American Journal of Medical Quality current issue

Introducing the HRET Patient Safety Fellowship and Action Learning Projects

Baron, D., Leonhardt, K. K., Page, N. — 2008-09-26

The Tipping Point: The Relationship Between Volume and Patient Harm

Pedroja, A. T. — 2008-09-26

This study purports to show the relationship between volume and patient harm due to health care error. Using 5 measures of volume and incident reports weighted for patient harm over the course of 515 days, it is shown that increased volume is related to increased harm to patients. As the number of areas in the hospital experiencing high volume increased, the likelihood of patients sustaining serious harm because of health care error also increased. This is attributed to reaching system capacity causing support services (ie, lab, pharmacy, radiology, housekeeping and engineering) to be overwhelmed and unable to keep up with requests from caregivers. (Am J Med Qual 2008;23:336-341)

Using the Case Mix of Pressure Ulcer Healing to Evaluate Nursing Home Performance

Kapoor, A., Kader, B., Cabral, H., Ash, A. S., Berlowitz, D. — 2008-09-26

Pressure ulcer healing is an important quality measure for nursing homes, but the factors that predict healing have not been well studied. Using the Minimum Data Set, the authors identified candidate variables for a logistic regression, risk-adjustment model to predict ulcer healing. The authors then assessed model discrimination and calibration. Finally, the authors compared unadjusted with risk-adjusted performance for the individual facilities within a nursing home chain. Significant predictors of healing included mobility in bed, presence of a stage 2 ulcer (compared with a stage 4 ulcer), absence of paraplegia and quadriplegia, and absence of end-stage illness. The model C statistic was 0.67, and the calibration was acceptable. Judgments about nursing performance varied in 2 cases depending upon whether unadjusted or risk-adjusted performance was used. The model that the authors developed contains credible predictors of healing. Pressure ulcer healing may be one of many indicators used to evaluate nursing home quality. (Am J Med Qual 2008; 23:342-349)

An Innovative Method to Assess Negotiation Skills Necessary for Quality Improvement

Varkey, P., Gupta, P., Bennet, K. E. — 2008-09-26

Quality improvement (QI) initiatives require leaders who can facilitate change through negotiation. Although a few education programs teach these skills, there is no published literature on methods to assess competency in negotiation. This study's purpose was to determine the psychometric properties of an Objective Structured Clinical Examination (OSCE) to assess negotiation skills. The OSCE uses an actor trained to respond to the learner in a standardized fashion. The negotiation station was part of an 8-station QI OSCE piloted in the Mayo Clinic Endocrinology and Preventive Medicine fellowship programs. External experts judged the content validity to be excellent. Interrater reliability was outstanding for the global competency assessment (0.80) and moderate for checklist scores (0.53). All participating faculty strongly agreed (33.3%) or agreed (66.7%) that the OSCE station was an authentic assessment tool. Further research is needed to study the predictive validity of such an OSCE and its application to assessing other quality improvement competencies. (Am J Med Qual 2008;23:350-355)

Clinical Ethics and the Quality Initiative: A Pilot Study for the Empirical Evaluation of Ethics Case Consultation

Nilson, E. G., Acres, C. A., Tamerin, N. G., Fins, J. J. — 2008-09-26

The Institute of Medicine's quality imperatives include the need to provide safe, effective, patient-centered, timely, efficient, and equitable care. Less attention has been paid to quality metrics as they relate to the assessment of clinical ethics consultation and its impact on care. A better understanding of how ethics consultation influences the quality of care might identify opportunities for improvement. A descriptive pilot study, involving 7 hospitals in the New York-Presbyterian Healthcare System, was conducted to identify key elements of the ethics consultative process that might impact clinical and psychosocial outcomes. A majority of consults involved medical or intensive care unit patients and end-of-life decision making; 75.5% had or received a do-not-resuscitate order, 90.6% lacked decision-making capacity, 43.4% had an advance directive. Conflict existed in a majority. Future research should include surrogate decision making, patients on nonmedical services who may have unrecognized ethical dilemmas, and the role of conflict in clinical care. (Am J Med Qual 2008;23:356-364)

Resource Use and Associated Care Effectiveness Results for People With Diabetes in Managed Care Organizations

