Healthcare Quality

Association of Magnet Nursing Status With Hospital Performance on Nationwide Quality Metrics Introduction: Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown. Methods: Within a propensity score–matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives. Results: The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p < .001), and HACRP penalties were more likely to be levied against Magnet hospitals (p = .003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p = .049). There were no significant difference in RRP penalties according to Magnet status (p = .999). Conclusions: Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing. Level of Evidence: Level III, retrospective study.

Understanding the High Frequency Use of the Emergency Department for Patients With Chronic Pain: A Mixed-Methods Study Introduction: Chronic pain (CP) is a common driver of emergency department (ED) visits despite the ED not being the ideal setting for CP because of increased risk of adverse events and high costs. Purpose: The purpose of this study is to understand factors contributing to CP-related ED visits, patients' care experiences, and patients' perspectives on alternatives to the ED. Methods: We used a mixed-methods design combining semi-structured interviews and questionnaires with 12 patients with CP who had 12 or more ED visits over 1 year. We analyzed test scores using descriptive statistics and interviews using applied thematic analysis. Results: Four themes emerged. Factors contributing to ED visits included the following: fear (e.g., pain and its impact); inability to cope with pain; family suggestions to go to the ED; and access to other services and resources. Patients had validating and invalidating experiences in the ED: needs were met or not met; and feeling acknowledged or unacknowledged. Patients' experiences with their family physician included feeling supported or unsupported. Alternatives to the ED included working with an interdisciplinary team, developing personalized care plans, and increased community-based resources. Conclusions: Patients with CP and frequent ED use present with complex pain and care experiences, requiring careful attention to management strategies and the patient–provider relationship.

Impact of a Resident-Centered Interprofessional Quality Improvement Intervention on Acute Care Length of Stay Competency in interprofessional quality improvement and performance measurement is required by the Accreditation Council for Graduate Medical Education. We implemented an interprofessional quality improvement project to support trainee involvement in systems-level improvement to reduce hospital length of stay and engage trainees in efforts to improve the validity and reliability of clinical documentation contributing to risk-adjusted performance measures. The intervention had three components: daily interprofessional disposition huddles to discuss discharge needs, medical documentation curriculum to improve clinical data accuracy, and scheduled coding huddles to provide real-time feedback on documentation. Outcome measures included an unadjusted and risk-adjusted measure of hospital length of stay. Case severity index (CSI) served as a process measure. Statistical process control charts were used to measure change over time. The mean unadjusted length of stay decreased from 5.84 to 4.98 days. Both the unadjusted and the risk-adjusted length of stay measures exceeded the lower control limit of the statistical control chart. The CSI increased and exceeded the upper control limit of the statistical control chart. Improvements were sustained in the year following implementation. The intervention offers a model for academic institutions to satisfy new Common Program Requirements by engaging trainees in performance measurement and interprofessional improvement efforts.

Multidisciplinary Approach to Improve Sepsis Outcomes Severe sepsis and septic shock cause significant morbidity and mortality with health care costs approximating $17 billion annually. The Surviving Sepsis Campaign 2012 recommended time-sensitive care bundles to improve outcomes for patients with sepsis. At our community teaching hospital, a review of sepsis management for patients admitted to a medical intensive care unit (ICU) between December 2015 and March 2016 found 70.8% compliance with timing of lactate draw, 65.3% compliance for blood cultures, and 51.4% compliance with antibiotic administration recommendations. Thus, a quality improvement initiative to improve detection and time to bundle completion for ICU-level patients was designed. Previous studies suggest that utilization of sepsis alert systems and sepsis response teams in the emergency department setting is associated with improved compliance with recommended sepsis bundles and improved hospital mortality. Therefore, a “sepsis alert” protocol was implemented that used both an electronic alert and an overhead team alert that mobilized nursing, pharmacy, phlebotomy, and a senior internal medicine resident to bedside. In addition, a template to document sepsis diagnosis and bundle adherence was created. After implementation, we noted improvement in appropriately timed serum lactate, 88.6% versus 70.8% (p = .008) with no significant improvements in blood cultures, antibiotic administration, or mortality.

Predictors of 30-day Postdischarge Readmission to a Multistate National Sample of State Psychiatric Hospitals Background: Early discharge from psychiatric inpatient care may pose challenges for the patient's recovery and may incite a rapid return to the hospital. This study identified demographic, clinical, and the continuing of care characteristics associated with rapid readmission into a sample of psychiatric inpatient hospitals. Methods: Cross-sectional analysis of 60,254 discharges from state psychiatric hospitals. Logistic regression explored the relationship between predictors of rapid readmission. Results: Eight percent of discharges were readmitted to the same hospital within 30 days after discharge. Factors significantly related with rapid readmission included white (odds ratio, 1.23; 95% confidence interval, 1.13–1.34), non-Hispanic (1.48, 1.26–1.73), not married (1.53, 1.32–1.76), voluntarily admitted (1.18, 1.05–1.33), with length of stay (LOS) ≤ 7 days (3.52, 3.04–4.08), or LOS 8–31 days (3.20, 2.79–3.66), or LOS 32–92 days (1.91, 1.65–2.22), with a schizophrenia or other psychotic disorders (1.69, 1.46–1.96) or personality disorder (1.76, 1.50–2.06), referred to a setting different from the outpatient (1.27, 1.16–1.40), or with a living arrangement different from private residence (1.54, 1.40–1.68). Conclusions: Disparities in rapid readmission rates exist among state psychiatric hospitals. A national overview of the individuals with mental illness at risk of being prematurely discharged may suggests insights into quality initiatives aimed at reducing rapid readmissions into psychiatric inpatient care.

