Supporting and improving clinician well-being has long been a safety focus and received renewed focus during the COVID-19 pandemic. This study sought to understand efforts undertaken to support clinicians’ well-being in Joint Commission-accredited hospitals and Federally Qualified Health Centers (FQHC). Only half of responding hospitals and FQHCs reported implementing at least one action towards improving clinician well-being (e.g., establishing a wellness committee) and few had implemented a comprehensive approach.

Testing process improvements prior to implementation can help identify and address potential unintended consequences on practice. This commentary explores how a quality improvement initiative seeking to reduce the opportunity for mistakes may have resulted in treatment delays.

The Joint Commission identifies inpatient suicide as a sentinel event. Little is known about the epidemiology of hospital suicides other than that they are rare and occur mostly in psychiatry wards. Researchers examined two national databases to develop the first data-driven appraisal of hospital suicide rates. Nationally, between 49 and 65 hospital suicides occur each year. Nearly 75% happen during psychiatric treatment, and the most common means of death is hanging. This hospital suicide rate is an order of magnitude lower than prior estimates. An accompanying editorial raises concerns about the much larger epidemic of suicide immediately after psychiatric hospital discharge. A prior WebM&M commentary highlighted additional strategies to reduce hospital suicide risk.

Following implementation of the web-based Targeted Solutions Tool in a 12-hospital health system, hand hygiene rates improved from a baseline rate of 58% to about 95%. Over the same period, rates of central line–associated bloodstream infections and ventilator-associated pneumonia both declined by more than 40%.

Professionalism in medicine is considered an essential component of safety culture, but efforts to monitor and address disruptive behaviors among physicians have not produced the desired outcomes. This commentary discusses the need for more explicit emphasis on building physician skills and attitudes to support zero harm, process improvement, high reliability, and commitment to excellence in all areas of medical care.

Although appropriate handwashing has been identified as an essential factor in preventing health care–associated infections, hand hygiene rates remain unacceptably low at many hospitals. This quality improvement project aimed to achieve adherence to hand hygiene practices at eight hospitals using change management methods drawn from human factors engineering. Each hospital investigated and identified specific causes of noncompliance with handwashing and developed specific interventions to address these barriers. These individualized efforts yielded a significant improvement in handwashing behavior. The authors argue that allowing each site to tailor the intervention to the specific causes of noncompliance led to the sustained improvements. This study suggests that local improvement may be a fruitful method to enhance the proven but incompletely implemented practice of hand hygiene. A recent AHRQ WebM&M interview and perspective discuss ways to enhance hand hygiene adherence.

… frustrating. This commentary, by patient safety expert Dr. Mark Chassin, recommends that health care shift its focus from … safety movement. A prior AHRQ WebM&M interview with Dr. Chassin discussed the role of the Joint Commission in …

… toward high reliability. The article's lead author, Dr. Mark Chassin, was interviewed for AHRQ WebM&M in 2009. …

Limited health literacy has been linked to poor comprehension of written instructions. This study found that spoken instructions were also frequently misunderstood by patients with poor health literacy.

Accreditation by The Joint Commission was associated with stronger performance on disease-specific measures of hospital quality of care. Accredited hospitals also appeared to achieve greater improvements in care over time compared to non-accredited hospitals.

Reviewing progress in quality improvement, this commentary offers a framework to guide health care organizations toward high reliability.

This study describes the development and validation of the TeamSTEPPS Teamwork Attitudes Questionnaire, a survey instrument designed to measure attitudes toward teamwork in health care delivery. The TeamSTEPPS teamwork training program was developed as a collaboration between the Agency for Healthcare Research and Quality and the Department of Defense.

… adverse consequences . Under the leadership of Dr. Mark Chassin, The Joint Commission has taken an increasingly …

This AHRQ-funded study found that physicians usually chose appropriate reasons for excluding patients from inclusion in quality measurement programs.

Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.

Introduction of an electronic discharge summary was associated with more timely communication with outpatient physicians and improved communication of potential patient safety problems, such as test results that were pending at the time of discharge.

This prospective cohort study found increased mortality among elderly persons with poor health literacy, even after adjusting for confounding factors. Poor health literacy has previously been linked to inability to understand prescription drug labels.

Patients discharged from the hospital experience an unacceptably high rate of medical errors. Prior research suggests that suboptimal communication between hospital physicians and outpatient physicians could contribute to these problems. This study systematically reviewed the literature to determine the frequency of communication problems between physicians at hospital discharge and to identify interventions that ameliorated this problem. The investigators found that direct communication occurred rarely, and the primary means of communication (the dictated discharge summary) generally was not available in a timely fashion and often contained inadequate information for proper follow-up care. Based on this review, the authors provide suggestions for standardizing information transfer at discharge and improving the timeliness of communication.

This article describes the development of the US Department of Defense's team training program for military health facilities, entitled TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). The program was based on two prior military crew resource management (CRM) programs and prior evidence in the field and was adapted to address issues encountered in military facilities, including the rapid turnover of personnel and the need to adapt to the cultures of specific military services. The program consists of teaching core skills in leadership, situation monitoring, team support, and communication through an interactive curriculum stressing application to everyday scenarios. The article extensively reviews the challenges of implementing the program and future plans for disseminating and evaluating the training.