Decade of Patient Experience Improvement at a Tertiary Care Urban Hospital

BACKGROUND AND OBJECTIVE

The purpose of this quality management study was to demonstrate how one hospital made a journey from average patient experience to become a regional leader in the experience of patient care for nationally recognized quality and safety metrics.

METHODS

Saint Francis Hospital & Medical Center (SFHMC) located in Hartford, Connecticut, serves a diverse sociodemographic community as part of Trinity Health. "Recommend the Hospital" (RTH) has been the main marker of patient experience at SFHMC and Trinity Health across the United States as part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). From 2010 to 2019, SFHMC implemented unit-based rounding hospital-wide, adopting charge nurse and executive leadership rounding as standard work. The intense support from senior leadership spurred the implementation of these changes across middle management and all frontline workers. The t test was used to determine differences between the mean RTH scores between SFHMC, Connecticut, and the United States.

RESULTS

Patient experience at SFHMC was regularly assessed by Press Ganey surveys and HCAHPS, which demonstrated higher scores than averages for the state of Connecticut and the United States between 2010 and 2019 (both Ps < .001). SFHMC was the top performer with an RTH score of 83%, with the state average being 71% and the national average being 72%. In the years following the implementation of a multipronged low-cost strategy, hospital RTH scores rose linearly from the state and national average. SFHMC observed gains in patient safety and quality scores as measured by national benchmarks, including Leapfrog patient safety scores of 7 A's and 1 B over a 4-year period. SFHMC was the only hospital in Connecticut to receive an A grade 4 years in a row.

CONCLUSION

A combination of nurse-led, unit-based rounding and executive team rounding with a consistent focus on patient experience resulted in significant improvement in RTH scores for a busy teaching urban hospital, with only a modest investment of resources. There was also improvement in quality and safety outcomes, which together with patient experience of care drove fiscal stability in an increasingly value-based health care environment.

Impact of a hospital unit-based leadership triad on key performance metrics

We piloted a triad leadership model consisting of a unit-based hospitalist medical director, nurse manager, and case manager on five medical inpatient units. The purpose of this explanatory case study was to determine what, if any, impact the triad team would have on commonly measured operational and quality metrics: observed to expected length of stay, likelihood to recommend the hospital, hand-washing compliance, all-cause 30-day readmission rates, percent of discharges by noon, and percent of discharge to skilled nursing facilities. Over the course of a year triad units demonstrated improvement in most metrics in comparison to the baseline period. While trends for the metrics were favorable, most striking was a statistically significant improvement in the observed to expected length of stay ratio (1.25 to 1.15, p < 0.001) which is the organization's most widely used marker for efficient hospital patient flow.As a result of these sustained operational, safety, quality, and financial performance metrics the model is being generalized to other medical as well as surgical units, including our observation unit. Intangible benefits include creating leadership development path for hospitalist, nursing, and case management colleagues.

Cotinine levels and green tobacco sickness among shade-tobacco workers

STUDY OBJECTIVE

Symptoms consistent with Green Tobacco Sickness (GTS) were found in 4% (13/331) to 15% (45/303) of the migrant, mostly Latino, shade-tobacco workers who sought medical care at a Connecticut clinic. The objective of this study was to determine whether or not shade-tobacco farm workers absorb nicotine from the tobacco leaves and have a corresponding increase in both salivary cotinine levels (a breakdown product of nicotine) and symptoms consistent with GTS.

METHODS

The study utilized a prospective cohort design to evaluate salivary cotinine and symptoms consistent with GTS in a population of shade tobacco farm workers compared to a control group of nursery workers. The workers were assessed at two points in time, the early tobacco planting season and the harvest season.

RESULTS

There was not a significant increase in salivary cotinine levels among shade-tobacco workers. Salivary cotinine levels over the work season did not significantly increase in shade-tobacco workers when compared with nursery workers. During the harvest season, none of the tobacco workers reported symptoms consistent with GTS.

CONCLUSIONS

Migrant workers in Connecticut who harvest shade-tobacco appear to have a low-risk of occupational nicotine dermal absorption and a low incidence of GTS. The work practices associated with harvesting shade-tobacco, in addition to the fact that shade tobacco may actually have a lower level of nicotine than either burley or flue cured tobacco, may explain these results. Our study appears to reinforce the GTS prevention recommendations made by investigators in other tobacco growing regions, specifically the importance of minimizing close skin contact with tobacco leaves and avoiding dermal contact with the plants when they are wet.

