SAFE™ Initiative: A Step Closer to Positive Safety Culture and Improved Patient Experience.

Background Positive safety culture is a key characteristic of a high-reliability organization; it is the leading service excellence standard and highest priority of The University of Texas MD Anderson Cancer Center. However, understanding the importance and impact of safety event reporting was limited at the MD Anderson campus in Sugar Land, Texas. Therefore, we implemented the Secure, Attentive, Focused, Engaged (SAFE™) initiative to create, foster, and continuously improve safety culture throughout the campus, with a secondary goal of impacting patient experience. Here, we review the SAFE™ initiative and its impact on our safety culture and patient experience. Methods The SAFE™ initiative was conceptualized and implemented in April 2017 by the leadership team at MD Anderson Cancer Center in Sugar Land. This initiative completely restructured our safety reporting and follow-up processes through leading by example, open safety meetings, transparent communication, emphasis on processes rather than people, and follow-up on any safety event entered or issue raised. We recorded quantitative measures and qualitative improvements, such as increased engagement and improved staff morale, using the results of institutional safety surveys in 2018 and 2020, which included a comparison to Agency for Healthcare Research and Quality's (AHRQ) national benchmarks and Press Ganey® patient experience scores. The AHRQ national benchmarks are based on the culture of safety surveys that measure staff views on safety, while the Press Ganey® patient experience scores measure patient perception. The SAFE™ initiative was then implemented at three additional MD Anderson Cancer Center campuses. Results During the data collection period of April 2017 to December 2021, we observed a sustained increase in safety event reporting at our campus, from 7.17 to 15.49 reports per month. We also observed a qualitative increase in safety meeting engagement and a higher participation rate in the institution-wide safety survey compared to MD Anderson Cancer Center overall. MD Anderson Cancer Center in Sugar Land scored above the national benchmarks in nine of the 13 domains in 2018 and all domains surveyed in 2020. Patient experience scores, measured by Press Ganey®, increased annually, with 2017, 2018, 2019, and 2020 fiscal year top box scores averaging 80.6%, 83.9%, 85.9%, and 86.4%, respectively. Two of the additional locations showed improvement from 2018 to 2020 in the institution-wide Culture of Safety Employee Survey and scored above the AHRQ's national benchmarks in all the domains. The third location showed improvement from 2018 to 2020 on the institution-wide Culture of Safety Employee Survey in 11 of 15 domains and scored above the AHRQ's national benchmarks in all except one domain. The greatest improvements were error feedback, employee safety, and communication openness. Conclusions Positive safety culture is a requirement for a health care organization to be designated as a high-reliability organization. At MD Anderson Cancer Center in Sugar Land, we implemented an initiative that had a meaningful impact on the creation of a positive safety culture and was successfully scaled to additional locations.

Evaluation and Improvement of Bottlenecking in a Multidisciplinary Oncology Clinic: An Electronic Medical Record Intervention.

PURPOSE: Clinic members reported slower patient flow in the mornings at a multidisciplinary oncology clinic. This study identified the causes of clinic bottlenecking via analysis of patient schedules and transit times, then corrected discrepancies through a quality improvement program. METHODS: Transit times were measured using tracking cards handed out at check-in, marked by each clinic member throughout the encounter, and collected upon discharge. Data were analyzed for differences between morning and afternoon patients, and a Pareto chart was formulated to assess for discrepancies in distribution. Repeat plan-do-study-act (PDSA) cycles were conducted, implementing two changes to redistribute appointments to optimize clinic workflow. RESULTS:  A total of 2951 patient appointments were analyzed: 589 at baseline, 277 following an initial intervention, and 2085 following a subsequent intervention. Analysis of patient transit times revealed no significant differences between morning and afternoon patient groups (t-test, p=.13-.99), with no transit interval markedly longer than others (t-test, p=.32-.83). However, upon evaluation of appointment times, a maldistribution was noted with 57% of patients concentrated between 9:00 am to 12:00 pm, accounting for the perception of bottlenecking. An initial intervention offering patients afternoon appointments on a voluntary basis was insufficient for rebalancing distribution (chi-square test, p=.299); however, an electronic medical record (EMR) intervention with rigid appointment templates was successful (chi-square test, p<.001). CONCLUSION: An imbalance of appointment times contributed to the perception of slow clinic throughput. This study emphasizes the importance of systematically investigating even consensus observations for validity prior to costly interventions. Furthermore, these results support the utility of information technology in optimizing clinic workflow.

