Inspiring studies related to two common sources of adverse events in healthcare – handoff communication failures, and bias and inequities in care – are featured in the August 2024 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS).
- A research team at The University of Texas MD Anderson Cancer Center, Houston, implemented an organization-wide initiative to improve handoffs and implement an evidence-based handoff tool across all inpatient services. The I-PASS tool, designed to standardize handoff documentation, was built into the electronic health record. I-PASS stands for illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver. Handoff adherence increased from 41.6% in 2019 to 70.5% in 2022, and safety culture scores on handoff favorability rose from 38% in 2018 to 59% in 2022.
- The Patient Equity Wheel, an equity tool and visual aid, was introduced during a two-hour interactive, case-based training across 11 acute care facilities at NYC Health + Hospitals, New York. The Patient Equity Wheel compiles a list of equity categories, including internal, external, and organizational dimensions of equity. A pre- and post-survey assessed knowledge and comfort embedding equity in patient safety event analysis, and measured discomfort or distress during the training. Findings revealed an increase in participant knowledge and level of comfort after training. Post-training feedback noted that tools were being used across the system in various stages of event analysis and improved health equity conversations.
Also featured in the August issue are:
- An Interview with Eduardo Salas, PhD, individual recipient of 2023 John M. Eisenberg Patient Safety and Quality Award
- Screening and Intervention to Prevent Violence Against Health Professionals from Hospitalized Patients: A Pilot Study (Tufts Medical Center, Boston)
- Evaluating Real-World Implementation of INFORM (Improving Nursing Home Care through Feedback on Performance Data): An Improvement Initiative in Canadian Nursing Homes (cohort of 26 nursing homes in British Columbia, Canada)
- Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative, a Cost-Effectiveness Analysis (The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan)
- Standardizing the Dosage and Timing of Dexamethasone for Postoperative Nausea and Vomiting Prophylaxis at a Safety-Net Hospital System (Case Western Reserve University—MetroHealth System, Cleveland)
- Racial/Ethnic Disparities in Peripartum Pain Assessment and Management (Cedars-Sinai Medical Center, Los Angeles)
Fifty three Michigan hospitals have taken action to improve the quality and safety of maternal health services by pursuing The Joint Commission’s Maternal Levels of Care (MLC) verification, announced the Michigan Department of Health and Human Services (MDHHS) on Aug. 22. Michigan has had more hospitals apply for verification than any other state, demonstrating the commitment to high-quality maternal health care.
“The Joint Commission commends the state of Michigan, the Michigan Health & Hospital Association, and Michigan hospitals for their commitment to excellence in maternal and neonatal care,” said Dr. Jonathan B. Perlin, president and CEO of The Joint Commission and Joint Commission International. “We look forward to working closely with Michigan hospitals to provide support and validation of their maternal capabilities and policies for formal level of maternal care determination.”
MLC verification is a comprehensive verification process, developed in collaboration with the American College of Obstetricians and Gynecologists (ACOG), to ensure hospitals meet rigorous standards for the care of pregnant and postpartum patients. This includes readiness, capability and effectiveness in identifying and managing complex maternal conditions, which may include transferring patients to a more appropriate care level as needed.
In April 2024, MDHHS announced it would begin providing quality payments to birthing hospitals fully participating in the Michigan Alliance for Innovation on Maternal Health (MI AIM) and for applying for MLC verification. Payments are based on the number of Medicaid-covered births and each hospital’s maternal morbidity rate. These payments support the continuation of maternal quality initiatives in hospitals and their associated implementation costs. The quality payments are funded by $9 million in Michigan’s state budget dedicated to investing in maternal health improvement efforts.