Team-Based Health Information Exchange Use Increased Mammography Documentation and Referral in an Academic Primary Care Practice: An Interrupted Time Series.

BACKGROUND: Few studies have examined the impact of health information exchanges (HIE) on quality in ambulatory settings. METHODS: From September 29, 2014, to September 4, 2015, we conducted an interrupted time series analysis of query-based use of the state HIE as part of team-based care to improve mammography screening in an academic primary care practice. Women aged 50-74 years with a practice visit and who were eligible for mammography were included. We conducted non-parametric data analysis using LOESS, followed by ARIMA analysis. RESULTS: During the study period, there were 2020 visits among 904 eligible patients, including 648 visits among 485 patients during 16 baseline weeks, and 1372 visits by 755 patients during 33 intervention weeks. During the intervention period, 16.0% of eligible women who were not up to date in our EHR had a mammogram in the HIE. Of eligible women, the proportion who had a documented up-to-date mammogram at the time of their visit increased by 11.3%, from 73.4% at baseline to 84.7% (p < 0.0001), the proportion who had mammography addressed at the time of their visit increased by 42.7%, from 32.7% at baseline to 75.4% (p < 0.0001), and the proportion who were up to date at 8 weeks post-visit increased by 11.7%, from 76.3% at baseline to 88.0% (p < 0.0001). DISCUSSION: Query-based use of the state HIE as part of team-based care improved documentation of mammography and led to an increase in the proportion of eligible women who received counseling on mammography screening in one primary care practice. These results suggest that HIE use in primary care could lead to improved delivery of other preventive services.

A Multi-hospital Before-After Observational Study Using a Point-Prevalence Approach with an Infusion Safety Intervention Bundle to Reduce Intravenous Medication Administration Errors.

INTRODUCTION: We previously found a high rate of errors in the administration of intravenous medications using smart infusion pumps. OBJECTIVES/DESIGN: An infusion safety intervention bundle was developed in response to the high rate of identified errors. A before-after observational study with a prospective point-prevalence approach was conducted in nine hospitals to measure the preliminary effects of the intervention. MAIN OUTCOME MEASURES: Primary outcome measures were overall errors and medication errors, with the secondary outcome defined as potentially harmful error rates. RESULTS: We assessed a total of 418 patients with 972 medication administrations in the pre-intervention period and 422 patients with 1059 medication administrations in the post-intervention period. The overall error rate fell from 146 to 123 per 100 medication administrations (p < 0.0001), and the medication error rate also decreased from 39 to 29 per 100 medication administrations (p = 0.001). However, there was no significant change in the potentially harmful error rate (from 0.5 to 0.8 per 100 medication administrations, p = 0.37). An intervention component aiming to reduce labeling-not-completed errors was effective in reducing targeted error rates, but other components of the intervention bundle did not show significant improvement in the targeted errors. CONCLUSION: Development and implementation of the intervention bundle was successful at reducing overall and medication error rates, but some errors remained and the potentially harmful error rate did not change. The error-rate reductions were not always correlated with the specific individual interventions. Further investigation is needed to identify the best strategies to reduce the remaining errors. CLINICAL TRIALS REGISTRATION: Registered at ClinicalTrials.gov, identifier: NCT02359734.

Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice.

BACKGROUND: While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. METHODS: As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. RESULTS: Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others. CONCLUSION: CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care.

Intermediate care to intensive care triage: A quality improvement project to reduce mortality.

PURPOSE: Medical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur. METHODS: To improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians. RESULTS: Among patients transferred from the IMCU to the MICU during baseline (n=83;July-December 2012) and intervention phases (n=94;July-December 2013), unadjusted mortality decreased from 34% to 21% (p=0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11-0.98). CONCLUSIONS: Using a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.

Increasing Advance Care Planning Completion at an Academic Internal Medicine Outpatient Clinic.

BACKGROUND: We sought to increase advance care planning (ACP) completion at an academic internal medicine clinic through an electronic health record. MEASURES: Number of eligible patients who completed a form of ACP. INTERVENTION: Multidisciplinary team approach with engagement from providers and clinic staff; implemented informational letter and appropriate forms to eligible patients before appointment; informational video and provider reminders at time of appointment. OUTCOMES: Of 480 eligible patients, 327 (68%) completed one or more forms of ACP or had a discussion with their provider. Discussed but not completed was highest (53%). The three types of ACP completed were 1) a state-formatted advance directive form (47%), 2) Medical Orders for Life-Sustaining Treatment (45%), and 3) power of attorney designation (8%). CONCLUSIONS: Implementation of a multi-disciplinary approach can facilitate ACP. However, challenges still arise because in more than half of the cases, advance care efforts led only to a discussion.

Towards high-reliability organising in healthcare: a strategy for building organisational capacity.

