Lapses In Quality Research Articles

Beyond the Hospital: Redefining the Role of Pharmacists in Transitions of Care

Unjustifiable medication discrepancies or inconsistency are responsible for more than half of medication errors occurring at transitions in care and up to one-third could have the potential to cause harm. Studies have shown that pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. In Singapore, the Hospital-to-Home (H2H) programme in Changi General Hospital (CGH) focuses on providing care to vulnerable patients transitioning from different settings, who are exposed to gaps in care and lapses in quality and safety. The Home Medical Service by Pharmacists was pioneered in CGH and Singapore in October 2020 to enhance provision of pharmacy-related services by certified collaborative prescribing pharmacists in the home setting. The purpose of this quality improvement project is to identify provider and patient characteristics that are predictive of the response towards this new pharmacy service, which in turn influences the referrals to the service.
 A fishbone diagram was used to analyse and categorise the problems into different factors – pharmacist-, nursing-, physician-, patient-, and process-related. Pharmacist-, nursing- and physician-related factors include poor awareness of the potential value-added roles of pharmacists due to the lack of prescribing experience in the home setting. Patient-related factors include difficulty in establishing the appropriate criteria to identify patients who need pharmacist’s intervention. Process-related factors include potential additional cost to patients.
 Based on the Model of Improvement, several changes were implemented in two Plan-Do-Study-Act (PDSA) cycles. The first cycle was to perform roadshows to the H2H team comprising of physicians and nurses, to raise awareness of the new pharmacy service and pharmacist's roles (more in-depth medication reconciliation, drug information, and prescribing). After three months, the second cycle was initiated by conducting regular monthly case audits with the H2H team to monitor progress, identify lapses, and receive feedback to further improve processes and explore potential areas that pharmacists can contribute.
 After implementing PDSA cycle 1, the average number of unique home visits by pharmacists per month increased from 1 visit to 4 visits, and subsequently increased to 8 visits after implementing PDSA cycle 2. A survey was also conducted to determine if the changes implemented were satisfactory to the team. Overall, 80% of responses were satisfied with the Home Medical Service by Pharmacists in managing patients under the H2H programme.
 This project had enabled us to achieve improvements in several processes which facilitated the refinement of pharmacist’s roles in the H2H programme to complement the team’s current roles and increased awareness of these roles within the team. Lastly, we will continue to further improve other problem areas yet be addressed and together with the H2H team, close the gaps in care for patients undergoing transitions of care.

Mortality Risk of Patients Treated in Dialysis Facilities with Payment Reductions under ESRD Quality Incentive Program.

The Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program (ESRD QIP) measures quality of care delivered by dialysis facilities and imposes Medicare payment reductions for quality lapses. We assessed the association between payment reductions and patient mortality, a quality indicator not included in the ESRD QIP measure set. Association between mortality and ESRD QIP facility payment reduction based on the year of performance was expressed as the unadjusted rate and patient case-mix-adjusted hazard ratio. We also measured association between mortality and 1-year changes in payment reductions. Retrospective patient cohorts were defined by their treating dialysis facility on the first day of each year (2010-2018). Facility performance resulted in payment reductions for 5%-42% of dialysis facilities over the 9 study years. Patients experienced progressively higher mortality at each payment reduction level. Across all years, unadjusted mortality was 17.3, 18.1, 18.9, 20.3, and 23.9 deaths per 100 patient-years for patients in facilities that received 0%, 0.5%, 1%, 1.5%, and 2% payment reductions, respectively. The adjusted hazard ratio showed a similar stepwise pattern by the level of payment reduction: 1.0 (reference), 1.08 (95% confidence interval [CI], 1.07 to 1.09), 1.15 (95% CI, 1.13 to 1.16), 1.19 (95% CI, 1.16 to 1.21), and 1.34 (95% CI, 1.29 to 1.39). Strength of the association increased from 2010 to 2016. Patients treated in facilities that improved over 1 year generally experienced lower mortality; patients in facilities that performed worse on ESRD QIP measures generally experienced higher mortality. Patient mortality was associated with ESRD QIP facility payment reductions in dose-response and temporal patterns.

Ethical Challenges in the Practice of Echocardiography: What Is Right and How Do We Do It?

