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This cross-sectional study uses data from the 2001 to 2011 Nationwide Inpatient Sample to compare International Statistical Classification of Diseases, Tenth Revision (ICD-10) with Ninth Revision coding systems for laryngectomy procedures.

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

This Viewpoint discusses the need for clinicians to be involved in every stage of the development of patient safety interventions in order to not only improve patient care, but also maximize the interventions’ effectiveness and ensure clinician well-being and buy-in.

Amid longstanding recognition that healthcare challenges are often managerial, not just clinical, many have called for greater attention to developing physicians’ business management abilities. However, the Covid-19 pandemic has amplified the urgency of building physicians’ business knowledge and skills—from understanding health economics and finances to managing dynamics of collaborative leadership and change—in order to respond to pandemic-induced business challenges that threaten healthcare organizations. Unfortunately, existing efforts to develop these critical skills among physicians remain limited, focusing primarily on early-career physicians-in-training or later-career physicians in formal leadership positions. These efforts leave a wide swath of frontline physician leaders “in the middle” without systematic resources for developing their business management abilities. We advocate for several key changes to professional practices and policies to help bring business of health knowledge and skills to the foreground for all physicians, both in the pandemic and beyond.

Mortality review is one approach to systematically examine delivery of care and identify areas for improvement. Health system leaders sought to ensure hospitals were adapting to the rapidly changing medical guidance for COVID-19 and delivering high-quality care. Thus, all patients with a COVID-19 diagnosis within the 6-hospital system who died between March and July 2020 were reviewed within 72 hours. Concerns for preventability advanced review to level 2 (content experts) or 3 (hospital leadership). Reviews included available autopsy and cardiac arrest data. Overall health system mortality for COVID-19 patient admissions was 12.5% and mortality for mechanically ventilated patients was 34.4%. Significant differences in mortality rates were observed among hospitals due to demographic variations in patient populations at hospitals. Mortality reviews resulted in the dissemination of evolving knowledge among sites using an electronic medical record order set, implementation of proning teams, and development of checklists for converting COVID-19 floors and units.

Medical error remains a far too common source of harm.1–4 After a medical error occurs, a physician has a decision to make: disclose the error and apologise, or keep quiet. Traditionally, defence attorneys and insurers counselled physicians against disclosing errors. Within the medical profession, however, the last two decades have witnessed a strong push for transparency. Healthcare organisations are adopting disclosure policies, providing training on how to talk with patients in the aftermath of an error and building communication and resolution programmes (CRP), programmes that ensure disclosure and apology to patients, followed by adverse event investigations, and when appropriate, offers of compensation or other remedies. Motivating factors for these changes include meeting ethical obligations, promoting greater patient trust and fostering patient safety. The law is slowly evolving to support these efforts. One notable development is that 39 states now have ‘apology laws’, about a third of which apply to both healthcare and other contexts.5 In the healthcare setting, apology laws protect aspects of healthcare providers’ communications with patients about adverse events from being used as evidence in malpractice litigation while some have general applicability.6 There is substantial variation across states in the scope of protection provided by apology laws, with most protecting only statements of sympathy (eg, ‘I’m sorry this happened’) and a minority extending protection to statements of explanation and statements of fault (eg, ‘I’m sorry I hurt you by giving you the wrong medication’).5 Apology laws may cultivate greater candour in healthcare by providing reassurance that the old warning that ‘anything you say can and will be used against you in a court of law’ does not apply to medical error discussions. But the impetus for state lawmakers was somewhat different: a belief that apologies could promote reconciliation and dissuade injured patients from suing, …

OBJECTIVES: Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been reported. The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module. METHODS: We assessed free-text allergy entries in a commercial EHR used at a multi-hospital integrated healthcare system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list. RESULTS: We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergens (18%), contrast media allergies (13%), “no known allergy” (12%), drug allergies (2%), and “no contrast allergy” (2%). The majority of free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in peri-operative settings (20%). We remediated a total of 52,206 free-text entries with automated methods, and 79,578 free-text entries with manual methods. CONCLUSION: Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent and safe guidelines for documenting allergies.

