BACKGROUND:Discussions surrounding the role of government have been and continue to be a favorite American pastime. A framework is provided for understanding the 10 roles that government plays in improving health care quality and safety in the United States. Examples of proposed federal actions to reduce medical errors and enhance patient safety are provided to illustrate the 10 roles: (1) purchase health care, (2) provide health care, (3) ensure access to quality care for vulnerable populations, (4) regulate health care markets, (5) support acquisition of new knowledge, (6) develop and evaluate health technologies and practices, (7) monitor health care quality, (8) inform health care decision makers, (9) develop the health care workforce, and (10) convene stakeholders from across the health care system.CONCLUSION:Government's responsibility to protect and advance the interests of society includes the delivery of high-quality health care. Because the market alone cannot ensure all Americans access to quality health care, the government must preserve the interests of its citizens by supplementing the market where there are gaps and regulating the market where there is inefficiency or unfairness. The ultimate goal of achieving high quality of care will require strong partnerships among federal, state, and local governments and the private sector. Translating general principles regarding the appropriate role of government into specific actions within a rapidly changing, decentralized delivery system will require the combined efforts of the public and private sectors.
BACKGROUND:The Agency for Healthcare Research and Quality (AHRQ) defines its venous thromboembolism (VTE) patient safety indicator (PSI) as surgical cases with a secondary diagnosis of pulmonary embolism or deep vein thrombosis. Short-term readmissions for VTE are excluded because most state administrative databases are unable to track readmissions.METHODS:Patients meeting the AHRQ VTE PSI definition and those readmitted with a VTE principal diagnosis within 30 days of a prior surgical hospitalization were identified on the basis of inpatient discharge data.RESULTS:A total of 4,906 surgical discharges in New York met the AHRQ VTE PSI definition in 2001. An additional 1,059 cases of VTE were found when surgical patients with a short-term readmission for VTE were identified. Patients readmitted with VTE were less likely to die but were more likely to have a pulmonary embolism and were more likely to be white and non-Hispanic compared to those who met the AHRQ VTE PSI definition.DISCUSSION:Short-term readmissions for VTE represent potentially important cases to capture when monitoring adverse events. Prophylaxis, monitoring, and patient education may be required after hospital discharge to prevent or treat VTE as early as possible. Data systems that can track patients across multiple admissions to identify complications resulting in short-term readmissions are needed.
BACKGROUND:Strategies to reduce health expenditures through the improvement of health and quality of care are in high demand. A group of experts formed a nonpartisan, independent work group, under the sponsorship of the National Managed Health Care Congress. Its goal was to establish a list of easy-to-understand, actionable, and usable recommendations to enable disease management program advocates to conduct basic-level evaluations.RECOMMENDATIONS:The work group made recommendations concerning identification of reference and intervention population, population definitions, quantitative methods and data quality, confounding and bias, and stakeholder agreements/contracting.CASE STUDY:A case study was created to quantitatively illustrate some of the major issues raised by the work group. Five typical errors were simulated by applying different rules to the intervention population than to the reference population: differential inclusion (high versus low risk), differential exclusion (high versus low risk) and differential claims run-out. Compared with the true impact, four of the five errors resulted in a bias toward "intervention effect," while one (differential inclusion of high-risk patients) was biased against the "intervention effect." The direction and magnitude of the bias in natural settings will not necessarily follow this pattern.
BACKGROUND:A study was undertaken to verify the accuracy of computer algorithms on administrative data to identify hospital complications. The assessment was based on a medical records indicator that differentiated hospital-acquired conditions from preexisting comorbidities.METHODS:The indicators for identifying potential hospital complications were applied to all secondary diagnoses to distinguish hospital-acquired from preexisting conditions for all 1997-1998 discharges.RESULTS:Of the 95 defined complication types, cases were found with secondary diagnoses that met the criteria for 71 different complications. Sixty-nine of these complications had one or more cases with the trigger diagnosis coded as an acquired condition. Thirty-five complications had at least 30 cases with acquired conditions. Hospital complications add greatly to costs; for example, postoperative septicemia increased the hospital bill by more $25,000, added 13 hospital days to the stay, and increased hospital mortality by 16.6%.CONCLUSIONS:Current complication algorithms identify many cases where the condition was actually present on hospital admission. This fact, coupled with the known variability in coding between institutions, makes comparisons between hospitals on many of the complications problematic. Collection of the present-on-admission flag significantly reduces the noise in monitoring complication rates.
