Ebrahim Barkoudah, MD, MPH

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; Ebrahim.Barkoudah@baystatehealth.org

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; Ebrahim.Barkoudah@baystatehealth.org

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; Ebrahim.Barkoudah@baystatehealth.org

This year marks the publication of the 30th volume of the Journal of Clinical Outcomes Management (JCOM). As we celebrate JCOM’s 30th year, we look forward to the future and continuing the journey to inform quality improvement leaders and practitioners about advances in the field and share experiences. The path forward on this journey involves collaboration across stakeholders, the application of innovative improvement methods, and a commitment to achieving health equity. Health care quality improvement plans must prioritize patient-centered care, promote evidence-based practices and continuous learning, and establish clear metrics to measure progress and success. Furthermore, engagement with patients and communities must be at the forefront of any quality improvement plan, as their perspectives and experiences are essential to understanding and addressing the root causes of disparities in health care delivery. Additionally, effective communication and coordination among health care providers, administrators, policymakers, and other stakeholders are crucial to achieving sustainable improvements in health care quality.

JCOM’s mission is to serve as a platform for sharing knowledge, experiences, and best practices to improve patient outcomes and promote health equity. The vision encompasses a world where all individuals have access to high-quality, patient-centered health care that is free of disparities and achieves optimal health outcomes. JCOM’s strategy is to publish articles that showcase innovative quality improvement initiatives, share evidence-based practices and research findings, highlight successful collaborations, and provide practical guidance for health care professionals to implement quality improvement initiatives in their organizations.

We believe that by sharing these insights and experiences, we can accelerate progress toward achieving equitable and high-quality health care for all individuals and communities, regardless of their socioeconomic status, race/ethnicity, gender identity, or any other factor that may impact their access to care and health outcomes. We continue to welcome submissions from all health care professionals, researchers, and other stakeholders involved in quality improvement initiatives. Together, we can work toward a future where every individual has access to the highest quality of health care and experiences equitable health outcomes.

A comprehensive and collaborative approach to health care quality improvement, which is led by a peer review process and scientific publication of the progress, is a necessary part of ensuring that all patients receive high-quality care that is equitable and patient-centered. The future of health care quality will require further research and scholarly work in the areas of training and development, data infrastructure and analytics, as well as technology-enabled solutions that support continuous improvement and innovation. Health care organizations can build a culture of quality improvement that drives meaningful progress toward achieving health equity and improving health care delivery for all by sharing the output from their research.

Thank you for joining us in this mission to improve health care quality, promote optimal health care delivery methods, and create a world where health care is not only accessible, but also equitable and of the highest standards. Let us continue to work toward building a health care system that prioritizes patient-centered care. Together, we can make a difference and ensure that every individual receives the care they need and deserve.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

This year marks the publication of the 30th volume of the Journal of Clinical Outcomes Management (JCOM). As we celebrate JCOM’s 30th year, we look forward to the future and continuing the journey to inform quality improvement leaders and practitioners about advances in the field and share experiences. The path forward on this journey involves collaboration across stakeholders, the application of innovative improvement methods, and a commitment to achieving health equity. Health care quality improvement plans must prioritize patient-centered care, promote evidence-based practices and continuous learning, and establish clear metrics to measure progress and success. Furthermore, engagement with patients and communities must be at the forefront of any quality improvement plan, as their perspectives and experiences are essential to understanding and addressing the root causes of disparities in health care delivery. Additionally, effective communication and coordination among health care providers, administrators, policymakers, and other stakeholders are crucial to achieving sustainable improvements in health care quality.

JCOM’s mission is to serve as a platform for sharing knowledge, experiences, and best practices to improve patient outcomes and promote health equity. The vision encompasses a world where all individuals have access to high-quality, patient-centered health care that is free of disparities and achieves optimal health outcomes. JCOM’s strategy is to publish articles that showcase innovative quality improvement initiatives, share evidence-based practices and research findings, highlight successful collaborations, and provide practical guidance for health care professionals to implement quality improvement initiatives in their organizations.

We believe that by sharing these insights and experiences, we can accelerate progress toward achieving equitable and high-quality health care for all individuals and communities, regardless of their socioeconomic status, race/ethnicity, gender identity, or any other factor that may impact their access to care and health outcomes. We continue to welcome submissions from all health care professionals, researchers, and other stakeholders involved in quality improvement initiatives. Together, we can work toward a future where every individual has access to the highest quality of health care and experiences equitable health outcomes.

A comprehensive and collaborative approach to health care quality improvement, which is led by a peer review process and scientific publication of the progress, is a necessary part of ensuring that all patients receive high-quality care that is equitable and patient-centered. The future of health care quality will require further research and scholarly work in the areas of training and development, data infrastructure and analytics, as well as technology-enabled solutions that support continuous improvement and innovation. Health care organizations can build a culture of quality improvement that drives meaningful progress toward achieving health equity and improving health care delivery for all by sharing the output from their research.

Thank you for joining us in this mission to improve health care quality, promote optimal health care delivery methods, and create a world where health care is not only accessible, but also equitable and of the highest standards. Let us continue to work toward building a health care system that prioritizes patient-centered care. Together, we can make a difference and ensure that every individual receives the care they need and deserve.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

This year marks the publication of the 30th volume of the Journal of Clinical Outcomes Management (JCOM). As we celebrate JCOM’s 30th year, we look forward to the future and continuing the journey to inform quality improvement leaders and practitioners about advances in the field and share experiences. The path forward on this journey involves collaboration across stakeholders, the application of innovative improvement methods, and a commitment to achieving health equity. Health care quality improvement plans must prioritize patient-centered care, promote evidence-based practices and continuous learning, and establish clear metrics to measure progress and success. Furthermore, engagement with patients and communities must be at the forefront of any quality improvement plan, as their perspectives and experiences are essential to understanding and addressing the root causes of disparities in health care delivery. Additionally, effective communication and coordination among health care providers, administrators, policymakers, and other stakeholders are crucial to achieving sustainable improvements in health care quality.

JCOM’s mission is to serve as a platform for sharing knowledge, experiences, and best practices to improve patient outcomes and promote health equity. The vision encompasses a world where all individuals have access to high-quality, patient-centered health care that is free of disparities and achieves optimal health outcomes. JCOM’s strategy is to publish articles that showcase innovative quality improvement initiatives, share evidence-based practices and research findings, highlight successful collaborations, and provide practical guidance for health care professionals to implement quality improvement initiatives in their organizations.

We believe that by sharing these insights and experiences, we can accelerate progress toward achieving equitable and high-quality health care for all individuals and communities, regardless of their socioeconomic status, race/ethnicity, gender identity, or any other factor that may impact their access to care and health outcomes. We continue to welcome submissions from all health care professionals, researchers, and other stakeholders involved in quality improvement initiatives. Together, we can work toward a future where every individual has access to the highest quality of health care and experiences equitable health outcomes.

A comprehensive and collaborative approach to health care quality improvement, which is led by a peer review process and scientific publication of the progress, is a necessary part of ensuring that all patients receive high-quality care that is equitable and patient-centered. The future of health care quality will require further research and scholarly work in the areas of training and development, data infrastructure and analytics, as well as technology-enabled solutions that support continuous improvement and innovation. Health care organizations can build a culture of quality improvement that drives meaningful progress toward achieving health equity and improving health care delivery for all by sharing the output from their research.