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement. This review contains 1 figure, 3 tables, and 56 references Keywords: Quality of care, performance measure, quality improvement, clinical practice, sigma six, transparency

More than 25% of adults in the United States remain unvaccinated for coronavirus disease 2019 [COVID-19 (1)]. Although some of the unvaccinated are vaccine-resistant and may never be convinced that they should get the shot, the hope is that a sizable proportion of the unvaccinated will accept vaccination under the right circumstances. The recent US Food and Drug Administration (FDA) approval of the Pfizer vaccine—and Centers for Disease Control and Prevention (CDC) recommendation for a booster—may aid acceptance. And various incentives have been instituted to encourage vaccination, including free transportation to vaccination locations, time off from work, and monetary lotteries for those who have been vaccinated. Outreach has entailed the use of trusted messengers such as personal physicians, local community and faith leaders, and social media influencers; partnering with familiar community sites such as houses of worship; and expanding vaccination sites to include pharmacies, primary care offices, and mobile units (2⇓–4). An increasing number of private businesses and universities have announced vaccination mandates as part of returns to in-person work and school (5). Hopefully, many more people will elect to get vaccinated. And when they do, they should have a choice of vaccines. Whether vaccinating in hard-to-reach communities or requiring vaccination as a condition of employment or on-campus education, we argue that offering a choice of vaccine should be an essential component of COVID-19 vaccination strategies. The speed and efficiency of vaccination programs are very important values. But vaccination efforts must also promote justice and mitigate health inequities. We should find ways to respect individual decision-making and offer people a choice of vaccines. Image credit: Dave Cutler (artist). Vaccine administration in underserved communities often requires mobile units to facilitate vaccination clinics in urban or rural communities or to deliver vaccine directly into the homes of people who … [↵][1] 1To whom correspondence may be addressed. Email: jeffkahn{at}jhu.edu. [1]: #xref-corresp-1-1

As 2019 draws to a close, the Journal of Patient Safety and Risk Management has reached a milestone for a new academic publishing enterprise: we have completed our first two full volumes. These are made up of 12 issues of research, case studies, descriptions of programs and policy, and related scholarship, on patient safety and medicolegal risk. In the Northern Hemisphere, we are approaching the winter solstice and the longest nights of the year. Also at hand are the corresponding festivities which originally must have been intended at least in part to ward off the dark and cold. To observe the season, we offer gifts of wisdom on patient safety and health care quality, nominated by our editors and international editorial board. In medicine, these bon mots are sometimes referred to as “pearls.” Although a few are freshly minted, most are venerable. As a rule, their origin is obscure. One of our members described his offerings as grains of sand rather than pearls, suggesting their potential to irritate more than enlighten. But over the years they have been repeated, paraphrased and repackaged on the wards by countless clinicians, much like nursery rhymes reinvented on the playground by generations of small children.

Purpose To assess the impact of a patient experience improvement program on national ranking in patient experience in a large academic radiology department. Materials and Methods This Health Insurance Portability and Accountability Act-compliant study was exempted from institutional review board approval. After initiating an electronic patient experience survey, 26 210 surveys and 22 213 comments were received from May 2017 to April 2018. During the study period, a multifaceted quality improvement initiative was instituted, focused on improving patient experience in the radiology department. The primary outcome was national percentile ranking as measured with the survey. Secondary outcome was the change in departmental percentile ranking compared with the overall hospital ranking for patient experience measured with a similar survey. Results The overall raw score for the department increased from 92.8 to 93.6 of 100 (P.001), and the national ranking improved from the 35th to 50th percentile (P = .001). Improvements in raw scores related to personnel were primarily responsible for the increase in overall raw score and ranking. Of the 22 213 comments received, 3458 (15.6%) were negative. The percentage of negative comments was highly correlated with lower monthly percentile ranking (Pearson correlation coefficient of -0.69; P = .01). Conclusion It is feasible to develop a large-scale electronic survey to assess patient experience in the radiology department, to identify improvement opportunities, and to measurably improve patient experience. Changes in the percentage of negative comments were correlated with changes in a practice's national percentile rank in patient experience. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Kruskal and Sarwar in this issue.

