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Joint Commission Journal on Quality and Patient Safety

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https://www.readbyqxmd.com/read/29579448/improving-satisfaction-with-pediatric-pain-management-by-inviting-the-conversation
#1
Thomas J Caruso, Tiffany H Kung, Julie Good, Kristine Taylor, Michele Ashland, Christine Cunningham, Elena Gonzalez, Matthew Wood, Paul Sharek
BACKGROUND: Patient satisfaction with pain management is associated with improved patient adherence to medical management and efficient service utilization. Pediatric pain control is challenging, given the inability to elicit reliable histories, particularly in younger patients. Several studies have suggested that communication surrounding pain management can improve satisfaction, although there are limited data describing structured interventions with measurable outcomes. A quality improvement project was conducted to determine if reliably asking families about pain management was associated with improved patient satisfaction with pain management...
April 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29579447/using-the-patient-safety-huddle-as-a-tool-for-high-reliability
#2
Steven D Brass, Garry Olney, Richard Glimp, Anne Lemaire, Mary Kingston
A Patient Safety Huddle was developed at a community hospital (Providence Little Company of Mary Medical Center, San Pedro, California) through consultation with key stakeholders. The goal was to become a high reliability organization by improving communication across different departments, troubleshooting operational problems, focusing on safety and quality metrics, and reporting unusual occurrences. The Patient Safety Huddle involved executives in development and implementation, respect for employee time, ensuring accountability, and empowering frontline staff to foresee and deal with safety issues...
April 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29579446/the-hidden-cost-of-regulation-the-administrative-cost-of-reporting-serious-reportable-events
#3
Bonnie B Blanchfield, Bijay Acharya, Elizabeth Mort
BACKGROUND: More than half of the 50 states (27) and the District of Columbia require reporting of Serous Reportable Events (SREs). The goal is to hold providers accountable and improve patient safety, but there is little information about the administrative cost of this reporting requirement. This study was conducted to identify costs associated with investigating and reporting SREs. METHODS: This qualitative study used case study methods that included interviewing staff and review of data and documents to investigate each SRE occurring at one academic medical center during fiscal year 2013...
April 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29579445/a-collaborative-for-implementation-of-an-evidence-based-clinical-pathway-for-enhanced-recovery-in-colon-and-rectal-surgery-in-an-affiliated-network-of-healthcare-organizations
#4
David W Larson, Jenna K Lovely, Jesse Welsh, Sho Annaberdyev, Chris Coffey, Cybil Corning, Bret Murray, Douglas Rose, Lawrence Prabhakar, Marcus Torgenson, Eugene Dankbar, Mark V Larson
BACKGROUND: In 2015 the Mayo Clinic Care Network (MCCN), in an effort to extend medical knowledge and share these best practices, embarked on an education mission to diffuse the clinical practice redesign involving the practice of colon and rectal surgery at Mayo Clinic (Rochester, Minnesota) to members of the MCCN. They elected to use a collaborative framework in an attempt to transfer knowledge to multiple teams in an efficient and supportive manner. METHODS: Eight MCCN members assembled a multidisciplinary team, which participated in both a didactic learning session delivered by frontline experts, as well as follow-up remote sessions regarding Mayo Clinic's enhanced recovery pathway for colon and rectal surgery...
April 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29579444/optimizing-hospitalist-patient-communication-an-observation-study-of-medical-encounter-quality
#5
Julie Apker, Margaret Baker, Scott Shank, Kristen Hatten, Sally VanSweden
BACKGROUND: Optimizing patient-hospitalist interactions heightens patient satisfaction, improves patient health outcomes, and improves hospitalist job satisfaction. A study was conducted to recognize hospitalist communication that enhance encounters, identify hospitalist behaviors for improvement interventions, and explore the association of time and gender with communication quality. METHODS: Researchers observed encounters between 36 hospitalists and 206 adult patients...
April 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29579443/how-patient-partners-influence-quality-improvement-efforts
#6
Jessica Greene, Diane Farley, Christine Amy, Kathy Hutcheson
BACKGROUND: There is growing acknowledgement that patients are key stakeholders in improving quality of medical care, yet a key barrier to integrating patients into quality improvement teams (QITs) as patient partners is the lack of evidence of their impact. This mixed-method study was conducted to identify the ways patient partners influence QITs and to document the extent of patient partners' impact. METHODS: Focus groups and in-depth interviews were conducted with 17 patient partners and 11 staff at WellSpan Health and Aligning Forces for Quality-South Central Pennsylvania to identify the specific mechanisms through which patients influenced QIT efforts...
