The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities.

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design. METHODS: RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months. DISCUSSION: This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities. TRIAL REGISTRATION: Clinicaltrials.govNCT02674464.

Statewide Collaborative to Reduce Surgical Site Infections: Results of the Hawaii Surgical Unit-Based Safety Program.

BACKGROUND: Surgical site infections (SSIs) after colorectal surgery are common, lead to patient harm, and are costly to the healthcare system. This study's purpose was to evaluate the effectiveness of the AHRQ Safety Program for Surgery in Hawaii. STUDY DESIGN: This pre-post cohort study involved 100% of 15 hospitals in Hawaii from January 2013 through June 2015. The intervention was a statewide implementation of the Comprehensive Unit-Based Safety Program and individualized bundles of interventions to reduce SSIs. Primary end point was colorectal SSIs. Secondary end point was safety culture measured by the AHRQ Hospital Survey on Patient Safety Culture. RESULTS: The most common interventions implemented were reliable chlorhexidine wash, wipe before operation, and surgical preparation; appropriate antibiotic choice, dose, and timing; standardized post-surgical debriefing; and differentiating clean-dirty-clean with anastomosis tray and closing tray. From January 2013 (quarter 1) through June 2015 (quarter 2), the collaborative colorectal SSI rate decreased (from 12.08% to 4.63%; p < 0.01). The SSI rate exhibited a linear decrease during the 10-quarter period (p = 0.005). Safety culture increased in 10 of 12 domains: Overall Perception/Patient Safety (from 49% to 53%); Teamwork Across Units (from 49% to 54%); Management-Support Patient Safety (from 53% to 60%); Nonpunitive Response to Error (from 36% to 40%); Communication Openness (from 50% to 55%); Frequency of Events Reported (from 51% to 60%); Feedback/Communication about Error (from 52% to 59%); Organizational Learning/Continuous Improvement (from 59% to 70%); Supervisor/Manager Expectations and Actions Promoting Safety (from 58% to 64%); and Teamwork Within Units (from 68% to 75%) (all p < 0.05). CONCLUSIONS: Participation in the national AHRQ Safety Program for Surgery in the state of Hawaii was associated with a 61.7% decrease in colorectal SSI rate and an increase in patient safety culture.

Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events.

OBJECTIVES: Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs. DESIGN: Longitudinal quasi-experimental study. SETTING: Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015. INTERVENTIONS: We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal. MEASUREMENTS AND RESULTS: ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively. CONCLUSIONS: A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.

Reducing preventable harm: observations on minimizing bloodstream infections.

Purpose The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms. Design/methodology/approach An existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA. Findings The following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions. Practical implications This framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms. Originality/value Implementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.

Measure accurately, Act rapidly, and Partner with patients: An intuitive and practical three-part framework to guide efforts to improve hypertension control.

Hypertension is the leading cause of cardiovascular disease in the United States and worldwide. It also provides a useful model for team-based chronic disease management. This article describes the M.A.P. checklists: a framework to help practice teams summarize best practices for providing coordinated, evidence-based care to patients with hypertension. Consisting of three domains-Measure Accurately; Act Rapidly; and Partner With Patients, Families, and Communities-the checklists were developed by a team of clinicians, hypertension experts, and quality improvement experts through a multistep process that combined literature review, iterative feedback from a panel of internationally recognized experts, and pilot testing among a convenience sample of primary care practices in two states. In contrast to many guidelines, the M.A.P. checklists specifically target practice teams, instead of individual clinicians, and are designed to be brief, cognitively easy to consume and recall, and accessible to healthcare workers from a range of professional backgrounds.

Assessing content validity and user perspectives on the Team Check-up Tool: expert survey and user focus groups.

OBJECTIVE: This study assesses content validity and user feedback on the Team Check-up Tool (TCT), an instrument used for measuring dynamic context of quality improvement (QI) teams and their implementation of QI activities. METHODS: We conducted two focus groups and one larger feedback session with TCT users to assess feasibility, importance of areas of inquiry and barriers to use. A panel of eight QI experts evaluated the item-by-item content (content validity) of TCT by rating the relevance of each item to implementation success. We calculated item-level and scale-level content validity using the content validity index (CVI). RESULTS: Scale-level CVI was 0.872. Highly rated items included implementation of recommended interventions, educational activities, team review of performance data, team sharing of performance data with staff and specific barriers to progress. Four items were rated relatively low: presentation of performance data to the hospital/health system board; manner of provision of feedback of data to staff; to what other units the team attempted to spread and turnover of QI team members. Items identified in user focus groups as important included whether there were events distracting staff from the initiative, number of team meetings and turnover of QI team members. Focus groups also identified barriers to the completion of the tool, including lack of feedback and response fatigue during stable activity periods. CONCLUSION: The findings support the conclusion that the TCT measures meaningful areas of context and implementation in team-based QI initiatives, particularly intervention activity tracking, review and sharing of performance data and team progress barriers. We offer a modified instrument with a framework for real-time measurement of important elements of implementation and context of QI teams based on the findings.

