Publications by authors named "Richard J Brilli"

85 Publications

Developing Tools to Enhance the Adaptive Capacity (Safety II) of Health Care Providers at a Children's Hospital.

Jt Comm J Qual Patient Saf 2021 Mar 13. Epub 2021 Mar 13.

Current safety efforts in health care use Safety I (find and fix), which has benefits and shortcomings. Safety leaders in multiple industries realize that complex adaptive systems require a new approach-Safety II (proactive safety). Our goal was to develop practical, usable tools to spread Safety II and resilience engineering competencies to clinical frontline staff. Using our prior research and Plan-Do-Study-Act cycles, we developed tools to enhance Safety II competencies that individuals with various backgrounds could understand. Tools address recognizing (Pause to Predict), responding (IDEA), and learning (Feed Forward). These are being taught organizationally in a unit-by-unit sequence. Use of these tools is expected to prompt a shift toward a more proactive mental model of safety that we want our frontline providers to adopt. Coordinating the expertise of bedside clinicians during unprecedented events can safely expand the boundaries of conditions under which we can provide high-quality care by increasing individuals' and subsequently our systems' adaptive capacity. We believe this is the first work describing attempts to operationalize Safety II concepts broadly in a health care organization.
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http://dx.doi.org/10.1016/j.jcjq.2021.03.006DOI Listing
March 2021

The Potential Interaction Is Important, but the Consequences and Solutions Are Paramount.

Pediatrics 2020 11 9;146(5). Epub 2020 Oct 9.

Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.

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http://dx.doi.org/10.1542/peds.2020-010181DOI Listing
November 2020

Evaluating Pediatric Sepsis Definitions Designed for Electronic Health Record Extraction and Multicenter Quality Improvement.

Crit Care Med 2020 10;48(10):e916-e926

1Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO. 2Section of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO. 3Nationwide Children's Hospital, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbus, OH. 4Division of Emergency Medicine, Advocate Children's Hospital, Park Ridge, IL. 5Division of Pediatric Emergency Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH. 6Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, MI. 7Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. 8Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH. 9Children's Hospital Association, Lenexa, KS. 10Pediatric Critical Care, Primary Children's Hospital, Department of Pediatrics, University of Utah, Salt Lake City, UT. 11Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN. 12Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 13Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.

Objectives: To describe the Children's Hospital Association's Improving Pediatric Sepsis Outcomes sepsis definitions and the identified patients; evaluate the definition using a published framework for evaluating sepsis definitions.

Design: Observational cohort.

Setting: Multicenter quality improvement collaborative of 46 hospitals from January 2017 to December 2018, excluding neonatal ICUs.

Patients: Improving Pediatric Sepsis Outcomes Sepsis was defined by electronic health record evidence of suspected infection and sepsis treatment or organ dysfunction. A more severely ill subgroup, Improving Pediatric Sepsis Outcomes Critical Sepsis, was defined, approximating septic shock.

Interventions: Participating hospitals identified patients, extracted data, and transferred de-identified data to a central data warehouse. The definitions were evaluated across domains of reliability, content validity, construct validity, criterion validity, measurement burden, and timeliness.

Measurements And Main Results: Forty hospitals met data quality criteria across four electronic health record platforms. There were 23,976 cases of Improving Pediatric Sepsis Outcomes Sepsis, including 8,565 with Improving Pediatric Sepsis Outcomes Critical Sepsis. The median age was 5.9 years. There were 10,316 (43.0%) immunosuppressed or immunocompromised patients, 4,135 (20.3%) with central lines, and 2,352 (11.6%) chronically ventilated. Among Improving Pediatric Sepsis Outcomes Sepsis patients, 60.8% were admitted to intensive care, 26.4% had new positive-pressure ventilation, and 19.7% received vasopressors. Median hospital length of stay was 6.0 days (3.0-13.0 d). All-cause 30-day in-hospital mortality was 958 (4.0%) in Improving Pediatric Sepsis Outcomes Sepsis; 541 (6.3%) in Improving Pediatric Sepsis Outcomes Critical Sepsis. The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated strengths in content validity, convergent construct validity, and criterion validity; weakness in reliability. Improving Pediatric Sepsis Outcomes Sepsis definitions had significant initial measurement burden (median time from case completion to submission: 15 mo [interquartile range, 13-18 mo]); timeliness improved once data capture was established (median, 26 d; interquartile range, 23-56 d).