In a high-reliability organisation (HRO), safety and quality (SQ) is an organisational priority, and all workforce members are engaged, continuously learning and improving their work. To build organisational capacity for SQ work, we have developed a role-tailored capacity-building framework that we are currently employing at the Johns Hopkins Armstrong Institute for Patient Safety and Quality as part of an organisational strategy towards HRO. This framework considers organisation-wide competencies for SQ that includes all staff and faculty and is integrated into a broader organisation-wide operating management system for improving quality. In this framework, achieving safe, high-quality care is connected to healthcare workforce preparedness. Capacity-building efforts are tailored to the needs of distinct groups within the workforce that fall within three categories: (1) front-line providers and staff, (2) managers and local improvement personnel and (3) SQ leaders and experts. In this paper we describe this framework, our implementation efforts to date, challenges met and lessons learnt.

Reducing preventable harm: observations on minimizing bloodstream infections.

Purpose The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms. Design/methodology/approach An existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA. Findings The following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions. Practical implications This framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms. Originality/value Implementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

INTRODUCTION: Intravenous medication errors persist despite the use of smart pumps. This suggests the need for a standardised methodology for measuring errors and highlights the importance of identifying issues around smart pump medication administration in order to improve patient safety. OBJECTIVES: We conducted a multisite study to investigate the types and frequency of intravenous medication errors associated with smart pumps in the USA. METHODS: 10 hospitals of various sizes using smart pumps from a range of vendors participated. Data were collected using a prospective point prevalence approach to capture errors associated with medications administered via smart pumps and evaluate their potential for harm. RESULTS: A total of 478 patients and 1164 medication administrations were assessed. Of the observed infusions, 699 (60%) had one or more errors associated with their administration. Identified errors such as labelling errors and bypassing the smart pump and the drug library were predominantly associated with violations of hospital policy. These types of errors can result in medication errors. Errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). 1 error of category E (0.1%), 4 of category D (0.3%) and 492 of category C (excluding deviations of hospital policy) (42%) were identified. Of these, unauthorised medication, bypassing the smart pump and wrong rate were the most frequent errors. CONCLUSION: We identified a high rate of error in the administration of intravenous medications despite the use of smart pumps. However, relatively few errors were potentially harmful. The results of this study will be useful in developing interventions to eliminate errors in the intravenous medication administration process.

Effect of a Nurse-Managed Telemetry Discontinuation Protocol on Monitoring Duration, Alarm Frequency, and Adverse Patient Events.

Telemetry monitoring is a limited resource. This quality improvement project describes a nurse-managed telemetry discontinuation protocol aimed at stopping telemetry monitoring when it is no longer indicated. After implementing the protocol, data were collected for 6 months and compared with a preintervention time frame. There was a mean decrease in telemetry monitor usage and a decreased likelihood of remaining on a telemetry monitor until discharge. A nurse-managed telemetry discontinuation protocol was effective in decreasing overmonitoring and ensuring telemetry availability.

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action.

Nurses have always been involved in the diagnostic process, but there remains a pervasive view across physicians, nurses, and allied health professionals that medical diagnosis is solely a physician responsibility. There is an urgent need to adjust this view and for nurses to take part in leading efforts addressing diagnostic errors. The purpose of this article is to define a framework for nursing engagement in the diagnostic process that can serve as a catalyst for nurses to engage in eliminating preventable harms from diagnostic error. We offer a conceptual model to formalize and expand nurses' engagement in the diagnostic process through education, maximize effectiveness of interprofessional teamwork and communication through culture change, and leverage the nursing mission to empower patients to become active members of the diagnostic team. We describe the primary barriers, including culture, education, operations, and regulations, to nurses participating as full, equal members of the diagnostic team, and illustrate our approach to addressing these barriers. Nurses already play a major role in diagnosis and increasingly take ownership of this role, removing barriers will strengthen nurses' ability to be equal, integral diagnostic team members. This model should serve as a foundation for increasing the role of the nurse in the diagnostic process, and calling nurses to take action in leading efforts to reduce diagnostic error.

Comprehensive Unit-based Safety Program (CUSP) to Improve Patient Experience: How a Hospital Enhanced Care Transitions and Discharge Processes.

