.

INTRODUCTION: UCLA Health embarked to transform care by integrating lean methodology in a key clinical project, Readmission Reduction Initiative (RRI). METHODS: The first step focused on assembling a leadership team to articulate system-wide priorities for quality improvement. The lean principle of creating a culture of change and accountability was established by: 1) engaging stakeholders, 2) managing the process with performance accountability, and, 3) delivering patient-centered care. The RRI utilized three major lean principles: 1) A3, 2) root cause analyses, 3) value stream mapping. RESULTS: Baseline readmission rate at UCLA from 9/2010-12/2011 illustrated a mean of 12.1%. After the start of the RRI program, for the period of 1/2012-6/2013, the readmission rate decreased to 11.3% (p<0.05). CONCLUSION: To impact readmissions, solutions must evolve from smaller service- and location-based interventions into strategies with broader approach. As elucidated, a systematic clinical approach grounded in lean methodologies is a viable solution to this complex problem.

A randomized, controlled trial of team-based competition to increase learner participation in quality-improvement education.

OBJECTIVE: Several barriers challenge resident engagement in learning quality improvement (QI). We investigated whether the incorporation of team-based game mechanics into an evidence-based online learning platform could increase resident participation in a QI curriculum. DESIGN: Randomized, controlled trial. SETTING: Tertiary-care medical center residency training programs. PARTICIPANTS: Resident physicians (n = 422) from nine training programs (anesthesia, emergency medicine, family medicine, internal medicine, ophthalmology, orthopedics, pediatrics, psychiatry and general surgery) randomly allocated to a team competition environment (n = 200) or the control group (n = 222). INTERVENTION: Specialty-based team assignment with leaderboards to foster competition, and alias assignment to de-identify individual participants. MAIN OUTCOME MEASURES: Participation in online learning, as measured by percentage of questions attempted (primary outcome) and additional secondary measures of engagement (i.e. response time). Changes in participation measures over time between groups were assessed with a repeated measures ANOVA framework. RESULTS: Residents in the intervention arm demonstrated greater participation than the control group. The percentage of questions attempted at least once was greater in the competition group (79% [SD ± 32] versus control, 68% [SD ± 37], P= 0.03). Median response time was faster in the competition group (P= 0.006). Differences in participation continued to increase over the duration of the intervention, as measured by average response time and cumulative percent of questions attempted (each P< 0.001). CONCLUSIONS: Team competition increases resident participation in an online course delivering QI content. Medical educators should consider game mechanics to optimize participation when designing learning experiences.

From discharge to readmission: Understanding the process from the patient perspective.

BACKGROUND: Patient engagement is critical in delivering high-quality care. However, literature investigating patient perspectives on readmissions is lacking. OBJECTIVES: To understand patients' beliefs and attitudes about 30-day readmissions and to elucidate areas for improvement aimed at reducing readmissions. DESIGN: In person survey. SETTING: Academic medical center and affiliated community hospital. PATIENTS: Patients with 30-day readmissions to medicine and cardiology services. MEASUREMENTS: Patient readiness, attitudes toward readmissions, discharge instructions, ambulatory resources, and follow-up care. RESULTS: Of 479 eligible patients approached for interviews, 230 (48%) were interviewed. Of these, 28% reported not feeling ready for discharge, and this correlated with inadequate symptom resolution, poor pain control, and concerns about self-care. Sixty-five percent remembered reviewing discharge paperwork, but over 22% could not identify critical information on this paperwork. Eighty-five percent reported having a primary doctor; however, only 56% of patients who received a contact number on discharge called a physician before returning to the hospital. One-third of patients knew where to obtain same-day care outside of the emergency room. Lastly, patients reported feeling more relieved than burdened upon readmission (7.7 [standard deviation {SD} 2.8) vs 5.9 [SD 3.4]; P < 0.001, scale of 1-10). CONCLUSIONS: By engaging readmitted patients we have illuminated areas for future interventions, including better symptom management and self-care planning before discharge, more clarity in discharge instructions, promoting awareness of outpatient resources, and improved alignment of patient and provider attitudes about readmissions. As the United States strives to reduce readmissions, attending to the patient perspective is critical in informing appropriate avenues for quality improvement. Journal of Hospital Medicine 2016;11:407-412. © 2016 Society of Hospital Medicine.