At the 2018 Scientific Sessions, the American Society of Echocardiography inaugurated the Richard E. Kerber Ethics/Humanitarian Lecture, continuing its tradition of providing ethics education and exploring the use of echocardiography to improve cardiovascular care in medically underserved settings. Echocardiography is one of the most widely applicable, safe, and cost-effective diagnostic tools available in cardiovascular medicine. The American Society of Echocardiography Foundation is well known for harnessing the power of echocardiography in its many successful humanitarian outreaches all over the world. Some practitioners might conclude that because of its important advantages, echocardiography involves few ethical complexities; however, several historical and recent scandals involving conflicts of interest and lapses in quality suggest otherwise. Every day, sonographers and echocardiographers grapple with ethical issues: integrity, truth telling, doing good and avoiding harm, altruism, and humanism. In the near future, population aging and technological advances, among other issues, will ensure that a steady stream of ethical issues will confront the practitioners of echocardiography. Medical science and engineering have given us many things that can be done, but central to the art of medical practice and research are decisions about what should be done. In this article, based in part on the first Richard E. Kerber Ethics/Humanitarian Lecture, the authors discuss ethical challenges in the practice of echocardiography, illustrated by accompanying online videos, and offer a general principle for meeting these challenges.

Who's Listening to Modernism? BBC Features and Audience Response

This article focuses on three literary features—A Room of One's Own (1946), centred on the work of Virginia Woolf, an adaptation of David Jones’ epic poem In Parenthesis (1946) and Herbert Read's verse play Moon's Farm (1951)—in order to examine how they reflected on and adapted various aspects of modernist innovation. It also examines the range of listener response offered in the BBC Listener Research Reports for these programmes—from surprise and delight to outright bewilderment, with many listeners pleased in principle with the challenging literary content, but looking for pointed guidance on how to approach it, whilst others who were receptive to avant-garde writing were quick to identify lapses in quality. This article therefore traces how literary modernism functioned, and was experienced, when adapted into an aural experience in the late 1940s and early ’50s, the most innovative period of the Features Department.

BIM-Based 4D Simulation to Improve Module Manufacturing Productivity for Sustainable Building Projects

Modular construction methods, where products are manufactured beforehand in a factory and then transported to the site for installation, are becoming increasingly popular for construction projects in many countries as this method facilitates the use of the advanced technologies that support sustainability in building projects. This approach requires dual factory–site process management to be carefully coordinated and the factory module manufacturing process must therefore be managed in a detailed and quantitative manner. However, currently, the limited algorithms available to support this process are based on mathematical methodologies that do not consider the complex mix of equipment, factories, personnel, and materials involved. This paper presents three new building information modeling-based 4D simulation frameworks to manage the three elements—process, quantity, and quality—that determine the productivity of factory module manufacturing. These frameworks leverage the advantages of 4D simulation and provide more precise information than existing conventional documents. By utilizing a 4D model that facilitates the visualization of a wide range of data variables, manufacturers can plan the module manufacturing process in detail and fully understand the material, equipment, and workflow needed to accomplish the manufacturing tasks. Managers can also access information about material quantities for each process and use this information for earned value management, warehousing/storage, fabrication, and assembly planning. By having a 4D view that connects 2D drawing models, manufacturing errors and rework can be minimized and problems such as construction delays, quality lapses, and cost overruns vastly reduced.

Error Disclosure in Pathology and Laboratory Medicine: A Review of the Literature

Since the 1990s, the fields of anatomic and clinical pathology have made strong commitments to improving patient safety, including the creation of formal and informal guidelines for assessing and reporting quality lapses. Unfortunately, some medical errors are inevitable. Patient safety experts advocate full and complete disclosure of all serious medical errors in an effort to preserve the patient-physician relationship and minimize the risk of harm to patients. While evidence suggests that most pathologists disclose serious medical errors, many do not disclose such errors to patients. A literature review of articles published on diagnostic error disclosure in pathology and laboratory medicine suggests that there are in fact persistent barriers to the disclosure of diagnostic errors that are specific to pathology. A number of these barriers are considered here, followed by recommendations for improving patient safety in pathology.