BACKGROUND:At The Johns Hopkins Hospital (JHH), the patient safety committee created a safety program that focused on encouraging staff in selected units to identify and eliminate potential errors in the patient care environment. As part of this program, senior hospital executives each adopted an intensive care unit and worked with the unit staff to identify issues and to empower staff to address safety issues. JHH PATIENT SAFETY PROGRAM: The program consisted of eight steps, which together require six months for implementation: (1) conduct a culture survey; (2) educate staff on the science of safety; (3) identify staff safety concerns through a staff safety survey; (4) implement the senior executive adopt-a-work unit program; (5) implement improvements; (6-7) document results, share stories, and disseminate results; and (8) resurvey staff.RESULTS:The senior executive adopt-a-work unit program was successful in identifying and eliminating hazards to patient safety and in creating a culture of safety.DISCUSSION:The program can be broadly implemented. The keys to program success are the active role of an executive advocate and staff's willingness to openly discuss safety issues on the units. Regular meetings between the advocates and the units have provided a forum for enhancing executive awareness, increasing staff confidence and trust in executive involvement, and swiftly and effectively addressing areas of potential patient harm.
BACKGROUND:Translating research findings into sustainable improvements in clinical and patient outcomes remains a substantial obstacle to improving the quality and safety of care. The Agency for Healthcare Research and Quality funded two initiatives to assess strategies for improvements--Translating Research into Practice (TRIP). The TRIP II initiative supported 13 quality improvement projects. SURVEYING THE TRIP II STUDIES: The principal investigators (PIs) of the 13 projects were surveyed regarding encountered barriers to implementation at 6 months and 18 months (when they were also asked about solutions).RESULTS:Seven of the 13 PIs responded to the survey at both times--6 and 18 months. For each project stage--Select a TRIP focus and develop intervention strategies (Stage 1), Conduct the intervention (Stage 2), and Measure the Impact (Stage 3)--barriers were described, and field-tested solutions were provided. For example, for Stage 2, if the target audience lacked buy-in and would not participate, solutions would be to get up-front buy-in from all staff, not just leaders; address root causes of problems; use opinion leaders and incentives; plan interventions ahead and provide make-up videos; and accept that targets vary in their readiness to change.DISCUSSION:The framework and examples provided should help overcome challenges in any work in which research findings are applied to clinical practice.
BACKGROUND:Among the most resource intensive and challenging of medical needs is the treatment of patients requiring long-term or chronic mechanical ventilation. Expenditures are significant, and definitions of "successful weaning," are often inconsistent. A weaning program was initiated for patients referred to a stand-alone nursing home ventilator unit.METHODS:Weaning entailed standardized weaning protocols, enhanced socialization, a multidisciplinary approach to care, empowerment of staff to initiate weaning, and aggressive utilization of noninvasive positive pressure ventilation (NPPV) in selected patients.RESULTS:Sixty-eight (67%) of 102 patients were successfully weaned during a six-year period. NPPV facilitated successful weaning in 27 (26%) of 102 patients. Of the 28 chronic ventilator-dependent patients admitted with a neuromuscular etiology for respiratory failure, NPPV was utilized in 73% (8/11) of the successfully weaned patients. Total variable costs per ventilator per patient per day for the years 1998-2000 were $319.79, $302.75, and $297.59. Six-year cost savings for referring hospitals were estimated at $18.5 million.DISCUSSION:Incentives were aligned between the hospital, nursing home, and physicians to develop a financially stable model. Developing an off-site nursing home ventilator unit resulted in significant cost savings to the referring hospitals and positively affected patient flow.
BACKGROUND:Epinephrine auto-injectors for food allergy emergency treatment is used as a case study to illustrate how human factors in device design has an impact on proper management of anaphylaxis. Because timely injection is so crucial, epinephrine comes in preloaded syringes or auto-injectors that patients can carry with them. However, many factors influence whether treatment is carried out properly.HUMAN FACTORS ENGINEERING (HFE) ANALYSIS:The incidence of incorrectly using auto-injectors is not isolated; studies have shown that a significant proportion of patients, and even physicians, do not know how to correctly use the devices. Some auto-injectors appear to be modeled with a metaphor in mind (a pen), but they do not appear and operate consistently with the metaphor. In addition, the device is difficult to transport. The portability issue creates a challenge that cannot be adequately addressed with traditional intervention measures--reminders or more education. They are all human factors issues and require human factors-based interventions.SUMMARY:Although education and training in how to use an auto-injector are important for effective management of anaphylaxis, a poorly designed device can lead to incorrect operation of such a device. HFE can improve device design so that it is reliably and correctly used even with minimal training. Manufacturers, allergists/immunologists, and pharmacists all have critical roles to play to ensure the correct use of this life-saving device.
