Journal for Healthcare Quality

Abstract: Nontechnical skills relating to team functioning are vital to the effective delivery of patient care and safety. In this study, we develop a reliable behavioral marker tool for assessing nontechnical skills that are critical to the success of ward-based multidisciplinary healthcare teams. The Team Functioning Assessment Tool (TFAT) was developed and refined using a literature review, focus groups, card-sorting exercise, field observations, and final questionnaire evaluation and refinement process. Results demonstrated that Clinical Planning, Executive Tasks, and Team Relations are important facets of effective multidisciplinary healthcare team functioning. The TFAT was also shown to yield acceptable inter-rater agreement.

Abstract: Suzanne F. Delbanco is the executive director of Catalyst for Payment Reform (CPR), a nonprofit organization working for coordinated action among the largest purchasers of healthcare and health plans to reform the way we pay for healthcare in the United States to improve quality and cost. In addition to her duties at CPR, Suzanne is on the Advisory Committee to the Director and the National Biosurveillance Advisory Subcommittee of the Centers for Disease Control and Prevention. She also serves on the boards of HCI3, the Anvita Health Advisory Council, the executive committee of the California Maternal Quality Care Collaborative, and participates in the Healthcare Executives Leadership Network. Before CPR, Suzanne was President, Health Care Division at Arrowsight Inc., a company using video to help hospitals measure the performance of healthcare workers and provide them with feedback while they are working to improve adherence to safety and quality protocols. From 2000 to 2007, Suzanne was the founding CEO of The Leapfrog Group. The Leapfrog Group uses the collective leverage of its large corporate and public members to initiate breakthrough improvements in the safety, quality, and affordability of healthcare for Americans. Before joining Leapfrog, Suzanne was a senior manager at the Pacific Business Group on Health where she worked on the Quality Team. Suzanne holds a PhD in Public Policy from the Goldman School of Public Policy and a MPH from the School of Public Health at the University of California, Berkeley.

Abstract: One of the most challenging problems facing healthcare providers is to determine the actual cost for their procedures, which is important for internal accounting and price justification to insurers. The objective of this paper is to find suitable categories to identify the diagnostic outpatient medical procedures and translate them from functional orientation to process orientation. A hierarchal task tree is developed based on a classification schema of procedural activities. Each procedure is seen as a process consisting of a number of activities. This makes a powerful foundation for activity-based cost/management implementation and provides enough information to discover the value-added and non-value-added activities that assist in process improvement and eventually may lead to cost reduction. Work measurement techniques are used to identify the standard time of each activity at the lowest level of the task tree. A real case study at a private hospital is presented to demonstrate the proposed methodology.

Abstract: Evidence-based guidelines exist for the management of patients with acute coronary syndromes (ACS), yet adherence is suboptimal. The Discharge Management of Acute Coronary Syndrome project used a quality improvement approach, with targeted intervention strategies to optimize: prescription of guideline-recommended medications; education regarding lifestyle modifications, including cardiac rehabilitation (CR); and communication between hospital staff, patients, and general practitioners. Hospitals across Australia participated in a quality improvement cycle of audit, feedback, intervention, and reaudit. Interventions involved educational meetings, academic detailing and point-of-care reminders, and feedback of baseline audit results. Outcome measures included prescription of guideline-recommended medications, referral to CR, and documentation and communication of management plan. At baseline, 49 hospitals recruited 1,545 patients, and postintervention, 45 hospitals remained active in the project and recruited 1,589 patients. Three thousand and thirty-four hospital staff attended group education or academic detailing sessions. Postintervention, there was a significant increase in the prescription of all four guideline-recommended medications (69% vs. 57%; p<.0001); short-acting nitrates (68% vs. 56%; p<.0001); and documented referral to CR (68% vs. 57%; p<.0001). There were significant increases in documented discharge medication counselling, smoking cessation counselling, and communication of management plans. Targeted educational interventions used as part of a quality improvement cycle can enhance adherence to evidence-based guidelines for the management of patients with ACS.

