美国医疗差错管理策略对我国医院质量管理的启示

目的阐述美国医疗差错管理的七项策略,研究其对医院提高医疗质量、减少医疗差错的借鉴意义。探讨这些策略在我国如何应用。方法采用问卷调查和现场访谈的方法,调查了34所医院的184位医院质量管理者对七项策略重要性的理解和执行情况,以及对执行策略障碍的认识。结果被调查者们认为最重要的三个策略为:(1)与医院相关利益者进行合作;(2)教育和培训;(3)文化变迁。实施减少医疗差错管理策略的主要阻碍因素是媒体的影响、缺乏人力物力资源、缺乏对差错的认识和害怕承担责任。结论我们应该借鉴国外经验,结合实际情况。逐步把七项策略应用到医疗差错管理中去。     

An empirical study for medication delivery improvement based on healthcare professionals’ perceptions of medication delivery system

Medication errors are major safety concerns in all hospital settings. The insufficient knowledge about managerial and process improvement strategies required to reduce medication errors can be considered as one of the most important factors holding back hospitals from achieving the desired goals for patient safety. However, strategies for medication error reduction cannot be successfully implemented without a clear understanding of factors affecting medication delivery errors. This paper presents a study in which healthcare professionals’ perceptions on three factors, namely (1) technical complexity of tasks/connections; (2) resources problems; and (3) qualification of human resources, are analyzed within the medication delivery system at one community hospital. The outcomes of this research are a theoretical model for reducing medication delivery errors and a set of workflow design rules for healthcare professionals to continuously reduce medication delivery errors.     

Cost of hospital-wide activities to improve patient safety and infection control: a multi-centre study in Japan

OBJECTIVE: The aim of this study was to assess the financial costs to hospitals for the implementation of hospital-wide patient safety and infection control programs. METHODS: We conducted questionnaire surveys and structured interviews in seven acute-care teaching hospitals with an established reputation for their efforts towards improving patient safety. We defined the scope of patient safety activities by use of an incremental activity measure between 1999 and 2004. Hospital-wide incremental manpower, material, and financial resources to implement patient safety programs were measured. RESULTS: The total incremental activities were 19,414-78,540 person-hours per year. The estimated incremental costs of activities for patient safety and infection control were calculated as US$ 1.100-2.335 million per year, equivalent to the employment of 17-40 full-time healthcare staff. The ratio of estimated costs to total medical revenue ranged from 0.55% to 2.57%. Smaller hospitals tend to shoulder a higher burden compared to larger hospitals. CONCLUSIONS: Our study provides a framework for measuring hospital-wide activities for patient safety. Study findings suggest that the total amount of resources is so great that cost-effective and evidence-based health policy is needed to assure the sustainability of hospital safety programs.     

Lean healthcare in developing countries: evidence from Brazilian hospitals

The present study evaluates how five sectors of two Brazilian hospitals have implemented lean healthcare concepts in their operations. The main characteristics of the implementation process are analyzed in the present study: the motivational factor for implementation, implementation time, form (consultancy or internal), team (hospital and consultants), lean implementation continuity/sustainability, lean healthcare tools and methods implemented, problems/improvement opportunities, lean healthcare barriers faced during the implementation process, and critical factors that affected the implementation and the results obtained in each case. The case studies indicate that reducing patient lead times and costs and making financial improvements were the primary factors that motivated lean healthcare implementation in the hospitals studied. Several tools and methods were used in the cases studied, especially value stream mapping and DMAIC. The barriers found in both hospitals are primarily associated with the human factor. Additionally, the results obtained after implementation were analyzed and improvements in financial aspects, productivity and capacity, and lead time reduction of the analyzed sectors were observed. Further, this study also exhibited four propositions elaborated from the results obtained from the cases that highlighted barriers and challenges to lean healthcare implementation in developing countries. Two of these barriers are hospital organizational structure (and, consequently, how the senior management works with medical staff), and outsourcing hospital activities. This study also concluded that the initialization and maintenance of lean healthcare implementation rely heavily on external support because lean healthcare subject knowledge is not yet available in the healthcare organization, which represents a challenge. Copyright © 2015 John Wiley & Sons, Ltd.     