BACKGROUND:A pre-post observational design was used to study the aggregate results of five national Breakthrough Series (BTS) collaboratives run within Veterans Health Administration (VHA) to identify the organizational, interpersonal, and systemic characteristics of successful improvement teams.METHODS:One hundred thirty-one medical quality improvement teams participated in five BTS collaboratives in the VHA between 1999 and 2002. Team characteristics were assessed using a team questionnaire before and after the BTS collaboratives.RESULTS:Fifty-seven percent of participating teams were rated as successful (a > or = 20% improvement from baseline for at least two months before the collaboratives' end). More high-performing medical quality improvement teams perceived their work to be part of their organization's key strategic goals. By the end of the BTS collaboratives, high-performing teams had more front-line staff support and stronger team leadership.DISCUSSION:Strong organizational support, strong team leadership, and high levels of interpersonal team skills help medical quality improvement teams go further to improve clinical care. It is recommended that quality improvement teams become integrated with their organization's key strategic goals, that improvement teams stay together, and that leadership and team training be provided to improve clinical outcomes.
Two individual teams, one from a small, rural clinic and one from a larger urban health system, were able to introduce innovations in care and realize improvement in patient outcomes.
BACKGROUND:The Hospital of the University of Pennsylvania (Philadelphia), a university-affiliated academic health center, developed and pilot tested a method for analyzing staffing effectiveness. SCREENING INDICATORS: Human resource screening indicators chosen for analysis included direct caregiver indicators (based on nursing and allied health resource data), such as registered nurse (R.N.) turnover rate, and indirect caregiver indicators (based on overall health care organization resource data), such as overall hospital turnover rate. Clinical/service screening indicators consisted of five nursing-sensitive outcome variables. DATA COLLECTION:Patient unit-based data collection at the hospital was institutionally aggregated on a quarterly basis for all human resource and clinical service indicators. Initial methodological development and pilot testing focused on statistical process control chart (SPCC) methodology for longitudinal measurements and the use of spider diagrams for examination of potential relationships within and among all variables, with all variables considered simultaneously in an interrelational analytical process. DISCUSSION:The design, development, and pilot-testing of the staffing-effectiveness methodology led to recommendations for clinical and operational interventions.
BACKGROUND:Domestic violence (DV) is a significant problem in terms of both patient harm and cost. To better address this problem, the diagnosis and treatment of DV are considered within the emerging model of patient safety and medical error reduction. The case of a female patient who presents in the clinical setting following an incident of DV shows how medical errors can be analyzed as they are in medical cases not involving DV, such as when a person with abdominal pain is sent away from the emergency department with instructions to take an acid reducer and later suffers a burst appendix. ROOT CAUSE ANALYSIS:A number of factors inhibit the correct diagnosis and treatment of DV victims seeking additional treatment. Physicians often fail to screen for DV, misidentify symptoms, or deny the possibility of underlying DV, and patients often hide the symptoms and refuse to admit the problem. However, human factor errors related to knowledge, cultural norms, and individual biases; organizational factors, including lack of training and reimbursement; and technology factors related to information accessibility appear to play significant roles. CONCLUSION:Failure to diagnose or adequately address DV can be interpreted as medical errors. Addressing DV requires a systemic response, which might begin with integrating education and training about DV into the clinical setting, ensuring the use of existing screening tools, and providing adequate and appropriate reimbursement levels.
