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1.
Pediatr Qual Saf ; 3(4): e093, 2018.
Article in English | MEDLINE | ID: mdl-30229203

ABSTRACT

INTRODUCTION: Total parenteral nutrition (TPN) provides vital intravenous nutrition for patients who cannot tolerate enteral nutrition but is susceptible to medical errors due to its formulation, ordering, and administrative complexities. At Johns Hopkins All Children's Hospital, 22% of TPN orders required clarification of errors and averaged 10 minutes per order for error correction by pharmacists. Quality improvement methodology improved patient safety by standardizing TPN formulations and incorporating TPN ordering processes into the electronic medical record. METHODS: A multidisciplinary group of providers developed standardized TPN solutions for neonatal and pediatric patients. Inclusion, exclusion, and discontinuation criteria were defined. The primary outcome measure was reducing TPN ordering error rate, and secondary outcomes were improving TPN ordering and processing time along with reducing blood draws. Through multiple plan-do-study-act cycles, we standardized TPN solutions, incorporated them in the electronic medical record, monitored blood draws, and evaluated resource efficiency. Data were analyzed using chi-square tests of independence and t tests for 2 independent samples. RESULTS: The TPN ordering error rate significantly decreased from baseline of 22% to 3.2% over the final quarter of the study period, χ2 (1, N = 2,467) = 89.13, P < 0.001. Order processing time fell from 10 to 5 minutes by project end. The average number of blood draws decreased significantly from 6.2 (SD = 3.12) blood draws to 4.3 (SD = 2.13) in the last quarter of the study, t (506) = 5.97, P < 0.001. CONCLUSIONS: Standardizing TPN and transitioning to electronic ordering effectively and significantly reduced ordering errors and processing time. It also substantially improved resource efficiency by reducing the number of blood draws.

2.
Jt Comm J Qual Patient Saf ; 43(5): 224-231, 2017 05.
Article in English | MEDLINE | ID: mdl-28434455

ABSTRACT

BACKGROUND: Large multihospital health systems with multiple children's hospitals are relatively few in number. With a paucity of national pediatric measures for quality and patient safety, there are unique challenges to ensuring consistent levels of care across diverse health care delivery settings. At Johns Hopkins Medicine, a Pediatric Joint Council was created to help ensure high-quality and safe care across a health system encompassing two full-service children's hospitals and two community hospitals with significant pediatric volumes across two states. APPROACH: Across the health system, a governance, leadership, and management structure was developed to coordinate the quality and safety of patient care throughout the academic health system. Within the pediatric service line, the multidisciplinary Pediatric Joint Council included representation from each pediatric entity and was supported by project managers, quality improvement (QI) team leaders, QI leads from each entity, infection control, and clinical analysts. The Pediatric Joint Council was responsible for setting standards and improvement goals, as well as monitoring and improving performance of pediatric services across the health system and identifying training gaps and research opportunities. CONCLUSION: The Pediatric Joint Council model, as implemented, provides a focused structure for coordinated efforts across disparate pediatric entities, ensuring horizontal peer learning and entity-specific improvements, as well as vertical lines of accountability and central oversight with shared governance. This model has served to help identify areas in need of pediatric expertise and has facilitated the use of resources from across the entire health system focused on improving pediatric care.


Subject(s)
Academic Medical Centers/organization & administration , Patient Safety/standards , Pediatrics/organization & administration , Quality Improvement/organization & administration , Quality of Health Care/organization & administration , Academic Medical Centers/standards , Advisory Committees/organization & administration , Documentation/standards , Hospitals, Community/standards , Hospitals, Pediatric/standards , Humans , Infection Control/organization & administration , Leadership , Patient Satisfaction , Pediatrics/standards , Staff Development/organization & administration , Time Factors
3.
N Engl J Med ; 356(5): 486-96, 2007 Feb 01.
Article in English | MEDLINE | ID: mdl-17259444

