American Journal of Medical Quality

Sepsis is an inflammatory response triggered by infection, with a high in-hospital mortality rate. Early recognition and treatment can reverse the inflammatory response, with evidence of improved patient outcomes. One challenge clinicians face is identifying the inflammatory syndrome against the background of the patient’s infectious illness and comorbidities. An approach to this problem is implementation of computerized early warning tools for sepsis. This multicenter retrospective study sought to determine clinimetric performance of a cloud-based computerized sepsis clinical decision support system (CDS), understand the epidemiology of sepsis, and identify opportunities for quality improvement. Data encompassed 6200 adult hospitalizations from 2012 through 2013. Of 13% patients screened-in, 51% were already suspected to have an infection when the system activated. This study focused on a patient cohort screened-in before infection was suspected; median time from arrival to CDS activation was 3.5 hours, and system activation to diagnostic collect was another 8.6 hours.

Depression is a leading cause of disability worldwide, and many internists diagnose and treat depression. This study aimed to examine the impact of a practice improvement intervention on screening and managing patients with depression in primary care. This pre–post study design included a physician practice survey designed to capture what the physicians believed they were doing in practice, a chart audit tool to capture what physicians were actually doing in practice, and an intervention that included an evidence-based educational program, online toolkit, and practice improvement coaching conference calls that promoted group learning. Following completion of the intervention, participants increasingly used the Patient Health Questionnaire-9 to detect, diagnose, and gauge treatment success for depression and reported increased use of guidelines and team-based care. Although barriers to improving depression care exist, this study suggests that evidence-based quality improvement programs can positively affect practice.

Cirrhotic complications portend high morbidity and mortality and burden the health care system. Established quality measures in management of cirrhotics include screening for esophageal varices (EV), screening for hepatocellular carcinoma (HCC), and hepatitis A and B immunization. A retrospective review was conducted to identify adherence to cirrhosis. Baseline rates were shared with providers. Compliance with quality measures was measured prospectively at 1-month, 2-month, 1-year, and 3-year follow-up after provision of performance feedback. Baseline HCC rate was 60%, EV was 68%, and hepatitis A and B immunization was 51% and 47%, respectively. After performance feedback, HCC, EV, and hepatitis A and B vaccination rates improved to rates ranging from 92% to 100% and remained statistically significant after 3 years. Provider feedback, a simple intervention, achieved significant improvement in compliance with quality measures for management of cirrhotics. This improvement in adherence to quality measures was sustainable over a 3-year time period.

Interested faculty enrolled in this 6-month-long quality improvement (QI) course to facilitate independent QI project work. The course included monthly 1.5-hour sessions: 20-minute presentations covering key QI concepts, then small group activities to facilitate project work. Faculty were required to identify, construct, and implement an independent QI project. They met individually with mentors twice during the course, with additional guidance offered virtually via phone or e-mail, and completed pretests and posttests of QI knowledge (maximum score = 15) and self-assessed confidence. A statistically significant difference in knowledge (pre-course mean = 7.75, standard deviation [SD] = 3.06; post-course mean = 11.75, SD = 3.28; P = .02) and self-assessed confidence (pre mean = 3.08, SD = 0.65; post mean = 4.5, SD = 0.68; P < .0001) was found. Of 8 faculty, 5 were able to conduct small tests of change; 3 studied the current processes and planned to run tests of change. Positive responses to this course helped obtain buy-in from leadership to develop a leadership program in QI.

Advances in neonatology led to survival of micro-preemies, who need central lines. Central line–associated bloodstream infection (CLABSI) causes prolonged hospitalization, morbidities, and mortality. Health care team education decreases CLABSIs. The objective was to decrease CLABSIs using evidence-based measures. The retrospective review compared CLABSI incidence during and after changes in catheter care. In April 2011, intravenous (IV) tubing changed from Interlink to Clearlink; IV tubing changing interval increased from 24 to 72 hours. CLABSIs increased. The following measures were implemented: July 2011, reeducation of neonatal intensive care staff on Clearlink; August 2011, IV tubing changing interval returned to 24 hours; September 2011, changed from Clearlink back to Interlink; November 2011, review of entire IV process and in-service on hand hygiene; December 2011, competencies on IV access for all nurses. CLABSIs were compared during and after interventions. Means were compared using the t test and ratios using the χ² test; P <.05. CLABSIs decreased from 4.4/1000 to 0/1000 catheter-days; P < .05. Evidence-based interventions reduced CLABSIs.