BACKGROUND:An approach to fall prevention was conducted under the assumption that all inpatients are at risk for falls and that all employees within the hospital setting have a role in fall prevention. FALL PREVENTION PROGRAMS: Northwestern Memorial Hospital (Chicago), a 725-bed tertiary care academic medical center, recently updated a longstanding fall prevention program, "Take a Glance," to standardize and simplify its approach to fall prevention. In the "Take a Second Glance" program, all patients were screened for higher-than-standard fall risk on admission and at least every 24 hours. Standard interventions were recommended and integrated into practice for all patients. The training session for managers provided information, materials, and job aids for staff to facilitate implementation. A reduced number (36 to 13) of interventions were prescribed for fall prevention, and important safety measures were to be incorporated into the patient's plan of care.RESULTS:A 20% reduction in total falls (p < 0.0001), a 15% reduction in the average hospital fall rate (p < 0.0001), and a more than doubling of the average days between falls with injuries were found when comparing 11 months of data to the previous year.DISCUSSION:The fall prevention program is now in the control phase after program implementation. Data are monitored closely for variation, and discussions regarding continued rigorous goal setting for further improvements are planned.
BACKGROUND:A retrospective cohort study was conducted to elucidate which hospital-based quality improvement (QI) strategies are most effective in facilitating improvement in care for patients with community-acquired pneumonia.METHODS:In 1999 telephone interviews were conducted with 29 acute care hospitals in Connecticut regarding their use of QI strategies for 1,234 patients at baseline and 1,081 patients at follow-up.RESULTS:Hospital-based QI strategies were grouped into two domains of implementation approach (epidemiologic and social influence). Hospitals scoring a 4 in either the epidemiologic or social influence approach (versus a score of < or = 3) experienced a greater-than-average increase in percentage of patients with blood culture collection within 24 hours of hospital presentation. Hospitals applying all four social influence QI strategies showed a greater-than-average increase in delivery of antibiotics within 8 hours of patients' hospital arrival when compared with all the other hospitals combined.DISCUSSION:The finding that an increased proportion of patients receiving antibiotics within 8 hours and blood cultures within 24 hours of hospital arrival when the greatest numbers of hospital-based QI strategies were implemented in suggestive of a possible "dose effect" of QI.
BACKGROUND:A fictional scenario based on a compilation of several real events describes seven medical errors that at first appear to be caused by the paramedics and nurses involved.HUMAN FACTORS ENGINEERING (HFE) ANALYSIS:An emergency medical services paramedic attempted to use a debrillator on a 67-year-old man with ventricular tachycardia Yet nothing happened. The defibrillator displayed an indication that it was in synchronized mode but provided no feedback to tell the user that it was not prepared to shock because of low QRS amplitude. USABILITY TESTING: A hands-on approach to discovering the difficulties and potential for error that people encounter when trying to use a product, usability testing can help to create medical devices and systems that are not only more "user friendly" and efficient-but safer.RECOMMENDATIONS:Recommendations are presented to enable health care leaders to apply human factors considerations in their product evaluation and purchasing decisions. Medical device manufacturers should involve human factors engineers in the design process from the outset and should perform usability testing. Health care organizations should expect an optimized and tested user interface in the medical devices they purchase.SUMMARY:Many adverse events in medicine are the result of poor interface design rather than human error. The HFE concepts of usability and standardization are critical to patient safety.
BACKGROUND:The Rockwood Clinic in Spokane, Washington, participated in the Washington State Diabetes Collaborative, which promoted spread of the Chronic Care Model. Eleven participating providers managed care for 698 patients with diabetes, while 19 non-participating providers had 1,300 patients. IMPLEMENTING THE CHRONIC CARE MODEL: Rockwood upgraded its clinical information system to allow for creation of a patient registry to track clinical measures and generate performance reports. Components included a referral mechanism to facilitate more frequent use of diabetes educators, monthly reports, and sharing of results and updated clinical information from consulting specialists. Rockwood created a self-management tool kit and implemented patient goal setting and group visits.OUTCOME MEASURES:Seven of the 12 patient outcomes were significantly better for participating providers (p < .05). Two favorable outcomes, eye examinations and blood pressure < 130/85 mm Hg, were significantly associated with greater participation levels at p < .05.DISCUSSION:Implementing the Chronic Care Model to improve care, using quality improvement staff and administrative support, required fundamental changes in the system of care delivery. These changes were designed to refocus diabetes care efforts at Rockwood on prevention rather than acute care episodes.
