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Patient Safety and Ouality lmprovement Name Common Uses Effectiveness Adverce Effects lmportant Drug lnteractions Black cohosh Treatment of menopausal Probably effeaive, low- Possible estrogenic effect hot flashes quality evidence on breast Avoid in women with estrogen receptor- positive breast cancer Reports of hepatotoxicity Cranberry Prevention of urinary tract Probably ineffective; low- lncreased glucose intake infections quality evidence with juice, Gl upset Echinacea Prevention o{ common Small effect GI upset, nausea, allergic colds reactions t Treatment of common Not effective colds Evening Treatment of breast pain Mixed data on effectiveness Gl upset, headache May increase bleeding if primrose oil used with warfarin Treatment of eczema Not effective May increase risk for pregnancy complications Treatment of diabetic Possibly effective neuropathy Garlic Treatment of high Not effective lncreased bleeding risk, May decrease l cholesterol breath and body odor, effectiveness of isoniazid heartburn and saquinavir Treatment of hypertension Possibly effective; weak :

Name Common Uses Effectiveness Adverce Effects lmportant Drug lnteractions Black cohosh Treatment of menopausal Probably effeaive, low- Possible estrogenic effect hot flashes quality evidence on breast Avoid in women with estrogen receptor- positive breast cancer Reports of hepatotoxicity Cranberry Prevention of urinary tract Probably ineffective; low- lncreased glucose intake infections quality evidence with juice, Gl upset Echinacea Prevention o{ common Small effect GI upset, nausea, allergic colds reactions t Treatment of common Not effective colds Evening Treatment of breast pain Mixed data on effectiveness Gl upset, headache May increase bleeding if primrose oil used with warfarin Treatment of eczema Not effective May increase risk for pregnancy complications Treatment of diabetic Possibly effective neuropathy Garlic Treatment of high Not effective lncreased bleeding risk, May decrease l cholesterol breath and body odor, effectiveness of isoniazid heartburn and saquinavir Treatment of hypertension Possibly effective; weak : evidence May increase bleeding if used with warfarin, likely due to antiplatelet effect i Ginger Treatment of nausea Probably effeaive for lncreased bleeding May increase risk for pregnancy-related and bleeding when used with ) chemothera py-related anticoagulants nausea I

evidence May increase bleeding if used with warfarin, likely due to antiplatelet effect i Ginger Treatment of nausea Probably effeaive for lncreased bleeding May increase risk for pregnancy-related and bleeding when used with ) chemothera py-related anticoagulants nausea I Treatment of inflammation Possibly effeaive t : Ginkgo biloba Treatment and prevention Not effective Headache, Gl upset, Mayincrease riskfor of cognitive decline allergic skin reactions, bleeding when used whh :

Treatment of inflammation Possibly effeaive t : Ginkgo biloba Treatment and prevention Not effective Headache, Gl upset, Mayincrease riskfor of cognitive decline allergic skin reactions, bleeding when used whh : increased risk for anticoagulants and Treatment of claudication Not effective bleeding NSAIDs; potentiates MAOIs Kava Treatment of anxiety Probably effective Hepatotoxicity Use with caution in patients with liver disease or at risk for liver disease Milk thistle Reduction in liver Not effective Nausea, indigestion, May interact with inflammation diarrhea medications metabolized by CYP2C9 Red yeast rice Treatment of Probably effeaive; risks Myalgia, liver function May interact with (contains hyperlipidemia likelyto outweigh benefits abnormalities medications metabolized monacolin K, by CYP3A4 enzymes identical active Some may contain citrinin (a harmful contaminant), ingredient to lovastatin) which can cause kidney failure Saw palmetto Treatment of benign Probably not effective Headache, nausea, dizziness prostatic hyperplasia Contraindicated in pregnancy and lactation soy Treatment of menopausal Probably effective; low- Gl upset, allergic reaction (isoflavones) symptoms quality evidence Avoid high doses in patients with breast cancer

increased risk for anticoagulants and Treatment of claudication Not effective bleeding NSAIDs; potentiates MAOIs Kava Treatment of anxiety Probably effective Hepatotoxicity Use with caution in patients with liver disease or at risk for liver disease Milk thistle Reduction in liver Not effective Nausea, indigestion, May interact with inflammation diarrhea medications metabolized by CYP2C9 Red yeast rice Treatment of Probably effeaive; risks Myalgia, liver function May interact with (contains hyperlipidemia likelyto outweigh benefits abnormalities medications metabolized monacolin K, by CYP3A4 enzymes identical active Some may contain citrinin (a harmful contaminant), ingredient to lovastatin) which can cause kidney failure Saw palmetto Treatment of benign Probably not effective Headache, nausea, dizziness prostatic hyperplasia Contraindicated in pregnancy and lactation soy Treatment of menopausal Probably effective; low- Gl upset, allergic reaction (isoflavones) symptoms quality evidence Avoid high doses in patients with breast cancer (Continued on the next page)

increased risk for anticoagulants and Treatment of claudication Not effective bleeding NSAIDs; potentiates MAOIs Kava Treatment of anxiety Probably effective Hepatotoxicity Use with caution in patients with liver disease or at risk for liver disease Milk thistle Reduction in liver Not effective Nausea, indigestion, May interact with inflammation diarrhea medications metabolized by CYP2C9 Red yeast rice Treatment of Probably effeaive; risks Myalgia, liver function May interact with (contains hyperlipidemia likelyto outweigh benefits abnormalities medications metabolized monacolin K, by CYP3A4 enzymes identical active Some may contain citrinin (a harmful contaminant), ingredient to lovastatin) which can cause kidney failure Saw palmetto Treatment of benign Probably not effective Headache, nausea, dizziness prostatic hyperplasia Contraindicated in pregnancy and lactation soy Treatment of menopausal Probably effective; low- Gl upset, allergic reaction (isoflavones) symptoms quality evidence Avoid high doses in patients with breast cancer (Continued on the next page) 20 t l

increased risk for anticoagulants and Treatment of claudication Not effective bleeding NSAIDs; potentiates MAOIs Kava Treatment of anxiety Probably effective Hepatotoxicity Use with caution in patients with liver disease or at risk for liver disease Milk thistle Reduction in liver Not effective Nausea, indigestion, May interact with inflammation diarrhea medications metabolized by CYP2C9 Red yeast rice Treatment of Probably effeaive; risks Myalgia, liver function May interact with (contains hyperlipidemia likelyto outweigh benefits abnormalities medications metabolized monacolin K, by CYP3A4 enzymes identical active Some may contain citrinin (a harmful contaminant), ingredient to lovastatin) which can cause kidney failure Saw palmetto Treatment of benign Probably not effective Headache, nausea, dizziness prostatic hyperplasia Contraindicated in pregnancy and lactation soy Treatment of menopausal Probably effective; low- Gl upset, allergic reaction (isoflavones) symptoms quality evidence Avoid high doses in patients with breast cancer (Continued on the next page) 20 t l \

