Organizational Dynamics and Failure to Rescue After Major Surgery

 描述(申请人提供)：每年至少有10万名美国人在接受住院手术时死亡。不同医院的死亡率差异很大，这表明有很大的改善机会。支付者和专业组织希望核对表、绩效付费计划和国家结果登记将降低手术并发症和最终死亡率。然而，最近的研究表明，高死亡率和低死亡率医院的区别与其说是他们的并发症发生率，不如说是他们在并发症发生后识别和处理并发症的成功程度。因此，尽量减少“抢救失败”(即，重大并发症后死亡)可能是努力降低手术死亡率的关键。成功的抢救关键在于及早认识到严重并发症并在发生时及时处理。关注患者在衰退的早期“黄金时段”的临床恶化，可能会为一些医院如何取得模范成果提供有价值的见解。不幸的是，之前的工作并没有确定医院如何提高救援率的可操作的见解。更好地了解医院微系统内的相互作用和关系对于通过实际和有效的干预措施改善救援工作更加关键。为了探索这些问题，我们提出了一项研究，旨在评估这些因素，并在密歇根州医院制定和实施旨在改善整体安全文化、沟通和救援率的干预措施。具体的研究目标是(I)深入了解并发症抢救所需的关键要素，如团队合作和沟通；(Ii)设计一种干预措施，促进改善抢救的关键因素；以及(Iii)试行旨在提高医院救援率的干预措施。这项工作将阐明医疗保健组织如何能够更好地感知、应对和响应手术后临床恶化的具有危及生命的并发症的患者提出的意外和不断变化的需求。该项目将在人口层面产生直接影响，为旨在降低密歇根州手术患者死亡率的干预措施提供信息，并最终在其他地方降低死亡率。这项研究的结果还将告知大付款人(包括CMS)和监管机构(特别是JCAHO)，他们制定激励措施和标准，以提高美国住院手术的安全性。此外，研究项目、经验丰富的多学科指导团队和无与伦比的研究环境非常适合满足候选人Amir A.Ghaferi医学博士的职业目标和教育需求。该提案包括一项详细的教育计划和培训，这对成功完成这项研究和Ghaferi博士的职业发展都是必不可少的。培训包括组织管理、行为和理论、定性研究方法和实施科学等研究生水平的课程。这一职业发展奖将为Ghaferi博士进行持续的创新医疗服务研究奠定基础，并成为患者安全和质量改进方面的独立调查者和全国领先者。

 DESCRIPTION (provided by applicant): Every year at least 100,000 Americans die undergoing inpatient surgical procedures. Wide variation in mortality rates across hospitals suggests substantial opportunities for improvement. Payers and professional organizations are hoping that checklists, pay for performance programs, and national outcomes registries will reduce rates of surgical complications and ultimately mortality. However, recent research suggests that high mortality and low mortality hospitals are distinguished less by their complication rates than by how successfully they recognize and manage complications once they occur. Thus, minimizing "failure to rescue" (i.e., death following a major complication) may be essential in efforts to reduce surgical mortality. Successful rescue hinges on early recognition and timely management of serious complications once they occur. Focusing on the clinical deterioration of patients during the early "golden hours" of decline may yield valuable insights into how some hospitals achieve exemplary outcomes. Unfortunately, previous work does not identify actionable insights into how hospitals can improve their rescue rates. A better understanding of how interactions and relationships within hospital micro-systems could be even more crucial to improving rescue through practical and effective interventions. To explore these issues, we propose a study designed to assess such factors and to develop and implement an intervention in Michigan hospitals aimed at improving overall safety culture, communication, and rescue rates. The specific research aims are (i) to develop an in-depth understanding of the key elements, such as teamwork and communication, necessary for complication rescue; (ii) to design an intervention that promotes key elements for improving rescue; and (iii) to pilot an intervention aimed at improving hospital rescue rates. This work will shed light on how healthcare organizations can be engaged to better sense, cope with, and respond to the unexpected and changing demands presented by clinically deteriorating post-surgical patients with life-threatening complications. This project will have direct, population-level impact to inform interventions aimed at reducing mortality in surgical patients in Michigan, and ultimately elsewhere. Results from this study will also inform large payer (including CMS) and regulators (particularly JCAHO) as they set incentives and standards for enhancing the safety of inpatient surgery in the United States. Further, the research project, highly experienced multidisciplinary mentorship team, and unparalleled research environment are ideally suited to address the career goals and educational needs of the candidate, Amir A. Ghaferi, MD, MS. The proposal includes a detailed educational plan with training that will be essential both for successful completion of this research and toward Dr. Ghaferi's career development. The training includes graduate level courses in organizational management, behavior, and theory, qualitative research methods, and implementation science. This career development award will lay the groundwork for Dr. Ghaferi to perform ongoing, innovative health services research, and to become an independent investigator and national leader in patient safety and quality improvement.