Conclusions: The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated feasibility for large-scale data abstraction. The patients identified provide important information about children treated for sepsis. When operationalized, these definitions enabled multicenter identification and data aggregation, indicating practical utility for quality improvement.
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http://dx.doi.org/10.1097/CCM.0000000000004505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677030PMC
October 2020

Improving the Health of All Children in Our Community: The Nationwide Children's Hospital and Franklin County, Ohio, Pediatric Vital Signs Project.

J Pediatr 2020 07 13;222:227-230. Epub 2020 May 13.

Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH.

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http://dx.doi.org/10.1016/j.jpeds.2020.03.049DOI Listing
July 2020

A National Approach to Pediatric Sepsis Surveillance.

Pediatrics 2019 12;144(6)

Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.

Pediatric sepsis is a major public health concern, and robust surveillance tools are needed to characterize its incidence, outcomes, and trends. The increasing use of electronic health records (EHRs) in the United States creates an opportunity to conduct reliable, pragmatic, and generalizable population-level surveillance using routinely collected clinical data rather than administrative claims or resource-intensive chart review. In 2015, the US Centers for Disease Control and Prevention recruited sepsis investigators and representatives of key professional societies to develop an approach to adult sepsis surveillance using clinical data recorded in EHRs. This led to the creation of the adult sepsis event definition, which was used to estimate the national burden of sepsis in adults and has been adapted into a tool kit to facilitate widespread implementation by hospitals. In July 2018, the Centers for Disease Control and Prevention convened a new multidisciplinary pediatric working group to tailor an EHR-based national sepsis surveillance approach to infants and children. Here, we describe the challenges specific to pediatric sepsis surveillance, including evolving clinical definitions of sepsis, accommodation of age-dependent physiologic differences, identifying appropriate EHR markers of infection and organ dysfunction among infants and children, and the need to account for children with medical complexity and the growing regionalization of pediatric care. We propose a preliminary pediatric sepsis event surveillance definition and outline next steps for refining and validating these criteria so that they may be used to estimate the national burden of pediatric sepsis and support site-specific surveillance to complement ongoing initiatives to improve sepsis prevention, recognition, and treatment.
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http://dx.doi.org/10.1542/peds.2019-1790DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889946PMC
December 2019

Writing Group Increases Quality Improvement Writing Competency.

Am J Med Qual 2020 Jul/Aug;35(4):349-354. Epub 2019 Nov 12.

The Ohio State University, Columbus, OH.

Quality improvement (QI) is critically important in current medical practice. Although many QI courses teach improvement science and methods, formal education in writing QI manuscripts for academic journal publication is lacking. The authors developed a QI Writing program, consisting of educational sessions with both coach and peer mentors, to improve comfort and productivity in preparing QI manuscripts for publication. Program participants conducted pre- and post-course QI writing skills self-evaluations in 4 competency domains: SQUIRE guidelines, writing for peer-reviewed journals, QI publication submission steps, and critically examining QI results. Course success was measured by the number of manuscripts submitted for publication. QI writing competencies doubled in 3 of 4 domains and increased 70% in the fourth. Fifteen of 17 (88%) course participants submitted manuscripts to a peer-reviewed journal, and 12 have been accepted to date. A formal writing group with didactic content and committed mentors increases QI writing competencies and manuscript submissions to peer-reviewed journals.
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http://dx.doi.org/10.1177/1062860619886910DOI Listing
November 2019

Fostering Quality Improvement Capacity in a Network of Primary Care Practices Affiliated With a Pediatric Accountable Care Organization.

Pediatr Qual Saf 2019 May-Jun;4(3):e175. Epub 2019 May 16.

Partners For Kids, Columbus, Ohio.

Objectives: Quality improvement (QI) methodologies are not widely implemented in primary care practices. As an accountable care organization serving pediatric Medicaid recipients in Ohio, Partners For Kids (PFK) sought to build QI capacity in affiliated primary care practices to improve organizational performance on key quality measures.