Purpose The aim of this study was to measure diagnostic imaging safety events reported to an electronic safety reporting system and assess steps at which they occurred within the diagnostic imaging workflow and contributing sociotechnical factors. Methods The authors evaluated all electronic safety reporting system reports related to diagnostic imaging during calendar year 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and 680,000 diagnostic imaging studies annually. Each report was assigned a harm score ranging from 0 to 4 by the reporter; scores of 2 (minor harm) to 4 (death) were classified as “potential harm.” Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and sociotechnical factors per the Systems Engineering Initiative for Patient Safety framework. The κ coefficient was used to measure interreviewer agreement on 10% of reports. The percentage of reports that could cause “potential harm” was compared for each step and sociotechnical factor using χ2 analysis. Results Of 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was imaging procedure (54% of reports), potential harm occurred more in result communication (odds ratio, 2.36; P = .05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to tasks compared with person factors (odds ratio, 5.03; P Conclusions Safety events were related to diagnostic imaging in 7% of reported events. Potential harm occurred primarily during imaging procedure and result communication. Safety events were attributed to multifactorial sociotechnical factors. Further work is necessary to decrease safety events related to diagnostic imaging.

Objective An electronic pathway for the management of adhesive small bowel obstruction (SBO) was built and implemented on top of the electronic health record. The aims of this study are to describe the development of the electronic pathway and to report early outcomes. Methods The electronic SBO pathway was designed and implemented at a single institution. All patients admitted to a surgical service with a diagnosis of adhesive SBO were enrolled. Outcomes were compared across three time periods: (1) patients not placed on either pathway from September 2013 through December 2014, (2) patients enrolled in the paper pathway from January 2017 through January 2018, and (3) patients enrolled in the electronic pathway from March through October 2018. The electronic SBO pathway pulls real-time data from the electronic health record to prepopulate the evidence-based algorithm. Outcomes measured included length of stay (LOS), time to surgery, readmission, surgery, and need for bowel resection. Comparative analyses were completed with Pearson's chi-squared, analysis of variance, and Kruskal–Wallis tests. Results There were 46 patients enrolled in the electronic pathway compared with 93 patients on the paper pathway, and 101 nonpathway patients. Median LOS was lower in both pathway cohorts compared with those not on either pathway (3 days [range 1–11] vs. 3 days [range 1–27] vs. 4 days [range 1–13], p = 0.04). Rates of readmission, surgery, time to surgery, and bowel resection were not significantly different across the three groups. Conclusion It is feasible to implement and utilize an electronic, evidence-based clinical pathway for adhesive SBOs. Use of the electronic and paper pathways was associated with decreased hospital LOS for patients with adhesive SBOs.

Objective Clinicians may hesitate to advocate for autopsies out of concern for increased malpractice risk if the pathological findings at time of death differ from the clinical findings. We aimed to understand the impact of autopsy findings on malpractice claim outcomes. Methods Closed malpractice claims with loss dates between 1995 and 2015 involving death related to inpatient care at 3 Harvard Medical School hospitals were extracted from a captive malpractice insurer's database. These claims were linked to patients' electronic health records and their autopsy reports. Using the Goldman classification system, 2 physician reviewers blinded to claim outcome determined whether there was major, minor, or no discordance between the final clinical diagnoses and pathologic diagnoses. Claims were compared depending on whether an autopsy was performed and whether there was major versus minor/no clinical-pathologic discordance. Primary outcomes included percentage of claims paid through settlement or plaintiff verdict and the amount of indemnity paid, inflation adjusted. Results Of 293 malpractice claims related to an inpatient death that could be linked to patients' electronic health records, 89 claims (30%) had an autopsy performed by either the hospital or medical examiner. The most common claim allegation was an issue with clinician diagnosis, which was statistically less common in the autopsy group (18% versus 38%, P = 0.001). There was no difference in percentage of claims paid whether an autopsy was performed or not (42% versus 41%, P = 0.90) and no difference in median indemnity of paid claims after adjusting for number of defendants ($1,180,537 versus $906,518, P = 0.15). Thirty-one percent of claims with hospital autopsies performed demonstrated major discordance between autopsy and clinical findings. Claims with major clinical-pathologic discordance also did not have a statistically significant difference in percentage paid (44% versus 41%, P > 0.99) or amount paid ($895,954 versus $1,494,120, P = 0.10) compared with claims with minor or no discordance. Conclusions Although multiple factors determine malpractice claim outcome, in this cohort, claims in which an autopsy was performed did not result in more paid outcomes, even when there was major discordance between clinical and pathologic diagnoses.

