The impact of electronic health record implementation and use on performance of the Surgical Care Improvement Project measures.

OBJECTIVE: To examine the impact of electronic health record (EHR) deployment on Surgical Care Improvement Project (SCIP) measures in a tertiary-care teaching hospital. DATA SOURCES: SCIP Core Measure dataset from the CMS Hospital Inpatient Quality Reporting Program (March 2010 to February 2012). STUDY DESIGN: One-group pre- and post-EHR logistic regression and difference-in-differences analyses. PRINCIPAL FINDINGS: Statistically significant short-term declines in scores were observed for the composite, postoperative removal of urinary catheter and post-cardiac surgery glucose control measures. A statistically insignificant improvement in scores for these measures was noted 3 months after EHR deployment. CONCLUSION: The transition to an EHR appears to be associated with a short-term decline in quality. Implementation strategies should be developed to preempt or minimize this initial decline.

Increasing demands for quality measurement.

Measurement of health care quality and patient safety is rapidly evolving, in response to long-term needs and more recent efforts to reform the US health system around "value." Development and choice of quality measures is now guided by a national quality strategy and priorities, with a public-private partnership, the National Quality Forum, helping determine the most worthwhile measures for evaluating and rewarding quality and safety of patient care. Yet there remain a number of challenges, including diverse purposes for quality measurement, limited availability of true clinical measures leading to frequent reliance on claims data with its flaws in determining quality, fragmentation of measurement systems with redundancy and conflicting conclusions, few high-quality comprehensive measurement systems and registries, and rapid expansion of required measures with hundreds of measures straining resources. The proliferation of quality measures at the clinician, hospital, and insurer level has created challenges and logistical problems. Recommendations include raising the bar for qualtiy measurements to achieve transformational rather than incremental change in the US quality measurement system, promoting a logical set of measures for the various levels of the health system, leaving room for internal organizational improvement, harmonizing the various national and local quality measurement systems, anchoring on National Quality Forum additions and subtractions of measures to be applied, reducing reliance on and retiring claims-based measures as quickly as possible, promoting comprehensive measurement such as through registries with deep understanding of patient risk factors and outcomes, reducing attention to proprietary report cards, prompt but careful transition to measures from electronic health records, and allocation of sufficient resources to accomplish the goals of an efficient, properly focused measurement system.

Implementing a Smoke-free Campus: a Medical Center initiative.

A large 2-campus Medical Center in Western New York, along with several other large area hospitals, planned for and simultaneously implemented successful "Smoke-Free Campus" initiatives in November of 2006. This coordinated initiative required that each system plan accordingly for the development and implementation of policies, training of employees, clinicians, support staff and provision of tobacco treatment services (directly or via referral). In order to efficiently and competently inform each of these aspects of a system-wide initiative, accurate information was needed on the prevalence of tobacco use among employees, staff, faculty, and clinicians in each system. A multi-system surveillance initiative was implemented, using a brief survey for all employees of several of the partnering institutions. Summary data from the baseline measures are discussed. Also presented are Lessons Learned from the year-long planning and implementation phases, including details on topics categorized by the specific sub-committees that coordinated each area (e.g., Policy and Procedure, Communication, Faculty/Staff/Student Issues, Patient Issues (Inpatient and Outpatient), Tobacco Dependence Treatment and Provider/Staff Training). The effort was effective in instituting system-wide changes in all of the participating hospitals in the greater metropolitan area. A community-wide consortium convened each month for a year, and subcommittees within each hospital allowed planners to break up the initiative into manageable pieces. The extended timeline of 1 year was appropriate for overcoming fears, biases, and barriers which then enabled "buy-in" and support from leadership as well as employees.

Can aviation-based team training elicit sustainable behavioral change?

OBJECTIVE: To quantify effects of aviation-based crew resource management training on patient safety-related behaviors and perceived personal empowerment. DESIGN: Prospective study of checklist use, error self-reporting, and a 10-point safety empowerment survey after participation in a crew resource management training intervention. SETTING: Seven hundred twenty-two-bed university hospital; 247-bed affiliated community hospital. PARTICIPANTS: There were 857 participants, the majority of whom were nurses (50%), followed by ancillary personnel (28%) and physicians (22%). MAIN OUTCOME MEASURES: Preoperative checklist use over time; number and type of entries on a Web-based incident reporting system; and measurement of degree of empowerment (1-5 scale) on a 10-point survey of safety attitudes and actions given prior to, immediately after, and a minimum of 2 months after training. RESULTS: Since 2003, 10 courses trained 857 participants in multiple disciplines. Preoperative checklist use rose (75% in 2003, 86% in 2004, 94% in 2005, 98% in 2006, and 100% in 2007). Self-initiated reports increased from 709 per quarter in 2002 to 1481 per quarter in 2008. The percentage of reports related to environment as opposed to actual events increased from 15.9% prior to training to 20.3% subsequently (P < .01). Perceived self-empowerment, creating a culture of safety, rose by an average of 0.5 point in all 10 realms immediately posttraining (mean [SD] rating, 3.0 [0.07] vs 3.5 [0.05]; P < .05). This was maintained after a minimum of 2 months. There was a trend toward a hierarchical effect with participants less comfortable confronting incompetence in a physician (mean [SD] rating, 3.1 [0.8]) than in nurses or technicians (mean [SD] rating, 3.4 [0.7] for both) (P>.05). CONCLUSIONS: Crew resource management programs can influence personal behaviors and empowerment. Effects may take years to be ingrained into the culture.

