Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project.

OBJECTIVE: Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. STUDY SETTING: In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. STUDY DESIGN: Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools. DATA COLLECTION METHODS: Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites. PRINCIPAL FINDINGS: Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all P<0.001). Mean days between laboratory test date and evidence of completed action/treatment plan decreased by 19.4 days (P<0.001). Staff surveys showed modest but nonsignificant improvement for intervention practices relative to controls overall and for the 3 high-risk domains that were the focus of PROMISES. CONCLUSIONS: A consortium of stakeholders, quality improvement tools, coaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.

Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.

BACKGROUND: Ambulatory practices deliver most health care services and contribute to malpractice risk. Yet, policymakers and practitioners often lack information about safety and malpractice risk needed to guide improvement. OBJECTIVE: To assess staff and administrator perceptions of safety and malpractice risk in ambulatory settings. RESEARCH DESIGN: We administered surveys in small-sized to medium-sized primary care practices in Massachusetts as part of a randomized controlled trial to reduce ambulatory malpractice risk. SUBJECTS: Twenty-five office practice managers/administrators and 482 staff, including [physicians, physician assistants, and nurse practitioners (MD/PA/NPs)], nurses, other clinicians, managers, and administrators. MEASURES: Surveys included structured questions about 3 high-risk clinical domains: referral, test result, and medication management, plus communication with patients and among staff. The 30-item administrator survey evaluated the presence of organizational safety structures and processes; the 63-item staff survey queried safety and communication concerns. RESULTS: Twenty-two administrators (88%) and 292 staff (61%) responded. Administrators frequently reported important safety systems and processes were absent. Suboptimal or incomplete implementation of referral and test result management systems related to staff perceptions of their quality (P<0.05). Staff perceptions of suboptimal processes correlated with their concern about practice vulnerability to malpractice suits (P<0.05). Staff was least positive about referral management system safety, talking openly about safety problems, willingness to report mistakes, and feeling rushed. MD/PA/NPs viewed high-risk system reliability more negatively (P<0.0001) and teamwork more positively (P<0.03) than others. CONCLUSIONS: Results show opportunities for improvement in closing informational loops and establishing more reliable systems and environments where staff feels respected and safe speaking up. Initiatives to transform primary care should emphasize improving communication among facilities and practitioners.

Normative data on cross-cultural neuropsychological tests obtained from Mandarin-speaking adults across the life span.

Although Mandarin is the world's most commonly spoken native language, normative data on neuropsychological tests for this population are limited. Therefore, samples of young (n=142, M age=35.77 years), middle-aged (n=71, M age=52.65), and elderly (n=111, M age=69.27) Mandarin speaking adults living in Beijing, China were given a battery of neuropsychological measures. The instruments selected for use were easily administered and had been validly used in other cultural settings (e.g., Trails A, Five Digit Test, Fuld Object-Memory Evaluation, Symbol Digit Modality Test (SDMT)). As expected, age and education where significantly related to neuropsychological performance. Gender, however, was a moderating variable only for the elderly group. In addition to their clinical applicability, findings are used to exemplify a particular multicultural assessment strategy.