Top 2018 articles on quality improvement

  • Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study – in print, March 2018 issue.

In this ambitious work, Curry et al. describe the effects on both culture and clinical outcomes of a 2-year organizational culture-improvement intervention at ten hospitals with at least 200 acute myocardial infarction (AMI) discharges per year. Each selected hospital had average or below-average national performance for 30-day risk-stratified mortality rates (RSMRs). The six hospitals that saw substantial positive changes across 5 aspects of organisational culture also exhibited increased uptake of evidence-based medical strategies and a decrease in RSMR of 1.07, whereas the four hospitals without a significant change in culture showed no significant improvement. The finding of an association between improvement in culture and improvement in patient outcomes in response to a specific intervention will be of great interest to hospital leaders.

Wong et al. report an evaluation of computerized decision support over-rides in the ICUs of a single institution immediately following transition from a home-grown legacy EHR to a commercial product. This transition was associated with a 5x increase in overall medication-related clinical decision support (CDS) alerts. Aiming to determine the appropriateness of the overrides and whether adverse drug events were increased after an override, the authors studied 2448 provider-overridden medication-related clinical decision support across six ICUs in the 10 months after roll-out. In chart review, 81.6% of the overrides were deemed appropriate, with high agreement among reviewers (Κ=0.89). Adverse drug events were rare, but, importantly, inappropriate overrides were 6x more likely to be associated with an adverse event. The authors’ recommendations on how to optimize the positive predictive value of CDS to reduce the burden of unnecessary alerts are consistent with the idea that more reliable alerts might decrease inappropriate overrides.

Building on a prior pilot study, Hirshberg et al. utilised mobile technology to improve rates of obtaining guideline-recommended postpartum blood pressure measurements in 206 patients with hypertensive disease of pregnancy. Patients in the intervention group received a home blood pressure cuff and twice daily text-message reminders to check their blood pressure. Patients responded to the text with their home readings, which were routed to a clinician for review if elevated. Overall, the rate of obtaining blood pressure measurements was significantly increased in patients randomised to a text messaging arm relative to a usual care in-office measurement arm (92.2% vs. 43.7%, p<0.001), and 84% of women in the messaging arm met ACOG criteria for multiple blood pressure measurements in the first 10 days postpartum. This study suggests that a low-cost platform may be able to improve patient engagement and outcomes and reduce the inconvenience of patients having to make in-person visits. It may well be scalable to other clinic types and institutions.

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