Koshiol MA, Dery R, Reiland L
… +4 more, Osei SP, Fix N, Ingham DP, Asaithambi G
Am J Med Qual
· 2026 Jul · PMID 42390118
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In this retrospective study of 1217 incidental imaging findings within a large integrated health system, 97% were classified as actionable and required follow-up, and an electronic medical record-based communication work...In this retrospective study of 1217 incidental imaging findings within a large integrated health system, 97% were classified as actionable and required follow-up, and an electronic medical record-based communication workflow contributed to follow-up in 29% of cases.
Ung L, Lee MH, Raju S
… +8 more, Li LZ, Senzel L, Guido M, Gabig TG, Bobek RM, Tharakan M, Lingam V, Wong R
Am J Med Qual
· 2026 Jul · PMID 42384909
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BACKGROUND: Thrombophilia testing is frequently overused despite limited clinical utility in most acute thrombotic settings and clear guideline recommendations, contributing to unnecessary health care utilization and cos...BACKGROUND: Thrombophilia testing is frequently overused despite limited clinical utility in most acute thrombotic settings and clear guideline recommendations, contributing to unnecessary health care utilization and costs. OBJECTIVE: To improve the appropriateness of thrombophilia testing through EHR-based clinical decision support. METHODS: Five thrombophilia PowerPlans containing outdated or inappropriate testing were revised into 4 evidence-based PowerPlans using current guidelines and local expert consensus. Orders were analyzed over 30 weeks before and after intervention for PowerPlan usage, inappropriate testing, ordering by provider type, and estimated laboratory charges. RESULTS: Appropriate testing remained stable, whereas nonevidence-based testing decreased from 19.0% to 12.6% (P = 0.00001), with ordering reduction across all provider groups. Postintervention, inappropriate PowerPlans orders decreased from 41.4% to 3.1%, with laboratory charges decreasing by $117 436 for nonevidence-based testing over 30 weeks. CONCLUSIONS: Updating PowerPlans reduced inappropriate thrombophilia testing and estimated laboratory charges without reducing appropriate testing, demonstrating the value of EHR-based interventions in promoting high-value care.
Ostreicher MR, Landers J, McCann Pineo M
… +6 more, Haddad G, Garver-Mosher T, Li T, Becker L, Rolston DM, Jafari D
Am J Med Qual
· 2026 Jul · PMID 42384905
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Audio and video recording of cardiac arrest (CA) is a valuable quality improvement, education, and research tool, but the interrater reliability (IRR) of data collection is not well studied. We aimed to evaluate the IRR...Audio and video recording of cardiac arrest (CA) is a valuable quality improvement, education, and research tool, but the interrater reliability (IRR) of data collection is not well studied. We aimed to evaluate the IRR of data abstracted from our review of video recordings of Emergency Department (ED) CAs. In this retrospective study, 2 blinded, expert physicians reviewed 21 randomly selected CA videos from a single academic ED. Predefined categorical (eg, initial rhythm) and noncategorical (eg, time to defibrillation, duration of compression interruptions) variables were abstracted. IRR was evaluated using Cohen's kappa for categorical variables and interclass correlation coefficient (ICC) with a 2-way mixed-effects model for noncategorical variables, including nested analysis for repeated events. IRR was excellent for noncategorical and time-to-event variables, such as time to defibrillator pad attachment (ICC = 0.99), first rhythm analysis (ICC = 0.94), first shock (ICC = 1.00), number of interruptions (ICC = 0.93), and time of death (ICC = 1.00). In contrast, categorical variables demonstrated moderate reliability for emergency medical services reported rhythm (κ = 0.61), initial ED rhythm (κ = 0.69), and endotracheal tube presence on arrival (κ = 0.70); though agreement was perfect for variables like mechanical compression or vascular access presence on arrival. The mixed linear model showed good IRR for durations of chest compression interruptions (ICC = 0.85), return of spontaneous circulation (ICC = 0.79), and number of intubation attempts (ICC = 0.96). CA video review demonstrates excellent IRR for collecting noncategorical, time-based data, but only moderate IRR for categorical variables.
