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Recent Publications of Note

Quality Tools in Practice

Hospitalist QI Process Improved ED Throughput

A pre-post study was used to examine whether a hospitalist-led, active bed management program could reduce emergency department throughput times and ambulance diversion hours at Johns Hopkins Bayview Medical Center in Baltimore, Md. The quality improvement intervention consisted of a hospitalist regularly visiting the emergency department, assessing inpatient bed availability, and helping triage admitted patients to particular units. The authors found that, after the program was implemented, the average time that admitted patients spent in the emergency department decreased from 458 to 360 minutes. The percentage of hours during which the emergency department had to divert ambulances because of crowding and lack of intensive care unit beds decreased by 6 percent and 27 percent, respectively. E. Howell, E. Bessman, S. Kravet et al., Active Bed Management by Hospitalists and Emergency Department Throughput, Annals of Internal Medicine, Dec. 2, 2008 149(11): 804–810.

Study Finds Rapid Response Team Effect Limited

A prospective cohort study was used to determine rates of hospital-wide codes and mortality before and after implementation of a long-term rapid response team intervention at Saint Luke's Hospital in Kansas City, Mo. A three-member rapid response team—composed of experienced ICU staff and a respiratory therapist—performed the evaluation, treatment, and triage of inpatients with evidence of acute physiological decline. There were a total of 376 rapid response team activations during the study period. The authors found that mean hospital-wide code rates decreased from 11.2 to 7.5 per 1000 admissions. Although this was not associated with a reduction in the primary end point of hospital-wide code rates, lower rates of non-ICU codes were observed. Hospital-wide mortality, however, did not differ between the pre-intervention and post-intervention periods. P. S. Chan, A. Khalid, L. S. Longmore et al., Hospital-wide Code Rates and Mortality Before and After Implementation of a Rapid Response Team, Journal of the American Medical Association, Dec. 3, 2008 300(21): 2506–2513.

Patient-Centered Access Benefits Patients, Not Providers

Interviews of 22 providers at Group Health Cooperative in Seattle, Wash., were used to assess their perceptions of an information technology-enabled organizational redesign initiative to promote patient-centered access. Analysis of these interviews identified fives themes with relevance for health care organizations pursuing such efforts: the initiative improved patient satisfaction, improved the quality of encounter-based care, compromised providers' focus on population health, created additional work for providers, and decreased job satisfaction for primary care providers and some medical specialists. The authors conclude that these reforms might not be sustainable under current organization and financing models. J. T. Tufano, J. D. Ralston, and D. P. Martin, Providers' Experience with an Organizational Redesign Initiative to Promote Patient-Centered Access: A Qualitative Study, Journal of General Internal Medicine, Nov. 2008 23(11): 1778–1783.

Study Finds Little Association Between EHRs, Quality

The ability of electronic health records (EHRs) to improve quality of care was assessed, using a cross-sectional analysis of primary care provider visits to examine associations between the presence of EHR components, or a complete EHR, and blood pressure control, as well as their association with appropriate chronic condition therapy. The authors found no consistent association between blood pressure control, management of chronic conditions, and specific EHR components. They suggest that future research, focusing on how an EHR is implemented and used and how care is integrated through an EHR, is needed to better understand the impact of EHRs on quality of care. S. Keyhani, P. Hebert, J. Ross et al., Electronic Health Record Components and the Quality of Care, Medical Care, Dec. 2008 46(12):1267–1272.

Quality Reporting

Hospital Ratings Need More Consistency, Transparency

This study compared five, consumer-oriented Web sites that provide hospital ratings, assessing the level of agreement in their rankings for four diagnoses at nine institutions located in the Boston area. The sites reported on multiple aspects of health care quality, including those reflecting structural aspects of care, processes, and outcomes; the sites did not use consistent patient definitions or reporting periods. The authors found that these rating services failed to consistently agree on either top- or bottom-performing hospitals in a single metropolitan area, with hospitals ranked first or second by one system often ranked seventh or eighth by another. Thus, they conclude that, as these sites are currently structured, they're more likely to confuse, rather than inform, consumers. M. B. Rothberg, E. Morsi, E. M. Benjamin et al., Choosing The Best Hospital: The Limitations Of Public Quality Reporting, Health Affairs, Nov./Dec. 2008 27(6): 1680–1687.

NICE Gains Responsibility for Improvement Indicators

This editorial reviews the quality and outcomes framework introduced into primary care in the United Kingdom in April 2004 to improve the quality of care delivered in general practice, to help recruitment and retention, and to reward practices for the delivery of existing high quality care. Two problems that have arisen are the difficulty creating good disease prevention and clinical outcomes indicators without piloting them, and the necessary focus on the cost effectiveness of each indicator. The authors review the Department of Health's decision to respond to these problems by making the National Institute for Health and Clinical Excellence (NICE) responsible for developing and reviewing the framework's clinical and health improvement indicators, and the implications of this proposal for patients and practitioners. H. Lester and A. Majeed, The Future of the Quality and Outcomes Framework: NICE Involvement Means the Framework will Remain Part of the Fabric of Primary Care, BMJ, Dec. 19, 2008 337: a3017.