This study examined how aspects of quality improvement (QI) culture changed during the introduction of the Veterans Health Administration (VHA) patient-centered medical home initiative and how they were influenced by existing organizational factors, including VHA facility complexity and practice location. A voluntary survey, measuring primary care providers’ (PCPs’) perspectives on QI culture at their primary care clinics, was administered in 2010 and 2012. Participants were 320 PCPs from hospital- and community-based primary care practices in Pennsylvania, West Virginia, Delaware, New Jersey, New York, and Ohio. PCPs in community-based outpatient clinics reported an improvement in established processes for QI, and communication and cooperation from 2010 to 2012. However, their peers in hospital-based clinics did not report any significant improvements in QI culture. In both years, compared with high-complexity facilities, medium- and low-complexity facilities had better scores on the scales assessing established processes for QI, and communication and cooperation.

Publicly reported hospital performance data have become widely available to health care consumers in recent years. In response to a growing demand for more readily available health care information, various organizations have begun assessing hospital performance. These performance reporting systems have tremendous potential to aid patients, families, and primary care providers in their clinical decision making. This study takes a systematic approach to review the main features of 9 existing hospital rating systems, each of which is described using 9 areas of evaluation. The hospital rating systems included in this study vary widely in scope, methodology, transparency, and presentation of their results. Their results often present conflicting conclusions regarding the performance of the same hospital. This review of hospital rating systems demonstrates how public reporting may add confusion to patients’ health care decision making.

The aim was to evaluate the effectiveness of a multipronged intervention on diabetic dilated fundus examination (DFE) adherence. In a prospective trial, 521 patients with diabetes who were due for follow-up DFEs were randomized to usual care or the intervention group. Usual care received a form letter reminder to schedule and an automated reminder phone call prior to their appointment. Intervention participants received an educational brochure about diabetic eye disease and a personalized letter reminder to schedule. A research assistant called intervention participants to help schedule the appointment, and they received a reminder letter and an automated phone call prior to the scheduled visit. Patients in the intervention group were significantly more likely to schedule (63% vs 40%; P < .0001) and complete their appointment (48% vs 30%; P < .0001) compared with usual care. A multipronged intervention, including an educational mailing and telephone assistance with scheduling an appointment, significantly improved diabetic DFE adherence.

The Veterans Healthcare Administration (VA) has embraced patient safety and quality improvement in the quest to improve care for veterans. The New Mexico VA Health Care System introduced a new morbidity and mortality conference, called the Interdisciplinary Quality Improvement Conference (IQIC), using patient case presentations to focus on underlying systems in the clinical care environment. The revised conference design also effectively teaches the 6 Accreditation Council for Graduate Medical Education (ACGME) core requirements for resident education. A formal process was established for case selection, presentation, systems issue identification, tracking, and follow-up. The IQIC has enabled the identification of more than 20 system issues at the study institution. Outcome data show lasting improvement in system issues that were addressed by this mechanism. The VA IQIC is an effective method to both identify and correct systems issues that affect patient care and is an effective method for teaching residents the 6 ACGME requirements for residency education.

Accountable care organizations (ACOs) were designed to improve the quality of care delivered to Medicare beneficiaries while also halting the growth in Medicare spending. Many existing health systems in the Northeast, Midwest, and West have formed ACOs, whereas implementation in Southern states has been slower. The study team conducted a survey of all physician members of the Medical Association of the State of Alabama to determine the likelihood of their participation in an ACO and their attitudes toward some of the characteristics, such as quality measures, regulations, and risks versus rewards. The team found that many physicians reported a lack of knowledge about these areas. Physicians who reported that they were either likely or not likely to participate overwhelmingly held unfavorable attitudes about ACOs. It would be advantageous for Alabama physicians to become more knowledgeable about ACOs in the case that they become a more predominant form of care delivery in the future.

Health care systems are increasingly burdened by the large numbers of safety measures currently being reported. Within the Veterans Administration (VA), most safety reporting occurs within organizational silos, with little involvement by the frontline users of these measures. To provide a more integrated picture of patient safety, the study team partnered with multiple VA stakeholders and engaged potential frontline users at 2 hospitals to develop a Guiding Patient Safety (GPS) tool. The GPS is currently in its fourth generation; once approval is obtained from senior leadership, implementation will begin. Stakeholders were enthusiastic about the GPS’s user-friendly format, comprehensive content, and potential utility for improving safety. These findings suggest that stakeholder engagement is a critical first step in the development of tools that will more likely be used by frontline users. Policy makers and researchers may consider adopting this innovative partnered-research model in developing future national initiatives to deliver meaningful programs to frontline users.