2025
Site-Level Variation in Tracheal Intubation in the Pediatric Emergency Department: A Report From the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM).
Greenwald E, Miller K, Wing R, Prieto M, Nagler J, Napolitano N, Polikoff L, Goldman M, Sterrett E, Jackson J, Melchionne Miseo C, Dean P, Nti B, Losito E, Caperell K, Kennedy C, Patel D, Deanehan J, Bharath A, Killion J, Judge P, Joseph D, Ikeyama T, Nishisaki A, Kerrey B. Site-Level Variation in Tracheal Intubation in the Pediatric Emergency Department: A Report From the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM). Pediatric Emergency Care 2025 PMID: 40859870, DOI: 10.1097/pec.0000000000003464.Peer-Reviewed Original ResearchPediatric emergency departmentPediatric emergency medicineNational Emergency Airway RegistryFirst-attempt successSite-level variationEmergency medicineAirway RegistryEmergency departmentInterquartile rangeMulticenter observational studyAdverse tracheal intubation-associated eventsTracheal intubation-associated eventsQuality improvement effortsAnnual site visitsTracheal intubationAdmission ratesImprovement effortsProportion of infantsRegistrySite visitsSubstantial variationPediatricOxygen desaturationAirway outcomesApneic oxygenationHospital Patient Experience Worsened With the COVID-19 Pandemic, Especially for Older Adults, and Remains Worse than Before.
Beckett M, W Cohea C, Saliba D, Cleary P, A Giordano L, Elliott M. Hospital Patient Experience Worsened With the COVID-19 Pandemic, Especially for Older Adults, and Remains Worse than Before. Medical Care Research And Review 2025, 10775587251349053. PMID: 40620127, DOI: 10.1177/10775587251349053.Peer-Reviewed Original ResearchHospital Consumer Assessment of Healthcare Providers and SystemsPatient experienceAssessment of Healthcare Providers and SystemsConsumer Assessment of Healthcare Providers and SystemsHealthcare Providers and SystemsHospital quality improvement effortsImpact of visitor restrictionsPatient’s greatest needsHospitalized patients' experiencesQuality improvement effortsCOVID-19 pandemicInpatient experienceVisitor restrictionsOlder adultsSummary scoreMaternity patientsPatient supportPre-pandemic levelsFamily accessInstrumental supportImprovement effortsGreater needAdult ageHospitalPre-pandemicThe potential for patient-reported data and narratives to improve quality during emergency department boarding
Gleason K, McDonald K, Peterson S, Kuhn D, Schlesinger M. The potential for patient-reported data and narratives to improve quality during emergency department boarding. Health Affairs Scholar 2025, 3: qxaf138. PMID: 40727592, PMCID: PMC12303624, DOI: 10.1093/haschl/qxaf138.Peer-Reviewed Original ResearchEmergency departmentConsumer Assessment of Healthcare ProvidersPatient experience surveysPatient-driven dataEmergency department boardingQuality improvement effortsPatient-reported dataPatient-reported outcomesOpen-ended questionsHealthcare providersBoarding patientsInpatient bedsED boardingPatient narrativesImprovement effortsLowest quartileExperiences SurveyDiagnostic experiencePatient outcomesQuality scoresDiagnostic quality scoreWaiting timeCAHPSSurveyOutcomesStrengthening Patient Experience Measurement and Improvement
Evans R, Shaller D, Edgman-Levitan S, Nembhard I. Strengthening Patient Experience Measurement and Improvement. JAMA Health Forum 2025, 6: e251223. PMID: 40445597, DOI: 10.1001/jamahealthforum.2025.1223.Peer-Reviewed Original ResearchFamily Experience With Hospital Care Teams: A Qualitative Investigation.