Postadmission Sepsis as a Screen for Quality Problems

The present on admission (POA) indicator used with diagnosis codes listed in hospital discharge abstracts makes it possible to screen for possible in-hospital complications, which may in turn point to quality of care problems. A case-control study was performed among 382 patients from 30 New York State hospitals to see if lapses in quality were associated with the development of postadmission sepsis. Cases with hospital-acquired sepsis (labeled not POA) were compared with matched controls without sepsis. The authors found that central venous catheters and emergently inserted peripheral intravenous catheters were associated with subsequent development of sepsis. Urethral catheters were associated with sepsis for medical patients but not for surgical patients. Adherence to several process of care guidelines was incomplete but none occurred statistically significantly more frequently among sepsis cases than controls. Using discharge abstract diagnosis codes to determine the presence of postadmission complications shows promise for identifying areas for quality improvement.

Patient Safety Strategies: A Call for Physician Leadership

In the supplement on patient safety that accompanies this issue, an expert panel has rated the strength of evidence for each safety strategy and recommended 10 patient safety strategies that should...

How and Why US Health Care Differs From That in Other OECD Countries

UNITED STATES HEALTH CARE, OFTEN HAILED AS “THE best health care system in the world,” is also faulted for being too costly, leaving many millions of individuals uninsured, and having avoidable lapses in quality. Criticism often draws on comparisons with other countries of the Organization for Economic Co-operation and Development (OECD). This Viewpoint also makes such comparisons, over a broad range of variables, and reaches one inescapable conclusion—US health care is very different from health care in other countries. Potential reasons for the differences are discussed, leading to the conclusion that future efforts to control cost, provide universal coverage, and improve health outcomes will have to consider the United States’ particular history, values, and political system.

Health Care Change Ahead: Are You Ready?

Health Care Change Ahead: Are You Ready?

High-Profile Investigations Into Hospital Safety Problems In England Did Not Prompt Patients To Switch Providers

Amid international concerns about health care safety and quality, there has been an escalation of investigations by health care regulators into adverse events. England has a powerful central health care regulator, the Care Quality Commission, which conducts occasional high-profile investigations into major lapses in quality at individual hospitals. The results have sometimes garnered considerable attention from the news media, but it is not known what effect the investigations have had on patients' behavior. We analyzed trends in admission for discretionary (nonemergency) care at three hospitals that were subject to high-profile investigations by the Healthcare Commission (the predecessor to the Care Quality Commission) between 2006 and 2009. We found that investigations had no impact on utilization for two of the hospitals; in the third hospital, there were significant declines in inpatient admissions, outpatient surgeries, and in numbers of patients coming for their first appointment, but the effects disappeared six months after publication of the investigation report. Thus, the publication and dissemination of highly critical reports by a health care regulator does not appear to have resulted in patients' sustained avoidance of the hospitals that were investigated. Our findings reinforce other evaluations: Reporting designed to affect providers' reputations is likely to spur more improvement in quality and safety than relying on patients to choose their providers based on quality and safety reports, and simplistic assumptions regarding the power of information to drive patient choices are unrealistic.