Additional Questions Improve CAHPS Hospital Survey

Surveys of patients at 181 hospitals participating in the California Hospitals Assessment and Reporting Taskforce were used to determine whether adding questions to the Consumer Assessment of Health Care Providers and Systems (CAHPS) Hospital Survey increases its reliability and validity. Among the findings, adding new discharge information questions improved the internal consistency reliability from 0.45 to 0.72 and the hospital-level reliability from 0.75 to 0.81. Likewise, new coordination of care composites were more closely correlated with overall hospital ratings and willingness to recommend than six of the seven original domains, leading the authors to conclude that the nine additional questions significantly improved the psychometric properties of the CAHPS Hospital Survey. A. A. Rothman, H. Park, R. D. Hays et al., Can Additional Patient Experience Items Improve the Reliability of and Add New Domains to the CAHPS Hospital Survey? Health Services Research, Dec. 2008 43(6): 2201–2222.

Patient Safety

Safety Perceptions Vary Among Work Areas, Disciplines

A Patient Safety Climate in Healthcare Organizations survey was administered to personnel, selected from a stratified random sample of 92 U.S. hospitals, to understand their perceptions of safety and how they vary between hospitals, work areas, and disciplines. The authors found that the patient safety climate differed by hospital and among and within work areas and disciplines. Personnel in the emergency department, for example, perceived a worse safety climate than those in nonclinical areas. Nurses were also more negative than physicians about their work unit's support and recognition of safety efforts. These findings led the authors to conclude that strategies for improving safety climate and patient safety should be tailored to specific work areas and disciplines. S. J. Singer, D. Gaba, A. Falwell et al., Patient Safety Climate in 92 US Hospitals: Differences by Work Area and Discipline, Medical Care, Jan. 2009 47(1): 23–31.

WalkRounds, Rigorously Applied, Can Improve Safety Climate

The impact of rigorously applied WalkRounds on frontline caregivers' assessments of the safety climate in their patient care area was assessed at seven Massachusetts hospitals. WalkRounds were conducted weekly, according to the seven-step WalkRounds Guide, and the Safety Attitudes Questionnaire was administered at baseline and again about 18 months post-WalkRounds implementation. At the two hospitals that complied with this rigorous approach, the number of care areas with safety climate scores below 60 percent decreased from 10 (of 21) to three care areas. The authors conclude that such implementation requires organization will, and its sustainability depends on leadership engagement. A. Frankel, S. P. Grillo, M. Pittman et al., Revealing and Resolving Patient Safety Defects: The Impact of Leadership WalkRounds on Frontline Caregiver Assessments of Patient Safety, Health Services Research, Dec. 2008 43(6): 2050–2066.

Effect of Medical Errors Continues After Discharge

In this study, the effect of medical errors on medical expenditures, death, readmissions, and outpatient care within 90 days after surgery were assessed. The authors used the Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) to identify 14 such indicators among 161,004 surgeries, followed by propensity score matching and multivariate regression analyses to predict expenditures and outcomes attributable to these 14 PSIs. They found that 11 percent of all deaths, 2 percent of readmissions, and 2 percent of expenditures were likely due to these 14 PSIs, leading them to conclude that there are potentially large national cost savings from reducing these events. W. E. Encinosa and F. J. Hellinger, The Impact of Medical Errors on Ninety-Day Costs and Outcomes: An Examination of Surgical Patients, Health Services Research, Dec. 2008 43(6): 2067–2085.

Error Disclosure Should Engage Entire Care Team

Focus groups were used to explore registered nurses' perspectives on the disclosure of errors to patients and the organizational factors that influence disclosure. Qualitative content analysis of these focus groups found that nurses routinely reported nursing errors that did not involve serious harm, but they felt attending physicians should lead disclosures when patient harm occurred or when errors involved the team. Nurses also were not usually involved in team discussions to plan for error disclosures or in actual disclosures. The authors conclude that integrating the entire health care team into the disclosure process will likely improve the quality of error disclosure. S. E. Shannon, M. B. Foglia, M. Hardy et al., Disclosing Errors to Patients: Perspectives of Registered Nurses, Joint Commission Journal on Quality and Patient Safety, Jan. 2009 35(1): 5–12.

Health Care System Performance

ED Performance Poor for Common Pediatric Respiratory Illnesses

This study measured U.S. emergency department performance in the care of pediatric asthma, bronchiolitis, and croup. Data on emergency department visits by children, drawn from the 2005 National Hospital Ambulatory Medical Care Survey, were analyzed with national rates of corticosteroid, antibiotic, and radiograph use as the main outcome measures. The authors found that physicians are underusing known effective treatments and overusing ineffective or unproven therapies and diagnostic tests. For example, physicians prescribed antibiotics to children with bronchiolitis in 53 percent of the estimated 228,000 annual visits, and obtained radiographs in 72 percent of bronchiolitis visits and 32 percent of croup visits. J. F. Knapp, S. D. Simon, and V. Sharma, Quality of Care for Common Pediatric Respiratory Illnesses in United States Emergency Departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey Data, Pediatrics, Dec. 2008 122(6): 1165–1170

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