Reynolds K, Zelazny S, Grob R, Parker A, Schlesinger M, Martino S. Family Experience With Hospital Care Teams: A Qualitative Investigation. Hospital Pediatrics 2025, 15: e179-e185. PMID: 40254297, DOI: 10.1542/hpeds.2023-007721.Peer-Reviewed Original ResearchConceptsFamily experiencesHospital typeHospital settingQuantitative assessments of patients' experiencesAssessment of patient experienceHospital care teamMedical conditionsQuality improvement effortsGuardians of childrenCare coordinationCare teamPatient experienceHospital careClinical qualityHospital experienceMedical traineesUS populationImprovement effortsQualitative interviewsPediatric hospitalParent interviewsService linesParental vigilanceHospitalCareForging a learning health system for early psychosis: Insights from the academic community EPINET
Vohs J, Cahill J, Taylor S, Heckers S, Weiss A, Chaudhry S, Silverstein S, Tso I, Breitborde N, Vinson A, Lapidos A, Visco A, Satchivi A, Gaunnac M, Breier A, Srihari V. Forging a learning health system for early psychosis: Insights from the academic community EPINET. Schizophrenia Research 2025, 278: 109-118. PMID: 40147210, PMCID: PMC12011207, DOI: 10.1016/j.schres.2025.03.020.Peer-Reviewed Original ResearchConceptsLearning healthcare systemEarly Psychosis Intervention NetworkQuality improvementClinical workflowLearning health systemProvision of intervention servicesQuality improvement effortsCulture of continuous learningIntervention NetworkHealth systemDisease trajectoryInterventional careHealthcare systemPractice-based researchImprovement effortsEvidence-basedClinical sitesIntervention servicesSocietal costsSteering CommitteeFirst-episode psychosisImplementation lessonsEarly psychosisEngaging stakeholdersSix-month intervals
2024
The Academic Community Early Psychosis Intervention Network: Toward building a novel learning health system across six US states
Vohs J, Srihari V, Vinson A, Lapidos A, Cahill J, Taylor S, Heckers S, Weiss A, Chaudhry S, Silverstein S, Tso I, Breitborde N, Breier A. The Academic Community Early Psychosis Intervention Network: Toward building a novel learning health system across six US states. Learning Health Systems 2024, 9: e10471. PMID: 40247900, PMCID: PMC12000763, DOI: 10.1002/lrh2.10471.Peer-Reviewed Original ResearchEarly Psychosis Intervention NetworkIntervention NetworkFirst-episode psychosisRegional clinical networksLearning health systemQuality improvement projectQuality improvement effortsCulture of continuous learningData elementsPrimary diagnosis of schizophreniaConsecutive 6-month intervalsFirst-episode psychosis clinicUsual careSuperior patient outcomesSpecialty servicesHealth systemClinical teamImplementation meetingsQuality assurance effortsImprovement projectClinical networksHealthcare systemPractice-based researchImprovement effortsQuality improvement“Nothing Is More Powerful than Words:” How Patient Experience Narratives Enable Improvement
Grob R, Lee Y, Shaller D, Warne E, Matta S, Schlesinger M, Nembhard I. “Nothing Is More Powerful than Words:” How Patient Experience Narratives Enable Improvement. Quality Management In Health Care 2024, 33: 149-159. PMID: 38941581, DOI: 10.1097/qmh.0000000000000477.Peer-Reviewed Original ResearchConceptsPatient experience scoresExperience scoresPatient experience assessmentQuality improvement projectResponsive service provisionThematic analysis techniqueImprove careImprovement projectQualitative studyMax QDAImprovement effortsQualitative interviewsOutpatient settingOutpatient clinicCoding reportsStaff strengthImprovement workTraining needsNarrative dataDay-to-day workService provisionStaffPositive practiceInterviewsExperience assessmentEmergency medical services in Armenia: national call trends and future directions
