Assessing Factors Influencing Commitment to a Disparities Reduction Intervention: Social Justice Attitudes and Organizational Mission.

ABSTRACT: This mixed-methods study aims to understand what the perceptions of leaders and healthcare professionals are regarding causes of disparities, cultural competence, and motivation before launching a disparity reduction project in hypertension care, contrasting perceptions in Federally Qualified Health Centers (FQHCs), and in a non-FQHC system. We interviewed leaders of six participating primary care systems and surveyed providers and staff. FQHC respondents reported more positive cultural competence attitudes and behavior, higher motivation to implement the project, and less concern about barriers to caring for disadvantaged patients than those in the non-FQHC practices; however, egalitarian beliefs were similar among all. Qualitative analysis suggested that the organizational missions of the FQHCs reflect their critical role in serving vulnerable populations. All system leaders were aware of the challenges of provider care to underserved groups, but comprehensive initiatives to address social determinants of health and improve cultural competence were still needed in both system types. The study provides insights into the perceptions and motivations of primary care organizational leaders and providers who are interested in improving chronic care. It also offers an example for care disparity programs to understand commitment and values of the participants for tailoring interventions and setting baseline for progress.

Puerto Rican healthcare workers' perspectives on the impact of COVID-19 pandemic on their role, patient care, and mental health.

PURPOSE: To explore the personal and work-related stressors of healthcare workers in Puerto Rico and the organizational support they received during the pandemic. DESIGN AND METHODS: We used a qualitative descriptive design and from April - November, 2021, conducted semi-structured individual interviews with Puerto Rican frontline healthcare workers (n = 12) and supervisors (n = 5). FINDINGS: Thematic analysis revealed five major themes: (a) Organizations' response to COVID-19; (b) increased complexity of patients; (c) intensified work and psychological demand for nurses; (d) overwhelmed and overworked; and (e) recommendations for healthcare leadership. Participants explained that their organizations' responses to COVID-19 were insufficient for  meeting the demands and acuity of the patients. Closure of outpatient services contributed to people presenting to hospitals with exacerbated chronic conditions - especially the elderly. With COVID-19 precautions prohibiting family visitation, nurses became responsible for total care, including emotional support of patients. In addition, the shortage of staff contributed to nurses assuming greater workloads, feeling overwhelmed and overworked, and healthcare worker resignations. Given their experiences, healthcare workers recommended that healthcare leadership show more appreciation for staff, demonstrate empathy, include frontline workers in decision-making, and provide mental health resources for staff. CONCLUSIONS: This study with Puerto Rican frontline workers and supervisors uncovers the multiple stressors experienced during the COVID-19 pandemic. Our findings underscore the need for prioritizing the well-being of healthcare workers, preparing healthcare leadership on how to support staff, and mandating nurse-to-patient ratios. CLINICAL RELEVANCE: Healthcare workers explained the barriers they experienced for providing quality care to their patients. They also presented recommendations for healthcare leadership to facilitate supporting frontline workers, which ultimately contributes to optimal patient care.

Evaluation of Patient and Family Engagement Strategies to Improve Medication Safety.

BACKGROUND: Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety. METHODS: We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles were additionally reviewed by two senior investigators for selection. One investigator abstracted data and two investigators reviewed the data for accuracy. Study quality was determined by consensus. Investigators developed a framework for defining the level of patient engagement: informing patients about medications (Level 1), informing about engagement with health care providers (Level 2), empowering patients with communication tools and skills (Level 3), partnering with patients in their care (Level 4), and integrating patients as full care team members (Level 5). RESULTS: We included 19 studies that mostly targeted older adults taking multiple medications. The median level of engagement was 2, ranging from 2-4. We identified no level 5 studies. Key themes for patient engagement strategies impacting medication safety were patient education and medication reconciliation, with a subtheme of patient portals. Most studies (84%) reported implementation outcomes. The most commonly reported medication safety outcomes were medication errors, including near misses and discrepancies (47%), and medication safety knowledge (37%). Most studies (63%) were of medium to low quality, and risk of bias was generally moderate. Among the 11 studies with control groups, 55% (n = 6) reported statistically significant improvement on at least one medication safety outcome. Further synthesis of medication safety measures was limited due to intervention and outcome heterogeneity. CONCLUSIONS: Key strategies for engaging patients in medication safety are education and medication reconciliation. Patient engagement levels were generally low, as defined by a novel framework for determining levels of patient engagement. As more patient engagement studies are conducted, this framework should be evaluated for associations with patient outcomes.

