Journal for Healthcare Quality

Abstract: Benchmarking expedites the quest for best practices and is crucial to hospitals' effective, reliable, and superior performance. Comparative performance data are used by accrediting and regulatory bodies to evaluate performance and by consumers in making decisions on where to seek healthcare. Nursing-sensitive quality measures affirmed by the National Quality Forum are now used in public reporting and pay-for-performance in addition to traditional medical outcome metrics. This report provides hospital nursing-sensitive benchmarks from medical/surgical, critical care, and step-down units drawn from 196 hospitals during six quarters in 2007 and 2008. Outcome measures include pressure ulcer prevalence rates and fall/falls with injury rates. Additional indicators that describe nursing care (nurse staffing care hours, skill mix, nurse/patient ratios, workload intensity, voluntary turnover, and use of sitters) and patient descriptors (age, gender, and diagnosis description) were also included. Specific benchmarks are provided using the 10th and the 90th percentiles, as well as quartiles to allow hospitals an opportunity to understand comparative performance with specificity. The purpose of this article is to provide hospitals not currently participating in comparative benchmarking databases with nursing-sensitive data from the Collaborative Alliance for Nursing Outcomes for use in performance improvement processes.

Abstract: Even though the expression "Patient and Family-Centered Care (PFCC)" is widely used, there remains a lack of clarity regarding how the fundamental tenets of PFCC fit with our current model of healthcare. The purpose of this manuscript was to describe the first step in developing an organizational understanding of the operational construct for PFCC utilizing a concept map and the fundamental concept mapping learning theories. The overall goals were to build a more robust organization-wide understanding of the basic PFCC tenets guided by the philosophy of concept mapping. The long-range aspirations of this process are to improve safety and quality of life by incorporating the PFCC philosophy in the career development path of our students and healthcare professionals.

Abstract: Even though rapid response teams (RRTs) have been widely adopted, reports about their efficacy in reducing mortality have been conflicting, both in terms of outcomes, and standardization of measures. Our data demonstrate that it is possible to detect significant changes within the patient population while overall mortality rates appear not to change. Our focus will be on three indicators: unplanned transfers to the ICU as an RRT outcomes measure, changes in ICU patient utilization, and mortality. Between 2005 and 2008, RRT intervention had an impact on patient outcomes by reducing the rate of unplanned transfers to our ICU following an RRT event by 35.9%. With less severe patients able to remain on the medical wards, 12.5% of ICU beds were able to be utilized by more severe patients, and the Hospital-Standardized Mortality Ratio decreased 31.2%. The All Patient Refined Diagnostic-Related Groups (APR DRGs) risk of mortality (ROM) was used to stratify and group patients by severity, and revealed reductions in mortality among specific risk groups as well as shifts in the proportion of patient risk groups within the ICU population which were not readily apparent.

Abstract: Where minorities receive their care may contribute to disparities in care, yet, the racial concentration of care in the Veterans Health Administration is largely unknown. We sought to better understand which Veterans Affairs (VA) hospitals treat Black veterans and whether location of care impacted disparities. We assessed differences in mortality rates between Black and White veterans across 150 VA hospitals for any of six conditions (acute myocardial infarction, hip fracture, stroke, congestive heart failure, gastrointestinal hemorrhage, and pneumonia) between 1996 and 2002. Just 9 out of 150 VA hospitals (6% of all VA hospitals) cared for nearly 30% of Black veterans, and 42 hospitals (28% of all VA hospitals) cared for more than 75% of Black veterans. While our findings show that overall mortality rates were comparable between minority-serving and non-minority-serving hospitals for four conditions, mortality rates were higher in minority-serving hospitals for acute myocardial infarction (AMI) and pneumonia. The ratio of mortality rates for Blacks compared with Whites was comparable across all VA hospitals. In contrast to the private sector, there is little variation in the degree of racial disparities in 30-day mortality across VA hospitals, although higher mortality among patients with AMI and pneumonia requires further investigation.

Abstract: In order to improve health outcomes, healthcare providers need to base practice on current evidence. The purpose of this qualitative study was to explore and compare the understanding and experiences with evidence-based practice (EBP) in three different disciplines. Researchers conducted individual interviews with psychiatrists, nurses, and dental hygienists. The majority of study participants demonstrated an understanding of EBP and were able to identify enhancers and barriers to implementing EBP. Using a grounded theory approach, several major themes acting as enhancers and barriers to EBP emerged and revealed both differences and similarities within and across the three health disciplines. While saturation was not attempted, this exploratory research is important in contributing to understanding the cultural practice milieu in relation to individual characteristics in implementing evidence into practice with the overall aim of improving healthcare delivery and outcomes.