In healthcare quality improvement, we are trained to believe that, “every system is perfectly designed to get the results it gets”.1 By focusing relentlessly on getting the process right, we will know we can arrive at better outcomes.2 Over the past decade, however, publicly reported metrics for hospitals have moved away from process metrics, further emphasising outcome metrics. The Centers for Medicare and Medicaid Services (CMS) has major pay-for-performance programmes for hospitals aimed squarely at improving outcomes, such as hospital-acquired infections and 30-day readmission rates. US News and World Report’s and Leapfrog’s hospital rankings heavily weight outcomes, such as 30-day mortality rates and postoperative complications. In this viewpoint, we propose that although process measures have had limitations that led to the shift towards outcome measures, new developments in electronic health records, data collection, and quality measurement have the potential to overcome these limitations and vastly improve the utility of process measures. The rationale for shifting towards outcome measures is more than reasonable, as process measures have had their challenges. If performance on a process measure improves (eg, increased haemoglobin A1c testing for diabetes management) but is not accompanied by sufficient resulting improvements in outcomes (eg, haemoglobin A1c results meeting desired levels), it may not make sense to continue optimising performance on that process measure.3 4 Also, seeking improvement in process measures, if not carefully constructed, may not always lead to meaningful changes in the clinical process. One notable example is smoking cessation counselling at discharge. A hospital could meet the smoking cessation counselling measure by simply adding to every discharge summary an instruction that says, “If you smoke, we advise you to stop”. As a result of the lack of meaningful change in clinical practice, that tobacco cessation measure was subsequently dropped. A more stringent measure was …

Objective To assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors. Materials and Methods This retrospective, Institutional Review Board-approved study was conducted at the ambulatory healthcare facilities associated with a large academic hospital. Five information sources were evaluated: an electronic safety reporting system (ESRS), alert notification for critical result (ANCR) system, picture archive and communication system (PACS)-based quality assurance (QA) tool, imaging peer-review system, and an imaging computerized physician order entry (CPOE) and scheduling system. Data from these sources (January-December 2015 for ESRS, ANCR, QA tool, and the peer-review system; January-October 2016 for the imaging ordering system) were collected to quantify the incidence of potential safety events. Reviewers classified events by the step(s) in the diagnostic process they could elucidate, and their socio-technical factors contributors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Results Potential safety events ranged from 0.5% to 62.1% of events collected from each source. Each of the information sources contributed to elucidating diagnostic process errors in various steps of the diagnostic imaging chain and contributing socio-technical factors, primarily Person, Tasks, and Tools and Technology. Discussion Various information sources can differentially inform understanding diagnostic process errors related to radiologic diagnostic imaging. Conclusion Information sources elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.

Through communication-and-resolution programs, hospitals and liability insurers communicate with patients when adverse events occur; investigate and explain what happened; and, where appropriate, apologize and proactively offer compensation. Using data recorded by program staff members and from surveys of involved clinicians, we examined case outcomes of a program used by two academic medical centers and two of their community hospitals in Massachusetts in the period 2013-15. The hospitals demonstrated good adherence to the program protocol. Ninety-one percent of the program events did not meet compensation eligibility criteria, and those events that did were not costly to resolve (the median payment was $75,000). Only 5 percent of events led to malpractice claims or lawsuits. Clinicians were supportive of the program but desired better communication about it from staff members. Our findings suggest that communication-and-resolution programs will not lead to higher liability costs when hospitals adhere to their commitment to offer compensation proactively.