Patient Safety and Ouality lmprovement TABLE 16. Common Herbal Supplements (Continued) Name Common Uses Effectiveness Adverse Effects lmportant Drug lnteractions St. John's wort Treatment of depression Mixed data on Gl upset, fatigue, lnducer of CYP3A4 and effectiveness headache. dizziness CYP2C9 enzymes Many interactions L Do not use with antidepressants Valerian Treatment of anxiety Not effective; evidence is Tremor, headache, inconclusive sedation, hepatotoxicity Treatment of sleep disorders, insomnia CYP2C9 = cytochrome P450 2C9; CYP3A4 = cytochrome P450 3A4; Gl = gastrointestinal; MAOI = monoamine oxidase inhibitor.

TABLE 16. Common Herbal Supplements (Continued) Name Common Uses Effectiveness Adverse Effects lmportant Drug lnteractions St. John's wort Treatment of depression Mixed data on Gl upset, fatigue, lnducer of CYP3A4 and effectiveness headache. dizziness CYP2C9 enzymes Many interactions L Do not use with antidepressants Valerian Treatment of anxiety Not effective; evidence is Tremor, headache, inconclusive sedation, hepatotoxicity Treatment of sleep disorders, insomnia CYP2C9 = cytochrome P450 2C9; CYP3A4 = cytochrome P450 3A4; Gl = gastrointestinal; MAOI = monoamine oxidase inhibitor. hepatic function) that may affect medication dosing. Medication Adherence Physicians must also be diligent in screening for possible Medication adherence, defined as the degree to which a patient medication interactions. adheres to the dose and interval oftheir prescribed pharmaco logic regimen, is poor among patients with chronic medical TABLE 17. Strategies to Prevent Medication Errors conditions. Nonadherence, typically defined as failure to take Stage Safety Strategy at least 80% of a prescribed medication regimen, has been associated with increased health care utilization, poor out- Prescribing Avoid unnecessary medications by adhering to conservative prescribing comes, and increased costs. An estimated 2O% to 30% of pre- principles (e.9., consider alternatives to scriptions are never filled, and an estimated 50% of patients medication, review evidence or guideline supporting medication use) with chronic medical conditions are nonadherent with their prescribed regimen. Medication adherence is a complex Use computerized physician order entry especially when paired with clinical decision behavior that is influenced by the patient, system, and pro- support systems vider. The factors most strongly associated with medication Perform medication reconciliation attimes adherence include strong provider-patient relationships and a of transitions in care patient's understanding of their medical conditions. Transcribing Use computerized physician order entry to Patient related and societal factors that may have a sig- eliminate handwriting errors nificant impact on medication adherence include a high bur Dispensing Have clinical pharmacists oversee the den of disease with complex medication regimens; financial medication dispensing process stressors; distrust of clinicians and health care institutions; Use "tall man" lettering and other strategies and lack of social support, including transportation. Individual to minimize confusion between look-alike, physicians can have a meaningful, positive impact on medica sound-alike medications. Starting on the left side of a drug name, tall man lettering tion adherence. Physicians should inquire at each visit about highlights the differences between similar medication adherence in a nonjudgmental manner and avoid drug names by capitalizing dissimilar letters negative comments if nonadherence is uncovered. Patient self- (e.9., DOPamine and DOBUTamine) report may overestimate adherence by 2OO%, and physicians Administration Adhere to the "five rights" of administering should attempt to clearly quantit/ the degree of adherence. medication safely (administering the right medication, in the right dose, at the right Patients should be encouraged to bring their medications to time, by the right route, to the right patient) appointments, and providers should discuss the purpose of Use barcode medication administration to each medication. When possible, family members should be ensure medications are given to the correct engaged. For some patients, a visiting nurse may be needed to patient complete home visits to further assess reasons for nonadher Minimize interruptions to allow nurses to ence and promote adherence. administer medications safely There are a variety of methods to increase adherence and Use smart infusion pumps for intravenous multimodal approaches are more likely to be successful. infusions Physicians can promote medication adherence through phar- Use patient education and revised medication labels to improve patient comprehension of macotherapy regimen simplification, consultation with a admi nistration instructions clinical pharmacist, and optimization of cost incentives. Simpliflzing a medication regimen (such as prescribing combi Adapted from Agency for Healthcare Research and Ouality. Patient safety primer: medication errors. September 201 9. https://psnet.ahrq.gov/primer/medication' nation pills or implementing a schedule to take pills simulta- errors-and adverse-drug-events. Accessed June 1 7, 2021. neously) is a feasible method for patients and may result in a