Recent advances in the patient safety and quality initiatives movement: implications for neurosurgery.

The US health care system is fragmented in terms of quality care, costs, and patient satisfaction. With the passage of the Affordable Care Act, national attention has been placed on the health care system, but effective change has yet to be observed. Unnecessary costs, medical errors, and uncoordinated efforts contribute to patient morbidity, mortality, and decreased patient satisfaction. In addition to national efforts, local initiatives within individual departments must be implemented to improve overall satisfaction without the sacrifice of costs. In this article, the current issues with the health care system and potential initiatives for neurosurgery are reviewed.

Impact of electronic health records on the patient experience in a hospital setting.

BACKGROUND: The impact of electronic health records (EHRs) and their effects on optimizing the patient experience has been debated nationally. Currently, there is a paucity of data in this area, and existing research offers conflicting results. Since 2006, the Assessing Residents' CI-CARE (ARC) program has evaluated the physician-patient interaction of resident physicians at University of California, Los Angeles (UCLA) Health utilizing a 20-item questionnaire administered through facilitator-patient interviews. OBJECTIVE: To evaluate the impact of EHR implementation on the patient experience. DESIGN: Retrospective cohort study. SETTING: Two academic medical campuses: Ronald Reagan UCLA Medical Center and UCLA Medical Center, Santa Monica. METHODS: A total of 3417 surveys, spanning December 1, 2012 to May 30, 2013, were assessed. This included patient representation from 9 departments within UCLA Health. Surveys were analyzed to assess physician-patient communication. Statistical comparisons were made using χ analysis. RESULTS: All 16 questions assessing physician-patient communication received better responses in the 3 months following EHR implementation, compared to the 3 months prior to implementation. Of these, 9 questions illustrated statistically significant improvement, whereas the improvement in the remaining 7 questions was not statistically significant. DISCUSSION: These results suggest that EHRs may improve physician-patient communication. The ARC infrastructure allowed for observation of this trend; however, future research should aim to further validate and understand the etiologies of this improvement.

Analysis of 30-day readmissions among neurosurgical patients: surgical complication avoidance as key to quality improvement.

UNLABELLED: OBJECT.: In terms of measuring quality of care and hospital performance, an outcome of increasing interest is the 30-day readmission rate. Recent health care policy making has highlighted the necessity of understanding the factors that influence readmission. To elucidate the rate, reason, and predictors of readmissions at a tertiary/quaternary neurosurgical service, the authors studied 30-day readmissions for the Department of Neurosurgery at two University of California, Los Angeles (UCLA), hospitals. METHODS: Over a 3-year period, the authors retrospectively identified adult and pediatric patients who had been discharged from the UCLA Medical Center after having undergone a major neurosurgical procedure and being readmitted within 30 days. Data were obtained on demographics, follow-up findings, diagnosis and reason for readmission, major operations performed, and length of stay during index admission and readmission. Reasons for readmission were broadly categorized into surgical, medical diagnosis/complication, problem associated with the original diagnosis, neurological decompensation, pain management, and miscellaneous. For further characterization, subgroup analysis and in-depth chart review were performed. RESULTS: Over the study period, 365 (6.9%) of 5569 patients were readmitted within 30 days. The most common diagnosis at index admission was brain tumor (102 patients), followed by CSF shunt malfunction (63 patients). The most common reason for readmission was surgical complication (50.1%). Among those with surgical complications, the largest subgroup consisted of patients with CSF shunt-related problems (77 patients). The second and third largest subgroups were surgical site infection and CSF leakage (41 and 31 patients, respectively). Medical diagnosis/complication was the second most frequent (27.9%) reason for readmission. CONCLUSIONS: Surgical complications seem to be a major reason for readmission at the neurosurgical practice studied. Results indicate that the outcomes that are amenable to and would have the greatest effect on quality improvement are CSF shunt-related complications, surgical site infections, and CSF leaks.

Tracking and sustaining improvement initiatives: leveraging quality dashboards to lead change in a neurosurgical department.