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.

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.

Access to Care, Treatment Ambivalence, Medication Nonadherence, and Long-Term Mortality Among Severely Hypertensive African Americans: A Prospective Cohort Study.

African Americans living in poor neighborhoods bear a high burden of illness and early mortality. Nonadherence may contribute to this burden. In a prospective cohort study of urban African Americans with poorly controlled hypertension, mortality was 47.6% over a median follow-up of 6.1 years. Patients with pill-taking nonadherence were more likely to die (hazard ratio, 1.80; 95% confidence interval [CI], 1.18-2.76) after adjustment for potential confounders. With regard to factors related to nonadherence, poor access to care such as difficulty paying for medications was associated with prescription refill nonadherence (odds ratio [OR], 4.12; 95% CI, 1.88-9.03). Pill-taking nonadherence was not associated with poor access to care; however, it was associated with factors related to treatment ambivalence including lower hypertension knowledge (OR, 2.97; 95% CI, 1.39-6.32), side effects (OR, 3.44; 95% CI, 1.47-8.03), forgetfulness (OR, 3.62; 95% CI, 1.78-7.34), and feeling that the medications do not help (OR, 2.78; 95% CI, 1.09-7.09). These data suggest that greater access to care is a necessary but insufficient remedy to the disparities experienced by urban African Americans with hypertension. To achieve its full promise, health reform must also address treatment ambivalence.

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.

Evaluating the impact of mandatory public reporting on participation and performance in a program to reduce central line-associated bloodstream infections: evidence from a national patient safety collaborative.

BACKGROUND: It is not clear whether mandatory reporting influences the efforts and performance of hospitals to prevent hospital-acquired infections. This study examines whether mandatory reporting impacted participation and performance in reducing central line-associated bloodstream infections (CLABSIs) in a national patient safety collaborative. METHODS: We analyzed 1,046 adult intensive care units (ICUs) participating in the national On the CUSP: Stop BSI program. We used a difference-in-difference approach to compare changes in CLABSI rates in states with no public reporting mandate, recent mandates, and longer-standing mandates. Chi-square tests were used to examine the differences in the participation rate. RESULTS: States enacting a law requiring mandatory public reporting of CLABSI rates around the time of the national program had the highest hospital participation rates (approximately 50%). Compared with units in states with no reporting requirement, units in the states with voluntary reporting systems or with longer periods of mandatory reporting experience had higher CLABSI rates at baseline and greater reductions in CLABSI in the first 6 months. State groups with mandatory public reporting of CLABSI showed a trend toward greater reduction in CLABSI after 1 year of program implementation. CONCLUSION: Mandatory reporting requirements may spark hospitals to turn to proven infection prevention interventions to improve CLABSI rates. Reporting requirements do not teach sites how to reduce rates. ICUs need both motivation and facilitation to reach consumer expectations for infection prevention.

On the CUSP: Stop BSI: evaluating the relationship between central line-associated bloodstream infection rate and patient safety climate profile.

BACKGROUND: Central line-associated bloodstream infection (CLABSI) remains one of the most common and deadly hospital acquired infections in the United States. Creating a culture of safety is an important part of healthcare-associated infection improvement efforts; however, few studies have robustly examined the role of safety climate in patient safety outcomes. We applied a pattern-based approach to measuring safety climate to investigate the relationship between intensive care unit (ICU) patient safety climate profiles and CLABSI rates. METHODS: Secondary analyses of data collected from 237 adult ICUs participating in the On the CUSP: Stop BSI project. Unit-level baseline scores on the Hospital Survey on Patient Safety, a survey designed to assess patient safety climate, and CLABSI rates, were investigated. Three climate profile characteristics were examined: profile elevation, variability, and shape. RESULTS: Zero-inflated Poisson analyses suggested an association between the relative incidence of CLABSI and safety climate profile shape. K-means cluster analysis revealed 5 climate profile shapes. ICUs with conflicting climates and nonpunitive climates had a significantly higher CLABSI risk compared with ICUs with generative leadership climates. CONCLUSIONS: Relative CLABSI risk was related to safety climate profile shape. None of the climate profile shapes was related to the odds of reporting zero CLABSI. Our findings support using pattern-based methods for examining safety climate rather than examining the relationships between each narrow dimension of safety climate and broader safety outcomes like CLABSI.

Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension.

BACKGROUND: Missed appointments are associated with an increased risk of hospitalization and mortality. Despite its widespread prevalence, little data exists regarding factors related to appointment non-adherence among hypertensive African-Americans. OBJECTIVE: To investigate factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension. DESIGN AND PARTICIPANTS: A cross-sectional survey of 185 African-Americans admitted to an urban medical center in Maryland, with severe, poorly controlled hypertension from 1999-2004. Categorical and continuous variables were compared using chi-square and t-tests. Adjusted multivariable logistic regression was used to assess correlates of appointment non-adherence. MAIN OUTCOME MEASURES: Appointment non-adherence was the primary outcome and was defined as patient-report of missing greater than 3 appointments out of 10 during their lifetime. RESULTS: Twenty percent of participants (n = 37) reported missing more than 30% of their appointments. Patient characteristics independently associated with a higher odds of appointment non-adherence included not finishing high school (Odds ratio [OR]  = 3.23 95% confidence interval [CI] (1.33-7.69), hypertension knowledge ([OR]  = 1.20 95% CI: 1.01-1.42), lack of insurance ([OR]  = 6.02 95% CI: 1.83-19.88), insurance with no medication coverage ([OR]  = 5.08 95% CI: 1.05-24.63), cost of discharge medications ([OR]  = 1.20 95% CI: 1.01-1.42), belief that anti-hypertensive medications do not work ([OR]  = 3.67 95% CI: 1.16-11.7), experience of side effects ([OR]  = 3.63 95% CI: 1.24-10.62), medication non-adherence ([OR]  = 11.31 95% CI: 3.87-33.10). Substance abuse was not associated with appointment non-adherence ([OR]  = 1.05 95% CI: 0.43-2.57). CONCLUSIONS: Appointment non-adherence among African-Americans with poorly controlled hypertension was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

BACKGROUND: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections. METHODS: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented. RESULTS: A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation. CONCLUSION: Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

Maintaining and sustaining the On the CUSP: stop BSI model in Hawaii.

BACKGROUND: Hawaii joined the On the CUSP: Stop BSI national effort in the United States in 2009 (CUSP stands for Comprehensive Unit-based Safety Program). In the initial 18-month study evaluation, adult ICUs decreased central line-associated bloodstream infection (CLABSI) rates by 61%. The impact of a series of novel strategies/tools in reducing infections and sustaining the collaborative in ICUs and non-ICUs in Hawaii was assessed. METHODS: This cohort collaborative consisted of 20 adult ICUs and 18 nonadult ICUs in 16 hospitals. Hawaii developed and implemented six tools between July 2010 and August 2011: a tool to investigate CLABSIs, a video to address cultural barriers, a standardized dressing change kit, a map of the cohort's journey, a 12-strategies leadership dashboard, and a geometric plot of consecutive infection-free days. The primary outcome measure was overall CLABSI rates (mean infections per 1,000 catheter-days). RESULTS: A comparison of baseline data from 28 ICUs with 12-quarter (36-month) postimplementation data indicated that the CLABSI rate decreased across the entire state: overall, 1.57 to 0.29 infections/1,000 catheter-days; adult ICUs, 1.49 to 0.25 infections/1,000 catheter-days; nonadult ICUs, 2.54 to 0.33 infections/1,000 catheter-days, non-ICUs (N= 14), 4.52 to 0.25 infections/1,000 catheter-days, and PICU/NICU (N = 4), 2.05 to 0.53 infections/1,000 catheter-days. Days between CLABSIs in the adult ICUs statewide increased from a median of 5 days in 2009 to 70 days in 2011. DISCUSSION: Hawaii successfully spread the program beyond adult ICUs and implemented a series of tools for maintenance and sustainment. Use of the tools shaped a culture around the continued belief that CLABSIs can be eradicated, and infections further reduced.