BackgroundLittle is known about the incidence or significance of diagnostic error in the inpatient setting. We used a malpractice claims database to examine incidence, predictors and consequences of diagnosis-related paid malpractice claims in hospitalised patients.MethodsThe US National Practitioner Database was used to identify paid malpractice claims occurring between 1 January 1999 and 31 December 2011. Patient and provider characteristics associated with paid claims were analysed using descriptive statistics. Differences between diagnosis-related paid claims and other paid claim types (eg, surgical, anaesthesia, medication) were assessed using Wilcoxon rank-sum and χ2 tests. Multivariable logistic regression was used to identify patient and provider factors associated with diagnosis-related paid claims. Trends for incidence of diagnosis-related paid claims and median annual payment were assessed using the Cochran-Armitage and non-parametric trend test.Results13 682 of 62 966 paid malpractice claims (22%) were diagnosis-related. Compared with other paid claim types, characteristics significantly associated with diagnosis-related paid claims were as follows: male patients, patient aged >50 years, provider aged ConclusionInpatient diagnosis-related malpractice payments are common and more often associated with disability and death than other claim types. Research focused on understanding and mitigating diagnostic errors in hospital settings is necessary.

Numerical ratings and narrative comments about physicians are increasingly available online. These physician rating websites include independent websites reporting crowd-sourced data from online users and health systems reporting data from their internal patient experience surveys. To assess patient and physician views on physician rating websites. Cross-sectional physician (electronic) and patient (paper) surveys conducted in August 2015. Eight hundred twenty-eight physicians (response rate 43%) affiliated with one of four hospitals in a large accountable care organization in eastern Massachusetts; 494 adult patients (response rate 34%) who received care in this system in May 2015. Use and perceptions of physician rating websites. Fifty-three percent of physicians and 39% of patients reported visiting a physician rating website at least once. Physicians reported higher levels of agreement with the accuracy of numerical data (53%) and narrative comments (62%) from health system patient experience surveys compared to numerical data (36%) and narrative comments (36%) on independent websites. Patients reported higher levels of agreement with trusting the accuracy of data obtained from independent websites (57%) compared to health system patient experience surveys (45%). Twenty-one percent of physicians and 51% of patients supported posting narrative comments online for all consumers. The majority (78%) of physicians believed that posting narrative comments online would increase physician job stress; smaller proportions perceived a negative effect on the physician–patient relationship (46%), health care overuse (34%), and patient-reported experiences of care (33%). Over one-fourth of patients (29%) believed that posting narrative comments would cause them to be less open. Physicians and patients have different views on whether independent or health system physician rating websites are the more reliable source of information. Their views on whether such data should be shared on public websites are also discordant.

W Edwards Deming is famously quoted as having said, “If you can’t measure it, you can’t manage it”. In truth, Deming’s full quotation reads, “It is wrong to suppose that if you can’t measure it, you can’t manage it—a costly myth”.1 2 In our journey to improve our hospital’s rates of Clostridium difficile , we learned first-hand the truth of Deming’s full statement—that in fact, even without the ability to measure perfectly, imperfect measures can still help us improve quality. US hospitals are currently required to report hospital-acquired C. difficile rates as a condition of participation in several Centers for Medicare and Medicaid Services (CMS) pay-for-performance programmes. CMS is seeking to shed light on this type of preventable patient harm and raising the stakes by putting financial penalties and a hospital’s public reputation at risk. However, there is a vigorous debate in the medical community over the C. difficile measurement technique used by CMS. CMS’s C. difficile rates are based on the National Healthcare Safety Network’s C. difficile ‘ LabID’ measure. This metric identifies C. difficile infections solely by positive laboratory test results, without regard to patients’ clinical signs or symptoms. This approach makes case assignments very objective (and therefore reduces ‘gaming’), but comes at the risk of misclassifying colonised patients as infected. The C. difficile tests we have only tell us whether C. difficile is present or not. They do not differentiate between colonisation and infection. This is particularly true of PCR-based testing that looks for the presence of the C. difficile toxin gene but does not determine whether the gene is producing toxin or not. The most specific test we have is the C. difficile toxin immunoassay, but even this is imperfect. The lack of specificity is the Achilles heel of the C. difficile LabID measure because …