OBJECTIVE: To determine whether Comprehensive Unit-based Safety Program (CUSP) teams could be used to enhance patient experience by improving care transitions and discharge processes in a 318-bed community hospital. METHODS: In 2015, CUSP teams produced feasible solutions by participating in a design-thinking initiative, coupled with performance improvement tools involving data analytics and peer-learning communities. Teams completed a 90-day sprint challenge, involving weekly meetings, monthly department leader meetings, and progress trackers. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was used, and the percent top (best) scores were reported for overall hospital ratings, discharge information, and care transitions. RESULTS: The percentage of patients choosing the top score increased from 61.0% preintervention to 68.0% postintervention for overall hospital rating and from 71.4% to 80.7% for recommending the hospital. The top scores increased from 76.0% preintervention to 84.5% postintervention for the discharge information domain and from 49.2% to 53.6% for the care transitions domain. CONCLUSION: CUSP teams improved patient experience. The teams could expand their scope to be the unit-level resource focused not only on safety but also on external quality measures to which patient experience is a broad category for HCAHPS scores, and potentially on value in future work.

CLABSI Conversations: Lessons From Peer-to-Peer Assessments to Reduce Central Line-Associated Bloodstream Infections.

A national collaborative helped many hospitals dramatically reduce central line-associated bloodstream infections (CLABSIs), but some hospitals struggled to reduce infection rates. This article describes the development of a peer-to-peer assessment process (CLABSI Conversations) and the practical, actionable practices we discovered that helped intensive care unit teams achieve a CLABSI rate of less than 1 infection per 1000 catheter-days for at least 1 year. CLABSI Conversations was designed as a learning-oriented process, in which a team of peers visited hospitals to surface barriers to infection prevention and to share best practices and insights from successful intensive care units. Common practices led to 10 recommendations: executive and board leaders communicate the goal of zero CLABSI throughout the hospital; senior and unit-level leaders hold themselves accountable for CLABSI rates; unit physicians and nurse leaders own the problem; clinical leaders and infection preventionists build infection prevention training and simulation programs; infection preventionists participate in unit-based CLABSI reduction efforts; hospital managers make compliance with best practices easy; clinical leaders standardize the hospital's catheter insertion and maintenance practices and empower nurses to stop any potentially harmful acts; unit leaders and infection preventionists investigate CLABSIs to identify root causes; and unit nurses and staff audit catheter maintenance policies and practices.

Provider-to-Provider Communication during Transitions of Care from Outpatient to Acute Care: A Systematic Review.

BACKGROUND: Most research on transitions of care has focused on the transition from acute to outpatient care. Little is known about the transition from outpatient to acute care. We conducted a systematic review of the literature on the transition from outpatient to acute care, focusing on provider-to-provider communication and its impact on quality of care. METHODS: We searched the MEDLINE, CINAHL, Scopus, EMBASE, and Cochrane databases for English-language articles describing direct communication between outpatient providers and acute care providers around patients presenting to the emergency department or admitted to the hospital. We conducted double, independent review of titles, abstracts, and full text articles. Conflicts were resolved by consensus. Included articles were abstracted using standardized forms. We maintained search results via Refworks (ProQuest, Bethesda, MD). Risk of bias was assessed using a modified version of the Downs' and Black's tool. RESULTS: Of 4009 citations, twenty articles evaluated direct provider-to-provider communication around the outpatient to acute care transition. Most studies were cross-sectional (65%), conducted in the US (55%), and studied communication between primary care and inpatient providers (62%). Of three studies reporting on the association between communication and 30-day readmissions, none found a significant association; of these studies, only one reported a measure of association (adjusted OR for communication vs. no communication, 1.08; 95% CI 0.92-1.26). DISCUSSION: The literature on provider-to-provider communication at the transition from outpatient to acute care is sparse and heterogeneous. Given the known importance of communication for other transitions of care, future studies are needed on provider-to-provider communication during this transition. Studies evaluating ideal methods for communication to reduce medical errors, utilization, and optimize patient satisfaction at this transition are especially needed.

The Armstrong Institute Resident/Fellow Scholars: A Multispecialty Curriculum to Train Future Leaders in Patient Safety and Quality Improvement.

The objective was to determine if a year-long, multispecialty resident and fellow quality improvement (QI) curriculum is feasible and leads to improvements in QI beliefs and self-reported behaviors. The Armstrong Institute Resident/Fellow Scholars (AIRS) curriculum incorporated (a) a 2-day workshop in lean sigma methodology, (b) year-long interactive weekly small-group lectures, (c) mentored QI projects, and (d) practicum-based components to observe frontline QI efforts. Pre-post evaluation was performed with the Quality Improvement Knowledge Application Tool (QIKAT) and the Systems Thinking Scale (STS) using the Wilcoxon matched-pairs signed-rank test. Sixteen residents and fellows started the AIRS curriculum and 14 finished. Scholars' pre and post mean scores significantly improved: STS 3.06 pre versus 3.60 post (P < .01) and QIKAT 1.24 pre versus 2.46 post (P < .01). Most scholars (92%) agreed that skills learned in the curriculum will help in their future careers. A multispecialty QI curriculum for trainees is feasible and increases QI beliefs and self-reported behaviors.