Thank you for joining us in this mission to improve health care quality, promote optimal health care delivery methods, and create a world where health care is not only accessible, but also equitable and of the highest standards. Let us continue to work toward building a health care system that prioritizes patient-centered care. Together, we can make a difference and ensure that every individual receives the care they need and deserve.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

Each year, 40,000 to 98,000 deaths occur due to medical errors.¹ The Harvard Medical Practice Study (HMPS), published in 1991, found that 3.7% of hospitalized patients were harmed by adverse events and 1% were harmed by adverse events due to negligence.² The latest HMPS showed that, despite significant improvements in patient safety over the past 3 decades, patient safety challenges persist. This study found that inpatient care leads to harm in nearly a quarter of patients, and that 1 in 4 of these adverse events are preventable.³

Since the first HMPS study was published, efforts to improve patient safety have focused on identifying causes of medical error and the design and implementation of interventions to mitigate errors. Factors contributing to medical errors have been well documented: the complexity of care delivery from inpatient to outpatient settings, with transitions of care and extensive use of medications; multiple comorbidities; and the fragmentation of care across multiple systems and specialties. Although most errors are related to process or system failure, accountability of each practitioner and clinician is essential to promoting a culture of safety. Many medical errors are preventable through multifaceted approaches employed throughout the phases of the care,⁴ with medication errors, both prescribing and administration, and diagnostic and treatment errors encompassing most risk prevention areas. Broadly, safety efforts should emphasize building a culture of safety where all safety events are reported, including near-miss events.

Two articles in this issue of JCOM address key elements of patient safety: building a safety culture and diagnostic error. Merchant et al⁵ report on an initiative designed to promote a safety culture by recognizing and rewarding staff who identify and report near misses. The tiered awards program they designed led to significantly increased staff participation in the safety awards nomination process and was associated with increased reporting of actual and close-call events and greater attendance at monthly safety forums. Goyal et al,⁶ noting that diagnostic error rates in hospitalized patients remain unacceptably high, provide a concise update on diagnostic error among inpatients, focusing on issues related to defining and measuring diagnostic errors and current strategies to improve diagnostic safety in hospitalized patients. In a third article, Sathi et al report on efforts to teach quality improvement (QI) methods to internal medicine trainees; their project increased residents’ knowledge of their patient panels and comfort with QI approaches and led to improved patient outcomes.

Major progress has been made to improve health care safety since the first HMPS was published. However, the latest HMPS shows that patient safety efforts must continue, given the persistent risk for patient harm in the current health care delivery system. Safety, along with clear accountability for identifying, reporting, and addressing errors, should be a top priority for health care systems throughout the preventive, diagnostic, and therapeutic phases of care.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

Each year, 40,000 to 98,000 deaths occur due to medical errors.¹ The Harvard Medical Practice Study (HMPS), published in 1991, found that 3.7% of hospitalized patients were harmed by adverse events and 1% were harmed by adverse events due to negligence.² The latest HMPS showed that, despite significant improvements in patient safety over the past 3 decades, patient safety challenges persist. This study found that inpatient care leads to harm in nearly a quarter of patients, and that 1 in 4 of these adverse events are preventable.³

Since the first HMPS study was published, efforts to improve patient safety have focused on identifying causes of medical error and the design and implementation of interventions to mitigate errors. Factors contributing to medical errors have been well documented: the complexity of care delivery from inpatient to outpatient settings, with transitions of care and extensive use of medications; multiple comorbidities; and the fragmentation of care across multiple systems and specialties. Although most errors are related to process or system failure, accountability of each practitioner and clinician is essential to promoting a culture of safety. Many medical errors are preventable through multifaceted approaches employed throughout the phases of the care,⁴ with medication errors, both prescribing and administration, and diagnostic and treatment errors encompassing most risk prevention areas. Broadly, safety efforts should emphasize building a culture of safety where all safety events are reported, including near-miss events.

Two articles in this issue of JCOM address key elements of patient safety: building a safety culture and diagnostic error. Merchant et al⁵ report on an initiative designed to promote a safety culture by recognizing and rewarding staff who identify and report near misses. The tiered awards program they designed led to significantly increased staff participation in the safety awards nomination process and was associated with increased reporting of actual and close-call events and greater attendance at monthly safety forums. Goyal et al,⁶ noting that diagnostic error rates in hospitalized patients remain unacceptably high, provide a concise update on diagnostic error among inpatients, focusing on issues related to defining and measuring diagnostic errors and current strategies to improve diagnostic safety in hospitalized patients. In a third article, Sathi et al report on efforts to teach quality improvement (QI) methods to internal medicine trainees; their project increased residents’ knowledge of their patient panels and comfort with QI approaches and led to improved patient outcomes.

Major progress has been made to improve health care safety since the first HMPS was published. However, the latest HMPS shows that patient safety efforts must continue, given the persistent risk for patient harm in the current health care delivery system. Safety, along with clear accountability for identifying, reporting, and addressing errors, should be a top priority for health care systems throughout the preventive, diagnostic, and therapeutic phases of care.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

Each year, 40,000 to 98,000 deaths occur due to medical errors.¹ The Harvard Medical Practice Study (HMPS), published in 1991, found that 3.7% of hospitalized patients were harmed by adverse events and 1% were harmed by adverse events due to negligence.² The latest HMPS showed that, despite significant improvements in patient safety over the past 3 decades, patient safety challenges persist. This study found that inpatient care leads to harm in nearly a quarter of patients, and that 1 in 4 of these adverse events are preventable.³

Since the first HMPS study was published, efforts to improve patient safety have focused on identifying causes of medical error and the design and implementation of interventions to mitigate errors. Factors contributing to medical errors have been well documented: the complexity of care delivery from inpatient to outpatient settings, with transitions of care and extensive use of medications; multiple comorbidities; and the fragmentation of care across multiple systems and specialties. Although most errors are related to process or system failure, accountability of each practitioner and clinician is essential to promoting a culture of safety. Many medical errors are preventable through multifaceted approaches employed throughout the phases of the care,⁴ with medication errors, both prescribing and administration, and diagnostic and treatment errors encompassing most risk prevention areas. Broadly, safety efforts should emphasize building a culture of safety where all safety events are reported, including near-miss events.

Two articles in this issue of JCOM address key elements of patient safety: building a safety culture and diagnostic error. Merchant et al⁵ report on an initiative designed to promote a safety culture by recognizing and rewarding staff who identify and report near misses. The tiered awards program they designed led to significantly increased staff participation in the safety awards nomination process and was associated with increased reporting of actual and close-call events and greater attendance at monthly safety forums. Goyal et al,⁶ noting that diagnostic error rates in hospitalized patients remain unacceptably high, provide a concise update on diagnostic error among inpatients, focusing on issues related to defining and measuring diagnostic errors and current strategies to improve diagnostic safety in hospitalized patients. In a third article, Sathi et al report on efforts to teach quality improvement (QI) methods to internal medicine trainees; their project increased residents’ knowledge of their patient panels and comfort with QI approaches and led to improved patient outcomes.