hepatic function) that may affect medication dosing. Medication Adherence Physicians must also be diligent in screening for possible Medication adherence, defined as the degree to which a patient medication interactions. adheres to the dose and interval oftheir prescribed pharmaco logic regimen, is poor among patients with chronic medical TABLE 17. Strategies to Prevent Medication Errors conditions. Nonadherence, typically defined as failure to take Stage Safety Strategy at least 80% of a prescribed medication regimen, has been associated with increased health care utilization, poor out- Prescribing Avoid unnecessary medications by adhering to conservative prescribing comes, and increased costs. An estimated 2O% to 30% of pre- principles (e.9., consider alternatives to scriptions are never filled, and an estimated 50% of patients medication, review evidence or guideline supporting medication use) with chronic medical conditions are nonadherent with their prescribed regimen. Medication adherence is a complex Use computerized physician order entry especially when paired with clinical decision behavior that is influenced by the patient, system, and pro- support systems vider. The factors most strongly associated with medication Perform medication reconciliation attimes adherence include strong provider-patient relationships and a of transitions in care patient's understanding of their medical conditions. Transcribing Use computerized physician order entry to Patient related and societal factors that may have a sig- eliminate handwriting errors nificant impact on medication adherence include a high bur Dispensing Have clinical pharmacists oversee the den of disease with complex medication regimens; financial medication dispensing process stressors; distrust of clinicians and health care institutions; Use "tall man" lettering and other strategies and lack of social support, including transportation. Individual to minimize confusion between look-alike, physicians can have a meaningful, positive impact on medica sound-alike medications. Starting on the left side of a drug name, tall man lettering tion adherence. Physicians should inquire at each visit about highlights the differences between similar medication adherence in a nonjudgmental manner and avoid drug names by capitalizing dissimilar letters negative comments if nonadherence is uncovered. Patient self- (e.9., DOPamine and DOBUTamine) report may overestimate adherence by 2OO%, and physicians Administration Adhere to the "five rights" of administering should attempt to clearly quantit/ the degree of adherence. medication safely (administering the right medication, in the right dose, at the right Patients should be encouraged to bring their medications to time, by the right route, to the right patient) appointments, and providers should discuss the purpose of Use barcode medication administration to each medication. When possible, family members should be ensure medications are given to the correct engaged. For some patients, a visiting nurse may be needed to patient complete home visits to further assess reasons for nonadher Minimize interruptions to allow nurses to ence and promote adherence. administer medications safely There are a variety of methods to increase adherence and Use smart infusion pumps for intravenous multimodal approaches are more likely to be successful. infusions Physicians can promote medication adherence through phar- Use patient education and revised medication labels to improve patient comprehension of macotherapy regimen simplification, consultation with a admi nistration instructions clinical pharmacist, and optimization of cost incentives. Simpliflzing a medication regimen (such as prescribing combi Adapted from Agency for Healthcare Research and Ouality. Patient safety primer: medication errors. September 201 9. https://psnet.ahrq.gov/primer/medication' nation pills or implementing a schedule to take pills simulta- errors-and adverse-drug-events. Accessed June 1 7, 2021. neously) is a feasible method for patients and may result in a 21

Patient Safety and Ouality lmprovement patient taking fewer pills. However. it may require clinician For more information. see Hospital Medicine Principles' time for making changes and combination pills may be more f,EY POIXTS expensive. Consultation rn'ith tr clir.rical pharmacist is a team based approach that facilitates disease co management, allow . To prevent medication errors, physicians must review a patient's complete medical record, including medical ing physicians to utilize their time perfbrming other tasks. history; medication list, including prescription and This method may be costly and may not be available at all over the counter medications, herbal remedies, and institutions. Utilizing cost incentives (such as selecting medi supplements; allergies; and laboratory data that may cations with lowest copays or available discounts) can be time affect medication dosing. intensive and may require clinicians to maintain knowledge of shifting copays among a large number ol health insurance o The most widely used method for handoff communica- companies. tion during transition of care is the SBAR (Situation. Patient education (online resources, handouts) is low Background, Assessment, and Recommendation) cost and widely available and usually requires the patient to technique. make a time investment to become educated. Cognitive behav ioral therapy in the form of selfr management strategies and motivational interviewing to promote adherence can be usedr Patient Safety and Ouality lssues when performed by a psychologist. clinicians can share responsibility of patient management. However, cognitive at the Systems Level behavioral therapy may not be available for all patients, Ouality lmprovement Models requires a patient's time investment. and has associated costs There are multiple QI models that provide structure for imple fbr use of a specialist. Patient reminders, such as text or voice menting QI interventions on a systems level. The American alerts, cirn be programmed into smart phones or other techno- College of Physicians (ACP) Advance curriculum provides a logical devices, but not allpatier.rts may have access to technol useful tool set and additional resources for implementing ogr and personal and interactive reminders may be more QI nterventions (r,r,r,rrw.acpon Iine. org practice - resources i r

patient taking fewer pills. However. it may require clinician For more information. see Hospital Medicine Principles' time for making changes and combination pills may be more f,EY POIXTS expensive. Consultation rn'ith tr clir.rical pharmacist is a team based approach that facilitates disease co management, allow . To prevent medication errors, physicians must review a patient's complete medical record, including medical ing physicians to utilize their time perfbrming other tasks. history; medication list, including prescription and This method may be costly and may not be available at all over the counter medications, herbal remedies, and institutions. Utilizing cost incentives (such as selecting medi supplements; allergies; and laboratory data that may cations with lowest copays or available discounts) can be time affect medication dosing. intensive and may require clinicians to maintain knowledge of shifting copays among a large number ol health insurance o The most widely used method for handoff communica- companies. tion during transition of care is the SBAR (Situation. Patient education (online resources, handouts) is low Background, Assessment, and Recommendation) cost and widely available and usually requires the patient to technique. make a time investment to become educated. Cognitive behav ioral therapy in the form of selfr management strategies and motivational interviewing to promote adherence can be usedr Patient Safety and Ouality lssues when performed by a psychologist. clinicians can share responsibility of patient management. However, cognitive at the Systems Level behavioral therapy may not be available for all patients, Ouality lmprovement Models requires a patient's time investment. and has associated costs There are multiple QI models that provide structure for imple fbr use of a specialist. Patient reminders, such as text or voice menting QI interventions on a systems level. The American alerts, cirn be programmed into smart phones or other techno- College of Physicians (ACP) Advance curriculum provides a logical devices, but not allpatier.rts may have access to technol useful tool set and additional resources for implementing ogr and personal and interactive reminders may be more QI nterventions (r,r,r,rrw.acpon Iine. org practice - resources i r ef fective. Pill boxes may also be used. acp quality improvement/acp advanceiquality improvement curriculum). The Plan Do Study Act (PDSA) cycle is a fre Transitions of Care quently used method in each of the models described in this When patients transition care between providers or care envi section and provides structure fbr continuous changes. ronments, they are at increased risk for harm. Handoffs between clinicians and teams are integral to this process and Model for Improvement are delined as the transf'er and acceptirnce of responsibility of The Model for Improvement is the most commonly used QI patient care between clinicians through effective communica model in health care. lt provides a simple framework for QI tion. Factors that contribute to suboptimal transitions include interventions that relies on rapid PDSA cycles. A key underly poor communication between health care team members, ing theme is that although not every change leads to improve incomplete transler of information, and inadequate patient ment, improvement cannot occur without change. This model education. Patient factors that increase likelihood ofsubopti works best when frontline health care staff,members are actile mal transition of care include older age, multiple medical participants. Users of this model begin by developing a goal by comorbidities, poor health literacy. language barriers, and asking, "What are we trying to accomplish?" Next. to deter cognitive impairment. mine how to track success. users must anst ler, "Hort'u'ill rte Excellent communication among health care team mem nleasure if a change yields an impro'"ement?" The final step in bers and between providers and patients is the key to success this model is to determine rthat change is going to be made b1' ful transition of care. The n.rost widely used method fbr asking the question, "What change can we make that rvill handoff communication is the SBAR (Situation, Background, result in improvement?" Because this QI model does not help Assessment, and Recommendation) technique (see Table 18). to identify causes of health care problems. it works best for Transitions are also enhanced by physician involvement in a problems with easily identifiable causes and evidence based multidisciplinary team utilizing a continuous, case based solutions. For example, a medical center may set the specific multidisciplinary team management approach. During transi goal of increasing adherence to stroke treatment guidelines tions, physicians should strive to provide clear, concise, and and use PDSA cycles to rapidly implement and assess the accurate patient records to subsequent providers. Accurate inlpact of changes. such as using a computerized admission medication reconciliation. although tinte consuming. is para order set. mount because errors frequently occur: several studies have shown medication reconciliation is best performed by a phar Lean macist. Upon hospital discharge, physicians must focus on The Lean model focuses on improving health care processes follow up plans, including educating patients on the expected through two principles: waste elimination and respect for course and red Ilag symptoms that necessitate reevaluation. individuals. ln this model, activities are classified as being