Abstract: Measuring and, ultimately, addressing disparities in long-term care quality continue to be a challenge. Although literature suggests that disparities in healthcare quality exist and nursing homes remain relatively segregated, healthcare professionals and policymakers stand to benefit from improvements in measuring both racial segregation and healthcare disparities. This paper quantifies the relationships between healthcare disparities and racial segregation using the disparities quality index and dissimilarity index. Results suggested that the more segregated the nursing homes, the greater the observed disparities. Multivariate regression analysis indicated that the proportion of Black residents in nursing homes is the variable that best predicts disparities.

Abstract: A comprehensive perinatal safety initiative (PSI) was incrementally introduced from August 2007 to July 2009 at a large tertiary medical center to reduce adverse obstetrical outcomes. The PSI introduced: (1) evidence-based protocols, (2) formalized team training with emphasis on communication, (3) standardization of electronic fetal monitoring with required documentation of competence, (4) a high-risk obstetrical emergency simulation program, and (5) dissemination of an integrated educational program among all healthcare providers. Eleven adverse outcome measures were followed prospectively via modification of the Adverse Outcome Index (MAOI). Additionally, individual components were evaluated. The logistic regression model found that within the first year, the MAOI decreased significantly to 0.8% from 2% (p<.0004) and was maintained throughout the 2-year period. Significant decreases over time for rates of return to the operating room (p<.018) and birth trauma (p<.0022) were also found. Finally, significant improvements were found in staff perceptions of safety (p<.0001), in patient perceptions of whether staff worked together (p<.028), in the management (p<.002), and documentation (p<.0001) of abnormal fetal heart rate tracings, and the documentation of obstetric hemorrhage (p<.019). This study demonstrates that a comprehensive PSI can significantly reduce adverse obstetric outcomes, thereby improving patient safety and enhancing staff and patient experiences.

Abstract: Using the classical process improvement framework of Plan-Do-Study-Act (PDSA), the diagnostic radiology department of a tertiary hospital identified several patient cycle time reduction strategies. Experimentation of these strategies (which included procurement of new machines, hiring of new staff, redesign of queue system, etc.) through pilot scale implementation was impractical because it might incur substantial expenditure or be operationally disruptive. With this in mind, simulation modeling was used to test these strategies via performance of “what if” analyses. Using the output generated by the simulation model, the team was able to identify a cost-free cycle time reduction strategy, which subsequently led to a reduction of patient cycle time and achievement of a management-defined performance target. As healthcare professionals work continually to improve healthcare operational efficiency in response to rising healthcare costs and patient expectation, simulation modeling offers an effective scientific framework that can complement established process improvement framework like PDSA to realize healthcare process enhancement.

Abstract: The purpose of the current study was to examine the role of communication competence in terms of predicting conflict style, job satisfaction, job stress, and job burnout among 221 healthcare workers. The results indicated that higher communication competence scores were predictive of integrating and obliging conflict styles among healthcare workers although lower communication competence scores were predictive of dominating and avoiding conflict styles. In addition, an integrating conflict style was predictive of reduced stress and increased job satisfaction whereas dominating and avoiding conflict styles were predictive of increased job burnout among the participants. The implications of these findings as well as study limitations are discussed.

Abstract: The inpatient medication delivery system used at a large regional acute care hospital in the Midwest had become antiquated and inefficient. The existing 24-hr medication cart-fill exchange process with delivery to the patients' bedside did not always provide ordered medications to the nursing units when they were needed. In 2007 the principles of the Toyota Production System (TPS) were applied to the system. Project objectives were to improve medication safety and reduce the time needed for nurses to retrieve patient medications. A multidisciplinary team was formed that included representatives from nursing, pharmacy, informatics, quality, and various operational support departments. Team members were educated and trained in the tools and techniques of TPS, and then designed and implemented a new pull system benchmarking the TPS Ideal State model. The newly installed process, providing just-in-time medication availability, has measurably improved delivery processes as well as patient safety and satisfaction. Other positive outcomes have included improved nursing satisfaction, reduced nursing wait time for delivered medications, and improved efficiency in the pharmacy. After a successful pilot on two nursing units, the system is being extended to the rest of the hospital.