Arzoumanian A, Agopian A, Hovhannisyan M, Chekijian S, Baghdassarian A. Emergency medical services in Armenia: national call trends and future directions. International Journal Of Emergency Medicine 2024, 17: 65. PMID: 38755551, PMCID: PMC11097514, DOI: 10.1186/s12245-024-00644-y.Peer-Reviewed Original ResearchLower-middle income countriesHigh blood pressureMedical servicesEMS systemExacerbation of chronic conditionsPopulation health needsEffectiveness of public health interventionsAcute conditionsPredominant complaintBackgroundEmergency medical servicesEmergency medical servicesBlood pressurePublic health interventionsSystem improvement effortsAcute exacerbations of chronic conditionsEMS utilizationIn-hospital treatmentHealth interventionsHealth needsChronic conditionsImprovement effortsRural provincesIncome countriesAcute exacerbationHealth indexPredicting Major Adverse Events in Patients Undergoing Transcatheter Left Atrial Appendage Occlusion
Faridi K, Ong E, Zimmerman S, Varosy P, Friedman D, Hsu J, Kusumoto F, Mortazavi B, Minges K, Pereira L, Lakkireddy D, Koutras C, Denton B, Mobayed J, Curtis J, Freeman J. Predicting Major Adverse Events in Patients Undergoing Transcatheter Left Atrial Appendage Occlusion. Circulation Arrhythmia And Electrophysiology 2024, 17: e012424. PMID: 38390713, PMCID: PMC11021146, DOI: 10.1161/circep.123.012424.Peer-Reviewed Original ResearchNational Cardiovascular Data RegistryLeft atrial appendage occlusionIn-hospital major adverse eventsMajor adverse eventsBedside risk scoreRisk scoreData registryIncreased fall riskAdverse eventsQuality improvement effortsWatchman FLXAppendage occlusionFall riskLeft atrial appendage occlusion procedureRegistry dataImprovement effortsRisk of in-hospital major adverse eventsPredicting major adverse eventsLogistic regressionAdverse event ratesModerate discriminationClinically relevant variablesFemale sexAtrial fibrillation terminationLAAO proceduresImproving Anesthesia Start Time Documentation Through a Departmental Education Initiative at Yale New Haven Hospital, New Haven, United States
Warren M, Mehta S, Glowka L, Goncalves O, Gutman E, Schonberger R. Improving Anesthesia Start Time Documentation Through a Departmental Education Initiative at Yale New Haven Hospital, New Haven, United States. Cureus 2024, 16: e54351. PMID: 38500895, PMCID: PMC10945460, DOI: 10.7759/cureus.54351.Peer-Reviewed Original ResearchYale-New Haven HospitalEducational emailCenters for Medicare & Medicaid ServicesEducational initiativesResults Baseline dataQuality improvement studyQuality improvement initiativesQuality improvement effortsNew HavenAnesthesia startUnited StatesImprovement initiativesMedicaid ServicesAnesthetic servicesImprovement studyImprovement effortsIn-room timeDocumentation accuracyAmerican Society of AnesthesiologistsTime documentationPatient factorsBaseline dataPreoperative holding areaNew Haven HospitalAnesthesia practitionersDiagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care
Auerbach A, Lee T, Hubbard C, Ranji S, Raffel K, Valdes G, Boscardin J, Dalal A, Harris A, Flynn E, Schnipper J, Feinbloom D, Roy B, Herzig S, Wazir M, Gershanik E, Goyal A, Chitneni P, Burney S, Galinsky J, Rastegar S, Moore D, Berdahl C, Seferian E, Suri K, Ramishvili T, Vedamurthy D, Hunt D, Mehta A, Katakam H, Field S, Karatasakis B, Beeler K, Himmel A, Eid S, Gandhi S, Pena I, Ranta Z, Lipten S, Lucier D, Walker-Corkery B, Kleinman Sween J, Kirchoff R, Rieck K, Kolar G, Parikh R, Burton C, Dugani C, Dapaah-Afriyie K, Finn A, Raju S, Surani A, Segon A, Bhandari S, Astik G, O’Leary K, Helminski A, Anstey J, Zhou M, Alday A, Halvorson S, Esmaili A, Barish P, Fenton C, Kantor M, Choi K, Schram A, Ruhnke G, Patel H, Virapongse A, Burden M, Ngov L, Keniston A, Talari P, Romond J, Vick S, Williams M, Marr R, Gupta A, Rohde J, Mao F, Fang M, Greysen S, Shah P, Kim C, Narayanan M, Wolpaw B, Ellingson S, Kaiksow F, Kenik J, Sterken D, Lewis M, Manwani B, Ledford R, Webber C, Vasilevskis E, Buckley R, Kripalani S, Sankey C, Ostfeld-Johns S, Gielissen K, Wijesekera T, Jordan E, Karwa A, Churnet B, Chia D, Brooks K. Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care. JAMA Internal Medicine 2024, 184: 164-173. PMID: 38190122, PMCID: PMC10775080, DOI: 10.1001/jamainternmed.2023.7347.Peer-Reviewed Original ResearchConceptsPatient harmIntensive care unitHospitalized adultsDiagnostic errorsAssociated with patient harmCohort studyMultivariate modelRandom sample of adultsAcademic medical centerSample of adultsDiagnostic error reductionTemporary harmGeneral medical conditionsAttributable fractionRetrospective cohort studyMain OutcomesMedical inpatientsTest orderingPermanent harmTrained cliniciansImprovement effortsMedical conditionsClinician assessmentMedical CenterPatient recordsProposed Quality Indicators for Aspects of Pediatric Acute Otitis Media Management
Cottrell J, Namavarian A, Yip J, Campisi P, Chadha N, Damji A, Hong P, Lachance S, Leitao D, Nguyen L, Saunders N, Strychowsky J, Yunker W, Vaccani J, Chan Y, de Almeida J, Eskander A, Witterick I, Monteiro E. Proposed Quality Indicators for Aspects of Pediatric Acute Otitis Media Management. Journal Of Otolaryngology 2024, 53: 19160216241248538. PMID: 38888942, PMCID: PMC11098001, DOI: 10.1177/19160216241248538.Peer-Reviewed Original ResearchConceptsAcute otitis mediaCandidate indicatorsPediatric acute otitis mediaQuality indicatorsMeasures of high-quality careExpert panelHigh-quality careQuality improvement initiativesRAND Corporation/University of CaliforniaQuality improvement effortsManagement of pediatric acute otitis mediaProposed quality indicatorsExpert panel meetingImprove patient outcomesSpecialty referralsSubstandard careFamily physiciansImprovement initiativesImprovement effortsGuideline recommendationsPanel meetingPatient outcomesPosition statementAntimicrobial managementOtolaryngology-Head
2022
Improving birth certificate data accuracy in Alabama
Gentle S, Moore M, Blackmon R, Brugh B, Todd A, Wingate M, Mazzoni S. Improving birth certificate data accuracy in Alabama. Health Science Reports 2022, 5: e607. PMID: 35509413, PMCID: PMC9059177, DOI: 10.1002/hsr2.607.Peer-Reviewed Original ResearchCertification accuracyMultidisciplinary quality improvement effortsBirth certificate variablesBirth certificate dataPerinatal Quality CollaborativeStrategizing public health interventionsQuality improvement effortsMonitoring population healthVital statistics dataHealth care specialistsPublic health interventionsProportion of hospitalsPublic health surveillanceThirty-one hospitalsPopulation healthCertificate dataHealth interventionsCare specialistsBirth certificatesVital statisticsIdentified several factorsIndividual hospitalsHealth surveillanceImprovement effortsBirth dataCommentary Article: Opioid use Disorder Cascade of Care Framework Design: A Roadmap
Williams AR, Johnson KA, Thomas CP, Reif S, Socías ME, Henry BF, Neighbors C, Gordon AJ, Horgan C, Nosyk B, Drexler K, Krawczyk N, Gonsalves GS, Hadland SE, Stein BD, Fishman M, Kelley AT, Pincus HA, Olfson M. Commentary Article: Opioid use Disorder Cascade of Care Framework Design: A Roadmap. Substance Abuse 2022, 43: 1207-1214. PMID: 35657670, PMCID: PMC9577537, DOI: 10.1080/08897077.2022.2074604.Peer-Reviewed Original ResearchConceptsOpioid use disorderHealth systemGold standard treatmentUnintentional overdose deathsYears of ageSpread of HIVQuality improvement effortsTreatment initiationClinical outcomesStandard treatmentOverdose deathsUse disordersUS deathsCare frameworkEarly dropoutDeathTreatmentImprovement effortsMedicationsOpioidsHIVYearsAvailable dataIndividuals