ABSTRACT

BACKGROUND: Public reporting and pay for performance are intended to accelerate improvements in hospital care, yet little is known about the benefits of these methods of providing incentives for improving care. METHODS: We measured changes in adherence to 10 individual and 4 composite measures of quality over a period of 2 years at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative, including 207 facilities that simultaneously participated in a pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services; we then compared the pay-for-performance hospitals with the 406 hospitals with public reporting only (control hospitals). We used multivariable modeling to estimate the improvement attributable to financial incentives after adjusting for baseline performance and other hospital characteristics. RESULTS: As compared with the control group, pay-for-performance hospitals showed greater improvement in all composite measures of quality, including measures of care for heart failure, acute myocardial infarction, and pneumonia and a composite of 10 measures. Baseline performance was inversely associated with improvement; in pay-for-performance hospitals, the improvement in the composite of all 10 measures was 16.1% for hospitals in the lowest quintile of baseline performance and 1.9% for those in the highest quintile (P<0.001). After adjustments were made for differences in baseline performance and other hospital characteristics, pay for performance was associated with improvements ranging from 2.6 to 4.1% over the 2-year period. CONCLUSIONS: Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.


Subject(s)
Hospitals/standards , Outcome and Process Assessment, Health Care , Quality Assurance, Health Care , Quality Indicators, Health Care , Reimbursement, Incentive , Benchmarking , Cardiac Output, Low/diagnosis , Economics, Hospital , Humans , Medicare , Myocardial Infarction/drug therapy , Pneumonia/physiopathology , Pneumonia/therapy , Societies, Hospital , United States
4.
Health Care Financ Rev ; 29(1): 45-57, 2007.
Article in English | MEDLINE | ID: mdl-18624079

ABSTRACT

We construct statistical models to assess whether hospital size will impact the ability to identify "true" hospital ranks in pay-for-performance (P4P) programs. We use Bayesian hierarchical models to estimate the uncertainty associated with the ranking of hospitals by their raw composite score values for three medical conditions: acute myocardial infarction (AMI), heart failure (HF), and community acquired pneumonia (PN). The results indicate a dramatic inverse relationship between the size of the hospital and its expected range of ranking positions for its true or stabilized mean rank. The smallest hospitals among the augmented dataset would likely experience five to seven times more uncertainty concerning their true ranks.


Subject(s)
Health Facility Size , Hospitals/classification , Outcome Assessment, Health Care , Quality Indicators, Health Care/statistics & numerical data , Quality of Health Care , Reimbursement, Incentive , Bayes Theorem , Community-Acquired Infections/therapy , Guideline Adherence/standards , Heart Failure/therapy , Hospitals/standards , Humans , Myocardial Infarction/therapy , Uncertainty
5.
Med Care ; 43(3 Suppl): I64-71, 2005 Mar.
Article in English | MEDLINE | ID: mdl-15746593

ABSTRACT

BACKGROUND: This article addresses measures of importance to women of reproductive age in the first National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR). METHODS: The authors review each of the 4 components of quality of care: effectiveness, safety, timeliness, and patient centeredness. The effectiveness component topics with relevance to women of childbearing age include breast cancer, cervical cancer, HIV, AIDS, mental health, and maternity care. The safety component includes 3 relevant measures of obstetric trauma. The quality aspects of timeliness of care and patient centeredness will be discussed in terms of women, although the NHQR and NHDR did not include them as a separate topic because the data were so limited regarding women. FINDINGS: There is a foundation of knowledge about many aspects of quality health care for women of reproductive age. However, gaps are evident in some measures, usually due to insufficient data. CONCLUSION: Further development of the measure set would benefit from additional process and outcome variables that can link screening, diagnosis, and treatment with health outcomes. Such linkages will expand our knowledge and capability to improve health outcomes for women of reproductive age.