April 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29579442/will-hospital-peer-grouping-by-patient-socioeconomic-status-fix-the-medicare-hospital-readmission-reduction-program-or-create-new-problems
#7
Richard L Fuller, John S Hughes, Norbert I Goldfield, Richard F Averill
BACKGROUND: In 2016 the U.S. Congress directed the Centers for Medicare & Medicaid Services (CMS) to implement the 21st Century Cures Act to fix a flaw in the Hospital Readmissions Reduction Program (HRRP). One section of the Act is intended to remove bias in calculating penalties for hospitals treating large percentages of low socioeconomic status (SES) patients. A study was conducted to analyze the effect of the introduction of SES hospital peer groups on the number and distribution of the hospitals being penalized...
April 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29579441/unending-complexity-in-the-readmission-program
#8
EDITORIAL
Helen R Burstin
No abstract text is available yet for this article.
April 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29499813/improving-quality-of-care-in-hospitals-for-victims-of-elder-mistreatment-development-of-the-vulnerable-elder-protection-team
#9
Tony Rosen, Nisha Mehta-Naik, Alyssa Elman, Mary R Mulcare, Michael E Stern, Sunday Clark, Rahul Sharma, Veronica M LoFaso, Risa Breckman, Mark Lachs, Nancy Needell
PROBLEM DEFINITION: Hospitals have an opportunity to improve the quality of care provided to a particularly vulnerable population: victims of elder mistreatment. Despite this, no programs to prevent or stop elder abuse in the acute care hospital have been reported. An innovative, multidisciplinary emergency department (ED)-based intervention for elder abuse victims, the Vulnerable Elder Protection Team (VEPT), was developed at NewYork-Presbyterian / Weill Cornell Medical Center (New York City)...
March 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29499812/highly-adoptable-improvement-a-practical-model-and-toolkit-to-address-adoptability-and-sustainability-of-quality-improvement-initiatives
#10
Christopher William Hayes, Don Goldmann
BACKGROUND: Failure to consider the impact of change on health care providers is a barrier to success. Initiatives that increase workload and have low perceived value are less likely to be adopted. A practical model and supporting tools were developed on the basis of existing theories to help quality improvement (QI) programs design more adoptable approaches. METHODS: Models and theories from the diffusion of innovation and work stress literature were reviewed, and key-informant interviews and site visits were conducted to develop a draft Highly Adoptable Improvement (HAI) Model...
March 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29499811/meeting-quality-measures-for-adolescent-preventive-care-assessing-the-perspectives-of-key-stakeholders
#11
Sarika Rane Parasuraman, Sarah Lindstrom Johnson, Dawn Magnusson, Tracy King
BACKGROUND: Health plans are increasingly implementing quality improvement strategies aimed at meeting adolescent clinical quality measures, yet clinics often struggle to meet these measures. This qualitative study was conducted to explore how efforts to meet the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) performance measure for adolescent well-care visits were perceived by a multidisciplinary group of stakeholders. METHODS: The research team conducted 26 in-depth, semistructured interviews with participants from three stakeholder groups: clinic staff with direct patient contact, health care institutional leaders, and representatives of a payer organization...
March 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29499810/when-clinicians-drop-out-and-start-over-after-adverse-events
#12
Jason Rodriquez, Susan D Scott
BACKGROUND: The impact of adverse clinical events on health care workers has become a growing topic of research. Previous research has confirmed that after adverse clinical events, clinical staff often feel as though they failed not only their patient but also themselves, resulting in second-guessing of their clinical skills, competencies, and even career choices. This exploratory study reports on the experiences of health care providers who changed career paths as a consequence of an adverse clinical event...
