Collaborative Quality Improvement Research Articles

Spreading Standardized Documentation of Pediatric Occupational and Physical Therapy Dose: A Quality Improvement Initiative.

Clinicians and researchers can leverage clinical documentation of therapy services for quality improvement and research purposes. However, documentation is often institution specific and may not adequately capture the dose of therapy delivered, thus limiting collaboration. To implement documentation of pediatric occupational and physical therapy dose from one institution to another institution. Dose documentation includes the frequency, intensity, time, and type of interventions delivered (FITT Epic® Flowsheet) at each session. Prospective time-series quality improvement study. Two large urban pediatric hospitals. Occupational and physical therapy staff members. Staff training and feedback loops utilizing existing groups. The process measure (number of available staff trained and using the FITT Epic Flowsheet over time) and the outcome measure (percentage of FITT Epic Flowsheets used for treatment visits each month) were analyzed using a statistical process control chart. The balancing measure (percentage of notes closed before 7 p.m. on the same day as the encounter) was analyzed using mean per month across three time periods. Fifty-seven staff members (68%) attended formal training. On average, clinicians documented 90% of sessions using the FITT Epic Flowsheet after implementation. There was no change observed in the balancing measure. Documentation of dose was spread from one institution to another. Shared documentation will facilitate future collaboration for quality improvement and research purposes. Occupational therapy practitioners and leaders should consider implementing documentation with common dose elements. Plain-Language Summary: Occupational therapy documentation is often institution specific and may not adequately capture the dose of therapy (frequency, intensity, time) or types of interventions that were delivered, thus limiting opportunities for collaboration between institutions. This article adds to the literature on administrative supports for clinical and quality improvement research by illustrating a specific example of how documentation of dose can be shared from one institution to another. The data show that clinicians at one institution started using a new style of documentation using the FITT Epic® Flowsheet and shared discrete dose elements with another institution, creating new opportunities for collaboration. Shared documentation can facilitate future collaboration for quality improvement and research purposes.

Quality improvement collaborative for improving patient care delivery in Argentine public health sector intensive care units

BackgroundThe demand for healthcare services during the COVID-19 pandemic was excessive for less-resourced settings, with intensive care units (ICUs) taking the heaviest toll.ObjectiveThe aim was to achieve adequate personal protective...

Moving from Prove to Improve: A collaborative continuous quality improvement process for advancing clinical and translational science

Moving from <i>Prove</i> to <i>Improve</i>: A collaborative continuous quality improvement process for advancing clinical and translational science

Supplementing Best Care with Specialized Rehabilitation Treatment in Parkinson's Disease: A Retrospective Study by Different Expert Centers.

Background: This is a retrospective longitudinal study comparing 374 patients with Parkinson's disease (PD) who were treated in centers offering a specialized program of enhanced rehabilitation therapy in addition to expert outpatient care to 387 patients with PD, who only received expert outpatient care at movement disorders centers in Italy. Methods: The data are from subjects recruited in the Parkinson's Outcome Project (POP) at six Italian centers that are part of a multicenter collaboration for care quality improvement (the Fresco Network). The effects were measured with a baseline and a follow-up clinical evaluation of the Timed-Up-and-Go test (TUG), Parkinson's Disease Questionnaire (PDQ-39), and Multidimensional Caregiver Strain Index (MCSI), the number of falls and hospitalizations for any cause. We used a generalized linear mixed model with the dependent variables being the response variable, which included the covariates demographics, evaluation, and treatment variables. Results: We found that the subjects who underwent specialized enhanced rehabilitation had a better motor outcome over time than those who were managed by expert neurologists but had participated in community programs for exercise and other allied health interventions. The greatest effects were seen in patients in the early stages of the disease with a high amount of vigorous exercise per week in the last six months. Similar effects were seen for PDQ39, MCSI, the number of falls, and hospitalization. Conclusions: Long-term benefits to motor function and the quality of life in patients with PD and burden reduction in their caregivers can be achieved through a systematic program of specialized enhanced rehabilitation interventions.