Patients' Perspectives on Reasons for Unplanned Readmissions Massachusetts has one of the highest rates of 30-day readmissions in the country. To identify patient-reported factors that may contribute to readmissions, we conducted semi-structured interviews with patients with unplanned readmissions within 30 days of inpatient discharge from the medicine services at an urban medical center between June and August 2016. Interviews with patients and/or proxies were conducted in English, Spanish, Mandarin, or Cantonese, then translated to English if necessary, transcribed verbatim, and deidentified. A team of four coders conducted the thematic analysis. Most patients did not identify factors associated with readmission beyond their underlying illness; however, a mismatch between the patient's clinical care needs and services available at postacute facilities, as well as poor communication between providers, facilities, and patients/proxies, were identified as contributing factors to readmissions. Non–English speaking patients and their families reported confusion with written discharge instructions, even if an interpreter provided verbal instructions. Patients will benefit from future interventions that aim to improve transfers to postacute care facilities, develop written materials in languages prevalent in the local population, and improve communication among providers, facilities, and patients and their families.

Improving Colorectal Cancer Screening Rates in Patients Referred to a Gastroenterology Clinic Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related death in the United States. Colonoscopy and fecal immunochemistry testing (FIT) are the primary recommended CRC screening modalities. The purpose of this study is to improve rates of CRC screening in Veterans and County hospital patients referred to gastroenterology fellow's clinics. A total of 717 patients between ages of 49 and 75 years were seen. Previous CRC screening was not performed in 109 patients (15.2%) because of not being offered (73.4%) or declining (26.6%) screening. Patients who received previous CRC screening compared with no previous screening were older (mean age 62.3 years vs. 60.3 years, p < .003), white (88.6% vs. 78.3%, p < .027), and more likely to be Veterans patients (90.8% vs. 77.5%, p < .001). After systematically discussing options for screening with 78 of the 109 unscreened patients, 56 of them (71.8%) underwent screening with either colonoscopy (32) or FIT (24). Patients seen by fellows in their last year of training agreed to undergo screening more often than those seen by other fellows (100% vs. 66.2%, p < .033). Systematic discussions about both colonoscopy and FIT can improve the overall rates of CRC screening.

Consumers' Association of Hospital Reputation With Healthcare Quality Why consumers consistently rank hospital reputation as one of the most important factors when selecting health care services remains unknown. We hypothesized that this is explained by consumers associating reputation with objective quality. We performed a cross-sectional, US population-based survey of consumers (N = 23,410) exploring this association. A Spearman rank order correlation was used to measure the strength of this relationship. Subgroups of consumers more likely to associate the two was explored with multivariable logistic regression. Consumers commonly agree (56%) that a hospital's reputation is the same as its quality of health care. Consumers also associate hospital reputation with the belief that they will be less like to suffer a complication (ρ = 0.509) or die (ρ = 0.441), although the strength of these relationships were modest (all p < 0.01). Consumers who were male (OR: 0.84), Hispanic (OR: 0.82), African American (OR: 0.86), married (OR: 0.85), self-reported as healthy (OR: 0.67), and had a recent hospitalization (OR: 0.70) were less likely to believe that reputation and quality were equivalent (all p < 0.01). This data suggests that consumers link the construct of hospital reputation with objective health care quality, but this pattern of behavior is of concern, particularly when reputation does not align with objective data.

Workforce Competencies for Healthcare Quality Professionals: Leading Quality-Driven Healthcare As healthcare delivery systems increasingly adopt models designed to reward cost-efficient and high-quality care, the demand for expertise in healthcare quality continues to grow. There has been wide variation and limited conformity in the definition of the quality competencies that are essential for healthcare professionals. To address the need for a standard, widely accepted, comprehensive definition of the competencies required for healthcare quality, the National Association for Healthcare Quality (NAHQ) made a strategic commitment to develop a comprehensive healthcare quality competency framework applicable to all practice settings across the care continuum. In this article, the authors describe the development of NAHQ's Healthcare Quality Competency Framework depicting eight competency dimensions required for success in current and future healthcare quality positions. In addition, they discuss a self-assessment survey tool to identify individual and organizational gaps in the workforce competencies of Healthcare Quality Professionals.

Readmission of High-Risk Discharged Patients at a Tertiary Hospital in Korea This study aims to investigate the readmission rates of major disease groups as stated by the Centers for Medicare and Medicaid Services and to identify risk factors related to readmission in Korea. We studied 2,973 patients discharged from a 2,200-bed tertiary referral hospital in South Korea, from April 1, 2016, to March 31, 2017. Using electronic medical records, we calculated the 30-day readmission rates of seven diseases: acute myocardial infarction, chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia, stroke, coronary artery bypass graft (CABG), and total hip arthroplasty/total knee arthroplasty. We used Cox proportional hazards regression analysis to identify risk factors affecting readmission in this retrospective, observational study. For 2,973 consecutively discharged patients, the 30-day unplanned readmission rate was 10.3%. The readmission rate of HF (19.0%) was the highest, followed by pneumonia (13.7%), CABG (12.0%), and COPD (10.5%). Factors associated with readmission were polypharmacy (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.60–2.64), hospitalization history in the previous 6 months (HR: 1.81; 95% CI: 1.41–2.32), and comorbidity (HR: 1.16; 95% CI: 1.11–1.23). Therefore, the discharge intervention program for high-risk discharge patients with polypharmacy, admission history, and comorbidity should include medication reconciliation.