CLABSI Conversations: Lessons From Peer-to-Peer Assessments to Reduce Central Line-Associated Bloodstream Infections.

A national collaborative helped many hospitals dramatically reduce central line-associated bloodstream infections (CLABSIs), but some hospitals struggled to reduce infection rates. This article describes the development of a peer-to-peer assessment process (CLABSI Conversations) and the practical, actionable practices we discovered that helped intensive care unit teams achieve a CLABSI rate of less than 1 infection per 1000 catheter-days for at least 1 year. CLABSI Conversations was designed as a learning-oriented process, in which a team of peers visited hospitals to surface barriers to infection prevention and to share best practices and insights from successful intensive care units. Common practices led to 10 recommendations: executive and board leaders communicate the goal of zero CLABSI throughout the hospital; senior and unit-level leaders hold themselves accountable for CLABSI rates; unit physicians and nurse leaders own the problem; clinical leaders and infection preventionists build infection prevention training and simulation programs; infection preventionists participate in unit-based CLABSI reduction efforts; hospital managers make compliance with best practices easy; clinical leaders standardize the hospital's catheter insertion and maintenance practices and empower nurses to stop any potentially harmful acts; unit leaders and infection preventionists investigate CLABSIs to identify root causes; and unit nurses and staff audit catheter maintenance policies and practices.

Locating Errors Through Networked Surveillance: A Multimethod Approach to Peer Assessment, Hazard Identification, and Prioritization of Patient Safety Efforts in Cardiac Surgery.

OBJECTIVES: The objectives were to develop a scientifically sound and feasible peer-to-peer assessment model that allows health-care organizations to evaluate patient safety in cardiovascular operating rooms and to establish safety priorities for improvement. METHODS: The locating errors through networked surveillance study was conducted to identify hazards in cardiac surgical care. A multidisciplinary team, composed of organizational sociology, organizational psychology, applied social psychology, clinical medicine, human factors engineering, and health services researchers, conducted the study. We used a transdisciplinary approach, which integrated the theories, concepts, and methods from each discipline, to develop comprehensive research methods. Multiple data collection was involved: focused literature review of cardiac surgery-related adverse events, retrospective analysis of cardiovascular events from a national database in the United Kingdom, and prospective peer assessment at 5 sites, involving survey assessments, structured interviews, direct observations, and contextual inquiries. A nominal group methodology, where one single group acts to problem solve and make decisions was used to review the data and develop a list of the top priority hazards. RESULTS: The top 6 priority hazard themes were as follows: safety culture, teamwork and communication, infection prevention, transitions of care, failure to adhere to practices or policies, and operating room layout and equipment. CONCLUSIONS: We integrated the theories and methods of a diverse group of researchers to identify a broad range of hazards and good clinical practices within the cardiovascular surgical operating room. Our findings were the basis for a plan to prioritize improvements in cardiac surgical care. These study methods allowed for the comprehensive assessment of a high-risk clinical setting that may translate to other clinical settings.

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

BACKGROUND: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections. METHODS: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented. RESULTS: A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation. CONCLUSION: Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

Technologies in the wild (TiW): human factors implications for patient safety in the cardiovascular operating room.

We describe different sources of hazards from cardiovascular operating room (CVOR) technologies, how hazards propagate in the CVOR and their impact on cognitive processes. Previous studies have examined hazards from poor design of a specific CVOR technology. However, the impact of different CVOR technologies functioning in context is not clearly understood. In addition, the impact of non-design hazards in technology devices is unclear. Our study identified hazards from organisational, physical/environmental elements, in addition to design of technology in a CVOR. We used observations, follow-up interviews and photographs. With qualitative analyses, we categorised the different hazard sources and their potential impact on cognitive processes. Patient safety can be built into technologies by incorporating user needs in design, decision-making and implementation of medical technologies. PRACTITIONER SUMMARY: Effective design and implementation of technology in a safety-critical system requires prospective understanding of technology-related hazards. Our research fills this gap by studying different technologies in context of a CVOR using observations. Qualitative analyses identified different sources for technology-related hazards besides design, and their impact on cognitive processes.

Decreasing central-line-associated bloodstream infections in Connecticut intensive care units.