A Historical Perspective on Clinical Trials Innovation and Leadership

THE RANDOMIZED CONTROLLED TRIAL (RCT), THE GOLD standard for evaluating the balance of risk and benefit in medical therapies, first emerged as a key clinical research tool in the mid-20th century thanks to visionary leadership of agencies such as the US National Institutes of Health (NIH), the UK Medical Research Council, and academic research institutions. Since then, clinical trials activity has shifted from the NIH and academia into the purviews of the medical products industry and regulatory authorities. Recent emphasis on evidence-based medicine, patient-centered outcomes research, and learning and accountable health care systems underscores the fact that most clinical trials fail to provide the evidence needed to inform medical decision making. However, the serious implications of this deficit are largely absent from public discourse, and a better balance between commercial interests and public health is critically needed. In this context, the word “academic” describes a diverse group of individuals exploring scholarly questions, with motivations arising not from pursuit of profit but from an interest in the public health. The wellsprings of such activity should reside in the NIH and other federal research agencies, coupled with external grantees—most of whom work in the nation’s academic health and science systems. The primary mission of academic health and science systems, as required by their not-for-profit status, places public health interests above return on investment to specific investors. This in no way disparages the motivations of the many excellent scientists working in industry or in the US Food and Drug Administration (FDA) that regulates its products. On the contrary, the development and appropriate use of medical technologies are vital to the public health. However, it is important to remain mindful that decisions affecting forprofit research will reflect fundamentally different priorities than those of academic researchers. In a sense, the academic enterprise seeks a “return on investment” for taxpayers who grant (and support) its nonprofit status. Thus, while all researchers are bound by the same standards when conducting human studies, the fundamental questions addressed will differ, and failure on the part of academia to increase its involvement will have predictable consequences. When fundamental trials methodologies were being developed at the NIH in the 1960s, an NIH-commissioned task force delineated recommendations for organizing and conducting RCTs. One significant early example is the Coronary Drug Project, a joint effort among NIH sponsors, an academic coordinating center, and a steering committee of academic leaders. In the 1970s and 1980s, the NIH often convened academic leaders to identify knowledge gaps and prioritize and conduct specific trials as funding permitted. During the 1960s, there was scant statistical literature examining clinical trials methodologies. Researchers learned by doing trials, noting successes and failures, and iterating to advance the field. In a series of discussions in the 1970s, ideas were debated and solutions to immediate problems were proposed. Throughout the 1970s and 1980s, NIH and academic biostatisticians developed many methods now in routine use, including sample size estimation, interim data monitoring, and repeated measure methods for analysis. At the outset of this era, few large randomized clinical outcomes trials were sponsored or conducted by industry. Meanwhile, the FDA was developing biostatistical teams to support review of new drug and device applications and increasingly demanded RCTs, often with clinical outcomes end points, as the standard for approval and labeling. By the early 1990s, academia was working with industry to lead and conduct clinical trials, using a modification of the NIH organizational structure. While some fields developed this hybrid model of academic leadership in industry-sponsored RCTs, most industry trials evolved in a different direction and were designed by industry scientists in concert with regulators, often with little or no independent academic input. As the clinical trials enterprise grew, statistical principles mandated adequate sample sizes to provide power for detecting typically modest differences in clinical outcomes. Concurrently, the enterprise’s rapid expansion, coupled with egregious instances of fraud or lapses in quality, resulted in the implementation of auditable data systems. This confluence of factors spurred massive increases in clinical trial costs.

Large Cardiac Registries: The Path to Higher Quality and Lower Cost in Our Healthcare System

This observer agrees with Stanford economist Victor Fuchs that the 3 major reasons to undertake systematic reform of the US healthcare system are (1) to provide coverage for the uninsured, (2) to correct significant lapses in quality, and (3) to control the high and rapidly increasing cost of care.1 The “how to” for achieving each of these objectives is clear. It merely requires defining who is to be covered under universal coverage, insisting that we have “effective care,” and deciding the best way to achieve payment reform. On the other hand, the devil is in the details, as became abundantly clear during this past year of congressional debate before the passing of the Patient Protection and Affordability Act. Of the 3 issues cited, coverage is the most clearly addressed in this legislation, although, as it now stands, some millions of uninsured will still remain. The other 2 issues, quality and cost of care, appear the most threatening. Michael Chernow of the Harvard Department of Health Care Policy, in discussing the increasingly larger annual deficits ($1.3 trillion dollars in 2010) and their resultant debt burden ($8.8 trillion at the end of 2010), representing 60% of the gross domestic product, underscores how unsustainable these figures are and cautions that the result will be a financial Armageddon.2 Accordingly, it is imperative that we members of the cardiovascular community provide workable solutions to improve quality and reduce the cost of care because, if we fail, it will bankrupt us. Article see p 2635 In this regard, and equally pertinent to the “devilish details” accompanying health reform law (PL 111–148; PL 111–152), is an informative article published in this issue of Circulation by Hannan and colleagues.3 This “tale of two cities” examines differences in utilization rates, practice patterns, and facilities available for …

Product quality and plant build complexity

This paper assesses the hypothesis that plant build complexity impacts quality, suggests mechanisms to explain how complexity impacts quality, and offers countermeasures to mitigate this impact. We analyse automotive assembly data that supports the proposition that plant build complexity negatively impacts quality. In addition, this paper provides actual automotive assembly line work instructions and shows how they can be represented by the Gilbreths’ fundamental work elements and plant build complexity impacts these work elements. To highlight complexity's adverse impact on quality, we compare the actual work instructions at two automotive assembly line stations–one with very little complexity and one with extreme complexity. We list common automotive assembly quality lapses and describe how they can be caused or exacerbated by complexity. Finally the paper presents practical countermeasures to mitigate complexity's impact on quality. While based on the automotive industry, the lessons apply to all complex assembly lines.