ef fective. Pill boxes may also be used. acp quality improvement/acp advanceiquality improvement curriculum). The Plan Do Study Act (PDSA) cycle is a fre Transitions of Care quently used method in each of the models described in this When patients transition care between providers or care envi section and provides structure fbr continuous changes. ronments, they are at increased risk for harm. Handoffs between clinicians and teams are integral to this process and Model for Improvement are delined as the transf'er and acceptirnce of responsibility of The Model for Improvement is the most commonly used QI patient care between clinicians through effective communica model in health care. lt provides a simple framework for QI tion. Factors that contribute to suboptimal transitions include interventions that relies on rapid PDSA cycles. A key underly poor communication between health care team members, ing theme is that although not every change leads to improve incomplete transler of information, and inadequate patient ment, improvement cannot occur without change. This model education. Patient factors that increase likelihood ofsubopti works best when frontline health care staff,members are actile mal transition of care include older age, multiple medical participants. Users of this model begin by developing a goal by comorbidities, poor health literacy. language barriers, and asking, "What are we trying to accomplish?" Next. to deter cognitive impairment. mine how to track success. users must anst ler, "Hort'u'ill rte Excellent communication among health care team mem nleasure if a change yields an impro'"ement?" The final step in bers and between providers and patients is the key to success this model is to determine rthat change is going to be made b1' ful transition of care. The n.rost widely used method fbr asking the question, "What change can we make that rvill handoff communication is the SBAR (Situation, Background, result in improvement?" Because this QI model does not help Assessment, and Recommendation) technique (see Table 18). to identify causes of health care problems. it works best for Transitions are also enhanced by physician involvement in a problems with easily identifiable causes and evidence based multidisciplinary team utilizing a continuous, case based solutions. For example, a medical center may set the specific multidisciplinary team management approach. During transi goal of increasing adherence to stroke treatment guidelines tions, physicians should strive to provide clear, concise, and and use PDSA cycles to rapidly implement and assess the accurate patient records to subsequent providers. Accurate inlpact of changes. such as using a computerized admission medication reconciliation. although tinte consuming. is para order set. mount because errors frequently occur: several studies have shown medication reconciliation is best performed by a phar Lean macist. Upon hospital discharge, physicians must focus on The Lean model focuses on improving health care processes follow up plans, including educating patients on the expected through two principles: waste elimination and respect for course and red Ilag symptoms that necessitate reevaluation. individuals. ln this model, activities are classified as being 22

Patient Safety and Ouality lmprovement either value added (directly corrtributing to meeting patient rEY POII{I needs) or non-value added (recluiring resources of time ancl r The Model for lmprovement, Lean, Six Sigma, and HVC space but not meeting patient needs). On average, most pro Operational Excellence are examples of quality improve- cesses are only 5'/, value added and 95'1, non-value addecl. 'l'he Lean model is best applied kr directly observed problems ment models that can be used in the health care setting.

either value added (directly corrtributing to meeting patient rEY POII{I needs) or non-value added (recluiring resources of time ancl r The Model for lmprovement, Lean, Six Sigma, and HVC space but not meeting patient needs). On average, most pro Operational Excellence are examples of quality improve- cesses are only 5'/, value added and 95'1, non-value addecl. 'l'he Lean model is best applied kr directly observed problems ment models that can be used in the health care setting. ancl when fiow, efficiency, and speed are prioritized; involve ment of fiontline health care stafl ntenrbers is crucial because they are in the best position to identify problems. Value stream Measurement of Ouality mapping is an example of the l-ean rrtodel in which the steps lmprovement of a process and time required fbr each step are graphically Multiple organizations and payers assess quality of care as a displayed, thereby highlighting process inefficiencies and condition of accreditation or participation. For exantple, the alkrwing for their improvement. Usir.rg the Lean model, results Joint Commission assesses a wide variety of quality metrics, cln typically be seen within weeks. such as timely provision of reperf usion therapy in acute myo cardial infarction, the inciclence ot potentially prever.rtable Six Sigma venous thromboembolic clisease. and rates ol influenza Six Sigma, which reters to six stanclrrrd deviations from the immunization. nrean, fbcuses on improvernent througl.r reducing variability Medicare also has a signilicant impact on measurement of' in pltient care. It relies or.r untlerstirnding and controlling health care quality. The Centers fbr Medicare & Medicaid Services processes by using quantitltive trurls, such as analysis ol assess areas of hospital perfbnrirnce, such as hospital mortality variance, control charts. ancl mathematic modeling. Six and readmission rates. ancl areas of anrbulatory care perfbmrance. Signra is a five phase process: Define. Measure, Analyze. such as lrypefiension control, prevention of diabetic nephropathy, Improve, and Control (DMAIC). ln the Define phase, key ar-rd colorectal cancer screening. l'}atients are surveyed reg:rrding nlersllres for determining success are established. In the the quality of their experience after hospitalization via the Hospital Measure phase, past perfbnnance levels are determined kr Consumer Assessmenf of llealthcare Provider and Systems provide a baseline to measure future improvement. In the Survey. Data related to hospital pcrfbmrance are publicly available Analyze phase, causes of the current problems and improve at www.medicare.gov/hospitalcompare. ment opportunities are identified. Finally, in the Contnil phase. improvement is standardize d to maintain sustainabil Patient Safety and Quality ity Six Sigma typically requires a time commitment of at I mprovement I nitiatives least several months and substantial institutional resources to ir.nplement effectively. As sucl.r, it is best applied to coll Patient-Centered Medical Home plex. multistep health care problcms in which an immediate TI.re patient centered n.redical home is :r model of providing