Methods: A team of QI specialists developed a comprehensive training program focused on pediatric QI initiatives. From 2014 to 2017, community-based, primary care practices affiliated with PFK were recruited to participate in QI. The primary outcome, assessed yearly, was the proportion of eligible PFK patients accessing care at a practice with ≥1 active QI project. The proportion of QI projects that demonstrated moderate improvement, defined as the implementation of ≥1 intervention and observed improvement in process measures, within 12 months of initiation was also calculated for 2017.

Results: Over the study period, the PFK QI team supported 72 projects in 33 primary care practices throughout central and southeast Ohio. In 2017, 26 practices were engaged in ≥1 active QI project, reaching 26% of all eligible PFK patients. Of the 21 projects active as of January 2017, 11 (52%) showed moderate improvement within 12 months.

Conclusions: The PFK QI team successfully supported QI capacity building in primary care practices throughout Ohio using a systematic approach to recruitment, training, and QI resource support. New, multilevel interventions are needed to promote the uptake of preventive services among patients.
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http://dx.doi.org/10.1097/pq9.0000000000000175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594781PMC
May 2019

Accelerating Improvement in Children's Healthcare Through Quality Improvement Collaboratives: A Synthesis of Recent Efforts.

Curr Treat Options Pediatr 2019 Jun 4;5(2):111-130. Epub 2019 May 4.

Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH.

Purpose Of Review: Quality improvement collaboratives can accelerate quality improvement and patient safety efforts. We reviewed major pediatric quality improvement collaboratives that have published results in the past five years and discussed common success factors and barriers encountered by these collaboratives.

Recent Findings: Many pediatric quality improvement collaboratives are active in neonatal, cystic fibrosis, congenital heart disease, hematology/oncoogy, chronic kidney disease, rheumatology, critical care, and general pediatric care.

Summary: Factors important to the success of these pediatric quality improvement collaboratives include data sharing and communication, trust among institutions, financial support, support from national organizations, use of a theoretical framework to guide collaboration, patient and family involvement, and incentives for participation at both the individual and institutional levels. Common barriers encountered by these collaboratives include insufficient funding or resources, legal concerns, difficulty coming to consensus on best practices and outcome measures, and overcoming cultural barriers to change. Learning from the successes and challenges encountered by these collaboratives will enable the pediatric healthcare quality improvement community to continue to evolve this approach to maximize benefits to children.
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http://dx.doi.org/10.1007/s40746-019-00155-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418888PMC
June 2019

Quality Improvement-Driven Reduction in Countywide Medicaid Acute Asthma Health Care Utilization.

Acad Pediatr 2019 03 29;19(2):216-226. Epub 2018 Dec 29.

Pediatric Pulmonology (ED Allen), Respiratory Therapy (G Ayres), The Center for Surgical Outcomes Research (J Cooper), Ambulatory Pediatrics (J Groner, S Hersey, and D Snyder), Hospital Pediatrics (G McGwire), Pediatric Allergy/Immunology (D Stukus), Pediatric Emergency Medicine (KS Stukus), Neonatology (C Timan), Data Resource Center (N Wegener), Chief Medical Officer (RJ Brilli), Nationwide Children's Hospital; Quality Improvement Services (T Montgomery), The Ohio State University Wexner Medical Center; Operations (J Gillispie), President (SP Gleeson), Children's Community Practices (C Rowe), Partners for Kids, Columbus, Ohio.

Objective: This study evaluates the impact of a coordinated effort by an urban pediatric hospital and its associated accountable care organization to reduce asthma-related emergency department (ED) and inpatient utilization by a large, countywide Medicaid patient population.

Methods: Multiple evidence-based interventions targeting general pediatric asthma care and high health care utilizers were implemented using standardized quality improvement methodologies. Annual asthma ED and inpatient utilization rates by 2- to 18-year-old members of an accountable care organization living in the surrounding county (>140,000 eligible members in 2016), adjusted per 1000 children from 2008 through 2016, were analyzed using Poisson regression. We compared these ED utilization rates to national rates from 2006 to 2014.