BACKGROUND:A culture of safety survey was used to study features of the safety culture and their relationship with patient safety indicators.STUDY DESIGN:Anonymous written surveys were collected from 455 of 1,027 (44%) workers at four Massachusetts hospitals. Respondents characterized their organizations' patient safety, workplace safety, and features of a safety culture, such as leadership commitment, professional salience, presence of a nonpunitive environment, error reporting, and communication.RESULTS:Employees universally regarded patient safety as an essential part of their job. Two-thirds of workers worried at least once a day about making a mistake that could injure a patient; 43% said that the work load hindered their ability to keep patients safe. Workers' overall assessment of patient safety was associated with their perceptions of workplace safety (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.02-3.43, p = .044) and leadership commitment to patient safety (OR 3.20, 95% CI 1.97-5.19, p < .001). Incident reporting rates correlated with survey results, while adoption of best practices and expert opinion did not.DISCUSSION:Patient safety is salient to workers, who universally embraced patient safety as an essential part of their job. Independent indicators of patient safety did not line up neatly with safety culture survey results. Incident reporting rates correlated directly, while adoption of best practices and expert opinion varied inversely with survey results. The safety culture is a complex phenomenon that requires further study.
BACKGROUND:An independent health care evaluating organization reported on the Internet that the 1996-1998 mortality rate for simple pneumonia (one of the diagnoses in diagnosis-related group [DRG] 89) was 11.06% (expected rate, 7.69%)--a rate much higher than suggested by the medical center's prospective quality surveillance. Chart review was undertaken to explain this reported higher mortality rate.METHODS:Two-hundred forty-six charts of patients (123 expired, and 123 alive at discharge) were reviewed; each chart concluded with a principal diagnosis. The differences between the originally coded principal diagnosis and the recoded principal diagnoses were examined.RESULTS:Application of Coding Clinic guidelines revealed that a principal diagnosis of simple pneumonia should have been coded in only 85 (34.6%) of the charts. The remaining charts should have been coded as respiratory failure (13.8%), congestive heart failure (11.4%), respiratory infections and inflammations (7.7%), and other diagnoses (32.5%). Coding occurred prior to discharge summary dictation in 48.4% of the cases. On the basis of the findings, the actual calculated mortality rate of simple pneumonia was 6.6%.DISCUSSION:Coding in advance of discharge summary completion and nonexplicit documentation of the principal diagnoses occurred frequently. Reasons for miscoding included failure to distinguish between principal and final diagnoses, delay in discharge summary dictation, and inadequate documentation.
BACKGROUND:Monitoring newborns within the first week is critical to assess the adequacy of feeding and weight gain and to identify instances of hyperbilirubinemia. As systems of maternal and newborn care have become increasingly fragmented, infants are at increased risk of poor outcomes because of poor follow-up. Structured focus groups were conducted in June--July 2001 to provide information about the barriers to timely newborn follow-up and strategies to address them.METHODS:One focus group for physicians and one for nurses were held at the Henry Ford Health System, Detroit, and two focus groups of parents were recruited by Blue Cross Blue Shield of Texas, Dallas.RESULTS:Barriers were identified in communication and information, systems and processes of care, and parental knowledge and education. Concerns raised by clinicians and parents were consistent and complementary. Some organizations have begun implementing some of the suggested strategies to achieve timely follow-up.DISCUSSION:Implementing the AAP guideline and improving safe care in the first week of newborn life will require attention to linkages and transitions between these various microsystems.
BACKGROUND:Although human factors engineering (HFE) is considered only in relationship to the design of medical devices or information systems technology, human factors issues arise in many aspects of work in health care organizations.HFE ANALYSIS:In one scenario, the resuscitation stretcher would not pass through the ED door closest to radiology. Many clinical work spaces were never formally designed for the work currently being performed in them; instead, they were adapted from existing space originally designed for a different use. In a second scenario, infusion pump malfunction was not apparent. The patient experienced a near miss secondary to poor design; users thought that the infusion pump had been turned off when it was not.RECOMMENDATIONS:Health care can significantly benefit from the incorporation of HFE into the workplace. Introductory classes in medical and nursing schools on HFE will assist students in detecting HFE-related issues, making them less likely to suffer with them or overlook them once in clinical practice. More extensive training for patient safety and risk managers, that is, at a minimum, a certificate-level course from an HFE program, would enhance case and root cause analyses since these issues are rarely factored in.CONCLUSION:Collaboration with HFE experts and use of HFE principles may not make health care fool-proof, but it will make it less dependent on improvisation and ingenuity to protect patients from the system's vulnerabilities.