Abstract: Catholic Health Initiatives (CHI) set a goal of reducing birth injuries throughout the system. Although the number of injuries was small, clinical and risk leadership agreed that even one injury is too many. Through a multidisciplinary partnership to initiate perinatal bundles, the CHI Perinatal Care Collaborative was able to continue the reduction of injuries each year.

Abstract: Benchmarking is an indispensable tool as hospital leaders face challenges to balance efficiency with safe and effective care. Selection of appropriate "like" hospitals is critical to the benchmarking aim of understanding comparative performance. Based on 10 years of observed outcome differences between small and large hospitals, the Collaborative Alliance for Nursing Outcomes (CALNOC) sought to empirically define small hospitals, and to determine if there were statistical differences between small and large hospitals for selected nursing sensitive outcome indicators. This article reports the examination of hospital size as a proxy characteristic to define "like" hospitals for the purpose of benchmarking outcomes. Findings suggest that optimal classifications into small and large hospital size based on the outcome indicators of falls, falls with injury, and hospital-acquired pressure ulcers stage 2 or worse (HAPU 2+) were not consistent with historical administrative categories based on average daily census and not consistent by outcome. Statistical differences were only found with HAPU 2+ in critical care units, with no differences in the fall outcomes. These data did not support the use of size-based categories to define like hospitals for benchmark comparisons.

Abstract: A low hand hygiene compliance rate by healthcare workers increases hospital-acquired infections to patients. At Presbyterian Healthcare Services in Albuquerque, New Mexico a Lean Six Sigma team identified the reasons for noncompliance were multifaceted. The team followed the DMAIC process and completed the methodology in 12 months. They implemented multiple solutions in the three areas: Education, Culture, and Environment. Based on methicillin-resistant Staphylococcus aureus (MRSA) mortality research the team's results included an estimated 2.5 lives saved by reducing MRSA infections by 51%. Subsequently this 51% decrease in MRSA saved the hospital US$276,500. For those readers tasked with increasing hand hygiene compliance this article will provide the knowledge and insight needed to overcome multifaceted barriers to noncompliance.

Abstract: Dale Bratzler, DO, MPH, currently serves as the President and CEO of the Oklahoma Foundation for Medical Quality (OFMQ). In addition, he provides support as the Medical Director of the Patient Safety Quality Improvement Organization Support Center at OFMQ. In these roles, he provides clinical and technical support for local and national hospital quality improvement initiatives. He is a Past President of the American Health Quality Association and a recent member of the National Advisory Council for the Agency for Healthcare Research and Quality. Dr. Bratzler has published extensively and frequently presents locally and nationally on topics related to healthcare quality, particularly associated with improving care for pneumonia, increasing vaccination rates, and reducing surgical complications. He received his Doctor of Osteopathic Medicine degree at the Kansas City University of Medicine and Biosciences, and his Master of Public Health degree from the University of Oklahoma Health Sciences Center College of Public Health. Dr. Bratzler is board certified in internal medicine.

Abstract: Hospital-acquired pressure ulcers (HAPUs) are a national concern due to patient morbidity, treatment cost, and reimbursement issues. Stages III and IV pressure ulcers (PUs) that occur during hospitalization are among the conditions considered preventable by the Centers for Medicare and Medicaid Services (CMS). Harborview Medical Center (HMC), located in Seattle, WA, is a Level 1 trauma/burn center and safety net hospital serving diverse populations. HMC is committed to providing excellence in care including optimal skin care and PU prevention to people from all walks of life. At HMC a new system for monitoring daily PU incidence, completing monthly multidisciplinary intensive reviews on HAPUs, and application of an algorithm used to determine if HAPUs were avoidable was developed and implemented. This system has assisted HMC in addressing PU tracking, prevention, compliance with regulatory mandates and has improved skin-related outcomes.