A Collaborative Learning Network Approach to Improvement: The CUSP Learning Network.

BACKGROUND: Collaborative improvement networks draw on the science of collaborative organizational learning and communities of practice to facilitate peer-to-peer learning, coaching, and local adaption. Although significant improvements in patient safety and quality have been achieved through collaborative methods, insight regarding how collaborative networks are used by members is needed. Improvement Strategy: The Comprehensive Unit-based Safety Program (CUSP) Learning Network is a multi-institutional collaborative network that is designed to facilitate peer-to-peer learning and coaching specifically related to CUSP. Member organizations implement all or part of the CUSP methodology to improve organizational safety culture, patient safety, and care quality. Qualitative case studies developed by participating members examine the impact of network participation across three levels of analysis (unit, hospital, health system). In addition, results of a satisfaction survey designed to evaluate member experiences were collected to inform network development. RESULTS: Common themes across case studies suggest that members found value in collaborative learning and sharing strategies across organizational boundaries related to a specific improvement strategy. CONCLUSION: The CUSP Learning Network is an example of network-based collaborative learning in action. Although this learning network focuses on a particular improvement methodology-CUSP-there is clear potential for member-driven learning networks to grow around other methods or topic areas. Such collaborative learning networks may offer a way to develop an infrastructure for longer-term support of improvement efforts and to more quickly diffuse creative sustainment strategies.

The power of involving house staff in quality improvement: an interdisciplinary house staff-driven vaccination initiative.

Immunization for influenza and pneumococcal pneumonia were incorporated into The Joint Commission "global immunization" core measure January 1, 2012. The authors' hospital chose to adhere strictly to guidelines to avoid overvaccination. An immunization order set was created to aid appropriate ordering practices. In spite of this effort, compliance rates remained below the goal. The objective was to improve compliance with inpatient vaccination core measures to >96%. An educational slide set was created and distributed by the Housestaff Patient Safety and Quality Council (HPSQC). A competition was established among departments. Finally, the HPSQC partnered with quality improvement staff to improve communication and optimize concurrent review processes. The average compliance prior to the HPSQC vaccination initiative was 78% for pneumococcal pneumonia and 84% for influenza; average compliance in the months following the intervention was 96% and 97.5%, respectively. This project yielded significant improvement in compliance with vaccination core measures.

Impact of self-reported guideline compliance: Bloodstream infection prevention in a national collaborative.

BACKGROUND: We sought to examine self-reported compliance with 5 evidence-based central line-associated bloodstream infection (CLABSI) prevention practices and link compliance to CLABSI rates in a national patient safety collaborative. METHODS: We analyzed data from a national CLABSI prevention program. Adult ICUs participating in the program submitted their CLABSI rates and a Team Checkup Tool (TCT) on a monthly basis. The TCT responses provided self-reported perceptions about how reliably the unit team performed the evidence-based practices in the previous month. Monthly data were aggregated into quarters for the analysis. We analyzed a total of 2775 ICU quarters during the program. RESULTS: Chlorhexidine skin preparation and hand hygiene had the highest adherence. Avoidance of the femoral site and removal of unnecessary lines had the lowest compliance. Regression results showed that consistent performance of all practices was significantly associated with lower CLABSI rates. In terms of each practice's independent effect, femoral site avoidance for line placement and removal of unnecessary lines were independently associated with lower CLABSI rates after controlling for other factors. CONCLUSION: Our findings suggest that uptake of the 2 low-compliance practices, avoidance of the femoral site and removal of unnecessary lines, is important for reducing CLABSI rates in conjunction with other practices.

Influence of a multifaceted intervention on central line days in intensive care units: results of a national multisite study.

BACKGROUND: Removing unnecessary central lines is a critical step in reducing risk of infection and was 1 focus of a national quality improvement collaborative. We examined if participating adult intensive care units (ICUs) reduced central line days during the project period compared with the period before implementation of the "On the CUSP: Stop BSI" program. METHODS: We used a linear regression model on a total of 9,225 ICU-quarters of data to examine the effect of the intervention on total central line days of ICU participants in the national project (2008-2012), adjusting for ICU type, hospital characteristics, project cohort, season, and accounting for repeated measures on the same unit and clustering within states using random intercepts. RESULTS: The regression results showed no significant change in preintervention quarters. However, significant decreases in total line days started during quarter 4 after intervention and differences were sustained through quarter 6. There were 4% fewer central line catheter days reported at the project's conclusion compared with the baseline. CONCLUSIONS: To keep central lines from doing patients harm, clinicians must assess the need for lines and remove them as soon as clinically advisable to halt the possibility of infection via the line. Effective communication and empowering providers to identify unnecessarily extended use of central lines could accelerate the realization, someday, of eliminating central line associated bloodstream infections in ICUs.