The Effect of a Comprehensive Care Transition Model on Cost and Utilization for Medically Complex Children With Cerebral Palsy.

INTRODUCTION: Our aim was to evaluate cost and acute care utilization related to an organized approach to care coordination and transitional care after major acute care hospitalization for children with medical complexities, including cerebral palsy. METHODS: A retrospective cohort of 32 patients from Ranken Jordan Pediatric Bridge Hospital (RJPBH) who received the Care Beyond the Bedside model was compared with 151 patients receiving standard care elsewhere across Missouri. Claims data (2007-2012) were obtained from MoHealthNet, Missouri's Medicaid program, for all children with moderate to severe cerebral palsy (defined using approximated Gross Motor Function Classification System levels) who had at least one hospital visit during the study period (N = 183). Risk-adjusted linear and Poisson regression models were used to analyze per-member-per-month costs and three indicators of acute care utilization (emergency department visits, readmissions, and inpatient days). RESULTS: RJPBH patients were associated with statistically significant reductions in per-member-per-month costs (-21%), hospital readmissions (-66%), and inpatient days (-57%). DISCUSSION: RJPBH's enhanced interprofessional medical home-like model, including intense care coordination, psychosocial therapy, family and caregiver empowerment, and transitional care, may be keys to reducing cost and unnecessary hospital use for children with medical complexities with cerebral palsy who receive Medicaid.

The Association between Medicare Advantage Market Penetration and Diabetes in the United States.

The objective of this study is to explore the extent to which managed care market penetration in the United States is associated with the presence of chronic disease. Diabetes was selected as the chronic disease of interest due to its increasing prevalence as well as the disease management protocols that can lessen disease complications. We hypothesized that greater managed care market penetration would be associated with (1) lower prevalence of diabetes and (2) lower prevalence of diabetes-related comorbidities (DRCs) among diabetics. Data for this analysis came from two sources. We merged Medicare Advantage (MA) market penetration data from the Centers for Medicare and Medicaid Services (CMS) with data from the Medical Expenditure Panel Survey (MEPS) (2004-2008). Results suggest that county-level MA market penetration is not significantly associated with prevalence of diabetes or DRCs. That finding is quite interesting in that managed care market penetration has been shown to have an effect on utilization of inpatient services. It may be that managed care protocols do not offer the same benefits beyond the inpatient setting.

Chronic Disease Prevalence and Medicare Advantage Market Penetration: Findings From the Medical Expenditure Panel Survey.

By March 2015, 30% of all Medicare beneficiaries were enrolled in Medicare Advantage (MA) plans. Research to date has not explored the impacts of MA market penetration on individual or population health outcomes. The primary objective of this study is to examine the relationships between MA market penetration and the beneficiary's portfolio of cardiometabolic diagnoses. This study uses 2004 to 2008 Medical Expenditure Panel Survey (MEPS) Household Component data to construct an aggregate index that captures multiple diagnoses in one outcome measure (Chronic Disease Severity Index [CDSI]). The MEPS data for 8089 Medicare beneficiaries are merged with MA market penetration data from Centers for Medicare and Medicaid Services (CMS). Ordinary least squares regressions are run with SAS 9.3 to model the effects of MA market penetration on CDSI. The results suggest that each percentage increase in MA market penetration is associated with a greater than 2-point decline in CDSI (lower burden of cardiometabolic chronic disease). Spill-over effects may be driving improvements in the cardiometabolic health of beneficiary populations in counties with elevated levels of MA market penetration.