Nkouli K, Tally E, Lutz J
… +7 more, Dao N, Rusco R, Marshall K, Seiger W, Case L, Morrey M, Jea A
Am J Med Qual
· 2026 Jul-Aug 01 · PMID 42358178
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BACKGROUND: In early 2025, OU Health identified an increase in contaminated surgical instrument sets reaching the operating room (OR). Contaminants, including bioburden, hair, holes in wrapping, debris, and wet sets, pos...BACKGROUND: In early 2025, OU Health identified an increase in contaminated surgical instrument sets reaching the operating room (OR). Contaminants, including bioburden, hair, holes in wrapping, debris, and wet sets, posed risks to patient safety, workflow efficiency, and OR productivity, suggesting systemic deficiencies across the sterile processing department (SPD) and perioperative workflow. METHODS: We convened a multidisciplinary quality-improvement team comprising administrators, surgeons, nurses, scrub technicians, SPD technicians, and quality specialists. Using the 8-Step methodology, we conducted root cause analysis, process mapping, and longitudinal data tracking. Interventions included standardized point-of-use cleaning, enhanced SPD personal protective equipment and gowning practices, washer maintenance, adoption of heavier wrapping materials, containerization of high-risk sets, limiting tray weight, removal of static-attracting materials, and targeted staff education. RESULTS: From July 1, 2025, through January 31, 2026, 388 contamination events were recorded across service lines. Neurosurgery accounted for 36% (136 events) of all events. Common contamination types were holes (113 events), debris (98), bioburden (51), and filter defects (28); hair (20), wet sets (15), and improper disassembly (15) were less common but clinically significant. Temporal analysis demonstrated intermittent short-term improvements but persistent recurrence across contamination types. Contaminated sets contributed to 57% of all documented OR delays, totaling 2851 minutes. Estimated direct costs were $176 762; projected annual costs were $589 042. CONCLUSIONS: Contaminated surgical instrument sets represented a recurrent systems-level failure. Institution-wide efforts, including multidisciplinary collaboration, structured quality-improvement methodology, and targeted interventions, produced measurable improvements. Continued monitoring, workforce competency reinforcement, and system redesign are needed to mitigate future risk.
Vattikonda A, Ibrahim M, Scott D
… +5 more, Gansert E, Phillipps J, Chase RC, Madaffari C, Valery JR
Am J Med Qual
· 2026 Jul-Aug 01 · PMID 42358177
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INTRODUCTION: Advance care planning (ACP) supports goal-concordant care but remains underused nationally. In resident clinics, limited continuity, short visits, and lack of standardized workflows create barriers to ACP i...INTRODUCTION: Advance care planning (ACP) supports goal-concordant care but remains underused nationally. In resident clinics, limited continuity, short visits, and lack of standardized workflows create barriers to ACP integration. In our Community Internal Medicine resident clinic, ACP discussion was documented in 2.5% of annual physicals, and 19.6% of paneled patients had an advance directive (AD) on file. We aimed to increase ACP documentation from 2.5% to 12.5% within 1 year without increasing perceived resident workflow burden. METHODS: We conducted a resident-led quality improvement project using Lean Six Sigma methodology. Three interventions were implemented sequentially: nursing distribution of ACP brochures, an electronic medical record DotPhrase to prompt and document ACP discussions, and targeted patient portal outreach to patients without an AD before annual visits. The primary outcome was documented ACP discussion during annual physicals. Secondary outcomes included AD uploads and ACP consult referrals. The balancing measure was resident-perceived workflow burden. Charts were reviewed over 5-week periods at baseline (n = 118) and after each implementation phase (n = 132, 158, 129). RESULTS: ACP documentation increased from 2.5% at baseline to 12.2%, 17.1%, and 24.0% across sequential phases (χ2(3) = 24.74, P < 0.0001). Pairwise comparisons versus baseline were significant (all P ≤ 0.005). AD upload rate increased from 1.7 to 6.0 per month, and ACP consult referrals increased from 0.0% to 10.9%. Mean perceived workflow burden decreased from 4.9 to 3.0. CONCLUSION: Workflow-embedded interventions improved ACP documentation, AD uploads, and ACP referrals without increasing perceived resident burden.