Improving pediatric atopic dermatitis care in the emergency department and primary care setting: a collaborative quality improvement pilot project

Improving pediatric atopic dermatitis care in the emergency department and primary care setting: a collaborative quality improvement pilot project

ECHO+: An Innovative Technology-Enabled Collaborative Learning and Quality Improvement Program Strengthening Rural Primary Care in Arkansas, West Virginia, and Oklahoma

ECHO+: An Innovative Technology-Enabled Collaborative Learning and Quality Improvement Program Strengthening Rural Primary Care in Arkansas, West Virginia, and Oklahoma

Improving Care for People Aging with HIV: A Collaborative Quality Improvement Approach.

Nearly 60% of people with HIV in New York State are over 50 years of age. After town halls and a statewide survey of long-term survivors, older people living with HIV, and their providers, the Quality of Care Program of the AIDS Institute in the New York State Department of Health developed a statewide quality improvement project that aimed to improve screening for functional impairments among people aging with HIV. Thirteen sites reported outcomes of a pilot project using a modification of the World Health Organization's Integrated Care of Older People (ICOPE) intrinsic capacity screen in small scale, short cycle tests of change. A total of 1,629 people were found to be eligible for screening, and of these, 638 people were screened. Both clinical and non-clinical sites were able to identify significant areas of need. Positive screens ranged from a low of 17% for the identification of hearing issues to 49% for vision concerns. Only 11% of people with memory or nutritional concerns were referred for services; hearing loss was the domain with the largest number of referrals, at 27%. Although in many cases, when referrals were not made, patients/clients were already under care for the identified functional deficit, in other cases no services were available for referral or patients/clients declined to use the offered service. Sites also responded to the findings of the screen by initiating process changes, and many reported continuing to screen for functional impairments after the close of the pilot. The modified ICOPE screen is still in use in sites throughout the state. This pilot demonstrated that a collaboration between people with lived HIV experience, the New York State Department of Health, clinicians, and service providers could result in improved quality of care for people aging with HIV.

Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition.

Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation. Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation. Reduced growth failure at discharge was observed in four of five NICUs, 11-32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2-5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable. Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes.

530 Understanding Strengths and Weaknesses of Clinical Research Operations in Regional Settings

OBJECTIVES/GOALS: An environmental scansoughtto understand research processes, areas for improvement, and opportunities for collaborative quality improvement (QI)across the Northwest Participant and Clinical Interactions Network (NW PCI). METHODS/STUDY POPULATION: NW PCI site champions were invited for semi-structured single and group Zoom-based interviews. Interviewers asked participants about local research processes, strengths and weaknesses, existing infrastructure to support QI, and interest in collaborative QI across the Network. Audio transcripts were coded using Dedoose and analyzed with deductive and inductive coding. RESULTS/ANTICIPATED RESULTS: Between February and April 2023, 10 interviews collected data from 7 research decision makers and 7 staff members across 7 sites. Most participants (n=13, 92%) agreed the diagram shown during the interview was representative of the local process. Organizations consistently identified strengths and weaknesses within the domains of study start-up, recruitment, budgets, and compliance. QI infrastructure was inconsistent (n=5, 36%) and all (n=14, 100%) saw potential for success in multisite QI initiatives to enhance efficiency. DISCUSSION/SIGNIFICANCE: NW PCI sites use similar processes, share common strengths and weaknesses, and universally reported interest in collaborating on QI. Study startup was reported as both a strength and weakness within the same organization, requiring unpacking of key elements before pursuing QI initiatives.

Implementation of perinatal quality collaborative statewide initiative improves obstetrical opioid use disorder care and outcomes

