Claire Horton

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients

Background The extent of outpatient adverse drug events (ADEs) remains unclear. Trigger tools are used as a screening method to identify care episodes that may be ADEs, but their value in a population with high chronic-illness burden remains unclear. Methods The authors used six abnormal laboratory triggers for detecting ADEs among adults in outpatient care. Eligible patients were included if they were >18 years, sought primary or urgent care between November 2008 and November 2009 and were prescribed at least one medication. The authors then used the clinical / administrative database to identity patients with these triggers. Two physicians conducted in-depth chart review of any medical records with identified triggers. Results The authors reviewed 1342 triggers representing 622 unique episodes among 516 patients. The trigger tool identified 91 (15%) ADEs. Of the 91 ADEs included in the analysis, 49 (54%) occurred during medication monitoring, 41 (45%) during patient self-administration, and one could not be determined. 96% of abnormal international normalised ratio triggers were ADEs, followed by 12% of abnormal blood urea nitrogen triggers, 9% of abnormal alanine aminotransferase triggers, 8% of abnormal serum creatinine triggers and 3% of aspartate aminotransferase triggers. Conclusions The findings imply that other tools such as text triggers or more complex automated screening rules, which combine data hierarchically are needed to effectively screen for ADEs in chronically ill adults seen in primary care.

“Choosing Wisely” in an Academic Department of Medicine

The “Choosing Wisely” campaign seeks to reduce unnecessary care in the United States through self-published recommendations by professional societies. The research team sought to identify factors related to low-value care in the Department of Medicine at the University of California San Francisco, using a subset of clinical scenarios published by the American College of Physicians. The team further explored respondents’ values on cost consciousness. A notable minority disagreed with the identified low-value tests. In 6 of 8 scenarios, faculty were more likely to rate the scenarios as representing low-value testing (P < .05). Level of training was the only predictor of attitudes toward unnecessary care after linear regression analysis (coefficient 3.14, P < .001). Increased postgraduate education about cost of care is recommended.

Interval Examination: Building Primary Care Teams in an Urban Academic Teaching Clinic

After designing the team structure, we defined the roles of each member. The medical home committee met for 6 months to identify the clinic’s tasks and match the right work to the right person. We eliminated duplicative or inefficient duties, creating space for team members to take on expanded roles. For example, MAs now review patient records to identify healthcare maintenance gaps using the electronic health record (EHR). Though we had implemented standing orders for routine cancer screening, immunizations, and diabetic foot monofilament exams two years prior, they were not being completed consistently. With the MAs, we mapped out their healthcare maintenance workflows and found that hectic clinic flow was the major barrier. We reorganized MA schedules to provide each MA with 4 hours per week of dedicated chart preparation time and they are now consistently able to review patient records prior to clinic to identify healthcare maintenance gaps. As another example, team clerks make appointment confirmation calls to patients, which has resulted in a 30 % reduction in the clinic no-show rate. When we initially proposed confirmation calls, clerical staff expressed concern about being able to handle this new task. We eliminated less critical duties such as extraneous paperwork, creating space for them to take on this expanded role. After training the clerks with written telephone scripts, they are now more comfortable calling patients. Our patient advisory board members have declared our confirmation calls “the best thing that’s happened to GMC in years.” GMC patients have a high burden of psychosocial as well as medical complexity, and coordinating their care often overwhelmed part-time providers. To address these challenges, we did two things. First, we integrated behavioral health onto our care teams. Each team has one behavioral health clinician—a licensed clinical social worker or psychologist—who is co-located in clinic. We reconfigured the roles of these existing staff to be team-based: they attend daily huddles to discuss behavioral health needs of scheduled patients; take warm hand-offs, meaning they meet with patients during provider visits, as well as schedule independent follow-up visits; and are available for consultation about behavioral health needs of team patients. Integrating behavioral health has allowed team members to communicate and address patients’ psychosocial needs in a more coordinated manner. Second, we developed a complex care management team. Led by a registered nurse, this interdisciplinary team works intensively to decrease admissions and emergency department (ED) visits for our most frequently admitted patients. The team supports part-time providers by caring for patients between visits and focusing on time-intensive tasks such as self-management support. Patients in the program have 49 % fewer inpatient hospital days (9.6 to 4.9 days/patient/year) and 21 % fewer ED visits (3.4 to 2.7 visits/patient/year) compared to the year prior. Despite these successes, redefining roles requires a continual juggling of responsibilities. One ongoing issue is the high volume of patients who drop-in to clinic every day, consuming RN time. While valuable, addressing drop-in patient needs limit RN availability for other team roles such as chronic care management. We have been working to improve our drop-in process as well as advocating for additional RN staffing to create capacity for expanded nurse team roles in the coming year.