Subject(s)
Quality of Health Care , Women's Health , Acquired Immunodeficiency Syndrome/prevention & control , Adult , Age Factors , Aged , Annual Reports as Topic , Antiretroviral Therapy, Highly Active , Breast Neoplasms/diagnostic imaging , Breast Neoplasms/epidemiology , Breast Neoplasms/mortality , Breast Neoplasms/prevention & control , Depression/epidemiology , Female , HIV Infections/drug therapy , Humans , Income , Mammography , Mass Screening , Maternal Mortality , Maternal Welfare , Patient-Centered Care , Pregnancy , Pregnancy Complications/epidemiology , Prenatal Care , Quality Indicators, Health Care , Racial Groups , Socioeconomic Factors , Suicide/trends , United States , United States Agency for Healthcare Research and Quality , Uterine Cervical Neoplasms/diagnosis , Uterine Cervical Neoplasms/mortality , Uterine Cervical Neoplasms/prevention & control , Vaginal Smears
6.
Pediatrics ; 115(1): 135-45, 2005 Jan.
Article in English | MEDLINE | ID: mdl-15579669

ABSTRACT

OBJECTIVES: Patient safety indicators (PSIs) were developed by the Agency for Healthcare Research and Quality. Our objectives were (1) to apply these algorithms to the National Association of Children's Hospitals and Related Institutions (NACHRI) Aggregate Case Mix Comparative Database for 1999-2002, (2) to establish mean rates for each of the PSI events in children's hospitals, (3) to investigate the inadequacies of PSIs in relation to pediatric diagnoses, and (4) to express the data in such a way that children's hospitals could use the PSIs determined to be appropriate for pediatric use for comparison with their own data. In addition, we wanted to use the data to set priorities for ongoing clinical investigations and to propose interventions if the indicators demonstrated preventable errors. METHODS: The Agency for Healthcare Research and Quality PSI algorithms (version 2.1, revision 1) were applied to children's hospital administrative data (1.92 million discharges) from the NACHRI Aggregate Case Mix Comparative Database for 1999-2002. Rates were measured for the following events: complications of anesthesia, death in low-mortality diagnosis-related groups (DRGs), decubitus ulcer, failure to rescue (ie, death resulting from a complication, rather than the primary diagnosis), foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care (ie, infections related to surgery or device placement), postoperative hemorrhage or hematoma, postoperative pulmonary embolism or venous thrombosis, postoperative wound dehiscence, and accidental puncture/laceration. RESULTS: Across the 4 years of data, the mean risk-adjusted rates of PSI events ranged from 0.01% (0.1 event per 1000 discharges) for a foreign body left in during a procedure to 14.0% (140 events per 1000 discharges) for failure to rescue. Review of International Classification of Diseases, Ninth Revision, Clinical Modification codes associated with each PSI category showed that the failure to rescue and death in low-mortality DRG indicators involved very complex cases and did not predict preventable events in the majority of cases. The PSI for infection attributable to medical care appeared to be accurate the majority of the time. Incident risk-adjusted rates of infections attributable to medical care averaged 0.35% (3.5 events per 1000 discharges) and varied up to fivefold from the lowest rate to the highest rate. The highest rates were up to 1.8 times the average. CONCLUSIONS: PSIs derived from administrative data are indicators of patient safety concerns and can be relevant as screening tools for children's hospitals; however, cases identified by these indicators do not always represent preventable events. Some, such as a foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care, decubitus ulcer, and venous thrombosis, seem to be appropriate for pediatric care and may be directly amenable to system changes. Evidence-based practices regarding those particular indicators that have been reported in the adult literature need to be investigated in the pediatric population. In their present form, 2 of the indicators, namely, failure to rescue and death in low-mortality DRGs, are inaccurate for the pediatric population, do not represent preventable errors in the majority of pediatric cases, and should not be used to estimate quality of care or preventable deaths in children's hospitals. The PSIs can assist institutions in prioritizing chart review-based investigations; if clusters of validated events emerge in reviews, then improvement activities can be initiated. Large aggregate databases, such as the NACHRI Case Mix Database, can help establish mean rates of potential pediatric events, giving children's hospitals a context within which to examine their own data.


Subject(s)
Hospitals, Pediatric/statistics & numerical data , Iatrogenic Disease/epidemiology , Medical Errors/statistics & numerical data , Quality Indicators, Health Care , Algorithms , Anesthesia/adverse effects , Cross Infection/epidemiology , Databases, Factual , Diagnosis-Related Groups , Health Services Research , Hospitals, Pediatric/standards , Humans , Safety Management , Software , United States , United States Agency for Healthcare Research and Quality
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