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Journal Article > Commentary
Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.
Leape LL, Rogers G, Hanna D, et al. Qual Saf Health Care. 2006;15:289-295.
This study reports on the experiences of a Massachusetts statewide collaborative to improve patient safety. The chosen interventions were medication reconciliation and prompt communication of critical test results, which were selected by an advisory committee of stakeholders advised by national opinion leaders. Each participating hospital sent a multidisciplinary team to four collaborative meetings, at which participants learned Plan-Do-Study-Act (PDSA) methodology and implementation strategies and later returned to share experiences and data. The project successfully enrolled 88% of acute care hospitals in the state, but only 50% of hospitals successfully implemented medication reconciliation, and 65% implemented communication of critical test results. Major barriers to implementation included lack of dedicated staff time and lack of support from hospital management. The investigators also identified problems with the collaborative process itself, chiefly, failure to define clear expectations and failure to emphasize measuring data to monitor efficacy.
Journal Article > Study
Kliger J, Singer S, Hoffman F, O'Neil E. Jt Comm J Qual Patient Saf. 2012;38:51-60.
While quality improvement projects can result in short-term, local success, ensuring the sustainability and spread of successful interventions can be extremely challenging. This follow-up study describes methods used to disseminate a successful project to reduce medication administration errors beyond the original pilot hospitals. The article details how stratiegies for communication, local adaptation, teamwork, and learning from failure were essential to implementing the intervention across a broad range of hospitals. This approach achieved sustained improvement in medication administration error rates in both the initial and subsequent groups of hospitals.
Journal Article > Study
Pronovost PJ, Demski R, Callender T, et al. Jt Comm J Qual Patient Saf. 2013;39:531-544.
In 2010, The Joint Commission created accountability measures, evidence-based practices that produce positive impacts on patient outcomes. Each year, The Joint Commission recognizes Top Performers that provide more than 95% of their patients with recommended therapies for at least 3 accountability metrics. This article details Johns Hopkins Hospital's efforts to exceed the Top Performer award thresholds on multiple core measures. To realize this goal, the group developed a conceptual model that addresses the challenges accompanying quality and safety interventions. They also employed the Lean framework of define-measure-analyze-improve-control to help teams systematically create improvement plans. In addition, a monthly performance dashboard provided transparency and accountability. These efforts led to Johns Hopkins Hospital achieving a compliance goal of 96% or higher on 95% of the core measures in 2012. A previous AHRQ WebM&M interview with Dr. Peter Pronovost, the lead author of this paper, discussed the science of improving patient safety.