Increasingly, hospitals and physicians are becoming acquainted with business intelligence strategies and tools to improve quality of care. In 2007, the University of California Los Angeles (UCLA) Department of Neurosurgery created a quality dashboard to help manage process measures and outcomes and ultimately to enhance clinical performance and patient care. At that time, the dashboard was in a platform that required data to be entered manually. It was then reviewed monthly to allow the department to make informed decisions. In 2009, the department leadership worked with the UCLA Medical Center to align mutual quality-improvement priorities. The content of the dashboard was redesigned to include 3 areas of priorities: quality and safety, patient satisfaction, and efficiency and use. Throughout time, the neurosurgery quality dashboard has been recognized for its clarity and its success in helping management direct improvement strategies and monitor impact. We describe the creation and design of the neurosurgery quality dashboard at UCLA, summarize the evolution of its assembly process, and illustrate how it can be used as a powerful tool of improvement and change. The potential challenges and future directions of this business intelligence tool are also discussed.

Healthcare reform from the inside: A neurosurgical clinical quality program.

During the past decade, the U.S. health care system has faced increasing challenges in delivering high quality of care, ensuring patient safety, providing access to care, and maintaining manageable costs. While reform progresses at a national level, health care providers have a responsibility and obligation to advance quality and safety. In 2009, the authors implemented a department-wide Clinical Quality Program. This Program comprised of an inter-disciplinary group of providers and staff working together to ensure the highest quality of patient care. The following methodology was followed to establish the Program: (1) Identifying the Department's quality improvement (QI) and patient safety priorities based on reviewing prior performance data; (2) Aligning the Department's priorities with institutional goals to select mutually significant initiatives; (3) Finalizing the goals for improvement based on departmental priorities, existing expertise and resources; (4) Launching the Program through an inter-disciplinary retreat that emphasizes open dialogue, innovative solutions, and fostering leadership in frontline providers; (5) Sustaining the QI initiatives through proactive performance review and management of barriers; and (6) Celebrating success to empower providers to remain engaged. Several challenges are inherent to the implementation of a clinical quality program, including lack of time and expertise, and the hierarchical nature of medicine, which can create a barrier to teamwork. This Program illustrates that improvement can lead to a sustainable clinical quality program and culture change.

Promoting patient-centred care through trainee feedback: assessing residents' C-I-CARE (ARC) program.

AIMS: In recent years, patient satisfaction has been integrated into residency training practices through core competency requirements as set forth by the Accreditation Council of Graduate Medical Education (ACGME). In 2006, the UCLA Health Systems established a program designed to obtain patient feedback and assess the communication abilities of resident physicians with a standard tool through the Assessing Residents' C-I-CARE (ARC) Program. METHODS: This Program utilized a 17-item questionnaire, completed via a facilitator-administered interview, which employed polar, Likert and comment scale questions to assess physician trainees' interpersonal and communication skills. RESULTS: From 2006 to 2010, the ARC Program provided patient feedback data to more than six clinical departments while collecting 5,634 surveys for 323 trainees. Scores for resident recognition and performance increased from the first to second year of activity by an average of 22.5%, while attending recognition scores decreased 19% over the four years. Additionally, residents and attendings in surgical specialties received higher recognition rates than those in non-surgical specialties. CONCLUSIONS: The ARC Program provided a standard tool for attaining patient feedback through a facilitator-administered survey that assisted in the accreditation process of training programs. Furthermore, hospitals, health organizations and medical schools may find the ARC Program valuable in collecting information for quality control as well as providing an opportunity for students to become involved in the healthcare field.

Hospital quality and patient safety competencies: development, description, and recommendations for use.

BACKGROUND: Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally emphasized healthcare quality and patient safety in their curricula. METHODS: Through a multistep process, the Society of Hospital Medicine (SHM) Quality Improvement Education (QIE) subcommittee developed the Hospital Quality and Patient Safety (HQPS) Competencies to provide a framework for developing and assessing curricula and other professional development experiences. This article describes the development, provides definitions, and makes recommendations on the use of the HQPS Competencies. RESULTS: The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Reflecting differing levels of hospitalist involvement in healthcare quality, 3 levels of expertise within each area of competence have been established: basic, intermediate, and advanced. Standards for each competency area use carefully selected action verbs to reflect educational goals for hospitalists at each level. CONCLUSIONS: Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.