ancl when fiow, efficiency, and speed are prioritized; involve ment of fiontline health care stafl ntenrbers is crucial because they are in the best position to identify problems. Value stream Measurement of Ouality mapping is an example of the l-ean rrtodel in which the steps lmprovement of a process and time required fbr each step are graphically Multiple organizations and payers assess quality of care as a displayed, thereby highlighting process inefficiencies and condition of accreditation or participation. For exantple, the alkrwing for their improvement. Usir.rg the Lean model, results Joint Commission assesses a wide variety of quality metrics, cln typically be seen within weeks. such as timely provision of reperf usion therapy in acute myo cardial infarction, the inciclence ot potentially prever.rtable Six Sigma venous thromboembolic clisease. and rates ol influenza Six Sigma, which reters to six stanclrrrd deviations from the immunization. nrean, fbcuses on improvernent througl.r reducing variability Medicare also has a signilicant impact on measurement of' in pltient care. It relies or.r untlerstirnding and controlling health care quality. The Centers fbr Medicare & Medicaid Services processes by using quantitltive trurls, such as analysis ol assess areas of hospital perfbnrirnce, such as hospital mortality variance, control charts. ancl mathematic modeling. Six and readmission rates. ancl areas of anrbulatory care perfbmrance. Signra is a five phase process: Define. Measure, Analyze. such as lrypefiension control, prevention of diabetic nephropathy, Improve, and Control (DMAIC). ln the Define phase, key ar-rd colorectal cancer screening. l'}atients are surveyed reg:rrding nlersllres for determining success are established. In the the quality of their experience after hospitalization via the Hospital Measure phase, past perfbnnance levels are determined kr Consumer Assessmenf of llealthcare Provider and Systems provide a baseline to measure future improvement. In the Survey. Data related to hospital pcrfbmrance are publicly available Analyze phase, causes of the current problems and improve at www.medicare.gov/hospitalcompare. ment opportunities are identified. Finally, in the Contnil phase. improvement is standardize d to maintain sustainabil Patient Safety and Quality ity Six Sigma typically requires a time commitment of at I mprovement I nitiatives least several months and substantial institutional resources to ir.nplement effectively. As sucl.r, it is best applied to coll Patient-Centered Medical Home plex. multistep health care problcms in which an immediate TI.re patient centered n.redical home is :r model of providing cause or solution cannot be readily identified, such as prirnary health care that is coorclinated by a team olclinicians, catheter related bloodstream infections. including physicians, advanced prdctice practitioners, nurses, pharnracists, physicat therapists, patient educators, itt.td case Operational Excellence managers, housed within a collaborative group practicc. 'l'he Operutional Excellence is a continuous QI model that has its fur-rctions of the patient centered rnedical home include prcr roots in industry and fieqr-rently uses aspects of Lean. Six viding comprehensive health care, coordinating care across Sigma. and other Qt models. It is a management system that settings. improving access to services with extended clinician aims lbr consistent and reliable operation of an institutional rrvailabilitlr and er-rgaging in quality and safetf improventent strate$/ by focusing on leadership, problem solving, and tean.t programs. Further infornration about the patient centered work. '['he main focus is on patier.rt needs, but it also aims kr n.redical home is available liorrr the Agency fbr Healthcare er.r.rpower and engage all stafl nrentbers. All levels of an organi Research and Qualiry (AIIIrQ) (https:/ipcmh.ahrq.gov/pagei zation must be invested in the nroclel tbr it to be successful. defining pcmh) and the ACP (www.acponline.org/practice StafT r.r-rembers must be em;lclwered tti identify problems artcl resources/business resources/payment/delivery and paynlent brir.rg these problems, as well as potential solutions, to thc models/patient-centered rnedical home). rlttention of others and leadership. Leadership must v:rlue the The concept ol the patient centered medical home has opinions and contributions of the fiontline st:rff and promote been expanded in the patient centered medical neighborhtttid; l no blirme culture in wl.rich there is t.t<t i'ear of reprisal. PDSA this includes other clinicians and institutions (such as special cvcles. often centered on the ideas ol fror.rtline rt'orkers. are ists and hospitals) involved in ar.r ir.rdividual patient's care. con.rr.nonly used as a structurll approach within the Operational Excellence tiamenttrk to promote change. High Value Care Opcrational Excellence can be used to improve quality by 'l'he ACP High Value Carc initiative aims to impnrve healtl't, fbcusing on key perfbrm:rnce it'tclicirtors o1'quality and safety, avoid harms, and eliminatc wastelul practices. This initiative such :rs timely completion of tr-redic:rtion reconciliation. adclresses high-value care broadly, oflering learning resources

