The Healthcare Improvement and Innovation in Quality (THINQ) Collaborative: A Novel Quality Improvement Training Program for Undergraduate and Postgraduate Students.

The Healthcare Improvement and Innovation in Quality (THINQ) Collaborative is a uniquely designed program that engages undergraduate and postgraduate students to participate in improving health care and addressing important clinical problems. In 9 years, over 120 THINQ Fellows have been trained in quality improvement (QI) frameworks and methodologies focusing on research skills, social justice, leadership development, and problem-solving. Program evaluation has included surveying current and former THINQ Fellows about their experiences with the program and its subsequent impact on their careers. THINQ's research and outreach initiatives have contributed to improvements in workflows and clinical care on topics such as interdisciplinary team communication, discharge and care transition, sepsis management, and physician burnout. The THINQ Program has equipped future health care leaders to engage with and address QI issues in clinical practice. The structures, processes, and outcomes discussed here can guide other institutions in creating similar QI programs.

A Multisite Electronic Health Record Integrated Remote Monitoring Intervention for Hypertension Improvement: Protocol for a Randomized Pragmatic Comparative Effectiveness Trial.

BACKGROUND: Hypertension is a major contributor to various adverse health outcomes. Although previous studies have shown the benefits of home blood pressure (BP) monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a BP monitor integrated into the electronic health record is superior to a nonintegrated BP monitor. OBJECTIVE: In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to nonintegrated BP monitors for hypertension improvement. METHODS: We will conduct a randomized, comparative effectiveness trial at 3 large academic health centers across California. The 3 sites will enroll a total of 660 participants (approximately n=220 per site), with 330 in the integrated BP monitor arm and 330 in the nonintegrated BP control arm. The primary outcome of this study will be the absolute difference in systolic BP in mm Hg from enrollment to 6 months. Secondary outcome measures include binary measures of hypertension (controlled vs uncontrolled), hypertension-related health complications, hospitalizations, and death. The list of possible participants will be generated from a central data warehouse. Randomization will occur after enrollment in the study. Participants will use their assigned BP monitor and join site-specific hypertension interventions. Cross-site learning will occur at regular all-site meetings facilitated by the University of California, Los Angeles Value-Based Care Research Consortium. A pre- and poststudy questionnaire will be conducted to further evaluate participants' perspectives regarding their BP monitor. Linear mixed effects models will be used to compare the primary outcome measure between study arms. Mixed effects logistic regression models will be used to compare secondary outcome measures between study arms. RESULTS: The study will start enrolling participants in the second quarter of 2023 and will be completed by the first half of 2024. Results will be published by the end of 2024. CONCLUSIONS: This pragmatic trial will contribute to the growing field of chronic care management using remote monitoring by answering whether a hypertension intervention coupled with an electronic health record integrated home BP monitor improves patients' hypertension better than a hypertension intervention with a nonintegrated BP monitor. The outcomes of this study may help health system decision makers determine whether to invest in integrated BP monitors for vulnerable patient populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT05390502; clinicaltrials.gov/study/NCT05390502. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45915.

Physician behaviors associated with increased physician and nurse communication during bedside interdisciplinary rounds.

BACKGROUND: Effective team communication during interdisciplinary rounds (IDRs) is a hallmark of safe, efficient, patient-centered care. However, there is limited understanding of optimal IDR structures and procedures. OBJECTIVE: This study aimed to analyze direct observations of physician and nurse interactions during bedside IDR to identify behaviors associated with increased interprofessional communication. DESIGNS, SETTINGS AND PARTICIPANTS: Trained observers audited general medicine ward rounds at an academic medical center using a standardized tool to record physician and nurse behavior and communication in 1007 patient encounters in October 2019 to March 2020. RESULTS: There were significant differences in physician and nurse interaction time among physicians with different levels of training, with attendings demonstrating higher interaction time than residents (5.4 ± 4.6 vs. 4.3 ± 3.7 min, p = .02) and interns or medical students (3.0 ± 3.2 min, p = .002). Attendings were more likely to initiate a conversation about nurse concerns (76.9%) compared to residents (67.9%) and interns or medical students (59.3%, p = .03). Early nurse participation in bedside visits was associated with increased physician and nurse interaction time (5.0 ± 4.6 vs. 1.9 ± 1.7 min, p < .001) and physician initiative to ask about nurse concerns (74.8% vs. 64.3%, p = .04). In addition, physician initiative to ask the nurse for concerns rather than waiting for the nurse to offer concerns without being prompted was associated with a subsequent conversation about those concerns (74.5% vs. 61.8%, p < .001) and the physician asking about patient or family concerns (94.2% vs. 88.4%, p = .01). CONCLUSIONS: Implementing IDR structures and procedures that promote attending physician involvement, physician initiative, and early nurse participation could optimize interdisciplinary communication and quality of care.

