Integrating Palliative Care to Promote Earlier Conversations and to Increase the Skill and Comfort of Nonpalliative Care Clinicians: Lessons Learned From an Interventional Field Trial.

While the uptake of palliative care in the United States is steadily improving, there continues to be a gap in which many patients are not offered care that explicitly elicits and respects their personal wishes. This is due in part to a mismatch of supply and demand; the number of seriously ill individuals far exceeds the workload capacities of palliative care specialty providers. We conducted a field trial of an intervention designed to promote the identification of seriously ill patients appropriate for a discussion of their goals of care and to advance the role of nonpalliative care clinicians by enhancing their knowledge of and comfort with primary palliative care skills. At 3 large Midwestern academic medical centers, a palliative care physician or nurse clinician embedded with a selected nonpalliative care service line or unit on a regularly scheduled basis for up to 6 months. Using agreed-upon criteria, patients were identified as being appropriate for a goals of care conversation; conversations with those patients and/or their families were then conducted with the palliative care specialist providing education, coaching, and mentoring to the nonpalliative care clinician, when possible. All of the sites increased the presence of palliative care within the selected service line or unit, and the nonpalliative care clinicians reported increased comfort and skill at conducting goals of care conversations. This intervention is a first step toward increasing patients' access to palliative care to alleviate distress and to more consistently deliver care that honors patient and family preferences.

Surgical Specimen Management: A Descriptive Study of 648 Adverse Events and Near Misses.

CONTEXT: - Surgical specimen adverse events can lead to delays in treatment or diagnosis, misdiagnosis, reoperation, inappropriate treatment, and anxiety or serious patient harm. OBJECTIVES: - To describe the types and frequency of event reports associated with the management of surgical specimens, the contributing factors, and the level of harm associated with these events. DESIGN: - A retrospective review was undertaken of surgical specimen adverse events and near misses voluntarily reported in the University HealthSystem Consortium Safety Intelligence Patient Safety Organization database by more than 50 health care facilities during a 3-year period (2011-2013). Event reports that involved surgical specimen management were reviewed for patients undergoing surgery during which tissue or fluid was sent to the pathology department. RESULTS: - Six hundred forty-eight surgical specimen events were reported in all stages of the specimen management process, with the most common events reported during the prelaboratory phase and, specifically, with specimen labeling, collection/preservation, and transport. The most common contributing factors were failures in handoff communication, staff inattention, knowledge deficit, and environmental issues. Eight percent of the events (52 of 648) resulted in either the need for additional treatment or temporary or permanent harm to the patient. CONCLUSIONS: - All phases of specimen handling and processing are vulnerable to errors. These results provide a starting point for health care organizations to conduct proactive risk analyses of specimen handling procedures and to design safer processes. Particular attention should be paid to effective communication and handoffs, consistent processes across care areas, and staff training. In addition, organizations should consider the use of technology-based identification and tracking systems.

Advancing a Culture of Health: Population Health Programs in Place at Essential Hospitals and Academic Medical Centers (2012-2014).

This study is a systematic review of a national sample of hospital-led population health programs in place at essential hospitals and academic medical centers in the US from 2012 to 2014. We conducted a content analysis of abstracts describing 121 population health initiatives to understand how hospital leaders are translating population health objectives into action. Intended patient population, services provided, and outcomes measured are described. The programs' relationship to an adapted conceptual model of population health as part of a culture of health was assessed. Nearly all programs in the study were hybrids, in that they possessed features belonging to each of the model's two program types (healthcare system and health community system). The majority were focused on patients already attributed to a particular hospital system, but many involved partnerships with community-based or social service resources. This finding reflects the missions of essential hospitals and academic medical centers to improve the lives and care of patients, while recognizing the fundamental need to improve the health of the broader population.

The Prevalence of Inpatients at 33 U.S. Hospitals Appropriate for and Receiving Referral to Palliative Care.