Abstract: Influenza vaccination of health care personnel (HCP) is a patient safety issue, but the national rate is only 42%. Following an intervention in 2006[ndash]2007, HCP in a large health system were surveyed. Self-reported influenza vaccination rate was 61.6% overall, did not differ by race, education level, or employment status but was higher for older HCP ([ge]50 years; p=.002). In logistic regression, the strongest predictor of vaccination was receiving influenza vaccine the previous year, although other factors were significantly associated for younger and older HCP groups. Establishing the influenza vaccination habit using age-based targeted messages may be the most effective way to increase rates for HCP without mandates.

Abstract: Fecal occult blood testing (FOBT) is recommended by national guidelines for colorectal cancer (CRC) screening and has been shown to reduce both the incidence and mortality of CRC. FOBT screening is a complex process and little is known concerning the best methods for implementing FOBT screening in primary care clinics. The purpose of this study was to determine if direct gastroenterology (GI) service notification of all positive FOBT results in improved time for provider response and colonoscopy. The secondary aims were to determine to what extent implementation of FOBT screening was appropriate in a large primary care clinic and correlate this with findings from colonoscopy. Data were collected prospectively following implementation of a direct referral strategy and compared with two retrospective time periods during which the ordering practitioners were responsible for follow-up of all positive FOBT. Implementation of immediate GI referral of positive tests eliminated improper and neglected follow-up, and resulted in shorter delays in provider response time and colonoscopy completion. Inappropriate use of FOBT was observed in 49% of patients, indicating that further interventions in primary care clinics to improve the quality of FOBT screening are necessary.

We describe a multipronged, multidisciplinary effort to improve the safety of blood transfusion in our hospital. System-wide practices related to the ordering, delivery, and transfusion of blood products were addressed including: (1) appropriate selection of patients and utilization of blood, (2) accurate blood product labeling and tracking, (3) reliable transportation of blood products between the transfusion service laboratory and the bedside, (4) electronic verification of patients and products at the point of transfusion, and (5) documentation of transfusion events in the patient's medical record. By implementing new technologies and focusing LEAN process improvement techniques on the preanalytical, analytical, and postanalytical phases of the transfusion cycle, we have been able to significantly reduce the risk of transfusion error in our patient population.

Abstract: Our study compared adverse patient safety events among hospitals that have received the distinction "Most Wired" as rated by the Hospital and Health Network publication versus comparison hospitals. Risk-adjusted Patient Safety Indicators (PSIs) were calculated for 558 general adult medical/surgical hospitals participating in the Agency for Healthcare Quality and Research's Nationwide Inpatient Sample. When compared using mean risk-adjusted PSI rates, no significant differences in performance for specific PSIs were observed between hospitals affiliated with the "Most Wired" label and those without the designation using objective measures of safety.

Abstract: The purpose of this study is to assess the impact of a group-based program on glucose control for adults with diabetes. Ninety-two adults completed the program aimed at identifying and overcoming barriers to diabetes self-management with the use of behavioral strategies. A comparison group consisted of 275 adults with diabetes not participating in the program matched for age, gender, type of insurance coverage, and initial hemoglobin A1c (HbA1c) result. Members completing the program demonstrated significant improvements in HbA1c results at both the first and second postgroup measurements. Regression analyses identified initial HbA1c result and the interaction of condition and initial HbA1c as significant predictors of improvement in HbA1c. The quality of diabetes care and treatment outcomes can be enhanced with the inclusion of a low-cost, structured program led by a behavioral health professional.

Abstract: The prevalence of medical errors and malpractice claims has been attributed to deficits in error reporting and disclosure. Increasingly, states are adopting error reporting and apology laws to reduce these information gaps thereby instituting error-transparent medical cultures. At the same time, doubts have been expressed about the capacity for legislation to influence medical professionals. In order to assess legislative potential to establish error transparency, a cross-sectional research design compared differences in malpractice claim rates among states adopting different legislative approaches. Two one-way analysis of variance tests were performed. The first analysis indicated that there are no significant mean differences in claims rates between states enacting only an apology law, only an error reporting law, both laws, and neither law, F (3,47)=1.13, p=.34. The second analysis indicated that there are no significant mean differences in claims rates between states enacting both laws, either law, and neither law, F (2,48)=1.08, p=.35. The findings show that legislation does not have a significant capacity to regulate malpractice claims rates. This suggests that laws governing error transparency are too remote from the delivery of healthcare services to regulate disclosure behavior and that fundamental changes in our medical culture should be initiated at an organizational level.