cause or solution cannot be readily identified, such as prirnary health care that is coorclinated by a team olclinicians, catheter related bloodstream infections. including physicians, advanced prdctice practitioners, nurses, pharnracists, physicat therapists, patient educators, itt.td case Operational Excellence managers, housed within a collaborative group practicc. 'l'he Operutional Excellence is a continuous QI model that has its fur-rctions of the patient centered rnedical home include prcr roots in industry and fieqr-rently uses aspects of Lean. Six viding comprehensive health care, coordinating care across Sigma. and other Qt models. It is a management system that settings. improving access to services with extended clinician aims lbr consistent and reliable operation of an institutional rrvailabilitlr and er-rgaging in quality and safetf improventent strate$/ by focusing on leadership, problem solving, and tean.t programs. Further infornration about the patient centered work. '['he main focus is on patier.rt needs, but it also aims kr n.redical home is available liorrr the Agency fbr Healthcare er.r.rpower and engage all stafl nrentbers. All levels of an organi Research and Qualiry (AIIIrQ) (https:/ipcmh.ahrq.gov/pagei zation must be invested in the nroclel tbr it to be successful. defining pcmh) and the ACP (www.acponline.org/practice StafT r.r-rembers must be em;lclwered tti identify problems artcl resources/business resources/payment/delivery and paynlent brir.rg these problems, as well as potential solutions, to thc models/patient-centered rnedical home). rlttention of others and leadership. Leadership must v:rlue the The concept ol the patient centered medical home has opinions and contributions of the fiontline st:rff and promote been expanded in the patient centered medical neighborhtttid; l no blirme culture in wl.rich there is t.t<t i'ear of reprisal. PDSA this includes other clinicians and institutions (such as special cvcles. often centered on the ideas ol fror.rtline rt'orkers. are ists and hospitals) involved in ar.r ir.rdividual patient's care. con.rr.nonly used as a structurll approach within the Operational Excellence tiamenttrk to promote change. High Value Care Opcrational Excellence can be used to improve quality by 'l'he ACP High Value Carc initiative aims to impnrve healtl't, fbcusing on key perfbrm:rnce it'tclicirtors o1'quality and safety, avoid harms, and eliminatc wastelul practices. This initiative such :rs timely completion of tr-redic:rtion reconciliation. adclresses high-value care broadly, oflering learning resources 23

Patient Safety and Ouality lmprovement for clinicians and medical educators, clinical guidelines, best CDS is the use of information technolory to facilitate practice advice, and patient resources on a wide variety of clinical decision making. When integrated into a CPOE system, related topics (r,tr,tr,v.acponline.orgiclinical information/high CDS can highlight potential contraindications to diagnostic value care). Components of the High Value Care initiative that tests, specilz dose recommendations, identiff potential drug are evident in MKSAP 19 include the identification of High interactions, and suggest modifications to drug dosages in Value Care key points in the text and a list ofhigh value care patients with kidney or liver dysfunction. CDS within the EHR recommendations assembled for each MKSAP section. can also promote protocols to improve care and provide ready access to clinical guidelines. Choosing Wisely Limitations of HIT include the expense associated with The Choosing Wisely initiative was developed by the American system implementation and maintenance as well as concerns Board of Internal Medicine Foundation in collaboration with related to protection of patient privacy. Although useful for Consumer Reports to encourage discussions between clini preventing many Spes of errors, HIT does not provide a lail cians and patients on selecting tests, treatments, and proce- safe against errors and may facilitate errors itself, such as those dures that are evidence-based and truly necessary thereby resulting from charting templates and use of the copy-and- avoiding unnecessary care. More than 80 specialist orgaliza paste function in composing notes. Alert fatigue, wherein cli- tions have participated to create lists of overused tests and nicians are subjected to so many alerts they begin to ignore all treatments in their specialties (wwwchoosingwisely.org/ of them. is a substantial drawback to CDS and can decrease the clinician-lists), and Consumer Reporfs has generated patient effectiveness of alert systems. education materials based on these lists to engage and Useful resources for incorporation of HIT in practice are empower patients to participate in care discussions. available from ACP (www.acponline.org/practice resources/ business resources/health information-technolory) and National Patient Safety Goals AHRQ (www.ahrq.gov/professionals/prevention chronic care/ The Joint Commission establishes annual National Patient Safety improve/health-it). Goals to address important issues in health care safety. Recommended by a panel of patient safef experts and applied to a variety of patient care settings, the National Patient Safety Health Literacy Goals center on interventions that have the highest impact on As defined by AHRQ, health literacy is the degree to which quality and safety. In publishing the goals, the Joint Commission individuals have the capacity to obtain, process, and under also provides specific metrics for each goal to facilitate implemen- stand the information required to make informed health deci tation. Goals are customized to the care setting and separate goals sions. Low health Iiteracy is more common among older are provided for hospitals, ambulatory health centers, and nurs adults, minority populations, persons with lower socioeco ing care centers, among others. The goals are updated annually nomic status, and medically underserved groups. Low health and are available at wr,vw.jointcommission.org/standards/ literacy may hinder patients' ability to describe their health national-patient safegr goals and www.jointcommission.org/ concerns, complete health forms accurately, understand standards /national-patient- safety goals /hospital-national medical information, and manage their health conditions. patient- safety- goals. Furthermore, evidence shows that low health literacy is asso- ciated with poorer health outcomes and decreased utilization of care. Clinicians need to be aware of the health literacy of their Health I nformation Tech nology patients and identiflz those who may need assistance. Tools to and Patient Safety assess health literacy in specific populations are available from Health information technolory (HIT) is the use of an electronic AHRQ (www.ahrq.gov/health-literacy/quality resources/ environment to share patient health information and facilitate tools/literacy/index.html) and include the Short Assessment patient management. The electronic health record (EHR), of Health Literacy and the Rapid Estimate of Adult Literacy in computerized physician order entry (CPOE), and computer Medicine. Another instrument available for use is the Newest ized clinical decision support (CDS) are some common exam- Vital Sign, which can help predict a patient's ability to com ples of HIT. prehend common instructions related to frequent primary The EHR is a compilation of all health data for a specific care scenarios. This tool and multiple other health literacy patient, including medical notes and test results, in a digital measures are available through the Health Literacy Tool Shed format. The EHR enables the timely sharing of patient infor (http: //healthliteracy.bu.edu/all). mation by multiple users, resulting in improved communica Clinicians can improve patient understanding by using tion and care efficiency. simple sentences, repeating information, providing an oppor CPOE is a system by which clinicians electronically enter tunity for the patient to ask questions, and supplying the medication, radiologr, and laboratory orders, thereby elimi patient with educational materials written in plain language. nating errors and delays related to illegible handwriting. The teach back method, wherein the clinician asks the patient