Background A commonly cited reason among nurses and physicians for not reporting safety events is a perceived lack of feedback from management on filed safety reports. This suggests that the value of a safety reporting system could be improved with a closed-loop feedback system between management and frontline staff on filed safety reports in which feedback was requested. Methods Ambulatory staff were surveyed on barriers to reporting to assess this challenge at an academic medical center. In response, system changes were implemented to the electronic safety reporting system, gained leadership buy-in, incorporated managers into a work group tasked with enhancing feedback to staff, established project management support, and developed a safety star manager recognition program. Ultimately, a process was developed to measure and ensure that feedback was provided to staff who requested it through a series of Plan-Do-Study-Act cycles termed the Feedback to Reporter program. Results At baseline in 2013, the team found that staff who indicated they wanted feedback on safety reports received it less than 50% of the time. By the end of fiscal year 2018, the monthly feedback to reporter rate was consistently 90% or higher. The percentage of safety reports in which feedback was requested ranged from 35.0% to 49.7% of all safety reports submitted. Conclusion Ultimately, a multidimensional approach improved closed-loop communication from local managers to frontline staff and between managers of different departments on ambulatory safety reports when feedback was requested. Improvements were sustained for more than one year.

Background Patient safety has traditionally focused on the inpatient setting; however, there is an increased awareness of ambulatory safety risk. However, successful strategies and programs to mitigate risk in the ambulatory setting are lacking. Program In 2012, we started building a multidisciplinary ambulatory safety program at an academic health system. Our team was composed of clinical, administrative, and patient safety membership. Based on organizational needs, our program initially focused on the following: (1) safety reporting, (2) safety culture measurement, (3) medication safety, and (4) test result management. What we did We were able to develop initiatives around safety reporting, safety culture survey administration, and medication safety and begin to work on test result management. Internal metrics were developed to measure performance and to drive improvement. Safety reporting When evaluating our ambulatory safety reports, we discovered that less than one-third of staff filing safety reports requested feedback. From 2013 to 2018, we tested various strategies to increase the rates of feedback to staff and ultimately found that a decentralized process that was supported by the ambulatory safety program could achieve rates of feedback of 90%. Safety culture measurement We administered the Agency for Healthcare Research and Quality Medical Office Survey in 2012, 2014, and 2016, achieving a more than 70% response rate across 70 unique ambulatory areas. Data from these surveys were shared with senior hospital leadership, local departmental directors, and managers and ultimately with frontline staff focusing on two key survey areas: communication openness and communication about error. Medication safety From 2012 to 2014, our rates of ambulatory medication reconciliation increased to more than 90% in both primary care and specialty practices in our homegrown electronic medical record system. From 2015 to 2016, rates of ambulatory medication reconciliation in our new vendor-based electronic medical record were 73% as of August 2017. Conclusions We were able to build an infrastructure to focus and support ambulatory safety efforts on safety reporting, safety culture change, and medication reconciliation with a team dedicated to ambulatory-focused safety risks and encountered many challenges along the way. Currently, we are expanding our program to concentrate on test result follow-up to prevent missed and delayed diagnosis and medication error reduction.

Who Goes First? Top government officials were among the first people vaccinated against Covid-19 in the United States. But prioritization frameworks do not grant government leaders special status, ...