Improving patient care outcomes by teaching quality improvement to medical students in community-based practices

PURPOSE

As part of the Undergraduate Medical Education for the 21st Century (UME-21) project, the University of Connecticut School of Medicine developed and implemented a quality improvement curriculum. This study examined its impact on educational outcomes and the effect of the students' continuous quality improvement (CQI) projects on the quality of care delivered at community practice sites.

METHOD

Seventy-seven second-year students working in groups of two to four conducted CQI projects on diabetes mellitus at 24 community-based primary care practices. They collected baseline data, implemented a results-specific intervention, and re-assessed quality indicators six months later. Students' knowledge, attitudes, and beliefs were evaluated using Likert-scale rated items as well as open-ended questions.

RESULTS

A total of 513 charts were abstracted for the baseline sample, with 380 charts abstracted post-intervention. Attitudinal data revealed students acknowledged the benefit of outcomes measurement in clinical practice despite their frustration with the tedium of the chart-abstraction process. The rate of documentation of performances of foot and eye exams increased significantly from baseline to remeasurement (51.3% to 70.2%; p <.001 and 26.9% to 37.8%; p <.001, respectively). The mean value for glycohemoglobin dropped from 7.71% at baseline to 7.22% at remeasurement (p <.001).

CONCLUSIONS

Medical student-driven CQI projects can improve the quality of care for diabetes at practices in which the students participate while introducing them and their preceptors to the process of quality measurement and improvement. Formative input from students should be used to optimize CQI experiences. Using medical students to lead CQI efforts in private practices may represent an underutilized resource to improve the care of patients in community-based practices.

How do Australian doctors with different pre-medical school backgrounds perform as interns?

AIM

To assess whether there is any advantage to be gained with respect to performance in the first year of postgraduate medical training (internship) by selecting medical school candidates with different educational backgrounds. Specifically, we were interested in comparing the performance ratings of interns who entered medical school with secondary (directly from high school) or tertiary (at least one year of a university degree) level educational backgrounds.

FOCUS

We compared the performance ratings of interns according to the subjects or degree undertaken at a secondary or tertiary level, respectively. The effects of age and gender were also examined to determine their influence on performance ratings.

METHOD

All graduates (N=235) from the University of Newcastle Medical School, Australia who commenced their intern year in the state of New South Wales from 1993 to 1996 inclusive were eligible for the study. The outcome measure was a score derived from a valid and reliable clinical supervisor rating scale. Independent variables were level of previous educational experience (secondary or tertiary entry), and subjects studied by secondary level entrants (predominantly science or equal proportions of humanities and science) and degree undertaken by tertiary level entrants (arts or science or allied health or nursing).

RESULTS

The records of 173 (73% of eligible sample) were included in the analyses. There were no significant differences between the mean ratings of interns with respect to previous educational background, subjects studied at secondary school or degree undertaken. Age and gender did not significantly affect performance ratings.

Severe skin rash in two consecutive patients treated with 2-chlorodeoxyadenosine for hairy cell leukaemia at a single institution

Although hairy cell leukaemia was first described 40 years ago, it is only in the last decade that newer therapeutic agents have enabled effective treatment. The purine nucleoside analogue, 2-chlorodeoxyadenosine (2-CdA) is currently considered as first-line therapy with a very high rate of complete remission. Although adverse events with 2-CdA are increasingly recognized, severe cutaneous reactions have been reported rarely. We describe two consecutive patients treated with 2-CdA for hairy cell leukaemia who both suffered extremely severe cutaneous reactions, one of which was life-threatening.

Effect on cell kill of addition of multidrug resistance modifiers cyclosporin A and PSC 833 to cytotoxic agents in chronic lymphocytic leukaemia