Major progress has been made to improve health care safety since the first HMPS was published. However, the latest HMPS shows that patient safety efforts must continue, given the persistent risk for patient harm in the current health care delivery system. Safety, along with clear accountability for identifying, reporting, and addressing errors, should be a top priority for health care systems throughout the preventive, diagnostic, and therapeutic phases of care.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

From the Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA.

Clinical inertia is defined as the failure of clinicians to initiate or escalate guideline-directed medical therapy to achieve treatment goals for well-defined clinical conditions.^1,2 Evidence-based guidelines recommend optimal disease management with readily available medical therapies throughout the phases of clinical care. Unfortunately, the care provided to individual patients undergoes multiple modifications throughout the disease course, resulting in divergent pathways, significant deviations from treatment guidelines, and failure of “safeguard” checkpoints to reinstate, initiate, optimize, or stop treatments. Clinical inertia generally describes rigidity or resistance to change around implementing evidence-based guidelines. Furthermore, this term describes treatment behavior on the part of an individual clinician, not organizational inertia, which generally encompasses both internal (immediate clinical practice settings) and external factors (national and international guidelines and recommendations), eventually leading to resistance to optimizing disease treatment and therapeutic regimens. Individual clinicians’ clinical inertia in the form of resistance to guideline implementation and evidence-based principles can be one factor that drives organizational inertia. In turn, such individual behavior can be dictated by personal beliefs, knowledge, interpretation, skills, management principles, and biases. The terms therapeutic inertia or clinical inertia should not be confused with nonadherence from the patient’s standpoint when the clinician follows the best practice guidelines.³

Clinical inertia has been described in several clinical domains, including diabetes,^4,5 hypertension,^6,7 heart failure,⁸ depression,⁹ pulmonary medicine,¹⁰ and complex disease management.¹¹ Clinicians can set suboptimal treatment goals due to specific beliefs and attitudes around optimal therapeutic goals. For example, when treating a patient with a chronic disease that is presently stable, a clinician could elect to initiate suboptimal treatment, as escalation of treatment might not be the priority in stable disease; they also may have concerns about overtreatment. Other factors that can contribute to clinical inertia (ie, undertreatment in the presence of indications for treatment) include those related to the patient, the clinical setting, and the organization, along with the importance of individualizing therapies in specific patients. Organizational inertia is the initial global resistance by the system to implementation, which can slow the dissemination and adaptation of best practices but eventually declines over time. Individual clinical inertia, on the other hand, will likely persist after the system-level rollout of guideline-based approaches.

The trajectory of dissemination, implementation, and adaptation of innovations and best practices is illustrated in the Figure. When the guidelines and medical societies endorse the adaptation of innovations or practice change after the benefits of such innovations/change have been established by the regulatory bodies, uptake can be hindered by both organizational and clinical inertia. Overcoming inertia to system-level changes requires addressing individual clinicians, along with practice and organizational factors, in order to ensure systematic adaptations. From the clinicians’ view, training and cognitive interventions to improve the adaptation and coping skills can improve understanding of treatment options through standardized educational and behavioral modification tools, direct and indirect feedback around performance, and decision support through a continuous improvement approach on both individual and system levels.

Addressing inertia in clinical practice requires a deep understanding of the individual and organizational elements that foster resistance to adapting best practice models. Research that explores tools and approaches to overcome inertia in managing complex diseases is a key step in advancing clinical innovation and disseminating best practices.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

From the Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA.

Clinical inertia is defined as the failure of clinicians to initiate or escalate guideline-directed medical therapy to achieve treatment goals for well-defined clinical conditions.^1,2 Evidence-based guidelines recommend optimal disease management with readily available medical therapies throughout the phases of clinical care. Unfortunately, the care provided to individual patients undergoes multiple modifications throughout the disease course, resulting in divergent pathways, significant deviations from treatment guidelines, and failure of “safeguard” checkpoints to reinstate, initiate, optimize, or stop treatments. Clinical inertia generally describes rigidity or resistance to change around implementing evidence-based guidelines. Furthermore, this term describes treatment behavior on the part of an individual clinician, not organizational inertia, which generally encompasses both internal (immediate clinical practice settings) and external factors (national and international guidelines and recommendations), eventually leading to resistance to optimizing disease treatment and therapeutic regimens. Individual clinicians’ clinical inertia in the form of resistance to guideline implementation and evidence-based principles can be one factor that drives organizational inertia. In turn, such individual behavior can be dictated by personal beliefs, knowledge, interpretation, skills, management principles, and biases. The terms therapeutic inertia or clinical inertia should not be confused with nonadherence from the patient’s standpoint when the clinician follows the best practice guidelines.³

Clinical inertia has been described in several clinical domains, including diabetes,^4,5 hypertension,^6,7 heart failure,⁸ depression,⁹ pulmonary medicine,¹⁰ and complex disease management.¹¹ Clinicians can set suboptimal treatment goals due to specific beliefs and attitudes around optimal therapeutic goals. For example, when treating a patient with a chronic disease that is presently stable, a clinician could elect to initiate suboptimal treatment, as escalation of treatment might not be the priority in stable disease; they also may have concerns about overtreatment. Other factors that can contribute to clinical inertia (ie, undertreatment in the presence of indications for treatment) include those related to the patient, the clinical setting, and the organization, along with the importance of individualizing therapies in specific patients. Organizational inertia is the initial global resistance by the system to implementation, which can slow the dissemination and adaptation of best practices but eventually declines over time. Individual clinical inertia, on the other hand, will likely persist after the system-level rollout of guideline-based approaches.

The trajectory of dissemination, implementation, and adaptation of innovations and best practices is illustrated in the Figure. When the guidelines and medical societies endorse the adaptation of innovations or practice change after the benefits of such innovations/change have been established by the regulatory bodies, uptake can be hindered by both organizational and clinical inertia. Overcoming inertia to system-level changes requires addressing individual clinicians, along with practice and organizational factors, in order to ensure systematic adaptations. From the clinicians’ view, training and cognitive interventions to improve the adaptation and coping skills can improve understanding of treatment options through standardized educational and behavioral modification tools, direct and indirect feedback around performance, and decision support through a continuous improvement approach on both individual and system levels.

Addressing inertia in clinical practice requires a deep understanding of the individual and organizational elements that foster resistance to adapting best practice models. Research that explores tools and approaches to overcome inertia in managing complex diseases is a key step in advancing clinical innovation and disseminating best practices.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

From the Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA.