In the USA, hospitals are increasingly evaluated and paid, based on a burgeoning list of publicly reported quality and safety metrics. Performance measurement is undoubtedly essential for improving healthcare quality, but developing the ‘right’ metrics has remained a formidable challenge1 and has resulted in significant discourse over the validity, authenticity and utility of several publicly reported measures.2–4 Yet, despite the debate, the amount of financial incentives tied to quality metrics continues to grow. As stakes for physicians and hospitals in the USA continue to rise, several of the measures used in performance programmes have come under greater scrutiny. For instance, the use of the Patient Safety Indicator-90 (PSI-90) measure—a metric comprised of eight distinct PSI measures weighted to varying degrees—in two major pay-for-performance initiatives has been questioned for its validity.2 Another measure increasingly tied to financial incentives in the USA is hospital mortality. We believe its use, while well intentioned and with some value, is too problematic to merit inclusion in pay-for-performance programmes. In 2008, the Center for Medicare and Medicaid Services (CMS, a US federal agency responsible for the administration of Medicare and Medicaid insurance products that provide health coverage for the elderly and the poor, respectively) began publicly reporting 30-day risk-adjusted hospital mortality rates (death within 30 days of admission adjusted for selected comorbidities) for Medicare patients admitted with one of three conditions: acute myocardial infarction, heart failure and pneumonia. The decision to use risk-adjusted hospital mortality rates in quality measurement and public reporting to drive improvement in care is understandable. Mortality is perhaps the ultimate outcome in healthcare, one that both providers and patients care deeply about. Indeed, the use of risk-adjusted mortality as a publicly reported measure appears now to be a fairly well-established practice. For example, public reporting of risk-adjusted mortality rates for …

Twenty years ago, few systematic efforts to make health care safer existed. Today, patient safety is a priority for patients, providers, payers, and policy makers. The Institute of Medicine’s 1999 report on medical error prompted a flurry of activity, including widespread adoption of error detection and reporting programs, movement toward systems approaches for addressing error, development of new clinical interventions to reduce error, and efforts to foster stronger safety cultures within healthcare organizations.1 Although there are some indications that these activities have yielded benefits, it is also evident that much of health care, including cardiovascular medicine, remains too unsafe.2,3 Mirroring the heterogeneity and complexity of errors in health care, the myriad initiatives underway to improve safety are multifaceted and wide ranging, which makes it difficult to overview them. However, many of the initiatives that involve legal and policy-based interventions may be characterized according to their alignment with 1 of the following 4 general approaches: greater transparency; financial incentives; new forms of regulation emanating from both inside and outside the provider community; and reform of the liability system. As patient safety improvement initiatives grow in scope and impact, understanding their precise role, effects, and limitations will become increasingly important for physicians and hospitals. Cardiologists, cardiac surgeons, and health services and policy researchers working on cardiovascular disease are especially likely to encounter these initiatives. Cardiac conditions are highly visible, frequently associated with substantial morbidity and mortality, and expensive, which helps to explain why cardiovascular care is often targeted for improvement efforts. In this article, we review the leading approaches to patient safety improvement, addressing both their rationale and available evidence of their effectiveness. We conclude with discussion of some implications for clinical practice. Health care is an opaque enterprise. Its machinery is understood best and controlled largely by …

This study assesses the agreement of the US Centers for Medicare & Medicaid Services Hospital Compare, Healthgrades, and US News & World Report Best Hospitals on hospital performance for chronic obstructive pulmonary disease and heart failure.

To promote communication with patients after medical injuries and improve patient safety, numerous hospitals have implemented communication-and-resolution programs (CRPs). Through these programs, hospitals communicate transparently with patients after adverse events; investigate what happened and offer an explanation; and, when warranted, apologize, take responsibility, and proactively offer compensation. Despite growing consensus that CRPs are the right thing to do, concerns over liability risks remain. We evaluated the liability effects of CRP implementation at four Massachusetts hospitals by examining before-and-after trends in claims volume, cost, and time to resolution and comparing them to trends among nonimplementing peer institutions. CRP implementation was associated with improved trends in the rate of new claims and legal defense costs at some hospitals, but it did not significantly alter trends in other outcomes. None of the hospitals experienced worsening liability trends after CRP implementation, which suggests that transparency, apology, and proactive compensation can be pursued without adverse financial consequences.