BackgroundMaternal deaths resulting from opioid use disorder (OUD) have been rising across the United States​. OUD among pregnant persons is associated with adverse pregnancy outcomes including preterm birth along with racial disparities in optimal OUD care. ObjectiveWe aimed to evaluate whether the Illinois Perinatal Quality Collaborative’s (ILPQC) implementation of the Mothers and Newborns affected by Opioids – Obstetric quality improvement initiative was associated with improvement of OUD identification, provision of optimal OUD care for birthing patients, and reduction in racial gaps of optimal OUD care. Study DesignUsing a prospective cohort design, hospitals reported monthly key measures for all patients with OUD at delivery between July 2018 – December 2020. ILPQC facilitated collaborative learning opportunities, rapid-response data, and quality improvement (QI) support. Generalized linear mixed effects regression models were used to​ evaluate improvement in optimal OUD care including increases in linkages to medication assisted treatment, recovery treatment services and naloxone counseling across time​; and to determine whether optimal OUD care was associated with positive outcomes such as lower odds of preterm birth. ResultsNinety- one hospitals submitted data on 2,095 pregnant persons with OUD. For the primary outcomes, the rates of patients receiving Medication Assisted Treatment (MAT) and recovery treatment services improved across the initiative from 41 to 78% and 48 to 67% respectively. For the secondary outcomes, the receipt of recovery treatment services and both recovery treatment services / MAT provided prenatally before delivery admission was associated with lower odds of preterm birth (aOR (95% CI) 0.67 (0.50, 0.91) and 0.49 (0.31, 0.75), respectively). During the first quarter of the initiative, Black patients with OUD were less likely to be linked to MAT (23% vs. 48%); however, an increase in MAT rates across the initiative occurred for all patients, with the greatest improvement for Black patients with an associated reduction in this disparity gap with greater than 70% of both Black and White patients linked to MAT. ConclusionThe MNO-OB initiative is associated with improvements in optimal OUD care for pregnant patients across Illinois hospitals, while racial disparity in OUD care was reduced across the MNO OB initiative. The findings further implicate how optimal OUD care can improve pregnancy outcomes and close persistent racial gaps in pregnant individuals with OUD.

Reducing severe maternal morbidity for birthing persons with severe hypertension through a statewide quality improvement initiative

BackgroundHypertensive disorders of pregnancy are a leading preventable cause of severe maternal morbidity and maternal mortality worldwide. ObjectiveTo assess the improvement in hospital care processes and patient outcomes associated with hypertensive disorders of pregnancy after introduction of a statewide Severe Maternal Hypertension quality improvement initiative. Study DesignA prospective cohort design comparing outcomes before and after introduction of the Illinois Perinatal Quality Collaborative statewide hypertension quality improvement initiative among 108 hospitals across Illinois. Participating hospitals recorded data for all cases of new-onset severe hypertension (>160 systolic or >110 diastolic) during pregnancy through 6 weeks postpartum from May 2016 to December 2017. Introduction of the statewide quality improvement initiative included implementation of severe maternal hypertension protocols, standardized patient education and discharge planning, rapid access to medications and standardized treatment order sets, and provider and nurse education. The main outcome measure was the reduction of severe maternal morbidity for pregnant/postpartum patients with severe hypertension. Key process measures include time-to-treatment of severe hypertension, frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow up. ResultsData were reported for 8,073 cases of severe maternal hypertension. The frequency of patients with new-onset severe hypertension treated within 60 minutes increased from 41% baseline to 87% (p<0.001) at the end of the initiative. The initiative was associated with increased proportion of patients receiving preeclampsia education at discharge (41% to 89%, p<0.001), scheduling follow-up appointments within 10 days of discharge (68% to 83%, p<0.001), and having a care team debrief after severe hypertension was diagnosed (17% to 59%, p<0.001). Conversely, severe maternal morbidity was reduced from 11.5% baseline to 8.4% (p<0.002) at the end of the study period. Illinois hospitals were able to achieve time-to-treatment goal regardless of hospital characteristics including geography, birth volume, and patient mix. ConclusionsIntroduction of a statewide quality improvement effort was associated with improved time-to-treatment of severe hypertension, as well as increased frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow up scheduled at discharge, and reduced severe maternal morbidity.

Unmasking patients' insight into SGLT2 inhibitors: A collaborative quality improvement project to enhance patient education and safety

Unmasking patients' insight into SGLT2 inhibitors: A collaborative quality improvement project to enhance patient education and safety

A cross-sectional survey of delivery room transitional care management for very/extremely preterm infants in 24 hospitals in Shenzhen City

