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IHI Innovation System

Institute for Healthcare Improvement -

Drawing on IHI's nearly 30 years of experience with innovation, this white paper provides a detailed description of IHI’s innovation system, including 90-Day Learning and Testing Cycles, and describes how a health care organization might create its own internal innovation system that focuses on improving health care delivery.

Identifying vendors in studies of electronic health records: the editor replies

Quality and Safety in Health Care Journal -

I thank Dr O’Donnell for his letter asking if we did not name the vendors in a study of the electronic health record (EHR)-generated discharge summaries1 as a matter of policy or simply due to an oversight. The vulnerabilities and unintended consequences of health information technologies have appeared as recurring themes in both research papers2–7 and editorials8–10 at BMJ Quality & Safety. We agree that such studies should generally mention the vendors involved, just as one would expect to occur in studies of medical devices, such as infusion pumps or surgical implants.

In this case, the omission of the vendors did indeed result from an oversight. We had asked the authors to identify the vendors in our comments as part of the editorial comments added to those from external...

Problems with discharge summaries produced by electronic health records: why are the vendors not named?

Quality and Safety in Health Care Journal -

The study by Sarzynski and colleagues1 uses rigorous analysis to obtain important insights about the real-time information that patients receive at discharge. It is puzzling that the electronic health records (EHRs) used were not named. One can infer from a look through the Michigan State University website that they have both Cerner and Epic, but why is such detective work necessary? The heart of quality/safety work is one of transparency balanced by humility. We should not expect health information technology systems to be any more perfect than we are. But, these systems would not improve if we do not have more openness about their shortcomings.

The lack of scientific foundations and published postmarketing surveillance for our EHRs, especially the ascendant ones, was initially surprising. However, as they achieve complete market dominance, with less overt scientific review and public guidance and commentary,2 the silence is deafening....

Questions regarding the authors conclusions about the lack of change in Hospital Survey on Patient Safety Culture (HSOPS) scores related to reduction of hospital-acquired infections

Quality and Safety in Health Care Journal -

We were very interested to read the article by Meddings et al which evaluated the association between patient safety culture and catheter-associated infections among hospitals in two infection-reducing collaboratives.1 The authors found that while infection rates declined, there was no association between 13 dimensions of patient safety culture, as measured by the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS), and unadjusted infection rates (catheter-associated urinary tract infections (CAUTI) and central-line-associated bloodstream infection (CLABSI) rates per 1000 catheter days).

We comment on several of the article’s conclusions and pose some questions about the data collection and analysis methods used to examine the relationship between HSOPS and infection rates.

First, the study reported HSOPS response rates averaging 24% for the CLABSI collaborative and 43% for the CAUTI collaborative, which were described as ’a low response rate' and ’important finding' which they attribute to...

On being human: reflections on a daily error

Quality and Safety in Health Care Journal -

The importance of the respiratory rate (RR) as a vital sign is hardly new, but the recent article by Badawy et al1 uses an elegant and scientific approach to shine new light on an old issue, that of the reliability of recorded vital signs. The article relates to an important function of healthcare: early detection and prevention of patient deterioration. From where I write, in Australia, recognising and responding to deterioration is one of ten National Health Standards.2 I believe RR is a microcosm of the challenges we face in healthcare and Badawy’s article has implications for patient safety and quality as a whole.

RR is an extremely valuable indicator; it is an integral part of early warning systems (EWS) and a diagnostic criterion for systemic inflammatory response syndrome.3 Its prognostic value can even rival complex prognostic tools such as the Pneumonia Severity...

Roadmap for improving the accuracy of respiratory rate measurements

Quality and Safety in Health Care Journal -

We thank Dr Wong for his detailed description of the importance of respiratory rate (RR) and his astute reflections on the interactions between predictable human errors and the systems in which humans work. We agree that RR is prone to error because of the human element. However, what is unique to healthcare compared with aviation is not that human error exists, but that tolerance for these errors has become an accepted part of everyday practice.1 We hypothesise that RRs can be measured both accurately and efficiently, but this requires institutional culture change starting with improvements in staff education, expectations and accountability, which can be accomplished through a quality improvement (QI) initiative. We have initiated this process at our own institution.

To guide our local ongoing QI initiative, we mapped the workflows for routine RR measurements by patient care assistants (PCA) through direct observation in a single inpatient...

Correction: Advancing Implementation Science for Quality and Safety in Primary Health Care: The Integrated Care for Older Adults with Complex Health Needs Study (iCOACH)

Quality and Safety in Health Care Journal -

Shaw J, McKillop A, Sheridan N, et al. BMJ Qual Saf 2017; doi:10.1136/bmjqs-2017-006696.2.