Results: Asthma ED utilization fell from 18.1 to 12.9 visits/1000 children from 2008 to 2016, representing a 28.7% reduction, with an average annual decrease of 3.9% (P < .001), during a time when national utilization was increasing. Asthma inpatient utilization did not change significantly during the study period.

Conclusions: Asthma-related ED utilization was significantly reduced in a large population of primarily urban, minority, Medicaid-insured children by implementing a multimodal asthma quality improvement program. With adequate support, a similar approach could be successful in other communities.
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http://dx.doi.org/10.1016/j.acap.2018.12.005DOI Listing
March 2019

The Aggregate Point Rule for Identifying Shifts on P Charts and U Charts.

Pediatr Qual Saf 2018 Sep-Oct;3(5):e103. Epub 2018 Sep 20.

Quality Improvement Department, Nationwide Children's Hospital, Columbus, Ohio.

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http://dx.doi.org/10.1097/pq9.0000000000000103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6221583PMC
September 2018

PICU Autopsies: Every One Is Important.

Pediatr Crit Care Med 2018 Dec;19(12):1173-1174

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH.

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http://dx.doi.org/10.1097/PCC.0000000000001747DOI Listing
December 2018

Clinical Indices to Drive Quality Improvement in Otolaryngology.

Otolaryngol Clin North Am 2019 Feb;52(1):123-133

Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 555 South 18th Street, Suite 2A, Columbus, OH 43205, USA; Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at Ohio State University, 915 Olentangy River Road, Columbus, OH 43212, USA. Electronic address:

A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.
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http://dx.doi.org/10.1016/j.otc.2018.08.008DOI Listing
February 2019

Variability Reduction-An Essential Aspect of Quality.

Pediatr Crit Care Med 2018 07;19(7):681-682

Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH.

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http://dx.doi.org/10.1097/PCC.0000000000001570DOI Listing
July 2018

Grab Your Fitbit-Let Us Move Forward.

Pediatr Crit Care Med 2018 05;19(5):501-502

Division of Hospital Pediatrics, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH Division of Critical Care Medicine and Hospital Administration, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH.

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http://dx.doi.org/10.1097/PCC.0000000000001530DOI Listing
May 2018

Inpatient Asthma Care and Future Morbidity: A Role for Quality Improvement.

Pediatrics 2018 05 5;141(5). Epub 2018 Apr 5.

Hospital Administration, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.

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http://dx.doi.org/10.1542/peds.2018-0420DOI Listing
May 2018

Pediatric Quality and Safety Come of Age.

J Healthc Qual 2018 Mar/Apr;40(2):67-68

John F. Wolfe Endowed Chair in Medical Leadership and Pediatric Quality and Safety; Chief Medical Officer, Nationwide Children's Hospital, Columbus, OH; and Professor of Pediatrics, Ohio State University College of Medicine, Columbus, OH Assistant to the Chief Medical Officer, Nationwide Children's Hospital, Columbus, OH; and Emeritus Professor of Surgery, Ohio State University College of Medicine, Columbus, OH.

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http://dx.doi.org/10.1097/JHQ.0000000000000136DOI Listing
March 2018

Clinical Indices Can Standardize and Monitor Pediatric Care: A Novel Mechanism to Improve Quality and Safety.

J Pediatr 2018 02 6;193:190-195.e1. Epub 2017 Dec 6.

Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Divison of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH.

Objective: The Cancer Care Index (CCI), a single metric that sums the number of undesirable patient events in a given time frame (either preventable harm events or missed opportunities to provide optimal care), resulted in a 42% improvement in performance. Our objective was to test the index concept in other service lines to determine whether similar performance improvement occurred.

Study Design: Care indices were developed and introduced in 3 additional service lines: Nephrology (Chronic Kidney Disease Care Index; CKDCI), Pulmonology (Lung Transplantation Care Index; LTCI), and Otolaryngology (Tracheostomy Care Index; TCI). After reaching agreement on specific harms to be avoided and elements of optimal care that should be reliably delivered, these items were compiled into indices that were updated monthly. Reports included each element individually and the total for all elements. Baseline performance was calculated retrospectively for the previous year.