Designing and Implementing an Electronic Patient Registry to Improve Warfarin Monitoring in the Ambulatory Setting

BACKGROUND Warfarin requires individualized dosing and monitoring in the ambulatory setting for protection against thromboembolic disease. Yet in multiple settings, patients spend upwards of 30% of time outside the therapeutic range, subjecting them to an increased risk of adverse events. At an urban, publicly funded clinic, the electronic health record (EHR) would not support integration with extant warfarin management software, which led to the creation and implementation of an electronic patient registry and a complementary team-based work flow to provide real-time health-system-level data for warfarin patients. METHODS Creation of the registry, which began in August 2014, entailed use of an existing platform, which could interface with the outpatient EHR. The registry was designed to help ensure regular testing and monitoring of patients while enabling identification of patients and subpopulations with suboptimal management. The work flow used for the clinics warfarin patients was also redesigned. An assessment indicated that the registry identified 341 (96%) of 357 patients actively seen in the clinic. RESULTS For the cohort of the 357 patients in the registry, the no-show rate decreased from 31% (preimplementation, August 2014-December 2014) to 21% (postimplementation, January 2015-November 2015). The ratio of visits to no-shows increased from 2.3 to 4.0 visits. CONCLUSION Design and implementation of an electronic registry in conjunction with a complementary work flow established an active tracking system that improved treatment monitoring for patients on anticoagulation therapy. Registry creation also facilitated assessment of the quality of care and laid the groundwork for ongoing evaluation and quality improvement efforts.

The bridge clinic.

A nurse-led postdischarge clinic improves care transitions in a public hospital.

Patient Safety in an Academic Medical Practice

Many different types of patient safety events can occur in the outpatient setting. This chapter reviews types of outpatient errors and strategies for prevention. Additionally, basic principles of risk management and educational opportunities focused on patient safety are discussed.

Missed Opportunities in Colorectal Cancer Prevention in Patients With Inadequate Bowel Preparations

*Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington; kDivision of Gastroenterology, University of California, San Francisco, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California; Division of General Internal Medicine, University of California, San Francisco, San Francisco, California; and **Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California

Summary of Proceedings From the Association of American Medical Colleges 2011 Integrating Quality Meeting

As Editor-in-Chief of the American Journal of Medical Quality (AJMQ), and as a member of the Association of American Medical Colleges (AAMC) Integrating Quality (IQ) Steering Committee, I am particularly pleased to bring this special supplement to fruition. The supplement highlights proceedings from the AAMC 2011 IQ Meeting, which was held in Chicago, Illinois, on June 9 and 10, 2011. Having delivered the keynote address at the 2010 version of the IQ meeting, I have seen firsthand how far this important initiative has come. Let us examine the full title more closely, that is, “Integrating Quality: Linking Clinical and Educational Excellence.” How exactly can we link clinical improvement and educational excellence? I believe the genesis of this linkage can be traced directly to October 26, 2009, when the Lucien Leape Institute at the National Patient Safety Foundation published Unmet Needs: Teaching Physicians to Provide Safe Care. The recommendations contained in this report came from an expert roundtable comprising Lucien Leape Institute board members and invited experts (including this author) from medical education and related fields. The report described the existing system of medical education as greatly lacking in the arena of quality and safety and called for sweeping reform of both undergraduate and graduate medical education curricula. My colleagues and I used the unmet needs report as a jumping-off point. Indeed, Academic Medicine received scores of papers from a national solicitation, and those that were published in this journal laid out multiple worthy plans for integrating clinical improvement and educational excellence in such a way that the die was cast by late in the fourth quarter of 2009. In the editorial accompanying the Academic Medicine special issue, I noted that there were “growing choruses of voices from across all of organized medicine, which have collectively spoken out about the crucial need for better care.” Astute observers noted that “unless everyone in health care recognizes that they have 2 jobs when they come to work every day—that is, doing the work and improving it—we will have difficulty maintaining and nurturing our true professionalism . . . continuously moving toward new and better levels of performance.” At this point, the AAMC launched its IQ initiative. Lending their national authority to this important topic, the AAMC has come a long way in providing leadership for this crucial linkage. They have gone beyond the Lucien Leape unmet needs report and eclipsed all previous work in this arena. The June 2011 meeting is further evidence of their success, luring hundreds of individuals to Chicago to ponder issues that only 3 or 4 years ago seemed like the distant future. This is all well and good, but the AAMC cannot rest on its laurels. What will success look like when we finally link clinical improvement and educational excellence? I envision the development of a national core curriculum on quality and safety, applicable to both undergraduate and graduate medical education settings. I envision a world where quality and safety are not simply add-ons or electives to be slotted somewhere in the second semester of the fourth year of medical school. I also envision growth in the number of endowed chairs in quality and safety and a great expansion in the number of master’s programs in our field. Furthermore, with the implementation of the highly anticipated Accreditation Council for Graduate Medical Education institutional visit program, we finally will quantify institutional responses to the quality and safety agenda at the residency training level. We will no longer be able to check a box regarding our capabilities in systems-based learning and practice-based improvement. We will have to prove, once and for all, that house officers get it—that they are intimately involved in self-evaluation, measurement, and improvement. House officers will embrace the 2 jobs that all practitioners must have. 445460 AJMXXX10.1177/106286061244 5460American Journal of Medical Quality