Facilitators and barriers to the implementation of patient flow improvement strategies

Patient flow improvement strategies have been effective in reducing emergency department (ED) crowding, but little guidance is available on the implementation process. By using a qualitative research design, our objective was to identify common facilitators and barriers to the implementation of patient flow improvement strategies and successful approaches for mitigating barriers. Six hospitals participated in an 18-month Urgent Matters learning network launched in October 2008. The hospitals selected strategies to improve patient flow that could be implemented within 3 months with measurable impact. Across 6 hospitals, 8 strategies were implemented. We conducted 2 rounds of key informant interviews with improvement teams, for a total of 129 interviews. Interviews were recorded, transcribed, and coded by using a grounded theory approach to identify common themes. Factors facilitating implementation included participation in the learning network and strategic selection of team members. Common challenges included staff resistance and entrenched organizational culture. Some of the challenges were mitigated through approaches such as staff education and department leaders' constant reinforcement. Our findings indicate that several facilitators and barriers are common to the implementation of different strategies. Leveraging facilitators and developing a strategy to address common barriers may leave hospital and ED leaders better prepared to implement patient flow improvement strategies.     

Patient safety: solutions in managed care organizations?

Despite the growing acknowledgment of the necessity for patient safety initiatives to address medical errors, the role of managed care organizations (MCOs) in these programs has only recently been challenged. Managed care quality improvement programs have mainly focused upon pay-for-performance initiatives, largely ignoring specific patient safety efforts. To effectively reduce medical errors, MCOs must leverage their unique positions to influence and educate both providers and consumers. This article describes MCOs' self-implemented barriers to quality improvement, and early initiatives by MCOs to encourage safe practices, including pay-for-performance. An approach for MCOs to facilitate progress and inspire a culture of patient safety is discussed. Avenues for strengthening the organizational and technological infrastructure of the health care system from a managed care perspective are examined, and strategies for implementing best practices within the constraints of managed care are explored. System-wide solutions that address the critical areas of culture, infrastructure, and best practices are necessary to continue to make significant strides in reducing medical errors and prioritizing patient safety.     

Disclosure,Apology, and Offer Programs: Stakeholders’ Views of Barriers to and Strategies for Broad Implementation

Context: The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few. Methods: Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states. Findings: We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles. Conclusions: Although more data are needed about the outcomes of DA&O programs, the model holds considerable promise for transforming the current approach to medical liability and patient safety.     

New initiatives to improve medication safety in hospitals

Medication errors constitute a significant public health problem and are recognised as such nowadays among healthcare professionals, societies, authorities and international organizations. This has led to seeking and implementing effective practices focused on improving medication use safety. This article briefly describes some of the most recent initiatives promoted to prevent medication errors in the hospital setting. These safety improvement initiatives are based upon progressively developing an institutional culture of safety and on establishing practices designed to reduce errors or detect them in time, thus avoiding adverse effects to patients. Among these recent initiatives are the safety practices approved by the National Quality Forum, and the National Patient Safety Goals that the Joint Commission on Healthcare Accreditation has required since 2003. Also mentioned are several strategies that have been offered to facilitate the application of these practices, among which are the Pathways to Medication Safely, the development of collaborative projects among hospitals and organizations of experts, and the inclusion of a medication safety specialist in hospitals as a support figure overseeing the application of safety measures. Finally, the challenges inherent in putting these preventive measures into real patient's care are discussed. The barriers confronting this step must obviously be faced if improvements in patient safety are truly to be achieved.     

The influence of organizational context on quality improvement and patient safety efforts in infection prevention: A multi-center qualitative study

Patient safety is a healthcare priority worldwide, with most hospitals engaging in activities to improve care quality, safety and outcomes. Despite these efforts, we have limited understanding of why quality improvement efforts are successful in some hospitals and not others. Using data collected as part of a multi-center study, we closely examined quality improvement efforts and the implementation of recommended practices to prevent central line-associated bloodstream infections (CLABSI) in U.S. hospitals. We compare and contrast the experiences among hospitals to better understand ‘how’ and ‘why’ certain hospitals were more successful with practice implementation when taking into consideration specific aspects of the organizational context. This study reveals that among a number of hospitals that focused on implementing practices to prevent CLABSI, the experience and outcomes varied considerably despite using similar implementation strategies. Moreover, our findings provide important insights about how and why different quality improvement strategies might perform across organizations with differing contextual characteristics.     