Roski, J., Turbyville, S., Dunn, D., Krushat, M., Scholle, S. H. — 2008-09-26

Objective: To examine how resource use varies with care quality for managed care populations with diabetes. Design and methods: Data from 31 commercial health plans (23 health maintenance organizations and 8 preferred provider organizations) were analyzed. Resource use was calculated using medical and pharmacy claims and enrollment data for members with diabetes. A standardized pricing methodology was applied for resource use associated with inpatient, pharmacy, evaluation and management, and procedural services. Quality of care results were calculated for 4 process quality indicators of the Healthcare Effectiveness Data and Information Set (HEDIS) comprehensive diabetes care measure set. Results: Resource use varied more between organizations than quality of care results. Pharmacy resource use was significantly associated with higher quality; inpatient, procedure and surgery, and ambulatory care visit resource use were not significantly associated. Conclusions: Quality and resource use for managed care populations with diabetes may vary considerably and be largely independent factors in health care delivery. Health plans may be able to favorably impact both factors. (Am J Med Qual 2008:23:365-374)

Quality of Lipid Management in Outpatient Care: A National Study Using Electronic Health Records

Gill, J. M., Yingxia Chen, — 2008-09-26

To examine lipid management in a large national outpatient network, a cross-sectional study was conducted that included 1 385 242 active patients ages 20 to 79 years of age in a national network of over 5000 providers using electronic health records (EHRs). Adequate lipid testing, achievement of lipid goals, and appropriate use of lipid-lowering medication were defined according to National Cholesterol Education Program (NCEP) guidelines. Lipid testing was adequate for 62% of high-risk, 67% of moderate-risk, and 36% of low-risk patients. Lipid goals were achieved in 65%, 66%, and 90% of these 3 risk groups; 35%, 45%, and 32% achieved adequate testing and optimal goals. Medications were appropriately prescribed for 70%, 47%, and 48%. There is significant room for improvement in lipid management, particularly among high-risk patients. National EHR networks are excellent vehicles for large outpatient quality of care studies, particularly for measuring clinical outcomes such as lipid levels. (Am J Med Qual 2008;23:375-381)

Innovation in Health Care: A Primer

Varkey, P., Horne, A., Bennet, K. E. — 2008-09-26

As organizations strive for ways to control health care spending, address the growing needs of an aging population, and respond satisfactorily to a more informed and demanding consumer base, the opportunities for innovation have increased exponentially. By means of this article, the authors describe the basic concepts of purposeful innovation, and compare and contrast it to quality improvement. The authors also provide an overview of the terminology and types of innovation, describe the innovation life cycle, and discuss diffusion and commercialization of innovations. This article provides a primer on innovation for quality improvement practitioners and physician leaders who play a key role in creating innovation and environments for innovations to flourish. (Am J Med Qual 2008;23:382-388)

The Quality of Qualitative Research

Collingridge, D. S., Gantt, E. E. — 2008-09-26

In general, an appreciation of the standards of qualitative research and the types of qualitative data analyses available to researchers have not kept pace with the growing presence of qualitative studies in medical science. To help rectify this problem, the authors clarify qualitative research reliability, validity, sampling, and generalizability. They also provide 3 major theoretical frameworks for data collection and analysis that investigators may consider adopting. These 3 approaches are ethnography, existential phenomenology, and grounded theory. For each, the basic steps of data collection and analysis involved are presented, along with real-life examples of how they can contribute to improving medical care. (Am J Med Qual 2008;23:389-395)

The Quality and Disparities Reports: Why Is Progress So Slow?

Brady, J., Ho, K., Clancy, C. M. — 2008-09-26

Literature Review

Quigley, G., Goldfarb, N. I. — 2008-09-26

Book Review: Science Business: The Promise, the Reality, and the Future of Biotech. (Boston, MA: Harvard Business School Press; 2006), by Gary Pisano

Johnson, A. — 2008-09-26

Give the Sahara Desert to a Health Care Administrator and a Few Weeks Later He Will Have to Import Sand

Braillon, A. — 2008-09-26

Author's Response

Ziegenfuss, J. T. — 2008-09-26

Author's Response

Sassani, J. W. — 2008-09-26

Predictors of Medication Errors

Schade, C. P. — 2008-09-26