Dykes A, Hall M, Tooley E
… +4 more, Burrus S, Johnson K, Harding A, Godambe SA
Am J Med Qual
· 2026 Jul-Aug 01 · PMID 42253142
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Preventable harm in pediatric care requires coordinated, cross-institutional learning. The Child Health Patient Safety Organization established weekly safety huddles to enhance situational awareness and strengthen a prot...Preventable harm in pediatric care requires coordinated, cross-institutional learning. The Child Health Patient Safety Organization established weekly safety huddles to enhance situational awareness and strengthen a protected learning network under the Patient Safety and Quality Improvement Act. This iterative time-series quality improvement study examined weekly huddle content, assessed targeted interventions to increase participation, and evaluated engagement trends over time. The primary outcome was composite engagement, defined as ≥80% annual attendance and ≥5 submitted reports. Secondary measures included attendance, quarterly reporting, and categorization of reported safety events. Frequently reported events involved medication issues, diagnostic errors, and device malfunctions. Targeted interventions increased composite engagement from 21% to 71.4%, alongside improvements in weekly attendance and quarterly reporting. Organizations also reported using huddle insights to guide internal risk assessments and escalate concerns. Child Health Patient Safety Organization safety huddles improved participation, supported shared learning, and strengthened safety culture consistent with learning-organization and high-reliability principles.
Uzun B, Duran H, Kula Atik T
… +2 more, Ozdamar M, Ayhan FY
Am J Med Qual
· 2026 May · PMID 42136378
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BACKGROUND: This study aims to select 9 of the quality indicators recommended by International Society for Blood Transfusion in five different transfusion centers and analyze the results. METHODS: Nine new indicators wer...BACKGROUND: This study aims to select 9 of the quality indicators recommended by International Society for Blood Transfusion in five different transfusion centers and analyze the results. METHODS: Nine new indicators were retrospectively examined monthly in 2024 in 5 centers, including 2 educational and research centers, 1 city, 1 university, and 1 private hospital. RESULTS: The rate of meeting blood requests varies between institutions and is in the wide range of 30.9%-99.0%. Expired erythrocyte suspension rates are similar and roughly <1% both among institutions and in the monthly analysis of the institutions themselves, while expired platelet suspension rates vary and are in the wide range of 0.7%-33.3%. Monthly analysis of institutions' disposal rates is lower and acceptable, but their expired platelet suspension rates are much higher. The rates of returned blood components and damaged blood components were roughly similar across all 5 institutions and were mostly <1%. To evaluate the errors in the preanalytical process of transfusion centers, the rate of improper pre-transfusion test requests was evaluated, it varied between institutions and was found to be <5%. The rate of erythrocyte suspension given without testing in an emergency was found to be <2%. Serious adverse reactions occurred only in Tekirdağ City Hospital during the 1-year period and the rate was found to be 0.08%. CONCLUSION: It was concluded that the indicators of transfusion centers in our country should be updated, and their number should be increased to cover the entire process.