Expression of P-glycoprotein (Pgp), the drug efflux pump which mediates multidrug resistance (MDR), has been widely reported in chronic lymphocytic leukaemia (CLL) and improved accumulation of daunorubicin has been reported using the MDR reversing agent cyclosporin A (CSA). We have investigated the effects on cell kill of the addition of CSA and its analogue PSC 833 to daunorubicin, doxorubicin, idarubicin, mitozantrone and fludarabine in samples from 51 patients with CLL using an MTT [3(4,5-dimethylthaizol-2-yl)-2,5-diphenyltetrazolium bromide] assay. Pgp expression was assessed by immunocytochemistry using the JSB-1 monoclonal antibody. Of the 51 samples, 10 (20%) were Pgp positive and all of these samples were from treated patients. With the exception of mitozantrone, the addition of CSA and PSC 833 to cytotoxic agents failed to significantly improve cytotoxicity, even in the Pgp positive group. With mitozantrone significant responses were seen in both Pgp positive and negative groups suggesting that the responses were due to direct cytotoxicity of the cytotoxic-modifier combination rather than reversal of MDR. Both CSA and PSC 833 showed significant direct cytotoxicity (P = 0.004 and 0.04 for PSC 833 at 1000 ng/ml and 500 ng/ml respectively; P < 0.001 for both concentrations of CSA). The responses were disappointing compared to the highly significant improvements in cytotoxicity seen using cells from the Pgp positive CEM VLB 100 acute myeloid leukaemia cell line, and it was not possible to demonstrate the superiority of PSC 833 over CSA which is also seen in cell lines. Our data do not support a role for Pgp modifiers in CLL. Further studies using larger numbers of Pgp positive CLL cells and higher doses of PSC 833 would be useful.

Delayed diagnosis and unnecessary percutaneous biopsies in cases of myeloma presenting as chest wall tumours

We report on five cases of myeloma presenting at a single institution over an 8-year period between 1988 and 1996. All presented with bony pain and a chest wall mass arising from a rib on chest X-ray. Myeloma was not confirmed until 22, 25 and 50 days after admission in three of the cases who each suffered a potentially hazardous percutaneous chest wall biopsy which was undiagnostic. A fourth case did not suffer diagnostic delay as his biopsy showed sheets of plasma cells although, as in all five cases, evidence of myeloma was clearly present on serum/urine electrophoresis, skeletal survey and marrow aspirate, making chest wall biopsy unnecessary. The only case who suffered no diagnostic delay and no percutaneous chest wall biopsy was the only case to have a comprehensive chest X-ray report listing myeloma as a differential diagnosis and suggesting a haematology referral.

Persistence of RAR alpha-PML fusion mRNA detected by reverse transcriptase polymerase chain reaction in patients in long-term remission of acute promyelocytic leukaemia

Acute promyelocytic leukaemia (APL) is characterized by t(15;17), which results in the formation of two chimaeric genes, PML-RAR alpha and RAR alpha-PML. PML-RAR alpha transcripts have been detected in all cases of APL whilst those of RAR alpha-PML have been detected in only about 67% of cases. We have used reverse transcriptase polymerase chain reaction (RT-PCR) to detect both fusion transcripts serially in 18 patients in remission of APL after chemotherapy and bone marrow transplantation. All patients were negative for PML-RAR alpha, whereas in six patients (remission 3-9 years) RAR alpha-PML was consistently detected. Only one patient at remission showed the 5' breakpoint RAR alpha-PML, with the rest showing the 3' breakpoint 144 bp RAR alpha-PML. The level of sensitivity for detecting RAR alpha-PML was some 10-fold higher than that for PML-RAR alpha. Serial negative tests for PML-RAR alpha have been correlated with durable remissions, suggesting possible eradication of residual leukaemia in APL. Our results, however, show persistence of t(15;17) cells expressing RAR alpha-PML fusion mRNA in patients in long-term remission of APL. They indicate that patients considered clinically 'cured' of APL still have molecular evidence of minimal residual disease and also provide further insight into the biology of acute myeloid leukaemia.

The medical care programs of the Farm Security Administration, 1932 through 1947: a rehearsal for national health insurance?

At a time of renewed interest in universal health insurance, an examination of earlier periods when society grappled with the link between socioeconomic status and health is fruitful. Between 1935 and 1947, the federal government sponsored a comprehensive medical care program for low-income farmers, sharecroppers, and migrant workers under the auspices of the Farm Security Administration (FSA). Despite the strong opposition of the American Medical Association, humanitarian and economic concerns at the local level often promoted physicians' participation in the program's group prepayment plans. Many FSA leaders clearly saw the program as a model upon which national health insurance might advance. However, in the wake of World War II, the FSA program declined as physicians' income improved, the rural population declined, and traditional ideological objections to federal intervention in medical care resurfaced. The FSA experience illuminates the complex ideological, economic, and humanitarian motivations of American physicians in the face of health care reform.