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

BACKGROUND: Patients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable. OBJECTIVES: To determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software ("smart pump") and to suggest potential improvements in smart-pump design. DESIGN: Using retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges. PARTICIPANTS: 4,604 critically ill adults at 1 academic and 1 nonacademic hospital. MEASUREMENTS: Preventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs. RESULTS: Of 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps' capabilities might enable them to prevent more IV-ADEs. CONCLUSION: The smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.

Costs of intravenous adverse drug events in academic and nonacademic intensive care units.

BACKGROUND: Adverse drug events (ADEs), particularly those involving intravenous medications (IV-ADEs), are common among intensive care unit (ICU) patients and may increase hospitalization costs. Precise cost estimates have not been reported for academic ICUs, and no studies have included nonacademic ICUs. OBJECTIVES: To estimate increases in costs and length of stay after IV-ADEs at an academic and a nonacademic hospital. RESEARCH DESIGN: This study reviewed medical records to identify IV-ADEs, and then, using a nested case-control design with propensity-score matching, assessed differences in costs and length of stay between cases and controls. SUBJECTS: : A total of 4604 adult ICU patients in 3 ICUs at an academic hospital and 2 ICUs at a nonacademic hospital in 2003 and 2004. MEASURES: Increased cost and length of stay associated with IV-ADEs. RESULTS: : Three hundred ninety-seven IV-ADEs were identified: 79% temporary physical injuries, 0% permanent physical injuries, 20% interventions to sustain life, and 2% in-hospital deaths. In the academic ICUs, patients with IV-ADEs had $6647 greater costs (P < 0.0001) and 4.8-day longer stays (P = 0.0003) compared with controls. In the nonacademic ICUs, IV-ADEs were not associated with greater costs ($188, P = 0.4236) or lengths of stay (-0.3 days, P = 0.8016). Cost and length-of-stay differences between the hospitals were statistically significant (P = 0.0012). However, there were no differences in IV-ADE severity or preventability, and the characteristics of patients experiencing IV-ADEs differed only modestly. CONCLUSIONS: IV-ADEs substantially increased hospitalization costs and length of stay in ICUs at an academic hospital but not at a nonacademic hospital, likely because of differences in practices after IV-ADEs occurred.

Using administrative data to improve compliance with mandatory state event reporting.

BACKGROUND: The New York Patient Occurrence and Tracking System (NYPORTS) is a mandatory adverse event reporting system that was redesigned in 1998. Analysis of the first full year of its use showed large regional and hospital variation in reporting frequency not due to hospital or case mix differences. In early 2001, New York State mandated that all hospitals conduct retrospective review for unreported adverse incidents for the previous 2 years. Hospitals could submit previously unreported incidents within a defined window without penalty. The hospital used an ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) analysis to screen for missed NYPORTS cases, to assist in focusing review resources. METHODS: NYPORTS categories were matched to corresponding combinations of inpatient ICD-9-CM diagnosis and procedure codes. Other variables considered included discharge disposition, primary or secondary coding position, readmissions, and NYPORTS exclusions. RESULTS: Among more than 60,000 discharges in 2 years, 5,500 records were identified for NYPORTS review based on the ICD-9-CM criteria; 211 cases had already been reported through normal reporting processes. Thirteen of the NYPORTS codes had a 30% or greater match rate to the ICD-9-CM codes, with an average "hit rate" of 56%. Five-hundred sixty reviews identified 187 (33.4%) reportable events for the same code the case was being screened for and 26 additional reportable events for a code other than the screening code. NYPORTS categories for procedure and operative-related occurrences had the highest yields. CONCLUSIONS: This retrospective effort helped identify previously unreported occurrences, increase institutional awareness of New York State's mandatory reporting process, and stimulate the redesign of our concurrent detection process.