Journal for Healthcare Quality

Abstract: The purpose of this article is to examine the relationship between sample size and cost using a benefit to cost ratio in the context of hospital accountability measures. We argue that the decision to use larger samples should include an assessment of the marginal benefit in terms of the cost to obtain the samples. Our main conclusion is that without recognizing and balancing the cost of different sampling schemes and developing reasonable cost limits we lose an opportunity at efficiency.

Abstract: Delays, omissions, and inaccuracy of discharge information are common at hospital discharge and put patients at risk for adverse outcomes. We assembled an interdisciplinary team of stakeholders to evaluate our current discharge process between hospitalists and primary care providers (PCPs). We used a fishbone diagram to identify potential causes of suboptimal discharge communication to PCPs. Opportunities for improvement (leverage points) to achieve optimal transfer of discharge information were identified using tally sheets and Pareto charts. Quality improvement strategies consisted of training and implementation of a new discharge process including: (1) enhanced PCP identification at discharge, (2) use of an electronic discharge order and instruction system, and (3) autofaxing discharge information to PCPs. The new discharge process's impact was evaluated on 2,530 hospitalist patient discharges over a 34-week period by measuring: (1) successful transfer of discharge information (proportion of discharge information sheets successfully faxed to PCPs), (2) timeliness (proportion of sheets faxed within 2 days of discharge), and (3) content (presence of key clinical elements in discharge sheets). Postintervention, success, and timeliness of discharge information transfer between pediatric hospitalists and PCPs significantly improved while content remained high.

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: In Morocco, injuries account for 11% of total burden of disease. Better organization of emergency care can improve the outcome of trauma patients. In Morocco, these services have been reorganized recently, but were never evaluated. The objective was to assess actual structure and processes of emergency trauma care in a Moroccan region. This comparative qualitative study was carried out in the region of Fez. The process and structure of contacting emergency care and prehospital emergency care were compared with the French 2002 standards. Emergency care at the University Teaching Hospital (UTH) was compared with World Health Organization 2005 Essential Trauma Care guidelines. Predefined care items were categorized as conforming to the standards or not. An emergency call center with a dedicated dial-up number has been established in the region since January 2007. Compared with the standards, this center was not protected by any legislation and was run by interns only. The center was underutilized during triage to help transportation of severe trauma patients. At the prehospital care level, only 3 out of 15 ambulances were equipped with resuscitation equipment and were used rarely. Only one of the ambulance staff out of three was trained in required skills. At the UTH, emergency care equipment and staff was nearly adequate. This study identified several opportunities for improvement in organizing trauma care in Fez particularly at emergency call center and ambulance service. A quality assurance program would be useful to further identifying improvements in this system.

Abstract: The core of healthcare quality is continuous improvement of processes and results. For cancer patients, psychosocial care can affect overall outcomes. In this article, we outline the efforts that a national comprehensive cancer center is using to bring psychosocial care to the same level of awareness, importance, and integration as clinical care. Improving all aspects of patient care, psychosocial as well as biological, must be pursued if progress in overall quality of cancer care is to be achieved.

Abstract: We audited the seven surgical departments of a university hospital before and after implementation of a program aiming to improve practices in postoperative pain management (POPM). Audits were conducted 2 years apart. During each evaluation, 10 medical charts from each surgical department (i.e., 70 charts) were analyzed for 9 quality criteria (five concerning anesthetist practices and four nursing practices). Two scores were calculated: one per department and the other per criteria. After the first audit, the seven departments received recommendations to improve their POPM. Targeted-training sessions were instituted for the three poorest performing departments (scores <4.5 out of 9 criteria). During the period between the two audits, all seven departments improved their scores; a statistically significant improvement was observed in five departments, including the three that had received targeted-training sessions. Moreover, overall scores for seven of the nine evaluated criteria improved, significantly for three criteria. Anesthetists significantly increased their overall score from 2.5±0.8 to 3.7±0.6 out of 5 points (p=.018), while surgical nurses' overall score did not change significantly from 2.3±0.7 to 2.9±0.7 out of 4 points (p=.128). In conclusion, using a standardized and validated instrument to evaluate POPM practices enables the identification of surgical departments requiring practice improvement and those quality criteria requiring reinforcement.

Abstract: This paper describes the work of a front-line team at a 200-bed hospital in southern California to improve the patient transfer process between the Intensive Care Unit (ICU) and the Medical/Surgical floors. Using a phased approach of assessing the problem, identifying opportunities, testing ideas, and then implementing successful ideas, the team was able to improve patient transfer time from the ICU to the Medical/Surgical Floor once the bed is assigned from 6 to <2 hr and to reduce the number of patients experiencing extreme delays (more than 12 hr waits since the bed is assigned) from 15% to 0%. Also, as a corollary of this work, nursing overtime was reduced by 25% year to year between March 2008 and March 2009 and patient satisfaction scores were improved. A key success factor of the front-line team was the implementation of a sustainability plan where metric and process accountability is specified, together with alert flags for the metrics and actions to take if the alert flags are triggered.