Clinical inertia is defined as the failure of clinicians to initiate or escalate guideline-directed medical therapy to achieve treatment goals for well-defined clinical conditions.^1,2 Evidence-based guidelines recommend optimal disease management with readily available medical therapies throughout the phases of clinical care. Unfortunately, the care provided to individual patients undergoes multiple modifications throughout the disease course, resulting in divergent pathways, significant deviations from treatment guidelines, and failure of “safeguard” checkpoints to reinstate, initiate, optimize, or stop treatments. Clinical inertia generally describes rigidity or resistance to change around implementing evidence-based guidelines. Furthermore, this term describes treatment behavior on the part of an individual clinician, not organizational inertia, which generally encompasses both internal (immediate clinical practice settings) and external factors (national and international guidelines and recommendations), eventually leading to resistance to optimizing disease treatment and therapeutic regimens. Individual clinicians’ clinical inertia in the form of resistance to guideline implementation and evidence-based principles can be one factor that drives organizational inertia. In turn, such individual behavior can be dictated by personal beliefs, knowledge, interpretation, skills, management principles, and biases. The terms therapeutic inertia or clinical inertia should not be confused with nonadherence from the patient’s standpoint when the clinician follows the best practice guidelines.³

Clinical inertia has been described in several clinical domains, including diabetes,^4,5 hypertension,^6,7 heart failure,⁸ depression,⁹ pulmonary medicine,¹⁰ and complex disease management.¹¹ Clinicians can set suboptimal treatment goals due to specific beliefs and attitudes around optimal therapeutic goals. For example, when treating a patient with a chronic disease that is presently stable, a clinician could elect to initiate suboptimal treatment, as escalation of treatment might not be the priority in stable disease; they also may have concerns about overtreatment. Other factors that can contribute to clinical inertia (ie, undertreatment in the presence of indications for treatment) include those related to the patient, the clinical setting, and the organization, along with the importance of individualizing therapies in specific patients. Organizational inertia is the initial global resistance by the system to implementation, which can slow the dissemination and adaptation of best practices but eventually declines over time. Individual clinical inertia, on the other hand, will likely persist after the system-level rollout of guideline-based approaches.

The trajectory of dissemination, implementation, and adaptation of innovations and best practices is illustrated in the Figure. When the guidelines and medical societies endorse the adaptation of innovations or practice change after the benefits of such innovations/change have been established by the regulatory bodies, uptake can be hindered by both organizational and clinical inertia. Overcoming inertia to system-level changes requires addressing individual clinicians, along with practice and organizational factors, in order to ensure systematic adaptations. From the clinicians’ view, training and cognitive interventions to improve the adaptation and coping skills can improve understanding of treatment options through standardized educational and behavioral modification tools, direct and indirect feedback around performance, and decision support through a continuous improvement approach on both individual and system levels.

Addressing inertia in clinical practice requires a deep understanding of the individual and organizational elements that foster resistance to adapting best practice models. Research that explores tools and approaches to overcome inertia in managing complex diseases is a key step in advancing clinical innovation and disseminating best practices.

Corresponding author: Ebrahim Barkoudah, MD, MPH; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Process improvement in any industry sector aims to increase the efficiency of resource utilization and delivery methods (cost) and the quality of the product (outcomes), with the goal of ultimately achieving continuous development.¹ In the health care industry, variation in processes and outcomes along with inefficiency in resource use that result in changes in value (the product of outcomes/costs) are the general targets of quality improvement (QI) efforts employing various implementation methodologies.² When the ultimate aim is to serve the patient (customer), best clinical practice includes both maintaining high quality (individual care delivery) and controlling costs (efficient care system delivery), leading to optimal delivery (value-based care). High-quality individual care and efficient care delivery are not competing concepts, but when working to improve both health care outcomes and cost, traditional and nontraditional barriers to system QI often arise.³

The possible scenarios after a QI intervention include backsliding (regression to the mean over time), steady-state (minimal fixed improvement that could sustain), and continuous improvement (tangible enhancement after completing the intervention with legacy effect).⁴ The scalability of results can be considered during the process measurement and the intervention design phases of all QI projects; however, the complex nature of barriers in the health care environment during each level of implementation should be accounted for to prevent failure in the scalability phase.⁵

The barriers to optimal QI outcomes leading to continuous improvement are multifactorial and are related to intrinsic and extrinsic factors.⁶ These factors include 3 fundamental levels: (1) individual level inertia/beliefs, prior personal knowledge, and team-related factors^7,8; (2) intervention-related and process-specific barriers and clinical practice obstacles; and (3) organizational level challenges and macro-level and population-level barriers (Figure). The obstacles faced during the implementation phase will likely include 2 of these levels simultaneously, which could add complexity and hinder or prevent the implementation of a tangible successful QI process and eventually lead to backsliding or minimal fixed improvement rather than continuous improvement. Furthermore, a patient-centered approach to QI would contribute to further complexity in design and execution, given the importance of reaching sustainable, meaningful improvement by adding elements of patient’s preferences, caregiver engagement, and the shared decision-making processes.⁹

Overcoming these multidomain barriers and reaching resilience and sustainability requires thoughtful planning and execution through a multifaceted approach.¹⁰ A meaningful start could include addressing the clinical inertia for the individual and the team by promoting open innovation and allowing outside institutional collaborations and ideas through networks.¹¹ On the individual level, encouraging participation and motivating health care workers in QI to reach a multidisciplinary operation approach will lead to harmony in collaboration. Concurrently, the organization should support the QI capability and scalability by removing competing priorities and establishing effective leadership that ensures resource allocation, communicates clear value-based principles, and engenders a psychological safety environment.

A continuous improvement state is the optimal QI target, a target that can be attained by removing obstacles and paving a clear pathway to implementation. Focusing on the 3 levels of barriers will position the organization for meaningful and successful QI phases to achieve continuous improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Process improvement in any industry sector aims to increase the efficiency of resource utilization and delivery methods (cost) and the quality of the product (outcomes), with the goal of ultimately achieving continuous development.¹ In the health care industry, variation in processes and outcomes along with inefficiency in resource use that result in changes in value (the product of outcomes/costs) are the general targets of quality improvement (QI) efforts employing various implementation methodologies.² When the ultimate aim is to serve the patient (customer), best clinical practice includes both maintaining high quality (individual care delivery) and controlling costs (efficient care system delivery), leading to optimal delivery (value-based care). High-quality individual care and efficient care delivery are not competing concepts, but when working to improve both health care outcomes and cost, traditional and nontraditional barriers to system QI often arise.³

The possible scenarios after a QI intervention include backsliding (regression to the mean over time), steady-state (minimal fixed improvement that could sustain), and continuous improvement (tangible enhancement after completing the intervention with legacy effect).⁴ The scalability of results can be considered during the process measurement and the intervention design phases of all QI projects; however, the complex nature of barriers in the health care environment during each level of implementation should be accounted for to prevent failure in the scalability phase.⁵

The barriers to optimal QI outcomes leading to continuous improvement are multifactorial and are related to intrinsic and extrinsic factors.⁶ These factors include 3 fundamental levels: (1) individual level inertia/beliefs, prior personal knowledge, and team-related factors^7,8; (2) intervention-related and process-specific barriers and clinical practice obstacles; and (3) organizational level challenges and macro-level and population-level barriers (Figure). The obstacles faced during the implementation phase will likely include 2 of these levels simultaneously, which could add complexity and hinder or prevent the implementation of a tangible successful QI process and eventually lead to backsliding or minimal fixed improvement rather than continuous improvement. Furthermore, a patient-centered approach to QI would contribute to further complexity in design and execution, given the importance of reaching sustainable, meaningful improvement by adding elements of patient’s preferences, caregiver engagement, and the shared decision-making processes.⁹

Overcoming these multidomain barriers and reaching resilience and sustainability requires thoughtful planning and execution through a multifaceted approach.¹⁰ A meaningful start could include addressing the clinical inertia for the individual and the team by promoting open innovation and allowing outside institutional collaborations and ideas through networks.¹¹ On the individual level, encouraging participation and motivating health care workers in QI to reach a multidisciplinary operation approach will lead to harmony in collaboration. Concurrently, the organization should support the QI capability and scalability by removing competing priorities and establishing effective leadership that ensures resource allocation, communicates clear value-based principles, and engenders a psychological safety environment.