The corrected affiliations for this paper should read as follows:

James Shaw,1, 4 Ann McKillop,2 Nicolette Sheridan,2 Carolyn Steele Gray,3, 4 Peter Carswell,2 Walter P Wodchis,4, 7, 8 Mylaine Breton,5 Jean-Louis Denis,6 G. Ross Baker,4 Timothy Kenealy2

  • Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada

  • Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

  • Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada

  • Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

  • Département des sciences de la santé communautaire, Universite de Sherborooke, Longueuil, Quebec, Canada

  • Département d’administration de la santé, Universite de Montreal, Montreal, Quebec, Canada

  • Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada

  • Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

  • doi:10.1136/bmjqs-2017-006696corr1

    Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care

    Quality and Safety in Health Care Journal -

    In his book on the psychology of persuasion, Robert Cialdini noted: "as the stimuli saturating our lives continue to grow more intricate and variable, we will have to depend increasingly on our shortcuts to handle them all".1 Such cognitive shortcuts, or heuristics, are responsible for much of human success in complex environments. Heuristics allow us to skip steps and save mental energy. Similarly, emotions provide a shorthand for remembering and reacting to complex situations and sociability allows us to function well in groups.

    Medicine is the art of managing complexity. Physicians’ success similarly depends on effective use of these heuristics, emotion and sociability. When admitting a patient to the hospital, a physician must diagnose the presenting symptoms, reconcile and start medications, order diagnostic testing, communicate with consultants and participate in shared-decision making. In ambulatory visits, the time pressure and tasks are slightly different, but comparably complex. In both...

    Impact of order set design on urine culturing practices at an academic medical centre emergency department

    Quality and Safety in Health Care Journal -

    Background

    Urinalysis and urine culture are commonly ordered tests in the emergency department (ED). We evaluated the impact of removal of order sets from the ‘frequently ordered test’ in the computerised physician order entry system (CPOE) on urine testing practices.

    Methods

    We conducted a before (1 September to 20 October 2015) and after (21 October to 30 November 2015) study of ED patients. The intervention consisted of retaining ‘urinalysis with reflex to microscopy’ as the only urine test in a highly accessible list of frequently ordered tests in the CPOE system. All other urine tests required use of additional order screens via additional mouse clicks. The frequency of urine testing before and after the intervention was compared, adjusting for temporal trends.

    Results

    During the study period, 6499 (28.2%) of 22 948 ED patients had ≥1 urine test ordered. Urine testing rates for all ED patients decreased in the post intervention period for urinalysis (291.5 pre intervention vs 278.4 per 1000 ED visits post intervention, P=0.03), urine microscopy (196.5vs179.5, P=0.001) and urine culture (54.3vs29.7, P<0.001). When adjusted for temporal trends, the daily culture rate per 1000 ED visits decreased by 46.6% (–46.6%, 95% CI –66.2% to –15.6%), but urinalysis (0.4%, 95% CI –30.1 to 44.4%), microscopy (–6.5%, 95% CI –36.0% to 36.6%) and catheterised urine culture rates (17.9%, 95% CI –16.9 to 67.4) were unchanged.

    Conclusions

    A simple intervention of retaining only ‘urinalysis with reflex to microscopy’ and removing all other urine tests from the ‘frequently ordered’ window of the ED electronic order set decreased urine cultures ordered by 46.6% after accounting for temporal trends. Given the injudicious use of antimicrobial therapy for asymptomatic bacteriuria, findings from our study suggest that proper design of electronic order sets plays a vital role in reducing excessive ordering of urine cultures.

    Implementation of a colour-coded universal protocol safety initiative in Guatemala

    Quality and Safety in Health Care Journal -

    Background

    Universal protocol implementation can be challenging in low-income or middle-income countries, particularly when providers work together across language barriers. The aim of this quality improvement initiative was to test the implementation of a colour-coded universal protocol in a Guatemalan hospital staffed by US and Guatemalan providers.

    Methods

    From 2013 to 2016, a US and Guatemalan team implemented a universal protocol at a Guatemalan surgical centre for children undergoing general surgical or urologic procedures. The protocol was a two-step patient identification and documentation checklist, with the first step of all chart element verification in the preoperative area, after which a blue hat was placed on the patient as a visual cue that this was completed. The second step included checklist confirmation in the operating room prior to the procedure. We tested protocol implementation over three phases, identifying implementation barriers and modifying clinical workflow after each phase. We measured the error rate in documentation or other universal protocol steps at each phase and made modifications based on iterative analysis.

    Results

    Over the course of programme implementation, we substantially decreased the rate of errors in documentation or other universal protocol elements. After the first phase, 30/51 patients (58.8%) had at least one error. By the third phase, only 2/43 patients (4.6%) had any errors. All errors were corrected prior to surgery with no adverse outcomes.

    Conclusions

    Care teams of providers from different countries pose potential challenges with patient safety. Implementation of a colour-coded universal protocol in this setting can prevent and reduce errors that could potentially lead to patient harm.

    Performance of statistical process control methods for regional surgical site infection surveillance: a 10-year multicentre pilot study

    Quality and Safety in Health Care Journal -

    Background

    Traditional strategies for surveillance of surgical site infections (SSI) have multiple limitations, including delayed and incomplete outbreak detection. Statistical process control (SPC) methods address these deficiencies by combining longitudinal analysis with graphical presentation of data.