Abstract: Patient waiting time and waiting room congestion are quality indicators that are related to efficiency of ambulatory care systems and patient satisfaction. Our main purpose was to test a program to decrease patient visit cycle time, while maintaining high-quality healthcare in a high-volume inner-city hospital-based clinic in New York City. Use of patient flow analysis and the creation of patient care teams proved useful in identifying areas for improvement, target, and measure effectiveness of interventions. The end result is reduced visit cycle time, improved provider team performance, and sustained patient care outcomes.

Abstract: The timely coordination of care in clinics that require frequent assessments by multiple specialists can be challenging for both patients and providers. The cornerstone of care at cystic fibrosis (CF) centers with superior clinical outcomes, as with reduced acuity of episodic disease and incidence of hospitalizations, is frequent clinical encounters coupled with aggressive therapies. However, inefficiencies in the clinical practice structure prevent optimal utilization of resources. To decrease non-value-added time, defined as time a patient spends alone in an examination room, without altering the time providers spend caring for a patient, the application of Lean methods was used to see whether reducing variation could significantly decrease lead time, considered the length of a patient visit, within a CF clinic setting. Baseline capability analyses revealed only 19.3% of patient visits were completed in 60 min or less, with mean and median visit times of 84 and 81 min, respectively. Final capability analyses demonstrated that 41.5% of patient visits were completed in 60 min or less, 23% greater than the baseline capability. Mean and median visit times decreased by 10 min per visit. Research efforts increased the available capacity by 500 patient visits per year, representing additional revenue of over US$165,000 annually with no additional administrative costs incurred.

Abstract: This paper explores the link between utilization of ambulatory care and the likelihood of rehospitalization for an avoidable reason in veterans served by the Veteran Health Administration (VA). The analysis used administrative data containing healthcare utilization and patient characteristics stored at the national VA data warehouse, the Corporate Franchise Data Center. The study sample consisted of 284 veterans residing in Florida who had been hospitalized at least once for an avoidable reason. A bivariate probit model with instrumental variables was used to estimate the probability of rehospitalization. Veterans who had at least 1 ambulatory care visit per month experienced a significant reduction in the probability of rehospitalization for the same avoidable hospitalization condition. The findings suggest that ambulatory care can serve as an important substitute for more expensive hospitalization for the conditions characterized as avoidable.

Abstract: As part of the Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) Validation Pilot Project, we evaluated the criterion validity of PSI 7. At the time of this study, PSI 7 was entitled “Selected Infections Due to Medical Care” and targeted catheter-related infections and inflammatory reactions. We conducted a retrospective cross-sectional study of 23 volunteer U.S. hospitals, where trained abstractors reviewed a sample of records that met PSI 7 criteria from October 1, 2005 to March 31, 2007. Of the 191 cases that met PSI 7 criteria, 104 (positive predictive value = 54%, 95% confidence interval: 40–69%) represented true infections. Of these cases, 77 (74%) were associated with central venous catheters, 15 (15%) were associated with peripheral intravenous (n=13) and or or arterial catheters (n=6), and 12 (11%) were associated with unknown catheters. Of the 87 (46%) false-positive cases, 41 (47%) did not have a qualifying infection identified by the abstractor, 38 (44%) had an infection present on admission, and 8 (9%) had an exclusionary diagnosis. PSI 7 has a low positive predictive value compared with other PSIs recently studied. Present on admission diagnoses and improved coding for infections related to central venous catheters (implemented October 2007) may improve validity.

Abstract: Improving outcomes is a central theme in the national healthcare reform discussions and the ongoing debate centers on ways to limit escalating costs while maintaining excellent patient outcomes. Facilities need to be able to make sense of their “numbers,” implement appropriate change in practice, evaluate the impact of this change, and understand what the new numbers are really conveying to the public. The need for a dynamic, longitudinal data system that allows rapid response to new insights and discoveries must be available on a local level. Atrial fibrillation, an electrical conduction disorder of the heart that carries significant morbidity with its onset, is a chronic condition that currently affects over 2 million people in the United States. Our institute has performed over 450 surgeries for atrial fibrillation and is one of the few facilities nationwide that offers surgery for atrial fibrillation. As an exemplar, we describe our experience with the establishment of a database process that links hospital databases together as well as creates a patient's longitudinal record of follow-up that includes later events, interventions, and outcomes out to 5 years. Furthermore, we discuss how these data have changed our practice and go beyond the reporting of just numbers.