March 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29499809/empowering-informal-caregivers-with-health-information-opennotes-as-a-safety-strategy
#13
Hannah Chimowitz, Macda Gerard, Alan Fossa, Fabienne Bourgeois, Sigall K Bell
BACKGROUND: Enabling family/friend caregivers with access to visit notes may help avoid errors, delayed diagnoses, or other ambulatory safety risks. Patient, parent, and caregiver perceptions of how shared notes affect safety behaviors and attitudes were studied in an exploratory study. METHODS: To assess the impact of OpenNotes on safety, 24,722 patients with active portal accounts and ≥ 1 available visit notes during the prior year at an urban hospital were surveyed between June and September 2016...
March 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29499808/improving-identification-and-diagnosis-of-hypertensive-patients-hiding-in-plain-sight-hips-in-health-centers
#14
Margaret Meador, Jerome A Osheroff, Benjamin Reisler
BACKGROUND: Hypertension is the most prevalent chronic condition diagnosed among patients served in the safety net in the United States; however, many safety-net patients with hypertension are not formally diagnosed and may remain untreated and at increased risk for cardiovascular events. Identifying undiagnosed hypertension using algorithmic logic programmed into clinical decision support (CDS) approaches is a promising practice but has not been broadly tested in the safety-net setting...
March 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29499807/applying-population-health-approaches-to-undiagnosed-hypertension
#15
EDITORIAL
Stephen D Persell
No abstract text is available yet for this article.
March 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29389465/a-novel-bedside-focused-ward-surveillance-and-response-system
#16
Frank Sebat, Mary Anne Vandegrift, Sid Childers, Geoffrey K Lighthall
BACKGROUND: Rapid response systems (RRSs) have been universally adopted in much of the developed world; yet, despite broad implementation, their success has often been limited. Even with successful systems, there is a small body of evidence regarding effective organizational elements that are responsible for improved outcomes. New organizational processes were implemented that restructured the existing RRS, and the impact on the number of rapid response team (RRT) alerts, cardiac arrest, and mortality rates was evaluated...
February 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29389464/surveying-care-teams-after-in-hospital-deaths-to-identify-preventable-harm-and-opportunities-to-improve-advance-care-planning
#17
David Lucier, Patricia Folcarelli, Cheryle Totte, Alexander R Carbo, Lauge Sokol-Hessner
BACKGROUND: Reviewing in-hospital deaths is one way of learning how to improve the quality and safety of care. Postdeath surveys sent to the care team for patients who died may have a role in identifying opportunities for improvement. As part of a quality improvement initiative, a postdeath care team survey was developed to explore how it might augment the existing process for learning from deaths. METHODS: A survey was sent to the care team for all inpatient deaths on the hospital medicine and medical ICU services at one institution...
February 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29389463/temporal-trends-in-fall-rates-with-the-implementation-of-a-multifaceted-fall-prevention-program-persistence-pays-off
#18
Catherine M Walsh, Li-Jung Liang, Tristan Grogan, Courtney Coles, Norma McNair, Teryl K Nuckols
BACKGROUND: Most fall prevention programs are only modestly effective, and their sustainability is unknown. An academic medical center implemented a series of fall prevention interventions from 2001 to 2014. METHODS: The medical center's series of fall prevention interventions were as follows: reorganized the Falls Committee (2001), started flagging high-risk patients (2001), improved fall reporting (2002), increased scrutiny of falls (2005), instituted hourly nursing rounds (2006), reorganized leadership systems (2007), standardized fall prevention equipment (2008), adapted to a move to a new hospital building (2008), routinely investigated root causes (2009), mitigated fall risk during hourly nursing rounds (2009), educated patients about falls (2011), and taught nurses to think critically about risk (2012)...
February 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29389462/the-expanding-role-of-antimicrobial-stewardship-programs-in-hospitals-in-the-united-states-lessons-learned-from-a-multisite-qualitative-study
#19
Shashi N Kapadia, Erika L Abramson, Eileen J Carter, Angela S Loo, Rainu Kaushal, David P Calfee, Matthew S Simon
BACKGROUND: Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost. To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs (ASPs), but implementation remains challenging. A key-informant interview study was conducted to describe the characteristics and innovative strategies of leading ASPs...
February 2018: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29389461/antibiotic-stewardship-grows-up
#20
EDITORIAL
Arjun Srinivasan
No abstract text is available yet for this article.
February 2018: Joint Commission Journal on Quality and Patient Safety
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