Recent Publications of Note
Selected articles on quality improvement from a number of journals, including the American Journal of Medicine, Annals of Internal Medicine, Archives of Pediatric and Adolescent Medicine, BMJ, Health Affairs, Health Services Research, International Journal for Quality in Health Care, Joint Commission Journal on Quality and Safety, Journal of the American Medical Association, Journal of General Internal Medicine, Journal of Patient Safety, Journal of Safety and Quality in Health Care, Medical Care, The Milbank Quarterly, The New England Journal of Medicine, and Pediatrics. The articles are nominated by Editorial Advisory Board members from a preselected list.
Health Care System Performance
Guideline Adherence and Outcomes
This study is based on observational analysis of hospital care in 350 academic and nonacademic centers enrolled in the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative. It examined how hospital performance varied among centers, identified characteristics predictive of higher guideline adherence, and assessed whether hospitals' overall guideline adherence was associated with observed and risk-adjusted in-hospital mortality rates. The study, completed between Jan. 1, 2001, and Sept. 30, 2003, found a significant association between care processes and outcomes, leading the authors to conclude that broad, guideline-based performance metrics can be used as a means to assess and improve hospital quality. E. D. Peterson et al. (2006) Association Between Hospital Process Performance and Outcomes Among Patients with Acute Coronary Syndromes. Journal of the American Medical Association 295, 1912–1920.
Screening, Tumor Differences Account for Disparities
A prospective cohort study found that African American, Hispanic, Asian, and Native American women were more likely than white women to have received inadequate mammography screening, and that African American women were more likely than white, Asian, and Native American women to have large, advanced-stage, high-grade, and lymph node–positive tumors of the breast. While screening differences may explain African American women's higher prevalence of advanced breast tumors, tumor characteristics also contribute as African American women have higher-grade tumors than white women, regardless of screening. These results suggest that adherence to recommended mammography screening intervals could reduce breast cancer mortality rates. R. Smith-Bindman et al. (2006) Does Utilization of Screening Mammography Explain Racial and Ethnic Differences in Breast Cancer? Annals of Internal Medicine 144, 541–553.
Health Care Team Effectiveness
A literature review (1985 to 2004) distinguished among intervention studies that compare team care with usual, or nonteam, care; intervention studies that examine the impact of team redesign on team effectiveness; and field studies that explore relationships between team context, structure, processes, and outcomes. An Integrated Team Effectiveness Model (ITEM) was used to summarize research findings and identify gaps in the literature. It found that the type and diversity of clinical expertise involved in team decision-making largely account for improvements in patient care and organizational effectiveness. Also, collaboration, conflict resolution, participation, and cohesion are most likely to influence staff satisfaction and perceived team effectiveness. The authors conclude that ITEM provides a useful framework for conceptualizing relationships between multiple dimensions of team context, structure, processes, and outcomes. L. Lemieux-Charles and W. L. McGuire (2004) What Do We Know about Health Care Team Effectiveness? A Review of the Literature. Medical Care Research and Review 63, 263–300.
Quality Tools in Practice
Phone Intervention Increased Minority Screenings
A randomized, controlled trial was used to evaluate the effect of a telephone support intervention on breast, cervical, and colorectal cancer screening rates among minority and low-income women. Women assigned to the intervention group received an average of four calls over an 18-month period from prevention care managers; those assigned to the control group received usual care. The proportion of women who were up to date for three tests increased from 0.21 to 0.43 with the intervention, leading the authors to conclude that telephone support can improve cancer screening rates among women who visit community and migrant health centers. A. J. Dietrich et al. (2006) Telephone Care Management to Improve Cancer Screening Among Low-Income Women: A Randomized, Controlled Trial. Annals of Internal Medicine 144, 563–571.
Medication Reconciliation Prevents Harm
The medication orders of 60 randomly selected patients at the time of admission to a Canadian community hospital were compared with pre-admission medication use, as well as with discharge orders and written instructions. Overall, 60 percent of patients had at least one unintended variance—considered a medication error—and 18 percent had at least one clinically important unintended variance. A medication reconciliation process, designed to identify and rectify medication errors at the time of hospital admission and discharge, identified 75 percent of the 20 clinically important variances prior to patient harm. The authors conclude that reconciliation warrants broader evaluation. T. Vira et al. (2006) Reconcilable Differences: Correcting Medication Errors at Hospital Admission and Discharge. Quality and Safety in Health Care 15, 122–126.