Central-line-associated bloodstream infections (CLABSIs) are a significant cause of preventable harm. A collaborative project involving a multifaceted intervention was used in the Michigan Keystone Project and associated with significant reductions in these infections. This intervention included the Comprehensive Unit-based Safety Program, a multifaceted approach to CLABSI prevention, and the monitoring and reporting of infections. The purpose of this study was to determine whether the multifaceted intervention from the Michigan Keystone program could be implemented in Connecticut and to evaluate the impact on CLABSI rates in intensive care units (ICUs). The primary outcome was the NHSN-defined rate of CLABSI. Seventeen ICUs, representing 14 hospitals and 104,695 catheter days were analyzed. The study period included up to four quarters (12 months) of baseline data and seven quarters (21 months) of postintervention data. The overall mean (median) CLABSI rate decreased from 1.8 (1.8) infections per 1,000 catheter days at baseline to 1.1 (0) at seven quarters postimplementation of the intervention. This study demonstrated that the multifaceted intervention used in the Keystone program could be successfully implemented in another state and was associated with a reduction in CLABSI rates in Connecticut. Moreover, even though the statewide baseline CLABSI rate in Connecticut was low, rates were reduced even further and well below national benchmarks.

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

Accurate patient identification is a National Patient Safety Goal. Misidentification of surgical specimens is associated with increased morbidity, mortality, and costs of care. The authors developed 12 practical, process-based, standardized measures of surgical specimen identification defects during the preanalytic phase of pathology testing (from the operating room to the surgical pathology laboratory) that could be used to quantify the occurrence of these defects. The measures (6 container and 6 requisition identification defects) were developed by a panel of physicians, pathologists, nurses, and quality experts. A total of 69 hospitals prospectively collected data over 3 months. Overall, there were identification defects in 2.9% of cases (1780/60 501; 95% confidence interval [CI] = 2.0%-4.4%), 1.2% of containers (1018/81 656; 95% CI = 0.8%-2.0%), and 2.3% of requisitions (1417/61 245; 95% CI = 1.2%-4.6%). Future research is needed to evaluate if hospitals are able to use these measures to assess interventions meant to reduce the frequency of specimen identification defects and improve patient safety.

Republished: development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students.

PURPOSE: To develop a patient safety curriculum and evaluate its impact on medical students' safety knowledge, self-efficacy and system thinking. METHODS: This study reports on curriculum development and evaluation of a 3-day, clinically oriented patient safety intersession that was implemented at the Johns Hopkins School of Medicine in January 2011. Using simulation, skills demonstrations, small group exercises and case studies, this intersession focuses on improving students' teamwork and communication skills and system-based thinking while teaching on the causes of preventable harm and evidence-based strategies for harm prevention. One hundred and twenty students participated in this intersession as part of their required second year curriculum. A pre-post assessment of students' safety knowledge, self-efficacy in safety skills and system-based thinking was conducted. Student satisfaction data were also collected. RESULTS: Students' safety knowledge scores significantly improved (mean +19% points; 95% CI 17.0 to 21.6; p<0.01). Composite system thinking scores increased from a mean pre-intersession score of 60.1 to a post-intersession score of 67.6 (p<0.01). Students had statistically significant increases in self-efficacy for all taught communication and safety skills. Participant satisfaction with the intersession was high. CONCLUSIONS: The patient safety intersession resulted in increased knowledge, system-based thinking, and self-efficacy scores among students. Similar intersessions can be implemented at medical, nursing, pharmacy and other allied health schools separately or jointly as part of required school curricula. Further study of the long-term impact of such education on knowledge, skills, attitudes and behaviours of students is warranted.

Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study.

BACKGROUND: Cardiac surgery is a complex, high-risk procedure with potential vulnerabilities for patient safety. The evidence base describing safety hazards in the cardiovascular operating room is underdeveloped but is essential to guide future safety improvement efforts. OBJECTIVE: To identify and categorise hazards (anything that has the potential to cause a preventable adverse patient safety event) in the cardiovascular operating room. METHODS: An interdisciplinary team of researchers used prospective methods, including direct observations, contextual inquiry and photographs to collect hazard data pertaining to the cardiac surgery perioperative period, which started immediately before the patient was transferred to the operating room and ended immediately after patient handoff to the post-anaesthesia/intensive care unit. Data were collected between February and September 2008 in five hospitals. An interdisciplinary approach that included a human factors and systems engineering framework was used to guide the study. RESULTS: Twenty cardiac surgeries including the corresponding handoff processes from operating room to post-anaesthesia/intensive care unit were observed. A total of 58 categories of hazards related to care providers (eg, practice variations), tasks (eg, high workload), tools and technologies (eg, poor usability), physical environment (eg, cluttered workspace), organisation (eg, hierarchical culture) and processes (eg, non-compliance with guidelines) were identified. DISCUSSION: Hazards in cardiac surgery services are ubiquitous, indicating numerous opportunities to improve safety. Future efforts should focus on creating a stronger culture of safety in the cardiovascular operating room, increasing compliance with evidence-based infection control practices, improving communication and teamwork, and developing a partnership among all stakeholders to improve the design of tools and technologies.

Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students.

PURPOSE: To develop a patient safety curriculum and evaluate its impact on medical students' safety knowledge, self-efficacy and system thinking. METHODS: This study reports on curriculum development and evaluation of a 3-day, clinically oriented patient safety intersession that was implemented at the Johns Hopkins School of Medicine in January 2011. Using simulation, skills demonstrations, small group exercises and case studies, this intersession focuses on improving students' teamwork and communication skills and system-based thinking while teaching on the causes of preventable harm and evidence-based strategies for harm prevention. One hundred and twenty students participated in this intersession as part of their required second year curriculum. A pre-post assessment of students' safety knowledge, self-efficacy in safety skills and system-based thinking was conducted. Student satisfaction data were also collected. RESULTS: Students' safety knowledge scores significantly improved (mean +19% points; 95% CI 17.0 to 21.6; p<0.01). Composite system thinking scores increased from a mean pre-intersession score of 60.1 to a post-intersession score of 67.6 (p<0.01). Students had statistically significant increases in self-efficacy for all taught communication and safety skills. Participant satisfaction with the intersession was high. CONCLUSIONS: The patient safety intersession resulted in increased knowledge, system-based thinking, and self-efficacy scores among students. Similar intersessions can be implemented at medical, nursing, pharmacy and other allied health schools separately or jointly as part of required school curricula. Further study of the long-term impact of such education on knowledge, skills, attitudes and behaviours of students is warranted.

Using the Opportunity Estimator tool to improve engagement in a quality and safety intervention.

Teams throughout the United States participating in a program to reduce central line-associated bloodstream infections (CLABSIs) are using the Opportunity Estimator. This web-based tool translates CLABSI-related data into "opportunity estimates" of the patient lives and money that could be saved by reducing these infections.

Using human factors engineering to improve patient safety in the cardiovascular operating room.

Despite significant medical advances, cardiac surgery remains a high risk procedure. Sub-optimal work system design characteristics can contribute to the risks associated with cardiac surgery. However, hazards due to work system characteristics have not been identified in the cardiovascular operating room (CVOR) in sufficient detail to guide improvement efforts. The purpose of this study was to identify and categorize hazards (anything that has the potential to cause a preventable adverse patient safety event) in the CVOR. An interdisciplinary research team used prospective hazard identification methods including direct observations, contextual inquiry, and photographing to collect data in 5 hospitals for a total 22 cardiac surgeries. We performed thematic analysis of the qualitative data guided by a work system model. 60 categories of hazards such as practice variations, high workload, non-compliance with evidence-based guidelines, not including clinicians' in medical device purchasing decisions were found. Results indicated that hazards are common in cardiac surgery and should be eliminated or mitigated to improve patient safety. To improve patient safety in the CVOR, efforts should focus on creating a culture of safety, increasing compliance with evidence based infection control practices, improving communication and teamwork, and designing better tools and technologies through partnership among all stakeholders.

Eradicating central line-associated bloodstream infections statewide: the Hawaii experience.

The authors' goal was to determine if a national intensive care unit (ICU) collaborative to reduce central line-associated bloodstream infections (CLABSIs) would succeed in Hawaii. The intervention period (July 2009 to December 2010) included a comprehensive unit-based safety program; a multifaceted approach to CLABSI prevention; and monitoring of infections. The primary outcome was CLABSI rate. A total of 20 ICUs, representing 16 hospitals and 61 665 catheter days, were analyzed. Median hospital bed size was 159 (interquartile range [IQR] = 71-212) and median ICU bed size was 10 (IQR = 8-12). Median unit catheter days per month were 112 (IQR = 52-197). The overall mean CLABSI rate decreased from 1.5 infections per 1000 catheter days at baseline (January to June 2009) to 0.6 at 16 to 18 months postintervention (October to December 2010). The median rate was zero CLABSIs per 1000 catheter days at baseline and remained zero throughout the study period. Hawaii demonstrated that the national program can be successfully spread, providing further evidence that most CLABSIs are preventable.

Toward improving patient safety through voluntary peer-to-peer assessment.

Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care's sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.