Is safety safe in the market’s hands?

There is no doubt that the proposal to establish market-based control mechanisms for patient safety is both interesting and intriguing. However, I am not optimistic that Coiera and Braithwaite’s (CB...

Reforming US Health Care

THE ELECTION OF PRESIDENT BARACK OBAMA HAS SET in motion high expectations that he will undertake systematic reform of the US health care system in his first term. Such reform must address 3 persistent problems: the uninsured, the high and rapidly increasing cost of care, and significant lapses in quality. Having studied these problems for more than 40 years, I would like to share in this Commentary some conclusions about reforming health care in the United States. Before suggesting what should and should not be done, however, it is important to learn from the failure of the proposed health reform in 1993. Sixteen years ago a bright, young, charismatic Democratic politician entered the White House with a high priority of reforming US health care. The First Lady, Hillary Clinton, led the effort; a 500-person task force worked on the plan for more than a year; and Democrats controlled both houses of Congress. Nevertheless, the Clinton plan never reached either house for a vote. What went wrong? Articles and books dissecting the Clinton plan’s failure are enough to fill a small library. Their discussions of political missteps, design complexity, and misleading arguments by opponents are instructive. They do not, however, get to the heart of the matter. Although public opinion polls reported clear majorities in favor of health care reform, support for substantial change was weak and divided. In an article directed to then President Clinton in April 1993, I pointed out that “[m]ost Americans have health insurance. Most Americans are satisfied with their doctor. . . .” More generally, numerous individuals and organizations preferred the status quo, and the political system gave them many opportunities to block change. Most critics of US health care incorrectly focused on “greedy” drug companies and “overpaid” physicians rather than on systemic problems in funding, organization, and delivery of care. Most workers mistakenly thought that their insurance was a gift from their employer rather than an offset to higher wages. The Clintons never rose to the challenge of explaining these problems to the public. Most importantly, the Clintons were not alone in failing to achieve reform. The experienced and influential Rep Pete Stark (D, California) submitted a bill calling for greater reliance on government than the Clinton plan. Rep Jim Cooper (D, Tennessee) put together a bipartisan group of 80 representatives in support of a more market-friendly plan, and Senators Breaux (D, Louisiana) and Durenberger (R, Minnesota) authored a similar bill in the Senate. Significantly, no reform plan was ever reported out of committee. Weak, divided, uninformed public support combined with failure of reformers to unite behind a single plan doomed the effort. What is different this time around? Not so much. Public opinion polls in 2008 show support for health care reform at levels somewhat below those in 1992. Public understanding of the problems still misses the mark; this time insurance companies are now the favorite villains. Few critics realize that insurance companies are usually only providing administrative services. Employers are typically self-insured, and most workers still do not understand the connection between insurance and wages. The major problems are as great or greater now than they were in 1993, but individuals and organizations who like the status quo are also still numerous. Furthermore, the inability of reformers to unite behind a single approach remains a major obstacle. The biggest difference is the economic climate. In 1993, the economy was on the rise after a mild recession in 1991. Now the economy is headed downward. The recession that began in December 2007 shows no sign of ending and may turn out to be the worst since the 1930s. Advisors to the president will probably differ on how the overall economy affects the prospects for health care reform. Some will say that declines in employment and employment-based insurance strengthen the pressure for bold new approaches to coverage. Others will argue that because the federal government already faces a large and increasing budget deficit, this is not an opportune time to increase government spending on health insurance. These conflicting views can be reconciled if reform addresses coverage and cost issues simultaneously. The need to control costs strengthens the case for universal coverage instead of targetingparticulargroups.An incremental strategymayhavea shortrun political payoff, but as long as millions are uninsured, poverty health clinics and public hospitals will still be needed. Also, uncompensated care by physicians and hospitals will still be inefficient and inequitable. Universal coverage creates opportunities for significant improvements in the organization and delivery of care.