A continuous improvement state is the optimal QI target, a target that can be attained by removing obstacles and paving a clear pathway to implementation. Focusing on the 3 levels of barriers will position the organization for meaningful and successful QI phases to achieve continuous improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Process improvement in any industry sector aims to increase the efficiency of resource utilization and delivery methods (cost) and the quality of the product (outcomes), with the goal of ultimately achieving continuous development.¹ In the health care industry, variation in processes and outcomes along with inefficiency in resource use that result in changes in value (the product of outcomes/costs) are the general targets of quality improvement (QI) efforts employing various implementation methodologies.² When the ultimate aim is to serve the patient (customer), best clinical practice includes both maintaining high quality (individual care delivery) and controlling costs (efficient care system delivery), leading to optimal delivery (value-based care). High-quality individual care and efficient care delivery are not competing concepts, but when working to improve both health care outcomes and cost, traditional and nontraditional barriers to system QI often arise.³

The possible scenarios after a QI intervention include backsliding (regression to the mean over time), steady-state (minimal fixed improvement that could sustain), and continuous improvement (tangible enhancement after completing the intervention with legacy effect).⁴ The scalability of results can be considered during the process measurement and the intervention design phases of all QI projects; however, the complex nature of barriers in the health care environment during each level of implementation should be accounted for to prevent failure in the scalability phase.⁵

The barriers to optimal QI outcomes leading to continuous improvement are multifactorial and are related to intrinsic and extrinsic factors.⁶ These factors include 3 fundamental levels: (1) individual level inertia/beliefs, prior personal knowledge, and team-related factors^7,8; (2) intervention-related and process-specific barriers and clinical practice obstacles; and (3) organizational level challenges and macro-level and population-level barriers (Figure). The obstacles faced during the implementation phase will likely include 2 of these levels simultaneously, which could add complexity and hinder or prevent the implementation of a tangible successful QI process and eventually lead to backsliding or minimal fixed improvement rather than continuous improvement. Furthermore, a patient-centered approach to QI would contribute to further complexity in design and execution, given the importance of reaching sustainable, meaningful improvement by adding elements of patient’s preferences, caregiver engagement, and the shared decision-making processes.⁹

Overcoming these multidomain barriers and reaching resilience and sustainability requires thoughtful planning and execution through a multifaceted approach.¹⁰ A meaningful start could include addressing the clinical inertia for the individual and the team by promoting open innovation and allowing outside institutional collaborations and ideas through networks.¹¹ On the individual level, encouraging participation and motivating health care workers in QI to reach a multidisciplinary operation approach will lead to harmony in collaboration. Concurrently, the organization should support the QI capability and scalability by removing competing priorities and establishing effective leadership that ensures resource allocation, communicates clear value-based principles, and engenders a psychological safety environment.

A continuous improvement state is the optimal QI target, a target that can be attained by removing obstacles and paving a clear pathway to implementation. Focusing on the 3 levels of barriers will position the organization for meaningful and successful QI phases to achieve continuous improvement.

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Disclosures: None reported.

As we transition out of the Omicron surge, the lessons we’ve learned from the prior surges carry forward and add to our knowledge foundation. Medical journals have published numerous research and perspectives manuscripts on all aspects of COVID-19 over the past 2 years, adding much-needed knowledge to our clinical practice during the pandemic. However, the story does not stop there, as the pandemic has impacted the usual, non-COVID-19 clinical care we provide. The value-based health care delivery model accounts for both COVID-19 clinical care and the usual care we provide our patients every day. Clinicians, administrators, and health care workers will need to know how to balance both worlds in the years to come.

In this issue of JCOM, the work of balancing the demands of COVID-19 care with those of system improvement continues. Two original research articles address the former, with Liesching et al¹ reporting data on improving clinical outcomes of patients with COVID-19 through acute care oxygen therapies, and Ali et al² explaining the impact of COVID-19 on STEMI care delivery models. Liesching et al’s study showed that patients admitted for COVID-19 after the first surge were more likely to receive high-flow nasal cannula and had better outcomes, while Ali et al showed that patients with STEMI yet again experienced worse outcomes during the first wave.

On the system improvement front, Cusick et al³ report on a quality improvement (QI) project that addressed acute disease management of heparin-induced thrombocytopenia (HIT) during hospitalization, Sosa et al⁴ discuss efforts to improve comorbidity capture at their institution, and Uche et al⁵ present the results of a nonpharmacologic initiative to improve management of chronic pain among veterans. Cusick et al’s QI project showed that a HIT testing strategy could be safely implemented through an evidence-based process to nudge resource utilization using specific management pathways. While capturing and measuring the complexity of diseases and comorbidities can be challenging, accurate capture is essential, as patient acuity has implications for reimbursement and quality comparisons for hospitals and physicians; Sosa et al describe a series of initiatives implemented at their institution that improved comorbidity capture. Furthermore, Uche et al report on a 10-week complementary and integrative health program for veterans with noncancer chronic pain that reduced pain intensity and improved quality of life for its participants. These QI reports show that, though the health care landscape has changed over the past 2 years, the aim remains the same: to provide the best care for patients regardless of the diagnosis, location, or time.

Conducting QI projects during the COVID-19 pandemic has been difficult, especially in terms of implementing consistent processes and management pathways while contending with staff and supply shortages. The pandemic, however, has highlighted the importance of continuing QI efforts, specifically around infectious disease prevention and good clinical practices. Moreover, the recent continuous learning and implementation around COVID-19 patient care has been a significant achievement, as clinicians and administrators worked continuously to understand and improve processes, create a supporting culture, and redesign care delivery on the fly. The management of both COVID-19 care and our usual care QI efforts should incorporate the lessons learned from the pandemic and leverage system redesign for future steps. As we’ve seen, survival in COVID-19 improved dramatically since the beginning of the pandemic, as clinical trials became more adaptive and efficient and system upgrades like telemedicine and digital technologies in the public health response led to major advancements. The work to improve the care provided in the clinic and at the bedside will continue through one collective approach in the new normal.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

As we transition out of the Omicron surge, the lessons we’ve learned from the prior surges carry forward and add to our knowledge foundation. Medical journals have published numerous research and perspectives manuscripts on all aspects of COVID-19 over the past 2 years, adding much-needed knowledge to our clinical practice during the pandemic. However, the story does not stop there, as the pandemic has impacted the usual, non-COVID-19 clinical care we provide. The value-based health care delivery model accounts for both COVID-19 clinical care and the usual care we provide our patients every day. Clinicians, administrators, and health care workers will need to know how to balance both worlds in the years to come.