Impact of COVID-19 on Primary Care Quality Measures in an Academic Integrated Health System.

BACKGROUND: Access to primary care was hindered by the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: Evaluate changes in health screening rates before and during the pandemic. DESIGN: Retrospective analysis of health maintenance and disease management screening rates among primary care patients before and during the pandemic. PARTICIPANTS: Over 150,000 patients of a large, academic health system. MAIN MEASURES: Six quality measures were analyzed: colon cancer, breast cancer, cervical cancer, diabetes Hgb A1C, diabetes eye, and diabetes nephropathy monitoring. Based on US Preventative Services Task Force screening guidelines, we determined which patients were due for at least one of the quality measures. We tracked completion rates during three time periods: pre-pandemic (January 1-March 3, 2020), stay-at-home (March 4-May 8, 2020), and phased reopening (May 9-July 8, 2020). Differences in quality measure completion rates were evaluated using mixed-effects logistic regression models. KEY RESULTS: Compared to pre-pandemic rates, completion of all health screenings declined during the stay-at-home period: mammograms (OR: 0.34; 95% CI: 0.31-0.37), cervical cancer (OR: 0.83; 95% CI: 0.76-0.91), colorectal cancer (OR: 0.25; 95% CI: 0.23-0.28), diabetes eye (OR: 0.34; 95% CI: 0.29-0.41), diabetes Hgb A1c (OR: 0.41; 95% CI: 0.37-0.46), and diabetes nephropathy (OR: 0.46, 95% CI: 0.41-0.53). During phased reopening, completion of all quality measures increased compared to the stay-at-home period, except for cervical cancer screening (OR: 0.83; 95% CI: 0.76-0.92). There was a persistent reduction in completion of all quality measures, except for diabetic nephropathy monitoring (OR: 0.99; 95% CI: 0.89-1.09), during phased reopening compared to pre-pandemic. CONCLUSIONS: Healthcare screening rates were reduced during the early part of the COVID-19 pandemic and did not fully recover to pre-pandemic rates by July 2020. Future research should aim to clarify the long-term impacts of delayed health screenings. New interventions should be considered for expanding remote preventative health services.

Rapid Mortality Review in the Intensive Care Unit: An In-Person, Multidisciplinary Improvement Initiative.

BACKGROUND: Significant resources have been allocated to decreasing the number of preventable deaths in hospitals, but identifying preventable factors and then leveraging them to effect system-wide change remains challenging. OBJECTIVE: To determine the ability of a novel in-person, multidisciplinary "rapid mortality review" process to identify deaths that are preventable and action items that lead to improvements in care. METHODS: Rapid mortality review sessions were conducted weekly for patients who died in the medical intensive care unit. Patient data and clinician opinions regarding preventable deaths were discussed and recorded. Bivariate analyses were done to detect associations between case variables and the formation of an action item. RESULTS: From 2013 to 2018, 542 patient deaths were reviewed; of those, 36 deaths (7%) were deemed potentially preventable. Facilitators identified issues in 294 cases (54%). A total of 253 action items were identified for 175 cases (32%); 60% of those action items were subsequently completed and led to tangible systemic change in 29 instances (11%). Action items were more likely to be identified for patients who had not been receiving comfort care (P < .001), for patients who had received cardiopulmonary resuscitation (P < .001), when the treatment team (P < .001) or the rapid mortality review facilitator (P < .001) had care-related concerns, and when the patient's death had been preventable (P < .001). CONCLUSIONS: Even in settings with low reported rates of preventable deaths, an in-person multidisciplinary mortality review can successfully identify areas where care can be improved, leading to systemic change.

Patient Navigation After Positive Fecal Immunochemical Test Results Increases Diagnostic Colonoscopy and Highlights Multilevel Barriers to Follow-Up.