Evidence-Based Practices Reduce Central Line Infections
A two-year project to reduce hospital-acquired infections, initiated through the Greater Cincinnati Health Council at nine health care systems, focused on evidence-based practices to reduce surgical site infections and catheter-related blood stream infections (CR-BSIs). This study evaluated the implementation of CR-BSIs safety practices—strict adherence to proper hand washing, maximum barrier precautions (sterile gown and gloves, cap, mask, and bed-sized sterile drape), and use of chlorhexidine gluconate antiseptic during placement—compared with usual practice (use of sterile gloves and sterile small drape, and betadine antiseptic). At all four initial implementation sites, central line infections were reduced by 50 percent. Also, at the project's midpoint, adherence to evidence-based practices increased from 30 percent to nearly 95 percent. Based on this experience, the authors conclude that the appropriate floor for central line infections in ICUs is < 1 infection/1,000 line days. M. L. Render et al. (2006) Evidence-Based Practice to Reduce Central Line Infections. Joint Commission Journal on Quality and Patient Safety 32, 253–260.
Error Identification and Prevention
Patients' Role in Error Prevention
A telephone survey of 2,078 patients discharged from 11 Midwest hospitals assessed whether patients took recommended actions to prevent errors. It found that 91 percent agreed patients could help prevent errors. But while patients were very comfortable asking a medication's purpose (91 percent), general medical questions (89 percent), and confirming their identity (84 percent), they were uncomfortable asking medical providers whether they had washed their hands (46 percent very comfortable). While hospitalized, many asked questions about their care (85 percent) and a medication's purpose (75 percent), but fewer confirmed they were the correct patient (38 percent), helped mark their incision site (17 percent), or asked about hand washing (5 percent). The authors conclude that educational interventions to increase comfort with error prevention may be necessary to help patients become more engaged. A. D. Waterman et al. (2006) Hospitalized Patients' Attitudes About and Participation in Error Prevention. Journal of General Internal Medicine 21, 367–370.
CPOE Reduces Pediatric Chemotherapy Ordering Errors
A before-and-after study was used to evaluate the impact of computerized provider order entry (CPOE), guided by multidisciplinary failure modes and effects analysis, on reducing ordering errors in pediatric chemotherapy. Conducted from 2001 to 2004, the study found that daily chemotherapy orders were less likely to have improper dosing, incorrect dosing calculations, missing cumulative doses calculations, and incomplete nursing checklists following CPOE system implementation. However, there was no difference in the likelihood of improper dosing on treatment plans and a higher likelihood of not matching medication orders to treatment plans. G. R. Kim et al. (2006) Error Reduction in Pediatric Chemotherapy: Computerized Order Entry and Failure Modes and Effects Analysis. Archives of Pediatric and Adolescent Medicine 160, 495–498.
Applying Ecological Lessons to Health Care
This study set out to determine whether lessons learned from the field of ecological restoration, which is concerned with the effective, efficient, and sustainable repair and recovery of ecosystems that have been degraded, damaged, or destroyed, can be used to increase medication safety. Twenty-six practitioners used the principles of good restoration to design and pilot a multifaceted medication safety intervention, including focus groups with practitioners, construction and administration of a research-based medication safety inventory, repeat digital photography of environmental safety issues, and targeted environmental modifications. Based on this research, hospital ward staff built a healthy reporting culture, introduced regular discussions of near misses, developed education strategies, redesigned delivery and storage processes, and renovated the environment. P. B. Marck et al. (2006) Building Safer Systems by Ecological Design: Using Restoration Science to Develop a Medication Safety Intervention. Quality and Safety in Health Care 15, 92–97.
SSI Guidelines Decreased Errors, Hyperglycemia
An observational before-and-after study was used to evaluate the impact of a standardized sliding scale insulin (SSI) protocol and preprinted physician order form, which included the SSI guidelines and an option for ordering one of three standardized insulin sliding scales or a patient-specific scale. One year after implementation, the physician order form was used for 91 percent of orders and, overall, 86 percent of SSI orders followed the guidelines. Further, the number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient-days at baseline to 1.2 at one year, and the number of hyperglycemia episodes decreased from 55.9 to 16.3 per 100 SSI patient days. A. C. Donihi et al. (2006) Use of a Standardized Protocol to Decrease Medication Errors and Adverse Events Related to Sliding Scale Insulin. Quality and Safety in Health Care 15, 89–91.
Information Technology
Health IT's Effect on Care
A literature review (from 1995 to January 2004, with expert-identified studies to April 2005) was conducted to evaluate the effect of information technology on health care quality, efficiency, and costs. About 25 percent of 257 identified studies originated from four academic institutions. Three major quality benefits were found: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The major efficiency benefit was decreased utilization of care; however, empirical cost data were limited. The authors conclude that it is unclear whether, and at what cost, other institutions can achieve similar benefits. B. Chaudhry et al. (2006) Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. Annals of Internal Medicine 144, 742–752.
