Improving and sustaining core measure performance through effective accountability of clinical microsystems in an academic medical center.

BACKGROUND: Evidence-based performance measures, known as core measures, have been established by The Joint Commission to improve the quality of care for patient populations, such as those with acute myocardial infarction (AMI), heart failure, and community-acquired pneumonia (CAP), as well as to improve the quality of surgical care--the Surgical Care Improvement Project (SCIP) measures. Hospital administrators have traditionally held academic and community physicians and hospital clinicians accountable for integrating the core measures into daily practice. Such efforts have often led to suboptimal results because of the belief that the "organization" (macrosystem) is the appropriate level at which to work to improve quality. Stanford Hospital and Clinics (Stanford, California) has instead held leaders of clinical microsystems--the clinical units where care is provided--accountable to improve performance on the core measures. The strategic approaches taken for this initiative include engagement of the hospital's board of directors; clear assignment of accountability among interdisciplinary care teams to drive the change; implementation of a unit-based medical director program; transparency of core measure performance at the microsystem, mesosystem, and macrosystem levels; and concurrent monitoring with rapid feedback of results. RESULTS: In 2007, the first year of this initiative, the 24-metric composite compliance score for all four core measures increased from 64% to 82%. The composite score was sustained at a minimum of 90% during 2009 and Quarter 1 of 2010. CONCLUSIONS: Holding clinical microsystems accountable for improving unit performance proved beneficial to macrosystem performance of the Joint Commission core measures.

Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion.

BACKGROUND: This study presents our implementation of a two-specimen requirement with no prior record of ABO/Rh to verify patients' blood type before transfusion. MATERIALS AND METHODS: Blood type verification was introduced, discussed, approved, and implemented over a 12-month period (May 2007 to May 2008). Potential barriers and impact on benchmark indicators were identified and tracked. RESULTS: Inpatient identification and/or specimen labeling for nursing and laboratory phlebotomists baseline corrected error rates were 1:467 and 1:5555, respectively. This study therefore sought and obtained approval to initiate a new policy of blood type verification before blood transfusion. Compliance in turnaround time (TAT) before and after implementation for completion of STAT type and screen/crossmatch within 60 minutes worsened marginally, from 90% to 80%. The impact on use of O-, uncrossmatched blood was found to be manageable. Seven (of 25 total) recorded electronic complaints were received after implementation. The corrected error rate for nurse phlebotomy draws after implementation was 1:630. CONCLUSION: Despite the lack of an instigating event, verification of blood type before blood transfusion was successfully implemented. An impact on resources and benchmark indicators such as TAT can be anticipated and managed. Further process improvement efforts will be needed to ensure safety (e.g., at time of blood transfusion) for patients receiving blood transfusions. ABO/Rh verification may be necessary even after future implementation of bar coding and/or RFID chips, because human errors continue to occur even with systems improvements.

Accelerating Biopharmaceutical Development in the Decade of Health Information Technology: Applications of EHRs for outcomes research and clinical trials recruitment.

Electronic health records hold vast potential for streamlining patient recruitment for clinical trials and improving outcomes research.