Results: Significant improvement in performance occurred in each program following implementation of the clinical indices. The CKDCI was decreased by 63.2% (P < .001), the LTCI was decreased by 89.5% (P < .001), and the TCI was decreased by 53.0% (P < .001). Surveyed staff indicated satisfaction with use of the metric.

Conclusions: Clinical indices are useful for evaluating and managing the overall reliability of a program's ability to deliver optimal care, and are associated with improved clinical performance and satisfaction by service line staff when incorporated into a program's operation.
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http://dx.doi.org/10.1016/j.jpeds.2017.09.073DOI Listing
February 2018

Pediatric Critical Care Medicine Training: 2004-2016.

Pediatr Crit Care Med 2018 01;19(1):17-22

Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA.

Objectives: To describe growth trends in the number of programs, positions, and applicants in pediatric critical care medicine fellowship training as part of the Pediatric Critical Care Medicine Training Study.

Design: Descriptive study.

Settings: Available archived Match data through the National Resident Matching Program and training data from the Accreditation Council for Graduate Medical Education.

Patients: None.

Interventions: None.

Measurements And Main Results: We analyzed all data on programs, positions, and applicants through the National Resident Matching Program Specialties Matching Service during the study period of 2004 to 2016. We also analyzed available training data available through the Accreditation Council for Graduate Medical Education for the corresponding study period. During the 12-year study period, there was a statistically significant expansion in programs (38%), positions (82%), and applicants (151%). Correspondingly, the percentage of pediatric critical care medicine programs participating in the Match as a percentage of all Accreditation Council for Graduate Medical Education-accredited programs for that academic year increased 24%. As of 2015, 94% of total first year positions offered for pediatric critical care medicine were through the Match.

Conclusions: For the period 2004 to 2016, there was a substantial increase in positions and applicants applying for training in pediatric critical care medicine. We document an increase in demand (i.e., applicants) that has been matched by an increase in supply (i.e., positions) for pediatric critical care medicine fellowship training. The nearly complete use of the National Resident Matching Program for placing applicants in training positions in pediatric critical care medicine suggests that these data can be used to inform workforce analysis in pediatric critical care medicine.
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http://dx.doi.org/10.1097/PCC.0000000000001375DOI Listing
January 2018

Interprofessional QI Training Enhances Competency and QI Productivity Among Graduates: Findings From Nationwide Children's Hospital.

Acad Med 2018 02;93(2):292-298

T. Bartman is associate professor, Department of Pediatrics, Division of Neonatology, Ohio State University College of Medicine, director of quality improvement for neonatal services, and associate medical director for quality, Nationwide Children's Hospital, Columbus, Ohio. K. Heiser is vice president for education and designated institutional official, Nationwide Children's Hospital, Columbus, Ohio. A. Bethune is quality improvement services education coordinator, Department of Education, Nationwide Children's Hospital, Columbus, Ohio. W. Crandall is professor, Department of Pediatrics, Ohio State University College of Medicine, Division of Gastroenterology, and medical director for quality, Nationwide Children's Hospital, Columbus, Ohio. R. McClead is emeritus professor, Department of Pediatrics, Division of Neonatology, Ohio State University College of Medicine, and associate chief medical officer, Nationwide Children's Hospital, Columbus, Ohio. J.T. Davis is emeritus professor of clinical surgery, Ohio State University College of Medicine, and assistant to the chief medical officer, Nationwide Children's Hospital, Columbus, Ohio. R.J. Brilli is professor, Department of Pediatrics, Division of Critical Care Medicine at Ohio State University College of Medicine, and chief medical officer, Nationwide Children's Hospital, Columbus, Ohio.

Purpose: Significant resources are expended on quality improvement (QI) training courses. The authors sought to determine whether education provided in QI course training improves self-assessed QI content competence and QI-related productivity among course graduates.