BACKGROUND: The fecal immunochemical test (FIT) is a common colorectal cancer screening modality in the USA but often is not followed by diagnostic colonoscopy. AIMS: We investigated the efficacy of patient navigation to increase diagnostic colonoscopy after positive FIT results and determined persistent barriers to follow-up despite navigation in a large, academic healthcare system. METHODS: The study cohort included all health system outpatients with an assigned primary care provider, a positive FIT result between 12/01/2016 and 06/01/2019, and no documentation of colonoscopy after positive FIT. Two non-clinical patient navigators engaged patients and providers to encourage follow-up, offer solutions to barriers, and assist with colonoscopy scheduling. The primary intervention endpoint was completion of colonoscopy within 6 months of navigation. We documented reasons for persistent barriers to colonoscopy despite navigation and determined predictors of successful follow-up after navigation. RESULTS: There were 119 patients who received intervention. Of these, 37 (31.1%) patients completed colonoscopy at 6 months. In 41/119 (34.5%) cases, the PCP did not recommend colonoscopy, most commonly due to a normal colonoscopy prior to the positive FIT (19, 46.3%). There were 41/119 patients (34.5%) that declined colonoscopy despite the patient navigator and the PCP order. Male sex and younger age were significant predictors of follow-up (aOR = 2.91, 95%CI, 1.18-7.13; aOR = 0.92, 95%CI, 0.87-0.99). CONCLUSIONS: After implementation of patient navigation, diagnostic colonoscopy was completed for 31.1% of patients with a positive FIT result. However, navigation also highlighted persistent multilevel barriers to follow-up. Future work will develop targeted solutions for these barriers to further increase FIT follow-up rates in our health system.

Developing Statewide Violence Prevention Programs in Health Care: An Exemplar From Massachusetts.

Workplace violence is on the rise in health care. This problem contributes to medical errors, ineffective delivery of care, conflict and stress among health professionals, and demoralizing and unsafe work conditions. There is no specific federal statute that requires workplace violence protections, but several states have enacted legislation or regulations to protect health care workers. To address this problem in their state, the Massachusetts Health & Hospital Association developed an action plan to increase communication, policy development, and strategic protocols to decrease workplace violence. The purpose of this article is to report on the quality and safety improvement work that has been done statewide by the Massachusetts Health & Hospital Association and to provide a roadmap for other organizations and systems at the local, regional, or state level to replicate the improvement process.

Creating Healthful Work Environments to Deliver on the Quadruple Aim: A Call to Action.

Nurses face workplace stressors that contribute to job dissatisfaction, burnout, and turnover, impacting not only patient safety but the nurses' physical and emotional well-being. At the 2018 American Academy of Nursing conference, a policy dialogue "Creating Healthy Work Environments to Address the Quadruple Aim" was convened focusing on creating healthy work environments by addressing stressors such as violence and bullying. That discussion is encapsulated in this article, providing proven and practical strategies for reducing risk.

Application of Behavioral Economics Principles Improves Participation in Mailed Outreach for Colorectal Cancer Screening.

INTRODUCTION: Colorectal cancer (CRC) is a major cause of cancer-related morbidity and mortality in the United States. Although various interventions have improved screening rates, they often require abundant resources and can be difficult to implement. Social psychology and behavioral economics principles offer an opportunity for low-cost and easy-to-implement strategies but are less common in clinical settings. METHODS: We randomized 2,000 patients aged 50-75 years eligible for CRC screening to one of the 2 mailed interventions: a previously used text-based letter describing and offering fecal immunochemical testing (FIT) and colonoscopy (usual care arm); or a letter leveraging social psychology and behavioral economics principles (e.g., implied scarcity and choice architecture), minimal text, and multiple images to offer FIT and colonoscopy (intervention arm). We compared total screening uptake, FIT uptake, and colonoscopy uptake at 1-month intervals in each group. RESULTS: There were 1,882 patients included in the final analysis. The mean age was 69.3 years, and baseline characteristics in the 2 groups were similar. Screening completion at 26 weeks was 19.5% in the usual care arm (16.3% FIT vs 3.2% colonoscopy, P < 0.01) and 24.1% in the intervention arm (22.1% FIT vs 2.0% colonoscopy, P < 0.01) (P = 0.02). DISCUSSION: Among primary care patients aged 50-75 years in an academic setting, mailed CRC outreach employing social psychology and behavioral economics principles led to a higher participation in CRC screening than usual care mailed outreach. TRANSLATIONAL IMPACT: Mailed interventions to increase CRC screening should incorporate social psychology and behavioral economics principles to improve participation.

Pain, agitation, and delirium guidelines: nurses' involvement in development and implementation.

The 2013 American College of Critical Care Medicine/Society of Critical Care Medicine clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit serves as a living example of nurses' involvement in the development and implementation of professional guidelines. Nurses who served on this guideline-writing panel describe their experiences. Specific examples from the pain, agitation, and delirium guidelines for care are used to explore the roles of the nurse leader, nurse informaticist, staff nurse, and nurse researcher in relationship to guideline implementation.