To investigate the current status of delivery room transitional care management for very/extremely preterm infants in Shenzhen City. A cross-sectional survey was conducted in November 2022, involving 24 tertiary hospitals participating in the Shenzhen Neonatal Data Network. The survey assessed the implementation of transitional care management in the delivery room, including prenatal preparation, delivery room resuscitation, and post-resuscitation management in the neonatal intensive care unit. Very/extremely preterm infants were divided into four groups based on gestational age: <26 weeks, 26-28+6 weeks, 29-30+6 weeks, and 31-31+6 weeks. Descriptive analysis was performed on the results. A total of 140 very/extremely preterm infants were included, with 10 cases in the <26 weeks group, 45 cases in the 26-28+6 weeks group, 49 cases in the 29-30+6 weeks group, and 36 cases in the 31-31+6 weeks group. Among these infants, 99 (70.7%) received prenatal counseling, predominantly provided by obstetricians (79.8%). The main personnel involved in resuscitation during delivery were midwives (96.4%) and neonatal resident physicians (62.1%). Delayed cord clamping was performed in 52 cases (37.1%), with an average delay time of (45±17) seconds. Postnatal radiant warmer was used in 137 cases (97.9%) for thermoregulation. Positive pressure ventilation was required in 110 cases (78.6%), with 67 cases (60.9%) using T-piece resuscitators and 42 cases (38.2%) using a blended oxygen device. Blood oxygen saturation was monitored during resuscitation in 119 cases (85.0%). The median time from initiating transitional care measures to closing the incubator door was 87 minutes. The implementation of delivery room transitional care management for very/extremely preterm infants in the hospitals participating in the Shenzhen Neonatal Data Network shows varying degrees of deviation from the corresponding expert consensus in China. It is necessary to bridge the gap through continuous quality improvement and multicenter collaboration to improve the quality of the transitional care management and outcomes in very/extremely preterm infants.

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

BackgroundDespite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis. MethodsUsing National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020–March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF). ResultsFive of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship. ConclusionHospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship. Level of EvidenceLevel V.

Motivational drivers for health professionals in a large quality improvement collaborative project in Brazil: a qualitative study

BackgroundThe success of collaborative quality improvement (QI) projects in healthcare depends on the context and engagement of health teams; however, the factors that modulate teams’ motivation to participate in these projects are still unclear. The objective of the current study was to explore the barriers to and facilitators of motivation; the perspective was health professionals in a large project aiming to implement evidence-based infection prevention practices in intensive care units of Brazilian hospitals.MethodsThis qualitative study was based on content analysis of semistructured in-depth interviews held with health professionals who participated in a collaborative QI project named “Improving patient safety on a large scale in Brazil”. In accordance with the principle of saturation, we selected a final sample of 12 hospitals located throughout the five regions of Brazil that have implemented QI; then, we conducted videoconference interviews with 28 health professionals from those hospitals. We encoded the interview data with NVivo software, and the interrelations among the data were assessed with the COM-B model.ResultsThe key barriers identified were belief that improvement increases workload, lack of knowledge about quality improvement, resistance to change, minimal involvement of physicians, lack of supplies, lack support from senior managers and work overload. The primary driver of motivation was tangible outcomes, as evidenced by a decrease in infections. Additionally, factors such as the active participation of senior managers, teamwork, learning in practice and understanding the reason for changes played significant roles in fostering motivation.ConclusionThe motivation of health professionals to participate in collaborative QI projects is driven by a variety of barriers and facilitators. The interactions between the senior manager, quality improvement teams, and healthcare professionals generate attitudes that modulate motivation. Thus, these aspects should be considered during the implementation of such projects. Future research could explore the cost-effectiveness of motivational approaches.

How social networks influence the local implementation of initiatives developed in quality improvement collaboratives in health care: A qualitative process study.

Quality improvement collaboratives (QICs) have facilitated cross-organizational knowledge exchange in health care. However, the local implementation of many quality improvement (QI) initiatives continues to fail, signaling a need to better understand the contributing factors. Organizational context, particularly the role of social networks in facilitating or hindering implementation within organizations, remains a potentially critical yet underexplored area to addressing this gap. We took a dynamic process perspective to understand how QI project managers' social networks influence the local implementation of QI initiatives developed through QICs. We explored the case of a QIC by triangulating data from an online survey, semistructured interviews, and archival documents from 10 organizations. We divided implementation into four stages and employed qualitative text analysis to examine the relationship between three characteristics of network structure (degree centrality, network density, and betweenness centrality) and the progress of each QI initiative. The progress of QI initiatives varied considerably among organizations. The transition between stages was influenced by all three network characteristics to varying degrees, depending on the stage. Project managers whose QI initiatives progressed to advanced stages of implementation had formed ad hoc clusters of colleagues passionate about the initiatives. Implementing QI initiatives appears to be facilitated by the formation of clusters of supportive individuals within organizations; this formation requires high betweenness centrality and high network density. Flexibly modifying specific network characteristics depending on the stage of implementation may help project managers advance their QI initiatives, achieving more uniform results from QICs.