Method: "Quality Improvement Essentials" is a four-month didactic and experiential course designed to prepare multidisciplinary professionals to participate in and lead QI efforts at Nationwide Children's Hospital (NCH). This study used a milestone-based self-assessment survey of graduates from 2012 to 2014 to gauge change in participants' self-assessed QI competency after course completion. Four competency domains were evaluated: QI knowledge; testing and implementing change using teams; data management and analysis; and spreading and sustaining science. Metrics for assessing individual QI productivity were presentation or publication of QI work outside NCH; local, regional, or national QI teaching; serving on a local, regional, or national QI committee; appointment as a QI leader; involvement in an internal or external QI collaborative; and leading a maintenance of certification Part IV project approved by NCH.

Results: Course participation more than doubled participants' self-assessed QI competence across all four domains. Gains continued after the course, increasing with time rather than degrading. Self-assessed competency increase was significantly associated with increased QI productivity.

Conclusions: Self-assessed QI competence dramatically improved after participation in an educational course and continued to increase over time. Increased self-assessed QI competency correlated with increased individual QI productivity. Further studies are necessary to fully evaluate "return on investment" for this type of course.
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http://dx.doi.org/10.1097/ACM.0000000000001862DOI Listing
February 2018

Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm.

Pediatrics 2017 Sep 16;140(3). Epub 2017 Aug 16.

Department of Pediatrics, Lucile Packard Children's Hospital Stanford, School of Medicine, Stanford University, Palo Alto, California.

Objectives: To determine if an improvement collaborative of 33 children's hospitals focused on reliable best practice implementation and culture of safety improvements can reduce hospital-acquired conditions (HACs) and serious safety events (SSEs).

Methods: A 3-year prospective cohort study design with a 12-month historical control population was completed by the Children's Hospitals' Solutions for Patient Safety collaborative. Identification and dissemination of best practices related to 9 HACs and SSE reduction focused on key process and culture of safety improvements. Individual hospital improvement teams leveraged the resources of a large, structured children's hospital collaborative using electronic, virtual, and in-person interactions.

Results: Thirty-three children's hospitals from across the United States volunteered to be part of the Children's Hospitals' Solutions for Patient Safety collaborative. Thirty-two met all the data submission eligibility requirements for the HAC improvement objective of this study, and 21 participated in the high-reliability culture work aimed at reducing SSEs. Significant harm reduction occurred in 8 of 9 common HACs (range 9%-71%; < .005 for all). The mean monthly SSE rate decreased 32% (from 0.77 to 0.52; < .001). The 12-month rolling average SSE rate decreased 50% (from 0.82 to 0.41; < .001).

Conclusions: Participation in a structured collaborative dedicated to implementing HAC-related best-practice prevention bundles and culture of safety interventions designed to increase the use of high-reliability organization practices resulted in significant HAC and SSE reductions. Structured collaboration and rapid sharing of evidence-based practices and tools are effective approaches to decreasing hospital-acquired harm.
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http://dx.doi.org/10.1542/peds.2016-3494DOI Listing
September 2017

Does a Medical Emergency Team Activation Define a New Paradigm of Mortality Risk?

Pediatr Crit Care Med 2017 06;18(6):601-602

Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH.

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http://dx.doi.org/10.1097/PCC.0000000000001165DOI Listing
June 2017

Taking Aim at Diagnostic Errors.

Pediatr Crit Care Med 2017 03;18(3):285-286

Division of Neonatology Department of Pediatrics The Ohio State University College of Medicine Nationwide Children's Hospital Columbus, OH Division of Critical Care Medicine Department of Pediatrics The Ohio State University College of Medicine Nationwide Children's Hospital Columbus, OH.

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http://dx.doi.org/10.1097/PCC.0000000000001064DOI Listing
March 2017

Identifying Adverse Events in Pediatric Surgery: Comparing Morbidity and Mortality Conference with the NSQIP-Pediatric System.

J Am Coll Surg 2017 May 22;224(5):945-953. Epub 2017 Feb 22.

Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH. Electronic address:

Background: Recent improvements to morbidity and mortality (M&M) conference have focused on the case review system. However, case selection occurs by physician reporting, which is limited by selection bias. We compared the effectiveness of our M&M conference with the NSQIP-Pediatric (NSQIP-P) system for identifying adverse events.