    Methods

    We performed a pilot study within a large network of community hospitals to evaluate performance of SPC methods for detecting SSI outbreaks. We applied conventional Shewhart and exponentially weighted moving average (EWMA) SPC charts to 10 previously investigated SSI outbreaks that occurred from 2003 to 2013. We compared the results of SPC surveillance to the results of traditional SSI surveillance methods. Then, we analysed the performance of modified SPC charts constructed with different outbreak detection rules, EWMA smoothing factors and baseline SSI rate calculations.

    Results

    Conventional Shewhart and EWMA SPC charts both detected 8 of the 10 SSI outbreaks analysed, in each case prior to the date of traditional detection. Among detected outbreaks, conventional Shewhart chart detection occurred a median of 12 months prior to outbreak onset and 22 months prior to traditional detection. Conventional EWMA chart detection occurred a median of 7months prior to outbreak onset and 14 months prior to traditional detection. Modified Shewhart and EWMA charts additionally detected several outbreaks earlier than conventional SPC charts. Shewhart and SPC charts had low false-positive rates when used to analyse separate control hospital SSI data.

    Conclusions

    Our findings illustrate the potential usefulness and feasibility of real-time SPC surveillance of SSI to rapidly identify outbreaks and improve patient safety. Further study is needed to optimise SPC chart selection and calculation, statistical outbreak detection rules and the process for reacting to signals of potential outbreaks.

    Reorganisation of stroke care and impact on mortality in patients admitted during weekends: a national descriptive study based on administrative data

    Quality and Safety in Health Care Journal -

    Objective

    To evaluate mortality differences between weekend and weekday emergency stroke admissions in England over time, and in particular, whether a reconfiguration of stroke services in Greater London was associated with a change in this mortality difference.

    Design, setting and participants

    Risk-adjusted difference-in-difference time trend analysis using hospital administrative data. All emergency patients with stroke admitted to English hospitals from 1 January 2008 to 31 December 2014 were included.

    Main outcomes

    Mortality difference between weekend and weekday emergency stroke admissions.

    Results

    We identified 507 169 emergency stroke admissions: 26% of these occurred during the weekend. The 7-day in-hospital mortality difference between weekend and weekday admissions declined across England throughout the study period. In Greater London, where the reorganisation of stroke services took place, an adjusted 28% (relative risk (RR)=1.28, 95% CI 1.09 to 1.47) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 9% higher risk (RR=1.09, 95% CI 0.91 to 1.32) in 2014. For the rest of England, a 15% (RR=1.15, 95% CI 1.09 to 1.22) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 3% higher risk (RR=1.03, 95% CI 0.97 to 1.10) in 2014. During the same period, in Greater London an adjusted 12% (RR=1.12, 95% CI 1.00 to 1.26) weekend/weekday 30-day mortality ratio in 2008 slightly increased to 14% (RR=1.14, 95% CI 1.00 to 1.30); however, it was not significant. In the rest of England, an 11% (RR=1.11, 95% CI 1.07 to 1.15) higher weekend/weekday 30-day mortality ratio declined to a non-significant 4% higher risk (RR=1.04, 95% CI 0.99 to 1.09) in 2014. We found no statistically significant association between decreases in the weekend/weekday admissions difference in mortality and the centralisation of stroke services in Greater London.

    Conclusions

    There was a steady reduction in weekend/weekday differences in mortality in stroke admissions across England. It appears statistically unrelated to the centralisation of stroke services in Greater London, and is consistent with an overall national focus on improving stroke services.

    Ratings game: an analysis of Nursing Home Compare and Yelp ratings

    Quality and Safety in Health Care Journal -

    Background

    Two strategies for rating the quality of nursing homes (NHs) in the USA are exemplified by the Nursing Home Compare (NHC) website, launched by the federal Centers for Medicare and Medicaid Services in 1998, and Yelp.com, an online consumer review site that has grown in popularity since its founding in 2004. Both sites feature a 5-star rating system. While much is known about NHC ratings, little is known about NH Yelp ratings. This study examines Yelp ratings for NHs in California and compares these ratings with NHC ratings. Understanding how these ratings relate can inform efforts to empower consumers and enhance NH decision-making.

    Methods

    We collected NHC and Yelp ratings for all California NHs between September and November 2016. For each NH with a Yelp review, we recorded the star rating and the total number of reviews. We also recorded the NHC 5-star rating and NHC ratings for inspections, staffing and quality measures (QMs). We conducted descriptive statistics and frequencies for these variables. We conducted correlations and tested means to compare the ratings.

    Results

    A total of 675 NHs (68.1% of the total sample of 991 NHs) had both Yelp ratings and NHC ratings. Correlations between the Yelp and NHC ratings were relatively weak. The Yelp rating was significantly lower than the 5-star NHC rating and the NHC ratings for staffing and QMs. It was significantly higher than the NHC inspection rating.

    Conclusions

    This study found that when consumers rate NHs on Yelp, their ratings differ considerably from NHC ratings, a finding in keeping with similar studies of NH quality measurement. Further research is needed to analyse the content of Yelp reviews and compare the themes and topics consumers identify with those reported on NHC.

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