American journal of medical quality : the official journal of the American College of Medical Quality
-
The purpose of this study was to generate national estimates of the prevalence of medically unnecessary emergency medical services (EMS) transports to emergency departments (EDs) over time and to identify characteristics that may be associated with medically unnecessary transports. A previously published algorithm was applied to operationalize medical necessity based on ED diagnosis to 10 years of data from the National Hospital Ambulatory Medical Care Survey. The trend over time was reported using descriptive statistics weighted to produce national estimates. ⋯ Individual demographic characteristics, including insurance status, were not predictive of inappropriate utilization. EMS transports for medically unnecessary complaints increased from 1997 to 2007. Our findings from a nationally representative sample highlight the opportunity for alternative patient delivery strategies for select patients seeking EMS services.
-
Surgical mortality is considered a benchmark for measuring quality of care. This study quantifies the incidence of death on the day of elective pediatric surgery, which generally is considered preventable and might be considered a "never" event. The authors conducted a retrospective analysis of national state inpatient databases from 1988 to 2007 that included elective pediatric surgical patients. ⋯ Surgical specialty mortality rates ranged from 0.06 (otolaryngology) to 17.4 (cardiothoracic surgery) deaths per 10 000 cases. Death on the day of elective pediatric surgery is rare, limiting its utility to compare performance in pediatric surgery. However, this metric may be useful at individual institutions as a case-finding tool for root-cause analysis in quality improvement efforts.
-
Using the ethical concepts of co-fiduciary responsibility in patient care and of preventive ethics, this article provides an ethical framework to guide physician and lay leaders of accountable care organizations. The concept of co-fiduciary responsibility is based on the ethical concept of medicine as a profession, which was introduced into the history of medical ethics in the 18th century. ⋯ A preventive ethics approach to co-fiduciary responsibility requires leaders of accountable care organizations to create organizational cultures of fiduciary professionalism that implement and support the following: improving quality based on candor and accountability, reasserting the physician's professional role in the informed consent process, and constraining patients' and surrogates' autonomy. Sustainable organizational cultures of fiduciary professionalism will require commitment of organizational resources and constant vigilance over the intellectual and moral integrity of organizational culture.
-
Registered nurses (RNs) play a critical role in health care delivery. With an aging US population, health care demand is growing at an unprecedented pace. Using projected changes in population size and age, the authors developed demand and supply models to forecast the RN job shortage in each of the 50 states. ⋯ The number of states receiving a grade of "D" or "F" for their RN shortage ratio will increase from 5 in 2009 to 30 by 2030, for a total national deficit of 918 232 (725,619 - 1,112,112) RN jobs. There will be significant RN workforce shortages throughout the country in 2030; the western region will have the largest shortage ratio of 389 RN jobs per 100,000. Increased efforts to understand shortage dynamics are warranted.
-
Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care's sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.