BACKGROUND: The extent of unmet need for palliative care in U.S. hospitals remains largely unknown. We conducted a multisite cross-sectional, retrospective point prevalence analysis to determine the size and characteristics of the population of inpatients at 33 U.S. hospitals who were appropriate for palliative care referral, as well as the percentage of these patients who were referred for and/or received palliative care services. We also conducted a qualitative assessment of barriers and facilitators to referral, focusing on organizational characteristics that might influence palliative care referral practices. METHODS: Patients appropriate for palliative care referral were defined as adult (≥18 years) patients with any diagnosis of a poor-prognosis cancer, New York Heart Association class IV congestive heart failure, or oxygen-dependent chronic obstructive pulmonary disease who had inpatient status in 1 of 33 hospitals on May 13, 2014. Qualitative assessment involved interviews of palliative care team members and nonpalliative care frontline providers. RESULTS: Nearly 19% of inpatients on the point prevalence day were deemed appropriate for palliative care referral. Of these, approximately 39% received a palliative care referral or services. Delivery of palliative care services to these patients varied widely among participating hospitals, ranging from approximately 12% to more than 90%. Factors influencing differences in referral practices included nonstandardized perceptions of referral criteria and variation in palliative care service structures. CONCLUSION: This study provides useful information to guide providers, administrators, researchers, and policy experts in planning for optimal provision of palliative care services to those in need.

The characteristics of patients frequently admitted to academic medical centers in the United States.

BACKGROUND: The recent intense attention to hospital readmissions and their implications for quality, safety, and reimbursement necessitates understanding specific subsets of readmitted patients. Frequently admitted patients, defined as patients who are admitted 5 or more times within 1 year, may have some distinguishing characteristics that require novel solutions. METHODS: A comprehensive administrative database (University HealthSystem Consortium's Clinical Data Base/Resource Manager) was analyzed to identify demographic, social, and clinical characteristics of frequently admitted patients in 101 US academic medical centers. RESULTS: We studied 28,291 frequently admitted patients with 180,185 admissions over a 1-year period (2011-2012). These patients comprise 1.6% of all patients, but account for 8% of all admissions and 7% of direct costs. Their admissions are driven by multiple chronic conditions; compared to other hospitalized patients, they have significantly more comorbidities (an average of 7.1 vs 2.5), and 84% of their admissions are to medical services. A minority, but significantly more than other patients, have comorbidities of psychosis or substance abuse. Moreover, although they are slightly more likely than other patients to be on Medicaid or to be uninsured (27.6% vs 21.6%), nearly three-quarters have private or Medicare coverage. CONCLUSIONS: Patients who are frequently admitted to US academic medical centers are likely to have multiple complex chronic conditions and may have behavioral comorbidities that mediate their health behaviors, resulting in acute episodes requiring hospitalization. This information can be used to identify solutions for preventing repeat hospitalization for this small group of patients who consume a highly disproportionate share of healthcare resources.

The reliability of AHRQ Common Format Harm Scales in rating patient safety events.

OBJECTIVES: A study was conducted to determine the reliability of Agency for Healthcare Research & Quality (AHRQ) Common Format Harm Scale versions 1.1 and 1.2 in rating patient safety events among users of the UHC Patient Safety Net, a Web-based incident reporting tool. METHODS: To test interrater agreement, UHC developed a survey tool consisting of patient event scenarios. In 2011, a survey evaluating Harm Scale v.1.1 was distributed to 921 quality, risk, and safety (QRS) managers at 89 organizations; in 2012, a second survey evaluating Harm Scale v.1.2 was sent to 13,280 managers at 102 organizations. RESULTS: Regardless of the version used, in 3 of 9 scenarios, fewer than 60% of respondents agreed on a single score. Interrater agreement increased for certain event scenarios with v.1.2 but decreased for other scenarios. Interrater reliability was moderate for both v.1.1 (k = 0.51) and v.1.2 (k = 0.47). Interrater agreement improved in v.1.2 when results were limited to more experienced raters but still remained in the moderate range (k = 0.58). CONCLUSIONS: AHRQ Common Format Harm Scale v.1.1 and v.1.2 both had moderate interrater reliability. Using Harm Scale v.1.1, respondents had difficulty distinguishing "injury limited to additional treatment" from "temporary harm," whereas, using Harm Scale v.1.2, respondents had difficulty distinguishing moderate harm from one of the adjacent levels-mild or severe harm. This study provides valuable data that can inform harm scale revision to improve the quality of aggregate safety data used to define and direct safety efforts.