Study Design: Complications from January 2010 to September 2015 were compared between M&M and NSQIP-P. Only M&M patients meeting NSQIP-P criteria were compared with patients from the NSQIP-P system; exclusions were studied separately. Complication rates in M&M conference before and after a 2012 format change designed to increase case reporting were also compared.

Results: Detection of mortality in M&M conference and NSQIP-P was not different. Morbidity events identified by NSQIP-P were significantly higher than M&M conference during the entire study period (194 vs 100 occurrences/1,000 cases) (p < 0.0001). Morbidity occurrences in M&M conference increased with the 2012 improvements, however, they still remained less than that identified by NSQIP-P (226 vs 141 occurrences/1,000 cases) (p < 0.0001). Of 863 patients presented in M&M conference, 210 were excluded from direct comparison because they did not meet NSQIP-P criteria. These included 62 deaths and 287 occurrences of morbidity. Their analysis in M&M conference resulted in 32 action initiatives directed at system failures.

Conclusions: The NSQIP-P identified more complications than M&M. The M&M conference improvements increased reported cases, but they still remained lower than NSQIP-P. However, M&M conference identified events resulting in systems changes that would not have been identified by NSQIP-P. Although NSQIP-P captures occurrences to compare large patient cohorts, M&M analyzes singular failures and initiates direct interventions. Integration of these systems can optimize their usefulness in quality improvement.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.02.008DOI Listing
May 2017

Impact of a Pressure Injury Prevention Bundle in the Solutions for Patient Safety Network.

Pediatr Qual Saf 2017 Mar-Apr;2(2):e013. Epub 2017 Feb 16.

Children's Healthcare of Atlanta Children's Hospital of Atlanta, Atlanta, Georgia; Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Liberty Mutual Insurance, Boston, Mass.; Hospital Administration, Department of Quality Improvement, Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; and The Ohio State University College of Medicine, Columbus, Ohio.

Background: Our objective was to describe changes in pressure injury (PI) rates in pediatric hospitals after implementation of an active surveillance and prevention bundle and to assess the impact of bundle elements.

Methods: The Children's Hospitals Solutions for Patient Safety (SPS) Network is a learning collaborative working together to eliminate harm to hospitalized children. SPS used a 3-pronged approach to prevent pressure injuries: (1) active surveillance, (2) implementing and measuring compliance with the prevention bundle, and (3) deploying a wound ostomy team. Among hospitals participating since 2011 (phase 1), we used negative binomial analyses to assess change in PI rates. Only phase 1 hospitals had a baseline period before any prevention bundle intervention. Among all hospitals participating in 2013 (phases 1 and 2), we used funnel charts to assess the association between reliable bundle implementation and PI rates.

Results: Among the 33 hospitals that participated in SPS from 2011 to 2013 (phase 1), the rate of stage 3 pressure injuries declined from 0.06 to 0.03 per 1,000 patient-days ( < 0.001). Stage 4 pressure injuries declined from 0.01 to 0.004 per 1,000 patient-days ( = 0.02). Among all 78 hospitals in phases 1 and 2, the cohort that adopted each bundle element, measured compliance, and achieved 80% prevention bundle compliance had significantly lower PI rates compared with all hospitals.

Conclusions: SPS hospitals saw a significant reduction in stage 3 and 4 PIs over a 2-year period. Reliable implementation of each element of a prevention bundle was associated with lower PI rates.
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http://dx.doi.org/10.1097/pq9.0000000000000013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6132915PMC
February 2017

A Population Intervention to Improve Outcomes in Children With Medical Complexity.

Pediatrics 2017 01 1;139(1). Epub 2016 Dec 1.

Nationwide Children's Hospital, Columbus, Ohio.

Background And Objectives: Children with medical complexity experience frequent interactions with the medical system and often receive care that is costly, duplicative, and inefficient. The growth of value-based contracting creates incentives for systems to improve their care. This project was designed to improve the health, health care value, and utilization for a population-based cohort of children with neurologic impairment and feeding tubes.

Methods: A freestanding children's hospital and affiliated accountable care organization jointly developed a quality improvement initiative. Children with a percutaneous feeding tube, a neurologic diagnosis, and Medicaid, were targeted for intervention within a catchment area of >300 000 children receiving Medicaid. Initiatives included standardizing feeding tube management, improving family education, and implementing a care coordination program.