Patient safety is not enough: targeting quality improvements to optimize the health of the population.

Ensuring patient safety is essential for better health care, but preoccupation with niches of medicine, such as patient safety, can inadvertently compromise outcomes if it distracts from other problems that pose a greater threat to health. The greatest benefit for the population comes from a comprehensive view of population needs and making improvements in proportion with their potential effect on public health; anything less subjects an excess of people to morbidity and death. Patient safety, in context, is a subset of health problems affecting Americans. Safety is a subcategory of medical errors, which also includes mistakes in health promotion and chronic disease management that cost lives but do not affect "safety." These errors are a subset of lapses in quality, which result not only from errors but also from systemic problems, such as lack of access, inequity, and flawed system designs. Lapses in quality are a subset of deficient caring, which encompasses gaps in therapeutics, respect, and compassion that are undetected by normative quality indicators. These larger problems arguably cost hundreds of thousands more lives than do lapses in safety, and the system redesigns to correct them should receive proportionately greater emphasis. Ensuring such rational prioritization requires policy and medical leaders to eschew parochialism and take a global perspective in gauging health problems. The public's well-being requires policymakers to view the system as a whole and consider the potential effect on overall population health when prioritizing care improvements and system redesigns.

An empirical investigation of firm public and private knowledge

AbstractMany studies examine firm private knowledge, but purport to be generalizable to the totality of firm knowledge, both public and private. This study demonstrates that public and private firm knowledge are empirically separable constructs that have significant and yet different influences on innovative outcomes. The example of product development effectiveness within this study shows that both public and private knowledge are significantly related to product development quality; however, public knowledge is negatively related to quality lapses while private knowledge is positively related to quality lapses. Copyright © 2002 John Wiley & Sons, Ltd.

From experience:: Reaping benefit from speed to market

Many companies have gained great benefit from a speed-to-market program. Others have tried but failed to achieve measurable, sustained value. Still others have not even tried, being concerned about adverse consequences. This article helps newcomers decide how to approach time to market. It first addresses some common fears about development acceleration, such as increased project expense and lapses in quality. An effective program overcomes these concerns, but it must do much more. It must stem from a statement, clear to all developers, explaining how faster development is tied directly to improved competitiveness and thus to higher profits for the company. A general corporate goal of a 50% across-the-board cut in cycle time will not do, nor will an underlying hope that faster development will improve developer productivity. To help establish a clear link from speed-to-market to profitability, I suggest calculating how much a week of delay impacts profit, and I show how to align a development acceleration program with corporate programs to improve quality or productivity.

Economic implications of compositional quality and production systems

Proposed changes in milk pricing to be introduced on 1 April 1984 will make milk fat payments 53% of total milk returns. Current breed averages indicate that Jersey returns will show the greatest improvement at £40 per cow but will still be £100 lower than Friesian returns. Additionally, the higher calf and barren cow values enhance the Friesian, although this can be offset if Jerseys achieve a 50% increase in longevity compared with Friesians.The proposed seasonal differentials give a milk price variation around the mean of 29%, compared with the present 13%. However, in 1969/70, the variation was 36%. Milk values by month of calving on the new proposals vary by a maximum of £87 at a yield of 5000 1. August to October calving gives the highest and February to May the lowest milk income after seasonal adjustment.Farm examples show that block-calving herds have seasonal quality trends that will be highlighted by contemporary payment. In the past, arithmetic averages have put block-calving herds into higher-quality classes than was warranted. Contemporary payment penalizes lapses in quality immediately. Conversely, improvements will be immediately rewarded. Summer-milk producers will have a dramatic decrease in their traditional cash flow in May and June. Comparison of weekly sample results and monthly averages with the same period last year, and with the England and Wales monthly average, enables economic corrective management steps to be taken.The cost of computerized out-of-parlour feeders depends on herd size. Justification of their cost can be based on changes in milk sales by volume and/or compositional quality.