Engaging health care professionals in quality improvement: A qualitative study exploring the synergies between projects of professionalisation and institutionalisation in quality improvement collaborative implementation in Denmark.

To examine the projects of professionalisation and institutionalisation forming health care professions' engagement in quality improvement collaborative (QIC) implementation in Denmark, and to analyse the synergies and tensions between the two projects given the opportunities afforded by the QICs. This was a cross-sectional interview study with professionals involved in the implementation of two national QICs in Denmark involving 23 individual interviews and focus group discussions with 75 people representing different professional groups. We conducted a reflexive thematic analysis of the data, drawing on institutional contributions to organisational studies of professions. Study participants engaged widely in QIC implementation. This engagement was formed by a constructive interplay between the professions' projects of professionalisation and institutionalisation, with only few tensions identified. The project of professionalisation relates to a self-oriented agenda of contributing professional expertise and promoting professional recognition and development, while the project of institutionalisation focuses on improving health care processes and outcomes and advancing quality improvement. Both projects were largely similar across professional groups. The interplay between the two projects was enabled by the bottom-up approach to implementation, participation of QI specialists, and a clear focus on developing and delivering high-quality patient care. Future strategies for QIC implementation should position QICs as a framework that promotes the integration of professions' projects of professionalisation and institutionalisation to successfully engage professionals in the implementation process, and thereby optimise the effectiveness of QICs in health care.

Insights on a National Safety Improvement Learning Collaborative: Using the Consolidated Framework for Implementation Research.

There is a growing interest in quality improvement collaboratives (QICs), even though less remains known about contextual factors that impact collective and local project implementation. A study was undertaken that used the Consolidated Framework for Implementation Research (CFIR) to explore the contextual factors impacting the use of this nationwide QIC in Canada. A deductive or direct qualitative content analysis using CFIR was employed to explore the contextual factors impacting the implementation of a nationwide QIC and participating organizations. Data were used from document analysis and semi-structured interviews with participants from 30 participating healthcare organizations across Canada. A variety of contextual factors emerged, which influenced the uptake of the QICs across different settings, including intervention characteristics, outer setting, inner setting, and process factors. This study illustrates how organizations can consider a multi-pronged, theory-driven approach to guide the evaluation of safety and quality improvement efforts. This study provides insights into contextual factors that impact the implementation of local safety projects involved in a larger QIC, which may serve as a template or blueprint for healthcare leaders in their efforts to guide the co-design, implementation and evaluation of safety and quality improvement efforts.

2015 Identifying and Managing Visual Impairment in Older Patients with Falls on a Care of the Elderly (COTE) ward

Abstract Introduction In 2019, the Royal College of Physicians (RCP) advised that all patients should have their vision screened if identified as a falls risk. Our aim was to implement a bedside visual screening test and establish an onward inpatient referral to Hospital Eye Services (HES). Method This is a collaborative Quality Improvement project involving Geriatric Medicine, HES and the Royal National Institute of Blind People (RNIB). A pilot study cross referenced falls admissions with previous known ophthalmic data to estimate the proportion of known vision loss in this group. In the second phase of the project, a bedside visual screening test has been introduced for all patients admitted to COTE with a fall. Patients failing the screening are reviewed by an RNIB Eye Clinic Liaison Officer (ECLO) and if necessary, a prompt inpatient HES review is arranged. Results Of 182 patients admitted following a fall, in the pilot study, 112 (61%) were known to ophthalmology previously. Of patients known to ophthalmology, 28 (25%) had vision of 6/18 or worse and would be considered to struggle with daily living tasks. 12 (10%) had a certificate of visual impairment (CVI) and 3 (3%) were eligible for CVI but had not been previously registered. One year following implementation of bedside vision testing, 287 patients had been reviewed after failing bedside screening. 97 of these had an onward referral sent or an intervention performed. The first ‘COTE ECLO’ post has been funded as a result of this work. Conclusion Assessing vision is a critical element of the assessment of patients with falls. Through collaboration with the RNIB and Ophthalmology a successful pathway has been developed to address visual impairment in this vulnerable group of patients.

Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative.

Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements. We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits. Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals. A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes. Therapeutic/Care Management; Level III.