1,300 Days and Counting: A Risk Model Approach to Preventing Retained Foreign Objects (RFOs).

BACKGROUND: A retained foreign object (RFO) is a devastating surgical complication that typically results in additional surgeries, increased length of stay, and risk of infections and is potentially fatal. Memorial Sloan Kettering Cancer Center (MSKCC) convened a multidisciplinary task force to undertake an improvement initiative to reduce the frequency of RFO incidents. METHODS: A needs assessment was undertaken using focus group interviews, review of past RFOs, and operating room (OR) observations, and a comprehensive intervention plan was initiated. Items at risk of retention were reclassified and new tracking sheets were developed. A probabilistic risk model was developed based on aviation industry methodology, an RFO risk projection, and the retention risk classification of surgical items. Training initiatives were launched to shift organizational culture and staff behaviors toward greater awareness of RFO risk and proactive prevention. RESULTS: Since the implementation of our task force's recommendations on March 24, 2014, there have been no RFO incidents at our institution to this day. The last RFO occurred in August 2013-more than 1,300 days ago (as of March 28, 2017). The RFO incident frequency was reduced from 1.69 per year to a risk model estimate of 1 in 22 years. Ongoing training maintains the staff's behavioral changes as well as the improved OR and organizational culture. CONCLUSION: Implementation of a multidisciplinary approach to preventing RFOs was successful at MSKCC. The use of an RFO risk model enabled the creation of a robust system for RFO prevention. Support from leadership, participation by all stakeholders, education, training, and cooperation from frontline staff are all important contributors to RFO prevention success.

Alternative Payment Models in Medical Oncology: Assessing Quality-of-Care Outcomes Under Partial Capitation.

BACKGROUND: Alternative payment models (APMs) in healthcare are emerging that reward quality of care over quantity of services. Most bundled payment programs that are described in published studies are related to episodes for a surgical inpatient hospital stay. With outpatient services, monthly capitated payments are an alternative to bundled payments for specialty services. OBJECTIVE: To assess the association of a capitated contractual arrangement between a primary care physician group and an oncology clinic group with the quality of care received. METHODS: We evaluated the effect of an oncology group's transition from a fee-for-service (FFS) arrangement to a partial-capitated-payment model with a primary care group. We compared outcomes for patients who received treatment after implementation of the new arrangement (ie, postcontract capitated group) with outcomes of patients receiving treatment before the change (ie, precontract capitated group). In addition, we conducted a parallel analysis of patients from a population that was not affected by the contract to assess temporal effects (ie, postcontract FFS group vs precontract FFS group). All patients were enrolled in Medicare Advantage plans of a single health plan (ie, Humana), and outcomes were measured using claims data provided by that company. Patients in the 2 precontract groups received treatment between July 1, 2010, and June 30, 2011; patients in the 2 postcontract groups received treatment between January 1, 2013, and December 31, 2013. Age- and sex-adjusted all-cause hospitalization, complications from cancer treatment, and ambulance transfers during 6 months of follow-up were evaluated. RESULTS: In the population subject to the partial-capitated-payment model, the postcontract group (N = 305) was younger than the precontract group (N = 165). In a subset of patients in the 2 capitated groups who had Deyo-Charlson Comorbidity Index (CCI) RxRisk scores, the postcontract capitated group had significantly higher CCI scores. Adjusted odds ratios for the postcontract capitated group versus the precontract capitated group showed no difference in the likelihood that any of the outcomes would occur. However, the mean number of chemotherapy-related complications and ambulance transports were greater postcontract. In the parallel analysis of the population not affected by the new payment arrangement, no differences were found between the pre- and postcontract groups. This suggests that temporal changes potentially affecting patients in the capitated and FFS populations would not have influenced postcontract outcomes. CONCLUSIONS: After the implementation of partial-capitated payments for medical oncology services in the oncology practice, the likelihood of a patient experiencing at least 1 event of a specific adverse outcome did not change; however, the average number of some adverse events did increase, which may in part be explained by a higher level of underlying morbidity in the postcontract group. The overall findings of this study suggest that quality of care was not compromised in this APM.

Standardized Physician-Administered Patient-Centered Discharge Protocol Improves Patients' Comprehension.

OBJECTIVES: Patients are 30% less likely to be readmitted or visit the emergency department if they have a clear understanding of their discharge instructions. A standardized approach to a hospital discharge plan has not been universally implemented, however. Our goal was to increase patients' comprehension of discharge instructions by implementing a standardized patient-centered discharge planning protocol that uses a physician team member to explain these plans. METHODS: This was a prospective study that included all of the patients discharged from an inpatient medical teaching service in a community-based hospital during the study period. We used two 4-week periods separated by 4 months in which training and practice with the study intervention took place. Patients' understanding of discharge instructions was assessed via a follow-up telephone call from a physician co-investigator within 1 week of each patient's discharge. Differences in patients' understanding between groups were analyzed. RESULTS: A total of 181 patients were enrolled, with 9 lost to follow-up. After implementation of the discharge planning protocol, a statistically significant improvement in patients' understanding was found in study subjects' knowledge of their diagnosis, the adverse effects of their medications, whom to call after discharge, and follow-up appointments. CONCLUSIONS: Institution of a standardized patient-centered discharge planning protocol can improve patients' understanding of several key components of their discharge process, which may lead to improved compliance with instructions and outcomes.