Selected articles on quality improvement from a number of journals, including the American Journal of Medicine, Annals of Internal Medicine, Archives of Pediatric and Adolescent Medicine, BMJ, Health Affairs, Health Services Research, International Journal for Quality in Health Care, Joint Commission Journal on Quality and Safety, Journal of the American Medical Association, Journal of General Internal Medicine, Journal of Patient Safety, Journal of Safety and Quality in Health Care, Medical Care, The Milbank Quarterly, The New England Journal of Medicine, and Pediatrics. The articles are nominated by Editorial Advisory Board members from a preselected list.
Health Care System Performance
Guideline Adherence and Outcomes
This study is based on observational analysis of hospital care in 350 academic and nonacademic centers enrolled in the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative. It examined how hospital performance varied among centers, identified characteristics predictive of higher guideline adherence, and assessed whether hospitals' overall guideline adherence was associated with observed and risk-adjusted in-hospital mortality rates. The study, completed between Jan. 1, 2001, and Sept. 30, 2003, found a significant association between care processes and outcomes, leading the authors to conclude that broad, guideline-based performance metrics can be used as a means to assess and improve hospital quality. E. D. Peterson et al. (2006) Association Between Hospital Process Performance and Outcomes Among Patients with Acute Coronary Syndromes. Journal of the American Medical Association 295, 1912–1920.
Screening, Tumor Differences Account for Disparities
A prospective cohort study found that African American, Hispanic, Asian, and Native American women were more likely than white women to have received inadequate mammography screening, and that African American women were more likely than white, Asian, and Native American women to have large, advanced-stage, high-grade, and lymph node–positive tumors of the breast. While screening differences may explain African American women's higher prevalence of advanced breast tumors, tumor characteristics also contribute as African American women have higher-grade tumors than white women, regardless of screening. These results suggest that adherence to recommended mammography screening intervals could reduce breast cancer mortality rates. R. Smith-Bindman et al. (2006) Does Utilization of Screening Mammography Explain Racial and Ethnic Differences in Breast Cancer? Annals of Internal Medicine 144, 541–553.
Health Care Team Effectiveness
A literature review (1985 to 2004) distinguished among intervention studies that compare team care with usual, or nonteam, care; intervention studies that examine the impact of team redesign on team effectiveness; and field studies that explore relationships between team context, structure, processes, and outcomes. An Integrated Team Effectiveness Model (ITEM) was used to summarize research findings and identify gaps in the literature. It found that the type and diversity of clinical expertise involved in team decision-making largely account for improvements in patient care and organizational effectiveness. Also, collaboration, conflict resolution, participation, and cohesion are most likely to influence staff satisfaction and perceived team effectiveness. The authors conclude that ITEM provides a useful framework for conceptualizing relationships between multiple dimensions of team context, structure, processes, and outcomes. L. Lemieux-Charles and W. L. McGuire (2004) What Do We Know about Health Care Team Effectiveness? A Review of the Literature. Medical Care Research and Review 63, 263–300.
Quality Tools in Practice
Phone Intervention Increased Minority Screenings
A randomized, controlled trial was used to evaluate the effect of a telephone support intervention on breast, cervical, and colorectal cancer screening rates among minority and low-income women. Women assigned to the intervention group received an average of four calls over an 18-month period from prevention care managers; those assigned to the control group received usual care. The proportion of women who were up to date for three tests increased from 0.21 to 0.43 with the intervention, leading the authors to conclude that telephone support can improve cancer screening rates among women who visit community and migrant health centers. A. J. Dietrich et al. (2006) Telephone Care Management to Improve Cancer Screening Among Low-Income Women: A Randomized, Controlled Trial. Annals of Internal Medicine 144, 563–571.
Medication Reconciliation Prevents Harm
The medication orders of 60 randomly selected patients at the time of admission to a Canadian community hospital were compared with pre-admission medication use, as well as with discharge orders and written instructions. Overall, 60 percent of patients had at least one unintended variance—considered a medication error—and 18 percent had at least one clinically important unintended variance. A medication reconciliation process, designed to identify and rectify medication errors at the time of hospital admission and discharge, identified 75 percent of the 20 clinically important variances prior to patient harm. The authors conclude that reconciliation warrants broader evaluation. T. Vira et al. (2006) Reconcilable Differences: Correcting Medication Errors at Hospital Admission and Discharge. Quality and Safety in Health Care 15, 122–126.