In this issue of JCOM, the work of balancing the demands of COVID-19 care with those of system improvement continues. Two original research articles address the former, with Liesching et al¹ reporting data on improving clinical outcomes of patients with COVID-19 through acute care oxygen therapies, and Ali et al² explaining the impact of COVID-19 on STEMI care delivery models. Liesching et al’s study showed that patients admitted for COVID-19 after the first surge were more likely to receive high-flow nasal cannula and had better outcomes, while Ali et al showed that patients with STEMI yet again experienced worse outcomes during the first wave.

On the system improvement front, Cusick et al³ report on a quality improvement (QI) project that addressed acute disease management of heparin-induced thrombocytopenia (HIT) during hospitalization, Sosa et al⁴ discuss efforts to improve comorbidity capture at their institution, and Uche et al⁵ present the results of a nonpharmacologic initiative to improve management of chronic pain among veterans. Cusick et al’s QI project showed that a HIT testing strategy could be safely implemented through an evidence-based process to nudge resource utilization using specific management pathways. While capturing and measuring the complexity of diseases and comorbidities can be challenging, accurate capture is essential, as patient acuity has implications for reimbursement and quality comparisons for hospitals and physicians; Sosa et al describe a series of initiatives implemented at their institution that improved comorbidity capture. Furthermore, Uche et al report on a 10-week complementary and integrative health program for veterans with noncancer chronic pain that reduced pain intensity and improved quality of life for its participants. These QI reports show that, though the health care landscape has changed over the past 2 years, the aim remains the same: to provide the best care for patients regardless of the diagnosis, location, or time.

Conducting QI projects during the COVID-19 pandemic has been difficult, especially in terms of implementing consistent processes and management pathways while contending with staff and supply shortages. The pandemic, however, has highlighted the importance of continuing QI efforts, specifically around infectious disease prevention and good clinical practices. Moreover, the recent continuous learning and implementation around COVID-19 patient care has been a significant achievement, as clinicians and administrators worked continuously to understand and improve processes, create a supporting culture, and redesign care delivery on the fly. The management of both COVID-19 care and our usual care QI efforts should incorporate the lessons learned from the pandemic and leverage system redesign for future steps. As we’ve seen, survival in COVID-19 improved dramatically since the beginning of the pandemic, as clinical trials became more adaptive and efficient and system upgrades like telemedicine and digital technologies in the public health response led to major advancements. The work to improve the care provided in the clinic and at the bedside will continue through one collective approach in the new normal.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

As we transition out of the Omicron surge, the lessons we’ve learned from the prior surges carry forward and add to our knowledge foundation. Medical journals have published numerous research and perspectives manuscripts on all aspects of COVID-19 over the past 2 years, adding much-needed knowledge to our clinical practice during the pandemic. However, the story does not stop there, as the pandemic has impacted the usual, non-COVID-19 clinical care we provide. The value-based health care delivery model accounts for both COVID-19 clinical care and the usual care we provide our patients every day. Clinicians, administrators, and health care workers will need to know how to balance both worlds in the years to come.

In this issue of JCOM, the work of balancing the demands of COVID-19 care with those of system improvement continues. Two original research articles address the former, with Liesching et al¹ reporting data on improving clinical outcomes of patients with COVID-19 through acute care oxygen therapies, and Ali et al² explaining the impact of COVID-19 on STEMI care delivery models. Liesching et al’s study showed that patients admitted for COVID-19 after the first surge were more likely to receive high-flow nasal cannula and had better outcomes, while Ali et al showed that patients with STEMI yet again experienced worse outcomes during the first wave.

On the system improvement front, Cusick et al³ report on a quality improvement (QI) project that addressed acute disease management of heparin-induced thrombocytopenia (HIT) during hospitalization, Sosa et al⁴ discuss efforts to improve comorbidity capture at their institution, and Uche et al⁵ present the results of a nonpharmacologic initiative to improve management of chronic pain among veterans. Cusick et al’s QI project showed that a HIT testing strategy could be safely implemented through an evidence-based process to nudge resource utilization using specific management pathways. While capturing and measuring the complexity of diseases and comorbidities can be challenging, accurate capture is essential, as patient acuity has implications for reimbursement and quality comparisons for hospitals and physicians; Sosa et al describe a series of initiatives implemented at their institution that improved comorbidity capture. Furthermore, Uche et al report on a 10-week complementary and integrative health program for veterans with noncancer chronic pain that reduced pain intensity and improved quality of life for its participants. These QI reports show that, though the health care landscape has changed over the past 2 years, the aim remains the same: to provide the best care for patients regardless of the diagnosis, location, or time.

Conducting QI projects during the COVID-19 pandemic has been difficult, especially in terms of implementing consistent processes and management pathways while contending with staff and supply shortages. The pandemic, however, has highlighted the importance of continuing QI efforts, specifically around infectious disease prevention and good clinical practices. Moreover, the recent continuous learning and implementation around COVID-19 patient care has been a significant achievement, as clinicians and administrators worked continuously to understand and improve processes, create a supporting culture, and redesign care delivery on the fly. The management of both COVID-19 care and our usual care QI efforts should incorporate the lessons learned from the pandemic and leverage system redesign for future steps. As we’ve seen, survival in COVID-19 improved dramatically since the beginning of the pandemic, as clinical trials became more adaptive and efficient and system upgrades like telemedicine and digital technologies in the public health response led to major advancements. The work to improve the care provided in the clinic and at the bedside will continue through one collective approach in the new normal.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Case narrative

A 35-year-old woman has worsening alcoholic cirrhosis and repeated admissions for ascites, hepato-renal syndrome, and alcoholic hepatitis. Upon recognition of her grave prognosis, we proceeded with a shared-management approach involving medicine, gastroenterology, social work, chaplaincy, and palliative care. When the team spoke with the patient’s health care proxy (HCP), family, and friends for collateral information and involvement in goals of care conversation, we realized that none were aware of her months-long decline and poor prognosis for recovery to hospital discharge.

Although several factors contributed to the disconnect between the patient and her support system, the obstacles were greatly exacerbated by profound changes in hospital protocol because of the COVID-19 pandemic. Physicians feel underprepared and challenged by prognostication and discussion of end of life during normal times; we believe COVID-19 has limited this essential physician role and led to tragic delays in effective communication and end of life planning.
 

Closing the loop

For patients with complex medical issues or those reaching end of life, effective communication within the health care system is critical. While inpatient teams often drive the plan, they care for their patients during a snapshot in time; contrarily, primary care providers and specialists often have established longitudinal relationships with their patients. Ergo, clinicians should communicate directly, and ideally with both patients and families, to achieve patient-centered and goal-concordant care.

For medically complex patients, PCPs tend to prefer verbal hand-offs. Timely and reliable communication between inpatient and outpatient providers has also been shown to prevent medical adverse events.¹ Despite this, direct communication occurs infrequently.² Given that hospitalists serve as primary inpatient providers for most general admissions, it is their responsibility to communicate with outpatient providers.

