A Quality Improvement Initiative to Identify Remediable System Factors in Ambulatory Preventative Harm

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Patient harm during health care causes significant mortality and morbidity worldwide. Patient harm is defined as unanticipated, unforeseen accidents that are as a direct result of the care dispensed rather than the patient’s underlying disease. Potentially preventable hospitalizations for diabetes and hypertension are expensive and cost the United States over 14 billion dollars annually. Christiana Care Health System (CCHS) is the largest tertiary referral health system in the state of Delaware. On an average, approximately five to twenty patients per month within CCHS ambulatory practices alone experience preventable harm due to diabetes and hypertension across the entire health system. Stakeholder analyses were conducted. Meetings were held to identify ICD-10 codes to define preventable harm. An affinity exercise was held to identify system factors that may have contributed to potentially preventable hospitalizations. Meetings were held with IT personnel to decide on how to implement the survey, how to store data, and how to feed data into Tableau dashboard. Process Maps were developed to indicate the workflow. Using information gleaned from affinity exercise and PDSA (Plan Do Study Act) cycles, a survey instrument was developed. Further PDSA cycles were then conducted to redesign the survey until the final set of questions were selected. The survey instrument which was developed with input from all the stakeholders was successfully implemented for use by all practice sites. The data from the survey instrument was transformed and visualized using a specifically designed Tableau dashboard. Organizations need to find a way to identify priority areas for mitigating preventable patient harm. Target areas for improvement include access to care, care coordination, organizational health literacy, and measures to identify social determinants of health in a community. Surveys are a powerful tool to identify care gaps and system deficiencies.



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