for clinicians and medical educators, clinical guidelines, best CDS is the use of information technolory to facilitate practice advice, and patient resources on a wide variety of clinical decision making. When integrated into a CPOE system, related topics (r,tr,tr,v.acponline.orgiclinical information/high CDS can highlight potential contraindications to diagnostic value care). Components of the High Value Care initiative that tests, specilz dose recommendations, identiff potential drug are evident in MKSAP 19 include the identification of High interactions, and suggest modifications to drug dosages in Value Care key points in the text and a list ofhigh value care patients with kidney or liver dysfunction. CDS within the EHR recommendations assembled for each MKSAP section. can also promote protocols to improve care and provide ready access to clinical guidelines. Choosing Wisely Limitations of HIT include the expense associated with The Choosing Wisely initiative was developed by the American system implementation and maintenance as well as concerns Board of Internal Medicine Foundation in collaboration with related to protection of patient privacy. Although useful for Consumer Reports to encourage discussions between clini preventing many Spes of errors, HIT does not provide a lail cians and patients on selecting tests, treatments, and proce- safe against errors and may facilitate errors itself, such as those dures that are evidence-based and truly necessary thereby resulting from charting templates and use of the copy-and- avoiding unnecessary care. More than 80 specialist orgaliza paste function in composing notes. Alert fatigue, wherein cli- tions have participated to create lists of overused tests and nicians are subjected to so many alerts they begin to ignore all treatments in their specialties (wwwchoosingwisely.org/ of them. is a substantial drawback to CDS and can decrease the clinician-lists), and Consumer Reporfs has generated patient effectiveness of alert systems. education materials based on these lists to engage and Useful resources for incorporation of HIT in practice are empower patients to participate in care discussions. available from ACP (www.acponline.org/practice resources/ business resources/health information-technolory) and National Patient Safety Goals AHRQ (www.ahrq.gov/professionals/prevention chronic care/ The Joint Commission establishes annual National Patient Safety improve/health-it). Goals to address important issues in health care safety. Recommended by a panel of patient safef experts and applied to a variety of patient care settings, the National Patient Safety Health Literacy Goals center on interventions that have the highest impact on As defined by AHRQ, health literacy is the degree to which quality and safety. In publishing the goals, the Joint Commission individuals have the capacity to obtain, process, and under also provides specific metrics for each goal to facilitate implemen- stand the information required to make informed health deci tation. Goals are customized to the care setting and separate goals sions. Low health Iiteracy is more common among older are provided for hospitals, ambulatory health centers, and nurs adults, minority populations, persons with lower socioeco ing care centers, among others. The goals are updated annually nomic status, and medically underserved groups. Low health and are available at wr,vw.jointcommission.org/standards/ literacy may hinder patients' ability to describe their health national-patient safegr goals and www.jointcommission.org/ concerns, complete health forms accurately, understand standards /national-patient- safety goals /hospital-national medical information, and manage their health conditions. patient- safety- goals. Furthermore, evidence shows that low health literacy is asso- ciated with poorer health outcomes and decreased utilization of care. Clinicians need to be aware of the health literacy of their Health I nformation Tech nology patients and identiflz those who may need assistance. Tools to and Patient Safety assess health literacy in specific populations are available from Health information technolory (HIT) is the use of an electronic AHRQ (www.ahrq.gov/health-literacy/quality resources/ environment to share patient health information and facilitate tools/literacy/index.html) and include the Short Assessment patient management. The electronic health record (EHR), of Health Literacy and the Rapid Estimate of Adult Literacy in computerized physician order entry (CPOE), and computer Medicine. Another instrument available for use is the Newest ized clinical decision support (CDS) are some common exam- Vital Sign, which can help predict a patient's ability to com ples of HIT. prehend common instructions related to frequent primary The EHR is a compilation of all health data for a specific care scenarios. This tool and multiple other health literacy patient, including medical notes and test results, in a digital measures are available through the Health Literacy Tool Shed format. The EHR enables the timely sharing of patient infor (http: //healthliteracy.bu.edu/all). mation by multiple users, resulting in improved communica Clinicians can improve patient understanding by using tion and care efficiency. simple sentences, repeating information, providing an oppor CPOE is a system by which clinicians electronically enter tunity for the patient to ask questions, and supplying the medication, radiologr, and laboratory orders, thereby elimi patient with educational materials written in plain language. nating errors and delays related to illegible handwriting. The teach back method, wherein the clinician asks the patient 24

i I L Hospital Medicine Principles t I I I ! prioritize, and implement recommendations by specialists and to describe his or her understanding of the situation in his or I her own words, can further assess a patient's command of the other consulting services in a timely fashion, if within the I situation and provide valuable insight into patient knowledge goals of care. Hospitalists are instrumental in synthesizing I I information and clearly communicating care plans to other and health literacy. i providers, clinicians, patients, and families. Meticulous coor- I dination of information among services and specialties t improves consistency of messaging to patients and reduces ; t Hospital Medicine fragmentation of care that can result in omissions, duplica Principles tions, or discrepancies of care. The frequent hand offs between clinical teams inherent I The specialty of hospital medicine has established itself as an to hospital medicine require specific aftention on the part of important leader in key domains critical to hospital function- the hospitalist to prevent errors. Two thirds ofsentinel events \

t Hospital Medicine fragmentation of care that can result in omissions, duplica Principles tions, or discrepancies of care. The frequent hand offs between clinical teams inherent I The specialty of hospital medicine has established itself as an to hospital medicine require specific aftention on the part of important leader in key domains critical to hospital function- the hospitalist to prevent errors. Two thirds ofsentinel events \ ing. ln addition to expertise in the management of inpatient in the hospital occur in the setting of inadequate handoffs. I medical issues, a hospitalist's core competencies, as defined by Handoffs are defined as the transfer and acceptance ofrespon- the Society of Hospital Medicine, include expertise in interdis- sibility of patient care between clinicians through effective ciplinary communication and team-based care, perioperative communication. Handoffs are high frequency events in the r and consultative medicine, prevention of health care associ- hospital and can be difficult to do well. Strategies aimed at I L ated conditions, transitions of care, and patient safety. standardizing and improving handofl's, such as I-PASS (lllness severity, Patient summary Action list, Situation awareness and