Evidence-Based Practices Reduce Central Line Infections
A two-year project to reduce hospital-acquired infections, initiated through the Greater Cincinnati Health Council at nine health care systems, focused on evidence-based practices to reduce surgical site infections and catheter-related blood stream infections (CR-BSIs). This study evaluated the implementation of CR-BSIs safety practices—strict adherence to proper hand washing, maximum barrier precautions (sterile gown and gloves, cap, mask, and bed-sized sterile drape), and use of chlorhexidine gluconate antiseptic during placement—compared with usual practice (use of sterile gloves and sterile small drape, and betadine antiseptic). At all four initial implementation sites, central line infections were reduced by 50 percent. Also, at the project's midpoint, adherence to evidence-based practices increased from 30 percent to nearly 95 percent. Based on this experience, the authors conclude that the appropriate floor for central line infections in ICUs is < 1 infection/1,000 line days. M. L. Render et al. (2006) Evidence-Based Practice to Reduce Central Line Infections. Joint Commission Journal on Quality and Patient Safety 32, 253–260.
Error Identification and Prevention
Patients' Role in Error Prevention
A telephone survey of 2,078 patients discharged from 11 Midwest hospitals assessed whether patients took recommended actions to prevent errors. It found that 91 percent agreed patients could help prevent errors. But while patients were very comfortable asking a medication's purpose (91 percent), general medical questions (89 percent), and confirming their identity (84 percent), they were uncomfortable asking medical providers whether they had washed their hands (46 percent very comfortable). While hospitalized, many asked questions about their care (85 percent) and a medication's purpose (75 percent), but fewer confirmed they were the correct patient (38 percent), helped mark their incision site (17 percent), or asked about hand washing (5 percent). The authors conclude that educational interventions to increase comfort with error prevention may be necessary to help patients become more engaged. A. D. Waterman et al. (2006) Hospitalized Patients' Attitudes About and Participation in Error Prevention. Journal of General Internal Medicine 21, 367–370.
CPOE Reduces Pediatric Chemotherapy Ordering Errors
A before-and-after study was used to evaluate the impact of computerized provider order entry (CPOE), guided by multidisciplinary failure modes and effects analysis, on reducing ordering errors in pediatric chemotherapy. Conducted from 2001 to 2004, the study found that daily chemotherapy orders were less likely to have improper dosing, incorrect dosing calculations, missing cumulative doses calculations, and incomplete nursing checklists following CPOE system implementation. However, there was no difference in the likelihood of improper dosing on treatment plans and a higher likelihood of not matching medication orders to treatment plans. G. R. Kim et al. (2006) Error Reduction in Pediatric Chemotherapy: Computerized Order Entry and Failure Modes and Effects Analysis. Archives of Pediatric and Adolescent Medicine 160, 495–498.
Applying Ecological Lessons to Health Care
This study set out to determine whether lessons learned from the field of ecological restoration, which is concerned with the effective, efficient, and sustainable repair and recovery of ecosystems that have been degraded, damaged, or destroyed, can be used to increase medication safety. Twenty-six practitioners used the principles of good restoration to design and pilot a multifaceted medication safety intervention, including focus groups with practitioners, construction and administration of a research-based medication safety inventory, repeat digital photography of environmental safety issues, and targeted environmental modifications. Based on this research, hospital ward staff built a healthy reporting culture, introduced regular discussions of near misses, developed education strategies, redesigned delivery and storage processes, and renovated the environment. P. B. Marck et al. (2006) Building Safer Systems by Ecological Design: Using Restoration Science to Develop a Medication Safety Intervention. Quality and Safety in Health Care 15, 92–97.
SSI Guidelines Decreased Errors, Hyperglycemia
An observational before-and-after study was used to evaluate the impact of a standardized sliding scale insulin (SSI) protocol and preprinted physician order form, which included the SSI guidelines and an option for ordering one of three standardized insulin sliding scales or a patient-specific scale. One year after implementation, the physician order form was used for 91 percent of orders and, overall, 86 percent of SSI orders followed the guidelines. Further, the number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient-days at baseline to 1.2 at one year, and the number of hyperglycemia episodes decreased from 55.9 to 16.3 per 100 SSI patient days. A. C. Donihi et al. (2006) Use of a Standardized Protocol to Decrease Medication Errors and Adverse Events Related to Sliding Scale Insulin. Quality and Safety in Health Care 15, 89–91.
Information Technology
Health IT's Effect on Care
A literature review (from 1995 to January 2004, with expert-identified studies to April 2005) was conducted to evaluate the effect of information technology on health care quality, efficiency, and costs. About 25 percent of 257 identified studies originated from four academic institutions. Three major quality benefits were found: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The major efficiency benefit was decreased utilization of care; however, empirical cost data were limited. The authors conclude that it is unclear whether, and at what cost, other institutions can achieve similar benefits. B. Chaudhry et al. (2006) Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. Annals of Internal Medicine 144, 742–752.