Results: Between January 2011 and December 2014, there was an 18.0% decrease (P < .001) in admissions and a 31.9% decrease (P < .001) in the average length of stay for children in the cohort. Total inpatient charges were reduced by $11 764 856. There was an 8.2% increase (P < .001) in the percentage of children with weights between the fifth and 95th percentiles. The care coordination program enrolled 58.3% of the cohort.

Conclusions: This population-based initiative to improve the care of children with medical complexity showed promising results, including a reduction in charges while improving weight status and implementing a care coordination program. A concerted institutional initiative, in the context of an accountable care organization, can be part of the solution for improving outcomes and health care value for children with medical complexity.
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http://dx.doi.org/10.1542/peds.2015-3076DOI Listing
January 2017

Critical Care Transport: How Perilous the Trip.

Pediatr Crit Care Med 2016 10;17(10):1008-1009

Department of Pediatrics Akron Children's Hospital Akron, OH; and Department of Pediatrics Northeast Ohio Medical University Rootstown, OHDepartment of Pediatrics Nationwide Children's Hospital Columbus, OH; and Department of Pediatrics Ohio State University College of Medicine Columbus, OH.

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http://dx.doi.org/10.1097/PCC.0000000000000927DOI Listing
October 2016

Let the Journey Begin.

Pediatr Qual Saf 2016 Sep-Oct;1(1):e488. Epub 2016 Sep 16.

Nationwide Children's Hospital, Division of Critical Care Medicine, Department of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio; and Nationwide Children's Hospital, Department of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio.

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http://dx.doi.org/10.1097/01.PQ9.0000490364.17054.88DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6132805PMC
September 2016

The Cancer Care Index: A Novel Metric to Assess Overall Performance of a Pediatric Oncology Program.

J Patient Saf 2020 09;16(3):e120-e125

Hospital Administration.

Objective: Childhood cancer metrics are currently primarily focused on survival rates and late effects of therapy. Our objectives were to design and test a metric that reflected overall quality and safety performance, across all cancer types, of an oncology-bone marrow transplant service line and to use the metric to drive improvement.

Method: The Cancer Care Index (CCI) aggregates adverse safety events and missed opportunities for best practices into a composite score that reflects overall program performance without regard to cancer type or patient outcome. Fifteen domains were selected in 3 areas as follows: (1) treatment-related quality and safety, (2) provision of a harm-free environment, and (3) psychosocial support. The CCI is the aggregate number of adverse events or missed opportunities to provide quality care in a given time frame. A lower CCI reflects better care and improved overall system performance. Multidisciplinary microsystem-based teams addressed specific aims for each domain. The CCI was widely followed by all team members, particularly frontline providers.

Results: The CCI was easy to calculate and deploy and well accepted by the staff. The annual CCI progressively decreased from 278 in 2012 to 160 in 2014, a 42% reduction. Improvements in care were realized across most index domains. Multiple new initiatives were successfully implemented.

Conclusions: The CCI is a useful metric to document performance improvement across a broad range of domains, regardless of cancer type. By the use of quality improvement science, progressive reduction in CCI has occurred over a 3-year period.
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http://dx.doi.org/10.1097/PTS.0000000000000267DOI Listing
September 2020

Unanswered Questions and Consternation: The Ventilator-Associated Pneumonia Diagnostic Challenge Continues.

Pediatr Crit Care Med 2016 Feb;17(2):175-6

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH Division of Pediatric Critical Care Medicine, Department of Pediatrics and Hospital Administration, Nationwide Children's Hospital, Columbus, OH.

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http://dx.doi.org/10.1097/PCC.0000000000000598DOI Listing
February 2016

Does the Medical Home Really Matter?

J Pediatr 2016 Mar 31;170:14-6. Epub 2015 Dec 31.

Nationwide Children's Hospital, Columbus, Ohio; Division of Pediatric Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio. Electronic address:

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http://dx.doi.org/10.1016/j.jpeds.2015.12.039DOI Listing
March 2016