L ated conditions, transitions of care, and patient safety. standardizing and improving handofl's, such as I-PASS (lllness severity, Patient summary Action list, Situation awareness and \ I nterprofessional Communication contingency planning, Synthesis), provide a framework for the transfer of important information and promote consistency of I and Team-Based Care practice (see Table 18). I The importance of quality communication among providers The potential for medical errors is particularly high at during a patient's hospitalization and care transitions has the time of hospital discharge, underscoring the importance I never been more evident. These periods typically involve of accurate information transler between sites of care. When numerous clinicians and providers when patients are vulner certain parts ofcare plans, including follow up testing and I able and the risk for medical errors is high. To minimize errors treatment, are appropriate to be deferred until a1'ter dis- and potential complications, excellence in intra- and interpro- charge, the hospitalist is responsible for the handoff of this fessional communication and strong team leadership are information to the appropriate accepting provider, typically expected competencies of all hospitalists. the primary care team. Hospitalists most commonly com Lines of communication for which an inpatient physician municate with primary care teams through the discharge is responsible include communication with patients and fami- summary but a hospitalist may also directly contact primary lies, specialty consultants, other hospitalists during handoffs, care providers at the time of discharge. Key information that staff in other disciplines (therapists, social workers, pharma- should be relayed at the time of discharge includes the rea- cists, nurses, case managers), primary care providers, and staff son for admission; diagnoses; hospital course; laboratory at skilled nursing and rehabilitation facilities. The use ofspe- and imaging results; discharge medication list; pending cific communication tools and techniques may improve out- tests; and postdischarge plan of care, including follow up comes and reduce errors (Table f8). appointments. Multidisciplinary team based care delivery is a key strat- egz to improve care quality, patient saf'ety, and overall outcomes. Critical elements of success in multidisciplinary teams include Consultation and Co-management effective communication, mutual respect, clear roles and Hospitalists are frequently asked to consult on the care of sur responsibilities, and alignment of goals. As a team leader, the gical, psychiatric, and nonmedical patients. This traditional hospitalist must monitor and bring together different parts of medical consultation model addresses specific questions on the care plan, incorporate input from multiple team members medical management. The consultant's responsibilities are to from different disciplines, provide feedback and mediate when confirm the question being asked, evaluate the patient, and conflict exists, ensure an environment of shared responsibility communicate recommendations on specific issues to the pri and respect, and appropriately delegate tasks. Regrlar team mary team. The primary team rvill then implement the plan if meetings with and without patients and families help ensure in agreement with the recommendations. A consultant may uniformity in treatment plans and care coordination and serve continue to follow a patient if the clinical condition is evolving to update providers on all aspects of patient care and progress. or when specifically asked to do so, or may sign off when input These meetings often occur in the setting of changes in a on the case is complete. In the consultant role, hospitalists do patient's clinical course or in preparation for care transitions. not tlpically write orders unless specifically asked to do so, but During complicated hospital stays with involvement of they maintain responsibility to review and interpret results of multiple specialty clinicians, hospitalists must also assess, recommended studies.

\ I nterprofessional Communication contingency planning, Synthesis), provide a framework for the transfer of important information and promote consistency of I and Team-Based Care practice (see Table 18). I The importance of quality communication among providers The potential for medical errors is particularly high at during a patient's hospitalization and care transitions has the time of hospital discharge, underscoring the importance I never been more evident. These periods typically involve of accurate information transler between sites of care. When numerous clinicians and providers when patients are vulner certain parts ofcare plans, including follow up testing and I able and the risk for medical errors is high. To minimize errors treatment, are appropriate to be deferred until a1'ter dis- and potential complications, excellence in intra- and interpro- charge, the hospitalist is responsible for the handoff of this fessional communication and strong team leadership are information to the appropriate accepting provider, typically expected competencies of all hospitalists. the primary care team. Hospitalists most commonly com Lines of communication for which an inpatient physician municate with primary care teams through the discharge is responsible include communication with patients and fami- summary but a hospitalist may also directly contact primary lies, specialty consultants, other hospitalists during handoffs, care providers at the time of discharge. Key information that staff in other disciplines (therapists, social workers, pharma- should be relayed at the time of discharge includes the rea- cists, nurses, case managers), primary care providers, and staff son for admission; diagnoses; hospital course; laboratory at skilled nursing and rehabilitation facilities. The use ofspe- and imaging results; discharge medication list; pending cific communication tools and techniques may improve out- tests; and postdischarge plan of care, including follow up comes and reduce errors (Table f8). appointments. Multidisciplinary team based care delivery is a key strat- egz to improve care quality, patient saf'ety, and overall outcomes. Critical elements of success in multidisciplinary teams include Consultation and Co-management effective communication, mutual respect, clear roles and Hospitalists are frequently asked to consult on the care of sur responsibilities, and alignment of goals. As a team leader, the gical, psychiatric, and nonmedical patients. This traditional hospitalist must monitor and bring together different parts of medical consultation model addresses specific questions on the care plan, incorporate input from multiple team members medical management. The consultant's responsibilities are to from different disciplines, provide feedback and mediate when confirm the question being asked, evaluate the patient, and conflict exists, ensure an environment of shared responsibility communicate recommendations on specific issues to the pri and respect, and appropriately delegate tasks. Regrlar team mary team. The primary team rvill then implement the plan if meetings with and without patients and families help ensure in agreement with the recommendations. A consultant may uniformity in treatment plans and care coordination and serve continue to follow a patient if the clinical condition is evolving to update providers on all aspects of patient care and progress. or when specifically asked to do so, or may sign off when input These meetings often occur in the setting of changes in a on the case is complete. In the consultant role, hospitalists do patient's clinical course or in preparation for care transitions. not tlpically write orders unless specifically asked to do so, but During complicated hospital stays with involvement of they maintain responsibility to review and interpret results of multiple specialty clinicians, hospitalists must also assess, recommended studies. 25