Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005–12. The most common contributing factors noted in the reports included coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of short-term follow-up. Other contributing factors were team-level decision making problems resulting from miscommunication of urgency between providers and providers' lack of awareness of or knowledge about a patient's situation; and communication failures among providers, patients, and other health care team members. Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination.
Implementing a non-monetary recognition award that was tied to specific improvement goals greatly improved the timeliness and quality of the RCA reports in the Veterans Health Administration System.
OBJECTIVE
The impact of healthcare system integration on infection prevention programs is unknown. Using catheter-associated urinary tract infection (CAUTI) prevention as an example, we hypothesize that U.S. Department of Veterans Affairs (VA) nursing homes have a more robust infection prevention infrastructure due to integration and centralization compared with non-VA nursing homes.
SETTING
VA and non-VA nursing homes participating in the “AHRQ Safety Program for Long-term Care” collaborative.
METHODS
Nursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to CAUTI prevention.
RESULTS
A total of 353 (71%; 47 VA, 306 non-VA) of 494 nursing homes from 41 states responded. VA nursing homes reported more hours/week devoted to infection prevention-related activities (31 vs. 12 hours, P<.001), and were more likely to have committees that reviewed healthcare-associated infections. Compared with non-VA facilities, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs. 66%, P<.001), sharing CAUTI data with leadership (94% vs. 70%, P=.014) and nursing personnel (85% vs. 56%, P=.003). However, fewer VA nursing homes reported having policies for appropriate catheter use (64% vs. 81%, P=.004) and catheter insertion (83% vs. 94%, P=.004).
CONCLUSIONS
Among nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems.
The Veterans Health Administration implemented a Virtual Breakthrough Series to prevent pressure ulcers. The pressure ulcer rate decreased from 1.2 to 0.9 per 1000 bed days of care (P = .017). The most common interventions were education (N = 26; 68%), improved documentation (N = 23; 61%), and the use of equipment and supplies (N = 21; 55%). In summary, this project helped improve pressure ulcer rates in the Veterans Health Administration and presents a promising model for implementing a virtual model for improvement.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.