A multidisciplinary team redesigned the process by which PCPs were contacted following patient discharge. The transmission of information should ideally occur prior to discharge.³ Deficits in communication are extremely common and may negatively impact patient care, patient satisfaction, and patient safety.
 

Changes during the COVID-19 era

During the pandemic, patients have only one visitor per day, restricted visiting hours, and limited interactions with clinicians per implemented policies. Along with the increased burdens from personal protective equipment, remote hospital providers (social workers, case managers), and increased bureaucratic duties, COVID-19 has elucidated limitations in medical capacity and revealed the difficulties that clinicians face in communicating with patients and families, especially about serious illness.

Tasks include facilitating virtual goodbyes between dying patients and families, conducting family meetings via teleconference, and discussing patient care with specialists through virtual technologies.⁴ While these tasks are arguably more important during a global disaster, COVID-19 paradoxically restricts physical presence and severely hinders communication.⁵ Clinicians should continue to utilize core skills like building rapport, assessing patient/family perspectives and agenda, and using empathy.⁶ Patients tend to more frequently value functional outcomes while clinicians tend to default to treatment modalities.⁷ Additionally, goals of care and end of life discussions are associated with improved quality of life, fewer aggressive medical interventions near death, and even increased survival.

Given the limited resources and difficulties in communication during the pandemic, clinicians should place greater emphasis on values-based shared decision-making. Internet-based solutions are essential and widely used, and videoconferencing has been initiated at the institutional scale at many hospitals. Many clinicians with little experience are broadly implementing these technologies.⁷ Despite these technological innovations, issues still arise in how to communicate effectively in the hospital setting, and we must acknowledge that strategies require devices, Internet access, and technological literacy, highlighting disparities in access to quality health care.⁶ Conversations during the pandemic will require listening, empathy, responsive action, and the acknowledgment of the social determinants of health.⁷

Improving communication and transition of care

Multiple steps will be warranted to implement the safe transition process and improve communication. High-quality patient care encompasses careful review of medications, communication between inpatient and outpatient providers, and close follow-up at discharge. These steps serve to increase our reliance on patient compliance and the exchange of information about global progression of disease.

The quantitative and qualitative steps of transition of care should overcome disconnect between teams, specifically deficit areas regarding postdischarge communication, monitoring, and understanding of prognosis around the relevance to this era of COVID-19.
 

Dr. Haddad is a resident physician in the psychiatry residency program at Brigham and Women’s Hospital, Boston. Dr. Halporn is clinic director, Division of Adult Palliative Care, in the department of psychosocial oncology and palliative care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Dr. Barkoudah is associate director of the Hospital Medicine Unit at Brigham and Women’s Hospital.

References

1. Goldman L et al. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S-39S. doi: 10.1016/s0002-9343(01)00968-8.

2. Kripalani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007 Feb 28;297(8):831-41. doi: 10.1001/jama.297.8.831.

3. Scotten M et al. Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient Educ Couns. 2015 Jul;98(7):895-900. doi: 10.1016/j.pec.2015.03.009.

4. Back A et al. Communication skills in the age of COVID-19. Ann Intern Med. 2020 Jun 2;172(11):759-60. doi: 10.7326/M20-1376.

5. Hart JL et al. Family-centered care during the COVID-19 era. J Pain Symptom Manage. 2020 Aug;60(2):e93-7. doi: 10.1016/j.jpainsymman.2020.04.017.

6. Rubinelli S et al. Implications of the current COVID-19 pandemic for communication in healthcare. Patient Educ Couns. 2020 Jun;103(6):1067-9. doi: 10.1016/j.pec.2020.04.021.

7. Simpson N et al. Don’t forget shared decision-making in the COVID-19 crisis. Intern Med J. 2020 Jun;50(6):761-3. doi: 10.1111/imj.14862.
 

Case narrative

A 35-year-old woman has worsening alcoholic cirrhosis and repeated admissions for ascites, hepato-renal syndrome, and alcoholic hepatitis. Upon recognition of her grave prognosis, we proceeded with a shared-management approach involving medicine, gastroenterology, social work, chaplaincy, and palliative care. When the team spoke with the patient’s health care proxy (HCP), family, and friends for collateral information and involvement in goals of care conversation, we realized that none were aware of her months-long decline and poor prognosis for recovery to hospital discharge.

Although several factors contributed to the disconnect between the patient and her support system, the obstacles were greatly exacerbated by profound changes in hospital protocol because of the COVID-19 pandemic. Physicians feel underprepared and challenged by prognostication and discussion of end of life during normal times; we believe COVID-19 has limited this essential physician role and led to tragic delays in effective communication and end of life planning.
 

Closing the loop

For patients with complex medical issues or those reaching end of life, effective communication within the health care system is critical. While inpatient teams often drive the plan, they care for their patients during a snapshot in time; contrarily, primary care providers and specialists often have established longitudinal relationships with their patients. Ergo, clinicians should communicate directly, and ideally with both patients and families, to achieve patient-centered and goal-concordant care.

For medically complex patients, PCPs tend to prefer verbal hand-offs. Timely and reliable communication between inpatient and outpatient providers has also been shown to prevent medical adverse events.¹ Despite this, direct communication occurs infrequently.² Given that hospitalists serve as primary inpatient providers for most general admissions, it is their responsibility to communicate with outpatient providers.

A multidisciplinary team redesigned the process by which PCPs were contacted following patient discharge. The transmission of information should ideally occur prior to discharge.³ Deficits in communication are extremely common and may negatively impact patient care, patient satisfaction, and patient safety.
 

Changes during the COVID-19 era

During the pandemic, patients have only one visitor per day, restricted visiting hours, and limited interactions with clinicians per implemented policies. Along with the increased burdens from personal protective equipment, remote hospital providers (social workers, case managers), and increased bureaucratic duties, COVID-19 has elucidated limitations in medical capacity and revealed the difficulties that clinicians face in communicating with patients and families, especially about serious illness.

Tasks include facilitating virtual goodbyes between dying patients and families, conducting family meetings via teleconference, and discussing patient care with specialists through virtual technologies.⁴ While these tasks are arguably more important during a global disaster, COVID-19 paradoxically restricts physical presence and severely hinders communication.⁵ Clinicians should continue to utilize core skills like building rapport, assessing patient/family perspectives and agenda, and using empathy.⁶ Patients tend to more frequently value functional outcomes while clinicians tend to default to treatment modalities.⁷ Additionally, goals of care and end of life discussions are associated with improved quality of life, fewer aggressive medical interventions near death, and even increased survival.

Given the limited resources and difficulties in communication during the pandemic, clinicians should place greater emphasis on values-based shared decision-making. Internet-based solutions are essential and widely used, and videoconferencing has been initiated at the institutional scale at many hospitals. Many clinicians with little experience are broadly implementing these technologies.⁷ Despite these technological innovations, issues still arise in how to communicate effectively in the hospital setting, and we must acknowledge that strategies require devices, Internet access, and technological literacy, highlighting disparities in access to quality health care.⁶ Conversations during the pandemic will require listening, empathy, responsive action, and the acknowledgment of the social determinants of health.⁷

Improving communication and transition of care

Multiple steps will be warranted to implement the safe transition process and improve communication. High-quality patient care encompasses careful review of medications, communication between inpatient and outpatient providers, and close follow-up at discharge. These steps serve to increase our reliance on patient compliance and the exchange of information about global progression of disease.