Am J Med Qual
· 2026 Jul-Aug 01 · PMID 42130349
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BACKGROUND: This quality improvement study aimed to enhance patient experience (PX) scores related to doctor communication (DC) on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Rec...BACKGROUND: This quality improvement study aimed to enhance patient experience (PX) scores related to doctor communication (DC) on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Recognizing that effective physician-patient communication is central to patient satisfaction, our institution sought to implement a structured, multidisciplinary approach to improving DC performance. METHODS: We implemented 7 coordinated interventions: (1) a weekly PX meeting with leadership oversight; (2) a standardized, system-wide approach to didactic PX content; (3) weekly one-on-one provider coaching; (4) quarterly hospital-wide educational sessions; (5) trainee-specific PX didactics; (6) detailed provider feedback based on patient comments; and (7) a formalized postdischarge telephone follow-up process. Data were extracted from 4859 completed HCAHPS surveys collected before and after intervention implementation. Mean percentile rankings and standard deviations for DC questions were calculated, and differences were evaluated for statistical significance. RESULTS: The average DC percentile ranking improved from 26 ± 5 to 49 ± 13 for all DC questions combined ( P < 0.05). Question-specific improvements were observed from 36 ± 8 to 57 ± 15, 30 ± 3 to 50 ± 13, and 17 ± 5 to 35 ± 11 for DC questions 1-3, respectively (all P < 0.05). CONCLUSIONS: A structured, multidisciplinary approach incorporating education, coaching, and feedback was associated with significant improvements in physician communication HCAHPS scores. This framework may be generalizable to other hospital settings seeking to improve patient experience.
Am J Med Qual
· 2026 May · PMID 42130346
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Intensive care unit-to-ward transitions are high-risk processes in which unstandardized communication can contribute to adverse events. Structured handoff tools such as ICU-PAUSE can improve these transitions. Thus, the...Intensive care unit-to-ward transitions are high-risk processes in which unstandardized communication can contribute to adverse events. Structured handoff tools such as ICU-PAUSE can improve these transitions. Thus, the authors introduced the standardized ICU-PAUSE framework and reassigned authorship from the receiving ward team to the sending ICU team and evaluated the impact of these interventions. A survey-based pre-post, staged quality improvement study of the ICU-to-ward transfer process at a single academic medical center was conducted. Internal Medicine housestaff were surveyed before and after the introduction of the tool to assess their satisfaction with the changes and their understanding of the patient's ICU course. The intervention was supplemented by 2 targeted educational sessions based on housestaff feedback. The first session was followed by a posteducation survey assessing similar domains as prior surveys but also focusing on perceptions of authorship and education. There was no difference in mean provider satisfaction scores pre- vs postintervention (6.0 vs 5.9, P = 0.75). Understanding of the ICU course was similar between pre- and postintervention surveys, although most respondents perceived ICU-PAUSE and targeted education to improve care transitions. After education, 67.9% of attendees reported an improved level of comfort writing ICU-PAUSE notes, and 61.2% believed ICU-PAUSE improved transitions of care. Most respondents (81.6%) believed the sending ICU team was best equipped to write the transfer notes. Standardizing the ICU downgrade note and changing authorship had no impact on provider satisfaction. However, providers felt authorship was best assigned to the ICU team.
Zhang JJ, Le B, Dowling E
… +4 more, Brown R, Villarama A, Ramirez S, Simon W
Am J Med Qual
· 2026 Jul-Aug 01 · PMID 42130330
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Post-hospital discharge primary care follow-up may reduce readmissions. Missed appointments without cancellation, "no-show" visits, may cause missed patient care and system inefficiencies. There is limited research on pa...Post-hospital discharge primary care follow-up may reduce readmissions. Missed appointments without cancellation, "no-show" visits, may cause missed patient care and system inefficiencies. There is limited research on patient perspectives of barriers to successful completion of post-discharge primary care follow-up visits. In a quality improvement process over 6 weeks, care coordinators called adult patients (N = 36) who had a missed post-discharge primary care follow-up visit with a primary care physician in an academic health system. Of 22 (61%) patients reached, categories of patient-reported barriers were: (1) missed communication opportunities (n = 15) (eg, patient did not know visit was scheduled, did not feel the need to see primary care physician, or forgot); (2) access difficulties (n = 7); and (3) family or work-related issues (n = 2). Most patients completed the rescheduled visit. Continued quality improvement efforts to improve post-discharge primary care follow-up should consider reframing "no-show" visits to address communication and access barriers at the health system level.