Exploring Disease Management Programs for Diabetes Mellitus

Diabetes mellitus is a chronic illness that affects the world on an epidemic scale. It requires complex healthcare and considerable economic resources. Diabetes disease management programs use a variety of strategies to improve clinical outcome measures and reduce costs. Studies have demonstrated the effectiveness of these programs on reducing glycosylated hemoglobin levels, improving cardiovascular risks, and reducing utilization of services. However, the most effective components of disease management strategies or combination of strategies remain unknown. This narrative review explores the components, impact, benefits, and barriers of current diabetes disease management models and also presents a novel hybrid model incorporating elements of both on-site and off-site programs.On-site disease management programs include strategies characterized by unique patient identification and evaluation, implementation of intervention methods, on-site health provider team members, and specific environmental resources. Advantages of this model include the face-to-face encounter between patients and providers, the proximity of the healthcare team members to facilitate ease of communication and build independence and trust between patients and providers, and technology resources, such as the electronic medical record. A number of clinical trials have demonstrated the effectiveness and cost effectiveness of on-site diabetes disease management programs. However, because of the methodological limitations of many studies, further studies are needed to confirm such findings. Barriers to the implementation of on-site programs may include patient population characteristics such as complexity of co-morbid illness and social Stressors, including low health literacy, that require adaptation of the disease management model. In comparison, off-site disease management programs utilize administrative resources to identify patients with chronic illnesses. Other key elements include the evaluation of clinical care practices using established guidelines with auditing and feedback to providers based on their performance, and the use of reminders for both patients and providers to influence better processes of care. This process is often independent of the traditional on-site care delivered directly by providers.A hybrid disease management model that incorporates both on-site and off-site disease management components could be the ideal model for optimizing care of patients with chronic illness. The suggested hybrid model incorporates many features of previous models of disease management but gives a new construct that can be customized to different clinic settings, provider practices, and patient populations, including patients with other complex chronic illness. This hybrid model could be applied to a variety of individual or multiple chronic illnesses. This model would engage both on-site healthcare providers and support staff along with off-site administrative staff and electronic medical data to provide patients optimal care while potentially reducing overall costs.     

Immediate Postpartum Long-Acting Reversible Contraception Programs in Texas Hospitals Following Changes to Medicaid Reimbursement Policy

Objectives

Provision of long-acting reversible contraception (LARC) after delivery and prior to discharge is safe and advantageous, yet few Texas hospitals offer this service. Our study describes experiences of Texas hospitals that implemented immediate postpartum LARC (IPLARC) programs, in order to inform the development of other IPLARC programs and guide future research on system-level barriers to broader adoption.

Methods

Eight Texas hospitals that had implemented an IPLARC program were identified, and six agreed to participate in the study. Interviews with 19 key hospital staff covered (1) factors that led the development of an IPLARC program; (2) billing, pharmacy, and administrative operations related to implementation; (3) patient demand and readiness; (4) the consent process; (5) staff training; and (6) hospital plans for monitoring and evaluation of IPLARC services.

Results

Most hospitals in this study primarily served Medicaid and un- or under-insured populations. Participants from all six hospitals perceived high levels of patient demand for IPLARC and provider interest in providing this service. The major challenges were related to financing IPLARC programs. Participants from half of the hospitals reported that leadership had concerns about financial viability of providing IPLARC. The hospitals with the longest-running IPLARC programs were safety net hospitals with family planning training programs.

Conclusions for Practice

We found that hospitals with IPLARC programs all had strong support from both providers and hospital leadership and had funding sources to offset costs that were not reimbursed. Strategies to reduce the financial risks related to IPLARC provision could provide the impetus for new programs to launch and support their sustainability.

     

The Environmental Context of Patient Safety and Medical Errors

The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural: healthcare organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events associated with learning, information flows, triage and transfer decisions, and culture of safety). Relevant organizational theories and strategies fo medical error reduction and prevention in rural health care settings were identified. Financial and technical assistance are needed to support the systematic collection of data from rural hospitals and other entities and to enhance relevant patient safety practices for rural America.     

Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals

Few U.S. hospitals have implemented computerized physician order entry (CPOE) in spite of its effectiveness at preventing serious medication errors. We interviewed senior management at twenty-six hospitals to identify ways to overcome barriers to adopting and implementing CPOE. Within the hospital, strong leadership and high-quality technology were critical. Hospitals that placed a high priority on patient safety could more easily justify the cost of CPOE. Outside the hospital, financial incentives and public pressures encouraged CPOE adoption. Dissemination of data standards would accelerate the maturation of vendors and lower CPOE costs. These findings highlight several policy levers to speed the adoption of this important patient safety technology.     

When patients get stuck: A systematic literature review on throughput barriers in hospital-wide patient processes

Hospital productivity is of great importance to policymakers, and previous research demonstrates that improved hospital productivity can be achieved by directing more focus towards patient throughput at healthcare organizations. There is also a growing body of literature on patient throughput barriers hampering the flow of patients. These projects rarely, however, encompass complete hospitals. Therefore, this paper provides a systematic literature review on hospital-wide patient process throughput barriers by consolidating the substantial body of studies from single settings into a hospital-wide perspective. Our review yielded a total of 2207 articles, of which 92 were finally selected for analysis. The results reveal long lead times, inefficient capacity coordination and inefficient patient process transfer as the main barriers at hospitals. These are caused by inadequate staffing, lack of standards and routines, insufficient operational planning and a lack in IT functions. As such, this review provides new perspectives on whether the root causes of inefficient hospital patient throughput are related to resource insufficiency or inefficient work methods. Finally, this study develops a new hospital-wide framework to be used by policymakers and healthcare managers when deciding what improvement strategies to follow to increase patient throughput at hospitals.     

Implementing a national strategy for patient safety: lessons from the National Health Service in England

Improving patient safety has become a core issue for many modern healthcare systems. However, knowledge of the best ways for government initiated efforts to improve patient safety is still evolving, although there is considerable commonality in the challenges faced by countries. Actions to improve patient safety must operate at multiple levels of the healthcare system simultaneously. Using the example of the NHS in England, this article highlights the importance of a strategic analysis of the policy process and the prevailing policy context in the design of the national patient safety strategy. The paper identifies a range of policy "levers" (forces for change) that can be used to support the implementation of the national safety initiative and, in particular, discusses the strengths and limitations of the "business case" approach that has attracted recent interest. The paper offers insights into the implementation of national patient safety goals that should provide learning for other countries.     

The roles of senior management in improving hospital experiences for frail older adults

With the aging of the population, healthcare executives are paying increased attention to fostering safe and high-quality care for older adults who become hospitalized. The Hospital Elder Life Program (HELP) is an evidence-based program that has been shown to be cost-effective in reducing episodes of delirium, functional decline, and long-term nursing home placement for older hospitalized adults. Senior administrators are known to play a role in quality improvement, but little is known about their roles in adopting clinical improvement programs such as HELP. Therefore, we conducted a mixed-methods study of 63 hospitals at different stages of adopting HELP to identify key roles and motivations of senior management to adopt HELP and the perceived impact of HELP on patient and staff outcomes. Our findings can be used by hospital management teams as they identify ways to influence and benefit from efforts to improve clinical quality, safety, and the experiences of older adults treated in their hospitals.     

Factors that impact the transfer and retention of best practices for reducing error in hospitals

Recent research and theory in organizational learning literature advances seven propositions that illuminate the nature and complexities of transferring and retaining best practices for reducing error and increasing patient safety in U.S. and Canadian hospitals.     

Healthcare innovation barriers: Results of a survey of certified professional healthcare risk managers

Medical errors cause significant patient injuries, including deaths. Innovations designed to improve quality and reduce risk are numerous, as are the barriers that prevent innovation implementation. The purpose of this research was to analyze the relationships, if any, between the independent variables of hospital bed size and organizational structure, and the dependent variable barriers to three innovations: implementing a surgical safety checklist, preventing catheter-associated urinary tract infections, and adopting patient- and family-centered care. The findings strengthen and expand existing research and serve as the foundation for understanding barriers to implementation of three healthcare innovations. Future research should focus on organizational culture instead of innovation-specific barriers and should incorporate other independent variables, such as organizational profitability.     