The quantitative and qualitative steps of transition of care should overcome disconnect between teams, specifically deficit areas regarding postdischarge communication, monitoring, and understanding of prognosis around the relevance to this era of COVID-19.
 

Dr. Haddad is a resident physician in the psychiatry residency program at Brigham and Women’s Hospital, Boston. Dr. Halporn is clinic director, Division of Adult Palliative Care, in the department of psychosocial oncology and palliative care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Dr. Barkoudah is associate director of the Hospital Medicine Unit at Brigham and Women’s Hospital.

References

1. Goldman L et al. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S-39S. doi: 10.1016/s0002-9343(01)00968-8.

2. Kripalani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007 Feb 28;297(8):831-41. doi: 10.1001/jama.297.8.831.

3. Scotten M et al. Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient Educ Couns. 2015 Jul;98(7):895-900. doi: 10.1016/j.pec.2015.03.009.

4. Back A et al. Communication skills in the age of COVID-19. Ann Intern Med. 2020 Jun 2;172(11):759-60. doi: 10.7326/M20-1376.

5. Hart JL et al. Family-centered care during the COVID-19 era. J Pain Symptom Manage. 2020 Aug;60(2):e93-7. doi: 10.1016/j.jpainsymman.2020.04.017.

6. Rubinelli S et al. Implications of the current COVID-19 pandemic for communication in healthcare. Patient Educ Couns. 2020 Jun;103(6):1067-9. doi: 10.1016/j.pec.2020.04.021.

7. Simpson N et al. Don’t forget shared decision-making in the COVID-19 crisis. Intern Med J. 2020 Jun;50(6):761-3. doi: 10.1111/imj.14862.
 

Case narrative

A 35-year-old woman has worsening alcoholic cirrhosis and repeated admissions for ascites, hepato-renal syndrome, and alcoholic hepatitis. Upon recognition of her grave prognosis, we proceeded with a shared-management approach involving medicine, gastroenterology, social work, chaplaincy, and palliative care. When the team spoke with the patient’s health care proxy (HCP), family, and friends for collateral information and involvement in goals of care conversation, we realized that none were aware of her months-long decline and poor prognosis for recovery to hospital discharge.

Although several factors contributed to the disconnect between the patient and her support system, the obstacles were greatly exacerbated by profound changes in hospital protocol because of the COVID-19 pandemic. Physicians feel underprepared and challenged by prognostication and discussion of end of life during normal times; we believe COVID-19 has limited this essential physician role and led to tragic delays in effective communication and end of life planning.
 

Closing the loop

For patients with complex medical issues or those reaching end of life, effective communication within the health care system is critical. While inpatient teams often drive the plan, they care for their patients during a snapshot in time; contrarily, primary care providers and specialists often have established longitudinal relationships with their patients. Ergo, clinicians should communicate directly, and ideally with both patients and families, to achieve patient-centered and goal-concordant care.

For medically complex patients, PCPs tend to prefer verbal hand-offs. Timely and reliable communication between inpatient and outpatient providers has also been shown to prevent medical adverse events.¹ Despite this, direct communication occurs infrequently.² Given that hospitalists serve as primary inpatient providers for most general admissions, it is their responsibility to communicate with outpatient providers.

A multidisciplinary team redesigned the process by which PCPs were contacted following patient discharge. The transmission of information should ideally occur prior to discharge.³ Deficits in communication are extremely common and may negatively impact patient care, patient satisfaction, and patient safety.
 

Changes during the COVID-19 era

During the pandemic, patients have only one visitor per day, restricted visiting hours, and limited interactions with clinicians per implemented policies. Along with the increased burdens from personal protective equipment, remote hospital providers (social workers, case managers), and increased bureaucratic duties, COVID-19 has elucidated limitations in medical capacity and revealed the difficulties that clinicians face in communicating with patients and families, especially about serious illness.

Tasks include facilitating virtual goodbyes between dying patients and families, conducting family meetings via teleconference, and discussing patient care with specialists through virtual technologies.⁴ While these tasks are arguably more important during a global disaster, COVID-19 paradoxically restricts physical presence and severely hinders communication.⁵ Clinicians should continue to utilize core skills like building rapport, assessing patient/family perspectives and agenda, and using empathy.⁶ Patients tend to more frequently value functional outcomes while clinicians tend to default to treatment modalities.⁷ Additionally, goals of care and end of life discussions are associated with improved quality of life, fewer aggressive medical interventions near death, and even increased survival.

Given the limited resources and difficulties in communication during the pandemic, clinicians should place greater emphasis on values-based shared decision-making. Internet-based solutions are essential and widely used, and videoconferencing has been initiated at the institutional scale at many hospitals. Many clinicians with little experience are broadly implementing these technologies.⁷ Despite these technological innovations, issues still arise in how to communicate effectively in the hospital setting, and we must acknowledge that strategies require devices, Internet access, and technological literacy, highlighting disparities in access to quality health care.⁶ Conversations during the pandemic will require listening, empathy, responsive action, and the acknowledgment of the social determinants of health.⁷

Improving communication and transition of care

Multiple steps will be warranted to implement the safe transition process and improve communication. High-quality patient care encompasses careful review of medications, communication between inpatient and outpatient providers, and close follow-up at discharge. These steps serve to increase our reliance on patient compliance and the exchange of information about global progression of disease.

The quantitative and qualitative steps of transition of care should overcome disconnect between teams, specifically deficit areas regarding postdischarge communication, monitoring, and understanding of prognosis around the relevance to this era of COVID-19.
 

Dr. Haddad is a resident physician in the psychiatry residency program at Brigham and Women’s Hospital, Boston. Dr. Halporn is clinic director, Division of Adult Palliative Care, in the department of psychosocial oncology and palliative care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Dr. Barkoudah is associate director of the Hospital Medicine Unit at Brigham and Women’s Hospital.

References

1. Goldman L et al. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S-39S. doi: 10.1016/s0002-9343(01)00968-8.

2. Kripalani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007 Feb 28;297(8):831-41. doi: 10.1001/jama.297.8.831.

3. Scotten M et al. Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient Educ Couns. 2015 Jul;98(7):895-900. doi: 10.1016/j.pec.2015.03.009.

4. Back A et al. Communication skills in the age of COVID-19. Ann Intern Med. 2020 Jun 2;172(11):759-60. doi: 10.7326/M20-1376.

5. Hart JL et al. Family-centered care during the COVID-19 era. J Pain Symptom Manage. 2020 Aug;60(2):e93-7. doi: 10.1016/j.jpainsymman.2020.04.017.

6. Rubinelli S et al. Implications of the current COVID-19 pandemic for communication in healthcare. Patient Educ Couns. 2020 Jun;103(6):1067-9. doi: 10.1016/j.pec.2020.04.021.

7. Simpson N et al. Don’t forget shared decision-making in the COVID-19 crisis. Intern Med J. 2020 Jun;50(6):761-3. doi: 10.1111/imj.14862.