2020
Organisational factors underpinning intra-hospital transfers: a guide for evaluating context in quality improvement
Fekieta R, Rosenberg A, Hodshon B, Feder S, Chaudhry SI, Emerson BL. Organisational factors underpinning intra-hospital transfers: a guide for evaluating context in quality improvement. Health Systems 2020, 10: 239-248. PMID: 34745587, PMCID: PMC8567872, DOI: 10.1080/20476965.2020.1768807.Peer-Reviewed Original ResearchIntra-hospital transferMedical intensive care unitTertiary medical centerIntensive care unitGeneral medicine unitsTransitions of careQuality improvement effortsCare unitEmergency departmentMedicine unitMultiple cliniciansMedical CenterHospital capacityHospital prioritiesApplication of protocolsOrganisational factorsCliniciansImprovement effortsSemi-structured interviewsQualitative assessmentPatientsUndesirable outcomesFactors
2018
Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies
Sather J, Rothenberg C, Finn EB, Sheth KN, Matouk C, Pham L, Parwani V, Ulrich A, Venkatesh AK. Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies. American Journal Of Medical Quality 2018, 34: 53-58. PMID: 29987938, DOI: 10.1177/1062860618785248.Peer-Reviewed Original ResearchConceptsEmergency departmentMultidisciplinary quality improvement effortNeuroscience intensive care unitTertiary health care systemIll neurologic patientsIntensive care unitAdvanced practice providersHealth care systemQuality improvement effortsClinician typeIll patientsNeurologic emergencyCare unitCare transitionsClinical surveyNeurologic patientsPractice providersPatient transferCare systemImportant safety risksPatientsRiskReal-time surveySafety risksImprovement efforts
2017
How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study
Bradley EH, Brewster AL, McNatt Z, Linnander EL, Cherlin E, Fosburgh H, Ting HH, Curry LA. How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study. BMJ Quality & Safety 2017, 27: 218. PMID: 29101290, PMCID: PMC5867433, DOI: 10.1136/bmjqs-2017-006574.Peer-Reviewed Original ResearchA155 Which Postoperative Complications Matter Most after Bariatric Surgery? Prioritizing Quality Improvement Efforts to Improve National Outcomes
Aminian A, Daigle C, Tu C, Petrick A, Morton J, Schauer P, Brethauer S. A155 Which Postoperative Complications Matter Most after Bariatric Surgery? Prioritizing Quality Improvement Efforts to Improve National Outcomes. Surgery For Obesity And Related Diseases 2017, 13: s28. DOI: 10.1016/j.soard.2017.09.062.Peer-Reviewed Original ResearchMaternal and neonatal services in Ethiopia: measuring and improving quality
Canavan ME, Brault MA, Tatek D, Burssa D, Teshome A, Linnander E, Bradley EH. Maternal and neonatal services in Ethiopia: measuring and improving quality. Bulletin Of The World Health Organization 2017, 95: 473-477. PMID: 28603314, PMCID: PMC5463811, DOI: 10.2471/blt.16.178806.Peer-Reviewed Original ResearchConceptsIntrapartum careQuality improvement effortsLead hospitalsMiddle-income countriesMedical record reviewHospital quality improvement effortsHospital quality improvementHospital-based trainingMean quality scoreAdditional replication studiesNeonatal servicesRecord reviewNeonatal careNeonatal mortalityOverall mean quality scoreHospital visitsGovernment hospitalsHospital clustersHospitalImprovement effortsQuality improvement mechanismsCareBaselineVisitsPoor quality
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