Training in Firearm Safety Counseling in Family Practice Residency Programs

The purpose of this study was to establish a national baseline regarding the prevalence of training of family practice residents regarding firearm safety counseling. A national survey of the residency directors at the 420 accredited family practice residency programs in the coterminous United States was used to assess the prevalance of training in firearm safety counseling, perceived effectiveness of such training, and perceived barriers to such counseling in residency programs. Program directors were sent a two-page questionnaire on firearm safety counseling activity in their programs and 71% responded. Few residencies (16%) had formal training in firearm safety counseling. The most common perceived barriers were no trained personnel (31%), too many other important issues (31%), not enough time (30%), and lack of educational resources (28%). Patient education materials (57%), video training programs (49%), and a curriculum guide (46%) were identified as resources, that would be most helpful in implementing a firearm safety counseling program. The results showed that formal training in firearm safety counseling is virtually absent from family practice residency training programs. This finding is not surprising given that less than 14% of the directors perceived firearm safety counseling would be effective in reducing firearm-related injuries or deaths and that research on effectiveness of such counseling is very limited.     

What Hospital Implementation Strategies Are Associated with Successful Performance Under Maryland’s All-Payer Model?

In January 2014, Maryland shifted its all-payer hospital rate setting system from one that paid hospitals based on charges per case to a fixed global budget payment model. Under Maryland’s All-Payer Model (MDAPM), hospitals had considerable flexibility to implement strategies to meet their global budget and other model goals, including improving quality, safety, and patient satisfaction. We conducted a comparative case study to identify the implementation strategies used in hospitals with successful outcomes under MDAPM. We conducted a mixed-method analysis that examined the association between changes in hospital performance and the use of different implementation strategies. We used data from a survey fielded among all Maryland acute care hospitals from October to December 2018 that examined whether hospitals implemented 28 strategies, either before or during MDAPM. We complemented survey data with qualitative data collected from site visits to all hospitals and focus group discussions with hospital-based nurses and physicians conducted from April 2015 to February 2019. We calculated two hospital-level measures to assess performance—operating margin (financial performance) and Medicare 30-day unplanned readmission rate (patient care performance). We used hospital financial reports to calculate change in operating margin from a two-year baseline period (FY2012-FY2013) to a five-year implementation timeframe (FY2014-FY2018). For readmissions, we calculated the change from a three-year baseline period (January 2011-December 2013) to a 4.5-year implementation timeframe (January 2014-June 2018). We established four performance categories for each outcome based on a hospital’s pre-post change: decline and low, medium, or high improvement. For financial performance, improvement was an increase in operating margin. For patient care, performance improvement was a decrease in readmissions. Cut points for low, medium, and high improvement were based on the distribution of each outcome. 46 Maryland acute care hospitals. Two strategies—employing physician staff and providing patients with clinically specific education—were associated with improvements in both performance outcomes. Eight strategies were associated with improved patient care performance, such as utilizing customized data analytics, engaging physicians in implementing MDAPM-related strategies, investing in interventions that address social determinants of health, and referring patients to alternative care settings. Three strategies were associated with improved financial performance, including using Maryland’s health information exchange and participating in a program to improve alignment with physicians. Six strategies were not associated with either performance measure. Eight strategies were employed by nearly all Maryland hospitals and, therefore, could not be associated with hospital performance. Almost half of the strategies examined were associated with at least one of the dimensions of successful performance examined. The comparative case study approach does not provide a causal perspective on hospital performance. Thus, we cannot determine whether adopting these strategies improved hospital performance or whether improvements in performance facilitated hospitals’ ability or desire to implement these strategies. Hospitals seeking to improve their performance may want to emphasize the two implementation strategies that were associated with greater success in both patient care and financial performance. Hospitals operating under a global budget model may consider adopting the eight strategies implemented by nearly all Maryland hospitals as implementation building blocks. Centers for Medicare and Medicaid Services.