Decreasing central-line-associated bloodstream infections in Connecticut intensive care units.

Central-line-associated bloodstream infections (CLABSIs) are a significant cause of preventable harm. A collaborative project involving a multifaceted intervention was used in the Michigan Keystone Project and associated with significant reductions in these infections. This intervention included the Comprehensive Unit-based Safety Program, a multifaceted approach to CLABSI prevention, and the monitoring and reporting of infections. The purpose of this study was to determine whether the multifaceted intervention from the Michigan Keystone program could be implemented in Connecticut and to evaluate the impact on CLABSI rates in intensive care units (ICUs). The primary outcome was the NHSN-defined rate of CLABSI. Seventeen ICUs, representing 14 hospitals and 104,695 catheter days were analyzed. The study period included up to four quarters (12 months) of baseline data and seven quarters (21 months) of postintervention data. The overall mean (median) CLABSI rate decreased from 1.8 (1.8) infections per 1,000 catheter days at baseline to 1.1 (0) at seven quarters postimplementation of the intervention. This study demonstrated that the multifaceted intervention used in the Keystone program could be successfully implemented in another state and was associated with a reduction in CLABSI rates in Connecticut. Moreover, even though the statewide baseline CLABSI rate in Connecticut was low, rates were reduced even further and well below national benchmarks.

Using the Opportunity Estimator tool to improve engagement in a quality and safety intervention.

Teams throughout the United States participating in a program to reduce central line-associated bloodstream infections (CLABSIs) are using the Opportunity Estimator. This web-based tool translates CLABSI-related data into "opportunity estimates" of the patient lives and money that could be saved by reducing these infections.

Eradicating central line-associated bloodstream infections statewide: the Hawaii experience.

The authors' goal was to determine if a national intensive care unit (ICU) collaborative to reduce central line-associated bloodstream infections (CLABSIs) would succeed in Hawaii. The intervention period (July 2009 to December 2010) included a comprehensive unit-based safety program; a multifaceted approach to CLABSI prevention; and monitoring of infections. The primary outcome was CLABSI rate. A total of 20 ICUs, representing 16 hospitals and 61 665 catheter days, were analyzed. Median hospital bed size was 159 (interquartile range [IQR] = 71-212) and median ICU bed size was 10 (IQR = 8-12). Median unit catheter days per month were 112 (IQR = 52-197). The overall mean CLABSI rate decreased from 1.5 infections per 1000 catheter days at baseline (January to June 2009) to 0.6 at 16 to 18 months postintervention (October to December 2010). The median rate was zero CLABSIs per 1000 catheter days at baseline and remained zero throughout the study period. Hawaii demonstrated that the national program can be successfully spread, providing further evidence that most CLABSIs are preventable.

Reducing medical errors and adverse events.

Medical errors account for ∼98,000 deaths per year in the United States. They increase disability and costs and decrease confidence in the health care system. We review several important types of medical errors and adverse events. We discuss medication errors, healthcare-acquired infections, falls, handoff errors, diagnostic errors, and surgical errors. We describe the impact of these errors, review causes and contributing factors, and provide an overview of strategies to reduce these events. We also discuss teamwork/safety culture, an important aspect in reducing medical errors.

Prevention of central line-associated bloodstream infections: a journey toward eliminating preventable harm.

Central line-associated blood stream infections (CLABSI) are among the most common, lethal, and costly health care-associated infections. Recent large collaborative quality improvement efforts have achieved unprecedented and sustained reductions in CLABSI rates and demonstrate that these infections are largely preventable, even for exceedingly ill patients. The broad acceptance that zero CLABSI rates are an achievable goal has motivated and stimulated diverse groups of stakeholders, including public and private groups to develop policy tools and to mobilize their local constituents toward achieving this goal. Nevertheless, attributing reductions in CLABSI rates achieved by multifaceted quality improvement efforts solely to the use of checklists to ensure adherence with appropriate infection control practices is an easily made but crucial mistake. National CLABSI prevention is a shared responsibility and creating novel partnerships between government agencies, health care industry, and consumers is critical to making and sustaining progress in achieving the goals toward eliminating CLABSI.