A lack of access to critical drugs in the USA, either due to exorbitant prices or shortages, has become a troubling norm that threatens the quality and safety of healthcare. In 2017, there were shortages of 146 commonly used drugs including electrolytes, chemotherapy, cardiovascular, and antibiotic agents. For example, there currently exists a shortage in intravenous fluids and injectable opioids (both in chronic short supply for years) that has been respectively ascribed to disruptions in pharmaceutical manufacturing by Hurricane Maria and manufacturing delays. These explanations, however, mask a more fundamental and avoidable cause: a lack of healthy competition in the generic drug market which is likely contributing to price hikes and shortages. By understanding this underlying cause, we hope to illuminate a pathway from our current state of complacency, where drug price hikes and shortages are routine, to a future state of effective action, where patients have reliable access to vital drugs. This article outlines a roadmap to influence incentives, regulations, new drug development, and ultimately stakeholder (i.e., patients, providers, and drug makers) behavior to enhance competition, with the ultimate aim of improving the quality and safety of healthcare for our patients.

The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge.An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system. An executive committee of hospital leaders was convened to empower and launch the program. To measure progress, metrics related to care of patients on opioids and those with opioid use disorder (OUD) were evaluated.The OSP created a holistic, health system-wide program that addressed opioid prescribing, treatment of OUD, education, and information technology tools. After implementation, the number of opioid prescriptions decreased (-73.5/month; p0.001), mean morphine milligram equivalents (MME) per prescription decreased (-0.4/month; p0.001), the number of unique patients receiving an opioid decreased (-52.6/month; p0.001), and the number of prescriptions ≥ 90 MME decreased (-48.1/month; p0.001). Prescriptions and providers for buprenorphine increased (+6.0 prescriptions/month and +0.4 providers/month; both p0.001). Visits for opioid overdose did not change (-0.2 overdoses/month; p = 0.29).This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts.

Amid calls for graduate medical education (GME) to better prepare a workforce that can address growing challenges in health care quality and cost, institutions must find ways to more effectively educate and engage housestaff in quality improvement (QI) initiatives. Although the benefits for trainees and institutions alike can be significant, creating and maintaining successful strategies has proven challenging. Multiple barriers (e.g., variable backgrounds and needs of trainees) have clouded the educational and clinical effectiveness of many efforts. Recent findings suggest that trainee engagement in QI is lacking and that contextual support for practice-based learning and systems-based practice is often suboptimal.Meaningful GME reform must include changes in how institutions approach QI education, particularly in how they create appropriate learning environments for trainees. Institutions can achieve these goals and foster a positive QI culture by aligning housestaff QI teaching with institutional priorities in several ways. First, they can create common, institutional-level QI curricula to standardize expectations for learners across training levels and specialties. Second, they can engage housestaff in ongoing institutional QI efforts by encouraging these trainees to develop and execute QI projects or assemble QI-focused groups that include faculty and institutional leaders. Third, institutions can appoint housestaff to institutional QI committees and have housestaff groups review and endorse proposed QI initiatives to enhance operational decision making. Institutions can leverage the new Accreditation Council for Graduate Medical Education Clinical Learning Environment Review program to implement these strategies, measure progress, and realize important gains in housestaff QI education.

Introduction The Surgical Care Improvement Project (SCIP) was launched in 2005. One of the SCIP metrics includes perioperative beta-blocker guideline (CARD-2), which measures the percentage of patients on a pre-operative beta-blocker with continued use in the perioperative period. Compliance is intended to decrease rates of acute myocardial infarction (AMI) and cardiac mortality among high-risk patients. We desired to create low cost, standardized processes on an institutional level to improve compliance with the SCIP CARD-2 metric. Methods We assessed the impact of interventions on provider compliance with the SCIP CARD-2 metric and on simulated impact on institutional cost. Results We were able to improve CARD-2 compliance at one hospital within a year of intervention implementation. The hospital decreased its losses due to noncompliance in FY 2014 by $27 273. Discussion A relatively low cost intervention, aimed at educating providers that utilized existing infrastructure resulted in improved SCIP beta-blocker compliance. Changes in the reimbursement system made at the time of publication demonstrate that reimbursement measures are constantly in flux; tailored interventions based upon our successes may still produce similar results.