Abstract: To address concerns about the quality of care, health plans have used varying approaches to support quality improvement (QI). Pay-for-performance (P4P) is the most commonly used and discussed approach. P4P programs have many challenges in design and execution, particularly for Medicaid providers. In order to find an alternative to P4P, CareOregon[mdash]a nonprofit health plan serving Medicaid and Medicare enrollees[mdash]developed the Care Support and System Innovation (CSSI) Program. An evaluation was conducted to assess the overall affect of the CSSI Program in promoting comprehensive improvements in quality of care and the extent to which it has the potential to offer a viable alternative to P4P. The evaluation found that the CSSI Program successfully addressed many challenges inherent in P4P. The CSSI Program engaged providers, fostered a culture of QI within CareOregon's network, and provided practices with the opportunity to develop sustainable and innovative solutions to address quality concerns. Success of the program was attributed to CareOregon's focus on building relationships while providing technical assistance and responsive funding. While health outcome data were not available to assess impact on CareOregon's members, evaluation findings highlight the importance of collaboration in QI efforts, and suggest that the model has the potential to overcome many of the challenges faced by P4P.

Abstract: The continuing problem of inaccurate medication records and resultant harm from medication errors has prompted the Institute of Medicine and others to encourage information technology (IT) solutions to improve medication list accuracy. There are few studies on how ambulatory care documentation contributes to medication list inaccuracies and medication reconciliation failures. To address medication reconciliation issues in ambulatory care, office-based physicians in a region with a high adoption rate for electronic medical records (EMRs) were surveyed about current reconciliation practices, the need for redesigning reconciliation processes, and acceptable IT solutions for improving availability of medication information. Physicians selected from a list of potential IT platforms that would create a single reconciled record of prescription medications, nonprescription medications, and supplements accessible wherever patients go. The two most popular platforms were either an aggregated list within existing EMRs accessible by inpatient and outpatient providers regardless of their EMR system, or a web-based repository that was not integrated into an EMR. Respondents felt that implementation of such platforms would not require major changes to clinical workflow, perhaps due to the region's existing familiarity with health IT. Leveraging community acceptance of health IT could result in rapid implementation of universally accessible medication list platforms.

Abstract: Kent Bottles, MD, President of the Institute for Clinical Systems Improvement (ICSI). Dr. Bottles is a board-certified pathologist who specialized in surgical and cyto-pathology. He earned a medical degree from Case Western Reserve University in Ohio. He has extensive experience in integrated healthcare delivery systems, research, academia, commercial laboratories, genomics, proteomics, and management of biotech start-up companies. Dr. Bottles was vice president and chief medical officer of the Iowa Health System. Before that, he served as president and CEO of Grand Rapids Medical Education and Research Center for Health Professions, a multi-institutional consortium of healthcare organizations, and as president of Genomics Repository and chief knowledge officer, Genomics Collaborative Inc. Dr. Bottles has extensive academic experience, serving as Professor and Acting Head, Department of Pathology and Laboratory Medicine at the University of Iowa. He was also the founding medical director of managed care plans for University of Iowa employees. Dr. Bottles has addressed topics ranging from quality and patient safety and disruptive technology to patient[ndash]physician relationships and the future of medicine. He has received numerous honors, including the Rodney T. West Literary Achievement Award for the most important article on medical management presented by the American College of Physician Executives. He has broad clinical experience with the University of Iowa and the San Francisco General Hospital, and has been a national leader in changing the practice of pathology and laboratory medicine to meet the challenges of managed care.

Abstract: Ecological momentary assessment methods were used to examine real-time relationships between work environment factors and stress in a sample of 119 registered nurses (RNs) in acute and critical care settings of three hospitals. The RNs carried handheld computers for 1 week of work shifts and were randomly surveyed within 90-min intervals to self-report work activity, perceived workload, and stress. Mixed effects linear regression analyses were completed to predict the stress score in the sample. The number of patients assigned significantly predicted stress; the greater the number of assigned patients, the higher the reported stress (p<.01). Age, gender, adult versus pediatric facility type, familiarity with patients, and proportion of direct care tasks were not significant predictors of stress. Further research is needed to link work environment factors and stress with errors among nurses.

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: Healthcare has long looked at decreasing risk in communication and patient care processes. Increasing the simplicity in communication and patient care process is a newer concept contained in Lean methodology. Lean is a strategy for achieving improvement in performance through the elimination of steps that use resources without contributing to customer value. This is known as cutting waste or nonvalue added steps. This article outlines how the use of Lean improved a key process that supports battlefield medical fitness.