Using Lean Performance Improvement for Patient-Centered Medical Home Transformation at an Academic Public Hospital.

Although Lean performance improvement (PI) has been used in health care for more than 15 years, little is known about how Lean has been used in Patient-Centered Medical Home (PCMH) transformation. We describe our experience implementing Lean in our safety-net, primary care teaching clinic. To advance high value care, a culture of systematic, sustainable PI methods needed to be integrated into primary care and taught to resident physicians.

Beta-adrenergic blockers for perioperative cardiac risk reduction in people undergoing vascular surgery.

Background: People undergoing major vascular surgery have an increased risk of postoperative cardiac complications. Beta-adrenergic blockers represent an important and established pharmacological intervention in the prevention of cardiac complications in people with coronary artery disease. It has been proposed that this class of drugs may reduce the risk of perioperative cardiac complications in people undergoing major non-cardiac vascular surgery.

Improving transitions of care for patients with thromboembolic disease.

Patients with or at risk for thromboembolic disease have many transitional interactions within the healthcare system. Transitions of care--when patients move between or within sites of care, or transition from inpatient to outpatient status--create repeated and diverse opportunities for medication errors, rehospitalization, and other adverse events that may increase costs. Although effective antithrombotic therapies are available, these therapies are complex, underprescribed, and frequently suboptimally managed, a situation further exacerbated by poor patient adherence to therapy.

Impact of hospital variables on case mix index as a marker of disease severity.

Case mix index (CMI) has become a standard indicator of hospital disease severity in the United States and internationally. However, CMI was designed to calculate hospital payments, not to track disease severity, and is highly dependent on documentation and coding accuracy. The authors evaluated whether CMI varied by characteristics affecting hospitals' disease severity (eg, trauma center or not).

Capturing the diagnosis: an internal medicine education program to improve documentation.

Background: Specific and accurate documentation of patient diagnoses and comorbidities in the medical record is critical to drive quality improvement and to ensure accuracy of publicly reported data. Unfortunately, inpatient documentation is taught to internal medicine trainees and practitioners sporadically, if at all. At Harbor-UCLA Medical Center, a public, tertiary care, academic medical center, we implemented an educational program to enhance documentation of diagnoses and comorbidities by internal medicine resident and attending physicians.

A controlled investigation of optimal internal medicine ward team structure at a teaching hospital.

Background: The optimal structure of an internal medicine ward team at a teaching hospital is unknown. We hypothesized that increasing the ratio of attendings to housestaff would result in an enhanced perceived educational experience for residents.

Methods: Harbor-UCLA Medical Center (HUMC) is a tertiary care, public hospital in Los Angeles County.

Choosing the right heparin prophylaxis strategy in medical patients at risk for developing VTE: an evidence-based approach.

Many acutely ill medical patients are at significant risk for developing venous thromboembolism (VTE) during hospitalization. Venous thromboembolism risk arises from both the presenting clinical condition as well as predisposing risk factors, such as advanced age. Thromboprophylaxis is underprescribed in these patients.

Peripheral vascular surgery using targeted beta blockade reduces perioperative cardiac event rate.

Background: Recent studies suggest that preoperative cardiac stress testing is unnecessary in low to intermediate cardiac risk patients undergoing operations, and that targeted beta blockade is cardiac protective.

Study Design: A cohort study of patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, but without cardiac stress testing, was performed. Targeted beta blockade was initiated preoperatively.