Governance practices and performance in US academic medical centers.

Recognition of the complex nature of modern health care delivery has led to interest in investigating the ways in which various factors, including governance structures and practices, influence health care quality. In this study, the chief executive officers (CEOs) of US academic medical centers were surveyed to elicit their perceptions of board structures, activities, and attitudes reflecting 6 widely identified governance best practices; the relationship between use of these practices and organizational performance, based on the University HealthSystem Consortium's Quality & Accountability rankings, was assessed. High-performing hospitals showed greater use of all 6 practices, but the strongest evidence supported a focus on board member education and development, the rigorous use of performance measures to guide quality improvement, and systematic board self-assessment processes. All hospitals, even those with the highest quality ratings, had major gaps in their use of best practices for CEO and board assessments. These findings can serve as the basis for developing sound board improvement plans.

Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.

BACKGROUND: Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. STUDY DESIGN: Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. RESULTS: Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. CONCLUSIONS: Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology.

An analysis of patient falls and fall prevention programs across academic medical centers.

UHC conducted an analysis of more than 25 000 patient fall reports entered into the UHC Patient Safety Net incident reporting tool. Gaps were found in the completion of fall risk assessments, the ability of tools to accurately assess risk, and prevention strategies in particular inpatient units and emergency department. Common factors in falls resulting in major harm or death included age more than 80 years, altered mental status, ambulation (often without assistance), toileting, and diuretics and anticoagulants.

Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.

BACKGROUND: Although creating a culture of safety to support clinicians and improve the quality of patient care is a common goal among health care organizations, it can be difficult to envision specific efforts to directly influence organizational culture. To promote transparency and reinforce a nonpunitive attitude throughout the organization, a forum for the open, interdisciplinary discussion of patient safety problems--the Patient Safety Morbidity and Mortality (M&M) Conference--was created at Northwestern Memorial Hospital (Chicago). The intent of the M&M conference was to inform frontline providers about adverse events that occur at the hospital and to engage their input in root cause analysis, thereby encouraging reporting and promoting systems-based thinking among clinicians. METHODS: Convened under the purview of the organization's quality program, and modeled on the traditional M&M conferences historically used by physicians, the conference is a monthly live meeting at which case studies are presented for retrospective (root cause) analysis by an interdisciplinary audience. RESULTS: Since its start in 2003, approximately 60 patient safety M&M programs have been presented. Audiences typically represent a mix of physicians, nurses, pharmacists, management, therapists, and administrative and support staff. Staff perceptions of culture, as measured by the Hospital Survey on Patient Safety Culture, showed statistically significant improvements over time. DISCUSSION: Ensuring the patient safety M&M conference program's sustained success requires an ongoing commitment to identifying events of clinical importance and to pursuing the productive discussion of these events in an open and safe forum. Patient safety M&M conferences are a valued opportunity to engage staff in exploring adverse events and to promote transparency and a nonpunitive culture.

Compliance with acute MI guidelines lowers inpatient mortality.

Within the last decade, health care providers have seen the emergence of numerous patient care guidelines that can be used to prevent or manage specific medical conditions. The American College of Cardiology (ACC) and American Heart Association (AHA) have issued guidelines for the management of patients with acute myocardial infarction (AMI). In November of 2002, at the annual scientific session of the AHA, researchers presented the results of the first study to show a direct relationship between inpatient mortality and the level of a hospital's compliance with these guidelines. It is hoped that this evidence of a reduction in AMI patient mortality will provide an incentive for all hospitals to improve their adherence to the ACC/AHA AMI guidelines.