Abstract: Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.

Abstract: Patient recognition of hospital providers is low and may affect patient knowledge and satisfaction with care. Our study aimed to determine the association between patient knowledge of their inpatient providers' face, name, or role with knowledge of their diagnosis, satisfaction with care, and 30-day readmission rate. We conducted a cross-sectional survey of inpatients discharged from medicine housestaff teams from 2008 to 2009. Patients identified providers by face, name, and role and stated their reason for hospitalization. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey assessed patient satisfaction with care. Eighty-nine of 95 patients (94%) participated. Seventy-five percent of patients recognized one provider face, 28% knew at least one provider name, and 21% correctly stated provider roles. Fifty-seven percent of patients knew their diagnosis. Satisfaction with care via HCAHPS varied: 78% always felt treated with courtesy and respect; 75% felt doctors always listened; and 67% felt complete involvement in care decisions. In bivariate and multivariate analyses, knowledge of providers by face, name, or role was not associated with knowledge of diagnosis, satisfaction, or 30-day readmission rates (all p>.05). Thus, patient recognition of providers was not associated with their knowledge, satisfaction, or readmission.

Abstract: A growing body of evidence suggests that patients who receive coordinated and uninterrupted health care services have better outcomes, more efficient resource utilization, and lower costs of health care. However, limited research has considered whether attributes of continuity in home health care service delivery are associated with improved patient outcomes. The present study examines the relationship between one dimension of continuity of care, consistency in nursing personnel, and three patient outcomes: hospitalization, emergent care, and improvement in activities of daily living. Analyses of data from a large population of home health patients (N=59,854) suggest that greater consistency in nursing personnel decreases the probability of hospitalization and emergent care, and increases the likelihood of improved functioning in activities of daily living between admission and discharge from home health care. These results provide preliminary evidence that efforts to decrease dispersion of nursing personnel across a series of home visits to patients may lead to improved outcomes. The implications of these findings for clinical practice and further research are discussed in the paper.

Abstract: Application of Six-Sigma methodology and Change Acceleration Process (CAP)/Work Out (WO) tools to track pap smear results in an outpatient clinic in a hospital-based residency-training program. Observational study of impact of changes obtained through application of Six-Sigma principles in clinic process with particular attention to prevention of sentinel events. Using cohort analysis and applying Six-Sigma principles to an interactive electronic medical record Soarian workflow engine, we designed a system of timely accession and reporting of pap smear and pathology results. We compared manual processes from January 1, 2007 to February 28, 2008 to automated processes from March 1, 2008 to December 31, 2009. Using the Six-Sigma principles, CAP/WO tools, including “voice of the customer” and team focused approach, no outlier events went untracked. Applying the Soarian workflow engine to track prescribed 7 day turnaround time for completion, we identified 148 pap results in 3,936, 3 nongynecological results in 15, and 41 surgical results in 246. We applied Six-Sigma principles to an outpatient clinic facilitating an interdisciplinary team approach to improve the clinic's reporting system. Through focused problem assessment, verification of process, and validation of outcomes, we improved patient care for pap smears and critical pathology.

Abstract: Hospital-acquired pressure ulcers in the United States were estimated to cost US$2.2 to US$3.6 billion per year in 1999. In the early 1990s clinical practice guidelines for the prevention and treatment of pressure ulcers were introduced. The purpose of this study was to examine the epidemiology of pressure ulcers in acute care in Canada. The current study is based on 12,787 individuals who were inpatients during a 1-day annual census conducted in an acute care facility in Ontario between 1994 and 2008. The prevalence and incidence of pressure ulcer decreased slightly over time while the risk of pressure ulcer increased. The coccyx sacrum (∼27%), heel (13%), ankle (∼12%), and ischial tubersosity (∼10%) were the most common ulcer sites. The implementation of clinical practice guidelines appears to have improved the quality of patient care, as demonstrated by increasing pressure ulcer risk while the prevalence and incidence of pressure ulcers has remained somewhat constant. From a policy perspective the importance of monitoring and tracking the risk and occurrence of this adverse event provides a general indicator of care, considering the many organizational aspects that may ameliorate risk.